Oregon SANE/SAE Lapse of Certification Application
First Name MI Last Name
Address
City, State, Zip Code Phone #
E-mail Address When were you previously certified?
License Number Years of SANE Experience
Employer County of Employment
Work Address
Work City, State, Zip Code Work Phone #
Please submit along with this completed application packet:
l Recertification fee: $100, non-refundable. Please send check or money order, payable to the Oregon SANE Certification Commission.
l Please do NOT use staples in your application. Thank you!
Active Practice Verification:
By signing below, I affirm that I hold a current unrestricted License in Oregon and that I am actively practicing in a clinical practice with an average of 16+ hours of direct patient contact per month.
Applicant Signature Date
Mail all materials to:
Oregon SANE/SAE Certification Commission
3625 River Road North, Suite 275
Keizer, OR 97303
Along with this completed application, please submit three de-identified sexual assault medical-forensic exams from within the past three years, on state exam forms.
All exams MUST be submitted on state exam forms,
NO EXCEPTIONS.
Exams submitted on facility forms will not be reviewed by the Commission and will be returned to you to be rewritten onto state exam forms. This is the only way for the Commission to evaluate all applicants fairly.
Common mistakes and how to avoid them:
Mistake # 1: Sending in exams on facility-specific forms.
Instead: Send them in on the latest state exam form.
Mistake # 2: Sending in an exam with missing pages.
Instead: Double check that you are sending in the state exam form, pages 1-15. In particular, make sure to include page 15, HIV Risk Assessment/Medications/Referrals.
Mistake #3: Blanks and missing information.
Instead: Include medication names and dosages. Explain “unknown” or “attempted” answers. Note when patient declines an option.
Mistake #4: Sending in extra pages.
Instead: Send in the state exam form, pages 1-15. Other medical records or extra exams will be shredded.
Mistake #5: Not de-identifying your charts.
Instead: Make sure ALL identifying information is blacked out or removed. Refer to the instructions if you’re unsure what information this includes.
If the Commission feels they cannot fully evaluate your competency for the reasons above or any other reason, you will be asked to send in additional information during the next application cycle.
Speculum Exam Active Practice
□ I conduct speculum exams as a regular part of my job. Estimated number in last 3 years
□ I have completed at least 15 sexual assault exams that included speculum exams within the last three years. Estimated number in last 3 years
□ I have completed at least 15 speculum exams within the last three years through the following arrangement (explain):
Contact person(s) for verification of speculum exams:
Name / Title / Organization / Contact Phone NumberSexual Assault Nurse Examiner
Practice Critique and Self-Reflection Instructions
This transition is an excellent opportunity to check in with yourself and with your practice. It is also an excellent opportunity to communicate with us about your individual needs and the needs of your community. Please attach a critique and self-reflection relating to these areas. Be thoughtful and thorough. If you need further guidance, suggested topics are below.
Topic Suggestions:
● What are some of your strengths in this work? What are particular areas of growth for you since you began practicing?
● What are areas you still feel unsure of in your practice? What do you feel you could improve on? What questions do you have?
● What keeps you motivated as a SANE?
● What do you struggle with as a SANE?
● What are some barriers you have identified in transitioning your practice to Oregon?
● How could we better support your transition to Oregon?
Continuing Education Hours Log
(to be completed by SANE/SAEs with 3+ years of practice outside of Oregon)
Applicant NameLearning: 15 CE Maximum
Includes: courses, trainings, conferences, article review, webinars
Title / Date(s) / Organization/School/Journal / CE Equivalent
1.
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10.
TOTAL
Teaching: 10 CE MaximumIncludes: teaching, presentations, policy, and publications by applicant
Title / Date(s) / Organization/School/Journal / CE Equivalent
1.
2.
3.
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5.
6.
7.
TOTAL
Activities: 10 CE MaximumIncludes: trial testimony, case review
Type of Activity / Typical Length / Frequency / CE Equivalent
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2.
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5.
6.
7.
TOTAL
Teams: 10 CE MaximumIncludes: SART, MDT, SATF
Type of Activity / Typical Length / Frequency / CE Equivalent
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2.
3.
4.
5.
6.
7.
TOTAL
Professional Memberships: 5 CE Maximum1 CE per year of membership
Organization / Years Active / CE Equivalent
1.
2.
3.
4.
5.
TOTAL
Please add up the totals above (do not exceed category maximums) to get your grand CE total.
Learning Total / / 15Teaching Total / / 10
Activities Total / / 10
Teams Total / / 10
Professional Memberships Total / / 5
GRAND TOTAL
Challenge Process
Please identify below which area you are challenging and explain below what you have done to maintain your competency as a SANE.
□ Continuing Education Hours
□ Sexual Assault Exam Competency
Revised November 2016