REGIONAL PDRP APPLICANT CONSENT FORM (A1)
Proficient/Expert/Accomplished Levels
Name: Ward/Dept:
Please complete the form by ticking the appropriate boxes and signing. Include this form in your portfolio.
Thank you for submitting your Professional Portfolio and completed workbook for assessment at level.
Please complete the following:
1. CONSENT FOR PORTFOLIO TO LEAVE HOSPITAL PREMISES
I am willing for my portfolio and associated documentation to be removed from my organisation’s premises if required and kept as securely as possible. I understand that all steps will be taken to maintain the safety and privacy of my portfolio and that I can request its return at anytime.
Yes
No
2. RETURN OF PORTFOLIO
At the end of the Assessment process your portfolio can be collected from the PDRP office or you may wish to have it sent via internal mail. This would be at your own risk.
3. MODERATION OF SUBMITTED PORTFOLIOS
The PDRP requires portfolios to be moderated to maintain consistency and objectivity of the process. One in every 10 portfolios will be reviewed by one of the PDRP Assessors who will moderate the original assessor(s) of your portfolio. All new assessors will have their assessments moderated initially. The moderation process does not affect the outcome of your assessment. Your portfolio may be selected for this process.
I understand and agree with the moderation process.
Yes
No
I understand that if a new assessor evaluates my portfolio, that a senior assessor will also assess my portfolio. The new assessor may use their assessment of my portfolio as an example of work completed in their Open Polytechnic studies. I agree to have a new assessor evaluate my portfolio.
Yes
No
The assessment will be carried out as soon as possible and should take no longer than
8 weeks.
All assessors have undertaken a recognised national qualification which requires objectivity, consistency and fairness. It is preferable that the assessor(s) do not know you, or recognise you through your portfolio. Attached is a list of all assessors for the Regional PDRP. To assist us with the selection process, could you please download this list, cross out any person you have worked closely with, been a line manager of, or who has been a personal friend.
It is not unusual for your assessor(s) to contact you for clarification or for extra evidence before a decision is made. This contact is generally by phone, but you may request a meeting.
When your portfolio assessment has been completed, you will be contacted with the decision, which will be one of the following:
Decisions
Ø Endorsement of Progression
This means criteria for the applied level have been successfully met.
Ø Reserved Decision
This means that the assessor is confident that you are practising at the level you have applied for, but further documented evidence is needed. You are given a timeframe of
8 weeks to provide this.
Ø Non-Progression
This means that your assessor is confident that the criteria for that level have not yet been met. Guidelines may have not been adhered to or there are clear gaps in evidence that prevent a fair decision. Your assessor will clearly tell you which areas require further development and make some suggestions. If you wish to appeal the decision or the process, this procedure is outlined on the website or in the PDRP Policy.
Appeals
All applicants will have detailed feedback from their assessment, which should override the need for an Appeals Process. If you disagree with the decision, you should write a letter of appeal to the PDRP Coordinator. The appeal should be lodged within 7 working days of decision using an Appeal Notification Form (A6). On receipt of this letter, the PDRP Coordinator will request two new assessors to re-assess the portfolio.
The new assessors will not be told of the original outcome. If the decision by the new assessors is that you have been unsuccessful, you may decide to continue with the appeal. An Appeals Panel will be formed and those present will interview you and the assessors. On completion of this process, a written report outlining recommendations will be sent to you with copies to the PDRP Assessors, PDRP Advisory Committee and the Nurse Coordinator - PDRP.
The decision of the Appeals Panel is final and binding.
NB: The assessment will not be able to proceed until this Consent Form has been completed.
Please ensure that all sections of this form are completed and signed. Details of your PDRP application are loaded onto our database to assist with our reports to Nursing Council to remove you from their audit process. For CDHB staff, details are also updated and placed on the payroll system to ensure information is correct for payment processing.
