CPD portfolio template

Personal and Registration DetailsName:_______________________________________________________Address: _______________________________________________________Telephone number: _______________________________________________Email address: ___________________________________________________Date of Birth: ____________________________________________________Nurses Board of Victoria Registration No.:___________________________ANF Membership No.:___________________________________________Principal place of employment:___________________________________Address: _______________________________________________________Telephone number: _______________________________________________Designed by Dandenong Casey General Practice Association July 20073

RN EducationUniversity/Hospital/TAFE:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Year commenced:_______________ Year completed: _____________Subjects:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Awards/activities:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4

Post Registration Modules/Education:University/College/Other:________________________________________________________________________________________________________________________________Module/date/result:________________________________________________________________________________________________________________________________Course in Medication Administration for Division 2Nurses in Victoria:University/College/Other:________________________________________________________________________________________________________________________________Module/date/result:________________________________________________________________________________________________________________________________Other courses:Further Education________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Designed by Dandenong Casey General Practice Association July 20075

CPD planning & Evaluation recordDate Identified learning needs Possible ways to fulfilllearning needsEvaluation of activitiesundertakenNeedmet Date6

CPD planning & Evaluation recordDate Identified learning needs Possible ways to fulfilllearning needsEvaluation of activitiesundertakenNeedmet Date7

In-service EducationDate Subject/title Hours Venue Educator/signature8

In-service EducationDate Subject/title Hours Venue Educator/signature9

In-service EducationDate Subject/title Hours Venue Educator/signature10

Employment HistoryWorkplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________Workplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________Workplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________12

Employment HistoryWorkplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________Workplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________Workplace:____________________________________________________Grade/Classification:Position:______________________________________________________________________________________Date Commenced: _________________Date finished: _______________No. of hours worked per week (average): ______________________________13

Membership of professional groupsOrganisation Date joined Registration number14

OrganisationsNBV:APNA:RCNA:ANF:DCGPA:Nurses Board Victoria595 Little Collins St, MelbournePhone: (03) 8635 1200Fax: (03) 8635 1248Registration Enquiries: (03) 8635 1222www.nbv.org.auAustralian Practice Nurse AssociationLevel 1, 595 Little Collins Street, MelbourneFreecall: 1300 303 184Phone: (03) 9614 7777Fax: (03) 9614 7776www.apna.asn.auRoyal College of Nursing Australia1 Napier Close, Deakin West, ACT 2600Freecall: 1800 061 660Phone: (02) 6283 3400Fax: (02) 6282 3565www.rcna.org.auAustralian Nursing Federation540 Elizabeth St, Melbourne. 3000Phone: (03) 9275 9333www.anfvic.asn.auDandenong Casey General Practice Association314B Thomas St, DandenongPhone: (03) 9706 7311Fax: (03) 9793 4050www.dddgp.com.auEmail: dandiv@dddgp.com.au15