Nursing Clinical Advancement Program
Children's National Medical Center
Document Submission Form for
*
First Name
Last Name
E-mail
*
24 month Accumulation Period
-
Month
-
Day
Year
Date
TO:
-
Month
-
Day
Year
Date
This is my:
First Submission
Advancement Submission
Maintenance Submission
Number of points achieved
ID#
Unit
Date:
/
Month
/
Day
Year
Date
Back
Next
Save
To be completed by Director or Manager
Name
First Name
Last Name
Date:
-
Month
-
Day
Year
Date
I have discussed the Nursing CAP program with the applicant. I verify the applicant has the appropriate position, tenure, education and experience for desired advancement level. The applicant received at least “Meets Criteria” on last performance appraisal and has had no corrective action in the interim.
Director / Manager Signature
Back
Next
Save
To be completed by Nursing Clinical Advancement Program Steering Committee
Number of Points Awarded:
Level Awarded:
This applicant’s Nursing CAP portfolio has been reviewed and we approve the appropriate pay adjustment.
Clinical Advancement Program Steering Committee signature:
Back
Next
Save
I am applying for:
LEVEL 1
LEVEL 2
LEVEL 3
Point Accumulation
(min. 7) and Supportive Evidence
Back
Next
Save
Point Options PART A
PROFESSIONAL EXPERIENCE
2-5 Years (1 Point)
6-10 Years (2 Points)
10 or more Years (3 Points)
Attach Decision Critical Profile documenting dates of prior Nursing Experience.
Upload a File
Cancel
of
NURSING DEGREE: Indicate highest Nursing Degree Held
Nursing Degree In Progress (1 Point)
BSN (2 Points)
MSN (3 Points)
Attach copy of degree/transcript and/or official enrollment documentation.
Upload a File
Cancel
of
NATIONAL SPECIALTY CERTIFICATION: Required for Levels 2 and 3:
Submit 1 (2 Points)
Submit 2 (4 Points)
Attach copy of current certification(s).
Upload a File
Cancel
of
PROFESSIONAL AWARD/RECOGNITION:
Any Nomination; Unit level award received (1 Point)
Children's National Award Received (2 Points)
External Professional Award Received (3 Points)
Attach each nomination or award letter
Upload a File
Cancel
of
PROFESSIONAL COUNCIL/COMMITTEE MEMBER:
Unit Level (1 Point)
Hospital Level (2 Points)
External Level (3 Points)
Attach letter from each chair, verifying active participation (>75% attendance)
Upload a File
Cancel
of
PROFESSIONAL COUNCIL/COMMITTEE CHAIR/LEADER
Unit/Hospital Level (2 Points)
External Level (3 Points)
Attach supportive evidence of chairmanship (e.g. minutes)
Upload a File
Cancel
of
PROFESSIONAL ORGANIZATION
Membership (1 Point)
Active member with evidence of participation (2 Points)
Leadership position in organization (3 Points)
Attach supportive evidence
Upload a File
Cancel
of
Points accumulation
Save
Submit
Print Form
Should be Empty: