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RN Competency Form: Generalist Competence Verification & Learning Guide: Facility Name (learner) Date Initiated Unit ☐RN ☐LPN ☐Recent Graduate ☐Experienced Nurse ☐New to Specialty ☐Traveling Nurse Note: for LPN practice guidelines, see state nursing statutes & regulations The preceptor will initial each competency when he/she, as preceptor and colleague, feels safe in allowing the learner to deliver this aspect of care without direct supervision. Self-Assessment: 1 – Identified Limitation (little or no experience); 2 – Capable (familiar but may need assistance); 3 – Independent - can perform these tasks safely; 4 – Proficient - extensive experience *For further information, see instruction sheet at end of this form. References IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following: Initiate life-saving/emergency measures consistent with patient needs and protocols Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment Learning Guide follows competency pages and contains items for each competency that need to be reviewed based on learner’s experience and unit need, they include reminders of important teaching points that may otherwise be missed. IA 1 Conduct initial assessment to identify patient’s needs and priorities of care (full physical assessment--RN only, LPN’s may perform limited, targeted assessments) IA 2 Develop individualized plan of care that reflects current practice standards (RN only) IA 3 Implement plan of care based on patient-related data and best practices IA 4 Integrate developmental and age specific needs in approach to and delivery of care IA 5 Use equipment based on age, weight and need IA 6 Implement measures and precautions to insure patient safety and well-being Complete restraint competencies as required. IA 7 Promote increase in client independence teach/assist patients with PT/OT/ST per protocols maximize client decision making IA 8 Implement mental health & alcohol/substance abuse behavior protocols IA 9 Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 1 References Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment RN Competency Form: Generalist Manage patient on cardiac monitor place leads correctly interpret rhythm correctly intervene as needed IA 10 Manage nutritional support - recognize need manage tube feedings per protocol administer total parenteral nutrition per protocol IA 11 IB. The learner will incorporate relevant A & I skills in delivery of medications, IV’s & blood to include the following: Administer medication to assigned patients implement safe practice with high risk medication complete procedural sedation implement the “rights” of med administration competency if req’d state indications, contra-indications and side effects (may use reference) administer IVPB solution administer IV push/bolus med (RN only) Manage peripheral IV care consistent with protocols verbalize pediatric and geriatric volume and dosage precautions Manage central/PICC line consistent with protocols use correct flush solution and technique apply policy for clotted line assess site for complications NOTE: LPN’s limited to specific training per state regs Administer blood/blood products (RN only) per protocol IB 1 IB 2 IB 3 complete PICC competency if required Perform venipuncture on an adult &/or child or infant heel stick as applicable IC. The learner will incorporate relevant A & I skills in performing procedures & utilizing equipment to include: Integrate sterile technique into practice according to agency policy IB 4 IB 5 IC 1 Perform point of care testing per lab and unit protocols by completing all required competencies IC 2 Utilize protocols and other references for unfamiliar or infrequently used procedures and equipment IC 3 Administer oxygen safely as ordered IC 4 Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 2 References Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment RN Competency Form: Generalist Perform the following types of suctioning as apply: trach suctioning naso or oropharyngeal bulb, yankaur, olive tip Manage a nasogastric tube per protocol IC 5 Implement pain management protocol initiate pain pump(s) used in unit (RN only) IC 7 Manage patient pre-, during, and post-procedure per protocol IC 6 IC 8 Also see separate comp for procedural sedation if applies Perform wound care consistent with protocols IC 9 Incorporate regulatory requirements into practice IC 10 Section II. The learner will incorporate relevant communication skills in all interactions to include the following: Document care given and patient response accurately in health care record. II 1 Interact in a respectful and collaborative manner with the healthcare team. II 2 Report pertinent, concise information to team members per policy II 3 Demonstrate verbal and nonverbal therapeutic communication with patients and staff II 4 Section III. The learner will incorporate critical thinking skills in delivery of all nursing care to include the following: Analyze patient laboratory data to use it in clinical decision making III 1 Manage unit phone calls per policy III 2 Prepare for moving a patient between levels of care within the facility or to/from another facility III 3 Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 3 References Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment RN Competency Form: Generalist Use resources effectively respond to significant changes in patient status per protocols and orders notify charge nurse or manager of significant changes or needs on unit Anticipate potential unit / patient crises and act to prevent them