Continuing Competency Program Professional Development Plan and Outcomes ● Clinical Form Name: ________________________________ Date form completed: __________________________ Item No. From Goal Learning Strategies/Activities Anticipated Clinical (What I want to learn, specific and (What I need to do to achieve my goal) Completion Date Current Status Goal __of __ Tool measurable) (Attainable and time oriented) Registration Completed Date: □ Year: Item 1 point:__ __________ □ Mar. 1, 20 _ _ Item 2 point:__ □ to Item 3 point:__ In Progress □ □ Feb. 28, 20_ _ Item 4 point:__ □ Item 5 point:__ Omit (Reason) □ □ Item 6 point:__ □ Item 7 point:__ □ Outcomes/ Impact On Practice Evidence Supporting Goal Completion/Progression (How this leaning impacted my practice) (Certificates, course material, books, notes, dates, etc.) Check all that apply and provide reflection: List evidence and location in portfolio: Validated my practice □ Enhanced my practice □ Expanded my knowledge □ Increased my awareness of existing resources □ Other _______________________________ □
Continuing Competency Program ● Professional Development Plan and Outcomes Clinical Form Name: ________________________________ Date form completed: __________________________ Goal __of __ Registration Year: Mar. 1, 20 _ _ to Feb. 28, 20_ _ Item No. From Clinical Tool Goal (What I want to learn, specific and measurable) Learning Strategies/Activities (What I need to do to achieve my goal) Anticipated Completion Date (Attainable and time oriented) Current Status □ Item 1 point:__ □ Item 2 point:__ □ Item 3 point:__ □ Item 4 point:__ □ Item 5 point:__ □ Item 6 point:__ □ Item 7 point:__ □ Completed Date: __________ □ In Progress □ Omit (Reason) Outcomes/ Impact On Practice (How this leaning impacted my practice) Evidence Supporting Goal Completion/Progression (Certificates, course material, books, notes, dates, etc.) Check all that apply and provide reflection: □ Validated my practice □ Enhanced my practice □ Expanded my knowledge □ Increased my awareness of existing resources □ Other _______________________________ List evidence and location in portfolio:
PDPO%20clinical%20form%20dec%202018.docx