Signature: Date:
List of PDRP Assessors as at June 2016
(Please cross out names of staff you work closely with, etc)
G:\Division\SDU\COMMON\PDRP\Assessment process\Application Consent Form – June 2016
CDHB
Margaret Burns
Michelle Casey
Jane Clarke
Stephanie Cook
Janette Dallas
Tania Freeman
Jo Greenlees-Rae
Becky Hickmott
Suzanne Johnson
Jacinda King
Jenni Manuel
Ashburton and Rural
Lisa Campbell
Heather Cullimore
Amanda Van Asperen
Burwood Hospital
Margaret Barclay
Helen Bloomer
Fiona Davie
Kerry Jones
Karen Marshall
Rachel Marshall
Kirstie Ross
Lynda Te Momo
Sue Williamson
Diane Wood
Medical Surgical
Heather Anderson
Christine Baxter
Amanda Berry
Anna Bush
Sharon Devon
Sharron Ellis
Vivienne Erickson
Sue Fawcett
Pip Francis
Ulrich Frank
Jacqui Gapes
Maggie Glasgow
Joanne Gore
Faye Greenwood
Lynne Hannaway
Carmel Harris
Neil Hellewell
Kirsty Humm
Tina Knutson
Carol Lechte
Julie Livesey
Pauline Mee
Rhonda Mikoz
Stephanie Pegg
Bronwyn Perry
Rommel Principe
Sandy Richardson
Jo Saunders
Fran Smith
Jenny Stewart
Olivia Strachan
Louise Sue
Lorraine Trebilcock
Felicity Turner
Robyn Van der Lely
Judy Ward
Louise Weatherall
Margaret Willcox
Janeen Williams
Ren Xiaoyong
Specialist Mental Health
Ian Averill
Tanya Ewart
Gail Houston
Sharon Isherwood
Cathy King
Helen Lloyd
Wendy Lowerson
Carolyn Murray
Phil Patira
Jane Patterson
Claire Roelink
Cassandra Staps
Heather Symes
Jason Watson
Mary Woods-Morgan
TPMH
Helen Denby
Dinesh Lal
Yvonne Marr
Karen Stenhouse
Rebecca Winsor
Women and Children’s
Tracey Bruce
Margaret Burns
Edna Byron
Patricia Connell
Tina Cook
Victoria Cullens
Anthea Franks
Linda King
Aimee MacKey
Donna Murray
Nicola Scott
Stella Yaxley
Nurse Maude
Hayley Creighton
Margaret Patterson
Philippa Sarjeant
Josie Tait-Jamieson
South Canterbury DHB
Judy Cooper
Karen Foster
Gill Graham
Ally Hale
Sue Morrow
Jane Procter
Megan Stark
Tracey Worthington
St. George’s Hospital
Marilyn Casey
Sue Claridge
Wendy Davie
Paul Donohue
Alison Fleetwood
West Coast DHB
Kas Beaufill
Chris Black
Vicki McGhie
Elaine Neesam
Diane Pollard
Helen Rodger
Helen Sawyers
Bruce Tomlinson
Department of Corrections
Raewyn Apiti
Debbie Gell
Jill Herridge
Fiona Irving
Jennifer Keen
Lyn McIntyre
Stephanie Muir
Linzi Sargant
Kay Sloan
Healthcare NZ
Norma Crooks
Rose McConchie
Rebbeca McCullough
Pegasus Health
Anne-Marie Baird
Jeanette Banks
Gill Currie
Di Bos
Sue Hart
Teresa Kilkenny
Jenny Marshall
Sheen McLeod
Kelly Robertson
NMDHB
Jocelyn Archer
Bridgett Baldwin
Anne-Marie Ballagh
Carolyn Bennison
Jane Besley
Jacqui Bowden-Tucker
Lois Boyd
Carol Burn
Margie Burt
Tricia Colling
Dee Emmet
Jan Gould
Sharon Hawken
Jane Heather
Jo Hendrickson
Jessica Irvine
Ruth Jarman
Ena Jansen Van Vuuren
Jenny Kane
Irene Langham
Sue Lush
Glenis McAlpine
Diane McLeod
Hilma Schieving
Pamela Shadlock
Kerri Shaw
Sue Smart
Shelly Shea
Robyn Smith
Melanie Terry
Annie Wallace
Southern DHB
Rebecca Aburn
Jenny Bishop
Trish Bloxsom
Victoria Bryant
Jacqui Cooke
Debz Cracknell
Christine Crawford
Justine Dahlenburg
Kerry Davis
Lesley Dennison
Jo Dobson
Mary Fahey
Richelle Fogarty
Linda Grady
Mike Hammond
Chris Hayde
Robyn Hewlett
Rhonda Johnson
Allison Lang
Cynthia Langford
Jillene Lee
Christine Lundy
Laurie Mahoney
Ruth Manning
Katherine Martin
Shirley McKewen
Prue Muschamp
Sue O’Brien
Rowena Paterson
Mel Rackham
Glenda Rickerby
Grant Ritchie
Sharon Sandilands
Linda Smillie
Alison Stewart-Piere
Chris Still
Jo Robertson Smith
Pauline Stringer
Helen Thompson
Jenni Topliss
Carolyn Upston
Rannerdale Veteran’s
Care
Christine Jones
Access Health
Juliet Nelson
Kaupapa Maori & Pacific Collective
Elly Grant
Christine Varley
Oxford Women’s
Debra Parr
G:\Division\SDU\COMMON\PDRP\Assessment process\Application Consent Form – June 2016