or minimize their impact III 4 Perform nursing role within scope of practice, unit limitations and individual competency use reflective judgment in self-assessment &planning recognizes own limitations create a plan for ongoing development of decision making ability III 6 Section IV. The learner will incorporate human caring & relationship skills in all interactions to include the following: Advocate for patient and family needs III 5 IV 1 Assist patient/family with ethical and/or legal issues with sensitivity IV 2 Display empathy, compassion and respect to patients and families IV 3 Maintain patient privacy and confidentiality at all times IV 4 Assist colleagues with care delivery IV 5 Incorporate cultural competence and respect for diversity into practice IV 6 Provide palliative care as part of the continuum of care. IV 7 Section V. The learner will incorporate management skills in all interactions to include the following: Plan shift to accomplish tasks and goals organize workload effectively prioritize and reprioritize work as needs change complete tasks or seek help Manage assignment complete full patient assignment ask for advice and delegate as needed V1 V2 Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 4 Manage self manage personal professional development keep certifications, license & employee health records current, wear appropriate attire and ID maintain calm, professional behavior during stressful situations use correct body mechanics and resources to prevent injury Identify area of interest in quality improvement (committees, projects, workgroups, etc.) Section VI. The learner will incorporate leadership skills in all interactions to include the following: Complete Clinical Nursing Leadership Competence Complete leadership competency form if required (charge nurse, manager, house supervisor, preceptor, etc.) References Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment RN Competency Form: Generalist V3 VI 1 Supervise staff monitor performance of supervised staff assist staff as needed provide feedback to staff & management as needed VI 2 Delegate work fairly and according to skill level and scope of practice VI 3 Coordinate care with healthcare team VI 4 Initiate chain of command VI 5 Section VII. The learner will incorporate teaching skills in delivery of all nursing care to include the following: Educate patients and families with consideration for age, culture, educational background and home environment or setting VII 1 Provide education to complete a successful patient discharge per policy VII 2 Coordinate education to ensure the patient gets a consistent message VII 3 Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 5 References Section VIII. The learner will incorporate knowledge integration skills to include the following: Identify care issues within the rural environment Learning Guide # D—Demonstrated; T—Test; M—Module/class; V—Verbalized Preceptor initials Verification method & facility specific requirements Learner initials Required Competencies Main categories followed by associated competencies and critical elements. (Preceptor needs to verify learner capability for these items.) Date all met Self-assessment RN Competency Form: Generalist VIII 1 Provide nursing care that is evidence based VIII 2 Use all computer systems successfully VIII 3 Accept teaching, coaching and mentoring to improve competence VIII 4 Seek continued learning opportunities to improve practice VIII 5 Comments/alternative learning plans: All preceptors are to sign & initial below. Ideally new graduates should have only one to two preceptors for the entire orientation. Preceptor Signature Initials Preceptor Signature Initials Signatures at completion of preceptorship/orientation: Preceptee/orientee Date Primary Preceptor Date Manager Date Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 6 RN Competency Form: Generalist LEARNER GUIDE: Reference content in the right-hand column that needs review. IA. The learner will incorporate relevant assessment & intervention (A&I) skills in delivery of care to include the following: IA 1 Initiate life-saving/emergency measures consistent with Review procedures for: patient needs and protocols -Correct response for all codes -Obtaining/interpreting an ECG -Emergency intubation -Allergic reaction (also latex allergy) -Seizure precautions including patient positioning/padding -Hyper and hypoglycemic episodes -Hyper and hypothermic episodes -Suicide prevention precautions -Nonviolent crisis intervention -Pediatric emergencies (including medication dosing and crash cart supplies -GI, post partum, other significant bleeds -Reporting abuse/neglect -Use of emergency equipment -Cardiac emergencies -Poison/overdose management IA 2 Conduct initial assessment to identify patient’s needs and priorities of care (full physical assessment--RN only, LPN’s may perform limited, targeted assessments) Review the following: -How to complete all intake forms & processes -How to complete assessment to identify primary needs of patient -How to distinguish abnormal from normal signs and symptoms -How to address age specific needs -Immunization policies (Review vaccination database--VAK TRAK or other) -Policy for treatment of minors and at risk adults -Skin integrity assessment and protocols -Physical, psychological, social and spiritual aspects of assessment IA 3 Develop individualized plan of care that reflects current practice standards (RN only) Implement plan of care based on patient-related data and best practices Integrate developmental and age specific needs in approach to and delivery of care Review care plan process and documentation requirements Use equipment based on age, weight and need Review the use of equipment (scales, pumps, restraints, lifts, etc.) in regards to age and weight. IA 4 IA 5 IA 6 Review priority setting practices and discharge criteria Review the following: -VS parameters -Communication techniques -Physical, developmental, spiritual & emotional needs Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 7 RN Competency Form: Generalist LEARNER GUIDE: Reference content in the right-hand column that needs review. IA 7 Implement measures and precautions to insure patient Review the following: safety and well-being -Wandering & fall prevention protocols -Patient identification measures -Restraint and seclusion policy including: assessing need for continued restraint, using least restraint necessary, and monitoring for complications/patient needs -Infection control policy including hand hygiene, personal protective equipment, patient isolation (respiratory, wound, neutropenic, etc.) and contaminated waste policies -Nosocomial risks: delirium, UTI’s, central line infections, pressure ulcers, etc. -Unusual occurrence reports IA 8 Promote increase in client independence Review physical, occupational and speech therapy procedures, introduce to PT/OT/ST team, review resources & equipment available and methods to support family involvement IA 9 Implement mental health & alcohol/substance abuse behavior protocols Review mental health policies re: suicide watch, behavioral management, consultations Review alcohol/substance abuse protocols and pathophysiology Review process for transferring to other facilities IA 10 Manage patient on cardiac monitor Review procedures and monitoring equipment and policies for handling abnormal rhythms Review rhythm interpretation IA 11 Manage nutritional support - recognize need Review protocols, available types of tube feeding, nutritional supplements and diets. Introduce to dietary personnel IB. The learner will incorporate relevant A & I skills in delivery of medications, IV’s & blood to include the following: IB 1 Administer medication to assigned patients Review medication administration policies and reference materials including med reconciliation and narcotic accounting Introduce to pharmacist and review pharmacy role and availability Must pass unit/hospital medication test if required before allowed to administer meds Review limits to medication administration (formulary, restricted meds, high alert meds) IB 2 Manage peripheral IV care consistent with protocols Practice with related equipment (syringe pump, IV pump and corresponding supplies) Review policies re: preparing IV meds, approved IV medication list per unit Review geriatric and pediatric considerations re: volume and dosages IB 3 Manage central/PICC line consistent with protocols NOTE: LPN’s limited to specific training per state statutes Review policies on flushing, drawing blood, declotting, dressing change, removal and general care of all central catheters used in the facility (PICC, triple lumen, groshong, portacath, etc.) Complete any specialty line competencies as required IB 4 Administer blood/blood products (RN only) per protocol Review blood bank and nursing policies and procedure for transfusion of blood products Review actions to take if suspected reaction occurs Review massive transfusion, autologous transfusion and giving uncrossmatched blood policies Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 8 RN Competency Form: Generalist LEARNER GUIDE: Reference content in the right-hand column that needs review. IB 5 Perform venipuncture on an adult &/or child or infant heel Review lab and nursing policies related to blood sampling stick as applicable Review blood culture protocol IC. The learner will incorporate relevant A & I skills in performing procedures & utilizing equipment to include the following: IC 1 Integrate sterile technique into practice according to If not demonstrated in patient care, have learner simulate a sterile dressing agency policy change, foley insertion or other sterile procedure. IC 2 Perform point of care testing per lab and unit protocols by completing all required competencies Review testing and quality control for the following as apply: rapid strep, glucometer, urine chemistry strip, occult blood, urine pregnancy tests, iStat, Ferning test IC 3 Utilize protocols and other references for unfamiliar or infrequently used procedures and equipment Review how and where to access all procedures, manuals and instructions. Infrequent procedures may include post-mortem care, organ donation, and many others Equipment may include heating or cooling devices, fluid warmers, and many others IC 4 Administer oxygen safely as ordered Review types of O2 equipment (cannula, NRB, BVM, ventimask and aerosol mask, tanks, etc.) Review O2 monitoring and signs of toxicity Set up and use pulse oximetry Review peak flow measurement IC 5 Perform the following types of patient suctioning as apply Review procedures for suctioning including safety considerations IC 6 Manage a nasogastric tube per protocol Review protocols including how to assess placement/proper function Practice insertion as needed IC 7 Implement pain management protocol Review policies Assess and reassess every patient for pain For epidural, and PCA: specifically review equipment manual, pain management techniques, teaching, troubleshooting and documentation Review role of anesthesiology dept for epidurals IC 8 Manage patient pre-, during, and post-procedure per protocol Review pre-op preparation and paperwork including site check Review protocols (including time out) for procedures performed in the unit (thoracentesis, paracentesis, spinal tap, etc.) Review protocols for post-op/unit procedure recovery & potential complications IC 9 Perform wound care consistent with protocols Review procedures and equipment (wound vacc, drains, etc.) Introduce to any resource personnel (ostomy/wound care nurse) IC 10 Implement regulatory requirements into practice National patient safety goals, CMS guidelines, Joint Commission, core measures, etc. Section II. The learner will incorporate relevant communication skills in all interactions to include the following: II 1 Document care given and patient response accurately in Review charting policy, forms, and computer programs. health care record. II 2 Interact in a respectful and collaborative manner with the Meet team members and review roles and responsibilities of each healthcare team. II 3 Report pertinent, concise information to team members Review hand-off report, info to share with charge nurse, manager, MD’s, etc. per policy Review how to reach team members (pager, phone, etc.) Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 9 RN Competency Form: Generalist LEARNER GUIDE: Reference content in the right-hand column that needs review. II 4 Demonstrate verbal and noverbal therapeutic Review care models for the organization (rounding, family driven care, etc.) communication with patients and staff Review organizational behavior standards Section III. The learner will incorporate critical thinking skills in delivery of all nursing care to include the following: III 1 Analyze patient laboratory data to use it in clinical Review lab norms and reports including fluid and electrolyte management and decision making critical values III 2 Manage unit phone calls per policy Review telephone triage policy (RN only) Review Health Aide roles and capabilities Review types of calls, scope of practice and information sharing limitations III 3 Prepare for moving a patient between levels of care within the facility or to/from another facility Review ground and air transfer policies and logistics Review EMTALA and medivac protocols III 4 Use resources effectively Review order sets and protocols and notification process Review after hour protocols, acuity process, supplies, etc. III 5 Anticipate potential unit / patient crises and act to prevent them or minimize their impact Review frequently occurring unit patient intervention needs Review unusual occurrence reporting system Discuss failure to rescue Review rapid response team role if available III 6 Perform nursing role within scope of practice, unit limitations and individual competency Review ANA and specialty standards, nurse practice act Review limitations of unit and competency process Section IV. The learner will incorporate human caring & relationship skills in all interactions to include the following: IV 1 Advocate for patient and family needs Review policy for patient complaints, advocacy and ethics IV 2 Assist patient/family with ethical and/or legal issues with sensitivity Review policy and resources for patient rights, advocacy, code status, living wills, POAs, etc. IV 3 Review customer service guidelines and mission statements IV 4 Display empathy, compassion and respect to patients and families Maintain patient privacy and confidentiality at all times IV 5 Assist colleagues with care delivery Review teamwork behaviors IV 6 Incorporate cultural competence and respect for diversity into practice Discuss local cultural beliefs and practices that impact healthcare, interpreter procedures, pastoral care, social services, etc. IV 7 Provide palliative care as part of the continuum of care. Review guidelines on pain and other symptom management Review education and support systems that help patients live as actively as possible until death Introduce to team and team approach to address needs of patients and families, including bereavement counseling Review confidentiality procedures for medical records, unit privacy, HIPPAA, and private places to talk Section V. The learner will incorporate management skills in all interactions to include the following: V1 Plan shift to accomplish tasks and goals Review unit shift expectations and time management techniques V2 Manage assignment Review position descriptions and capabilities of other staff on the unit Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 10 RN Competency Form: Generalist LEARNER GUIDE: Reference content in the right-hand column that needs review. V3 Manage self Review unit and hospital requirements, lift policies, employee safety process, dress code, etc. Review quality process used in facility Section VI. The learner will incorporate leadership skills in all interactions to include the following: VI 1 Complete Clinical Nursing Leadership Competence Review policies along with the competence form including staffing, acuities, disaster management, etc. VI 2 Supervise staff Review position descriptions VI 3 Introduce to all unit staff and describe their job responsibilities and limitations VI 4 Delegate work fairly and according to skill level and scope of practice Coordinate care with healthcare team VI 5 Initiate chain of command Review organizational structure and situations requiring notification Introduce to all professional and support team members, review their roles & contact procedures Section VII. The learner will incorporate teaching skills in delivery of all nursing care to include the following: VII 1 Educate patients and families with consideration for age, Review teaching principles and local culture and resources culture, educational background and home environment or setting VII 2 Provide education to complete a successful patient Identify community resources for the patient discharge per policy Review discharge policy and procedures (pharmacy, standardized teaching materials, etc.) VII 3 Coordinate education to ensure the patient gets a Review standards for patient education consistent message Section VIII. The learner will incorporate knowledge integration skills to include the following: VIII 1 Identify care issues within the rural environment Discuss general rural care issues & those specific to each rural site Problems common in frontier areas: older population, socioeconomic status, access, transportation and financial issues, employee benefits, fewer practitioners Rural nurse generalist concepts: isolation and distance, lack of anonymity, old timer/newcomer and insider/outsider, informal networks, rural concepts of health, definition of health, possibly delayed treatment seeking, self reliance, cultural issues, boundary expansion and pinch hitting, “practicing medicine” without a license, family centered care, career development and education, accessing patient care information on the fly VIII 2 Provide nursing care that is evidence based Review computer/library resources, local experts and classes VIII 3 Use all computer systems successfully Obtain computer systems training VIII 4 Accept teaching, coaching and mentoring to improve competence VIII 5 Seek continued learning opportunities to improve practice Other facility specific items to cover: Review resources available for learning Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 11 RN Competency Form: Generalist REQUIREMENTS: All nurses will complete these competencies upon hire. Some competencies may be reviewed annually. This form follows the Competency Outcomes and Performance Assessment (COPA) model. PRECEPTEE/LEARNER INSTRUCTIONS: Complete self-assessment: Rate your skill in each area to identify the areas where you need additional experience, access to teaching resources, and/or lab practice. Discuss your results with your preceptor to help establish a plan and goals for your learning experience and to aid in choosing patient assignments. Scoring per instructions at the top of page 1. PRECEPTOR INSTRUCTIONS: A. Review self-assessment with preceptee/learner to establish plan. B. Required Competencies: The specialty area competency forms are required for independent practice on this unit. This column represents the Alaska Statewide required competencies per ACE-HC and should not be altered. The preceptor will sign each one off when he/she, as preceptor and colleague, feels safe in allowing the preceptee/learner to deliver this aspect of care without direct supervision. C. Verification Method & Agency Specific. Document comments/check marks for the competency and any agency specific requirements. Verification methods include: 1. Demonstration – Preceptor watches learner perform task/procedure in safe, capable manner in a simulated lab or computer setting or as part of direct care performance. The expectation for new graduates is that they demonstrate as many of the competencies as possible. 2. Test – Learner passes a test provided by the facility to measure competence for this skill. (Minimum passing grade indicated. Initial only after test passed.) 3. Module –Learner has completed a training tool (computerized or written module, class, video, etc.) provided by the facility to measure competence for this skill. 4. Verbalization - Learner explains to the preceptor the process and/or planning that evidences safe, reliable knowledge base. This may include case scenarios, discussion, and/or description of plan. NOTE: some competencies may have the verification method specified per facility guidelines (e.g. “test only”) Record N/A and initials only for items that never apply to this learner’s role or performance. D. Sign-off: Sign and date when all elements of the competency are met. If unable to sign off an area due to patient population issues or learner needs more time, document a plan in the comments section at the end of the form. Discuss alternative ways of meeting the requirement(s) as well as any additional time needed with the nurse manager and/or nurse educator. All preceptors assisting in orientation of a new staff member/intern must sign and initial in the signature chart at the end of this document. E. References: Competencies should be met in accordance with these. Add your facility approved references here. F. Learning Guide: These are memory ticklers. The amount of time spent on each of them depends on the learner’s experience. New graduates will likely need time on almost all of the areas listed. REFERENCES COLUMN: List foundational documents to support the learning experience and to use as the official measure by which the competencies are assessed. The ACE-HC group recognizes the following as sources for evidence based practice that can be included in the reference list along with local policies, procedures and forms: Perry & Potter, Elsevier/Mosby, Lippincott, Kozier & Erb, ANA, nationally recognized hospital related regulatory organizations (CLIA, CDC, CMS, JC, etc.), and specialty nursing organizations’ scope, standards and core curricula. This column’s content may be changed to be facility specific. NOTE: ACE-HC competency forms are intended to be used between facilities within Alaska. Form based on Dr. Carrie Lenburg’s “Competency Outcomes & Performance Assessment” model. Copyright © May, 2008. Updated May, 2012. Alaska Coalition of Educators—Health Care. All rights reserved. Page 12
