Ien Application Package: Type Text Here

INTERNATIONALLY EDUCATED NURSES
IEN APPLICATION PACKAGE
Below is a brief description of what is necessary to begin the application process. Please read through carefully.
MANDATORY FORMS TO RETURN DIRECTLY TO CLPNA (DO NOT SUBMIT NNAS ADVISORY REPORT)
 Application for Registration Form
Complete this application form and submit directly to CLPNA. If you answer yes to any questions in the declaration, be
sure to provide an explanation in the box on page 4.
 Criminal Record Check

In order to meet the requirements of registration the CLPNA will only consider Criminal Record Checks issued by
myBackCheck directly to the CLPNA through the online system. To register for an account and complete your Criminal
Record Check visit: https://www.sterlingtalentsolutions.ca/clpna/ Criminal Record Checks are considered valid for 6
months from the date of issue.
 Resume
Resume must include all previous nursing employment with dates and position(s) held.
 Job Description(s)
Job description(s) must be provided to the CLPNA directly from the previous employer(s) by mail.
 Declaration of Hours Form

This form is to be completed by the applicant and should include all nursing practice hours obtained in the past four
years. Hours should be separated by year and by employer. Enter zero (0) for any years that nursing hours were not
obtained. CLPNA has established a policy that you must be actively engaged in practice within the previous 4 years to
qualify for registration as a Practical Nurse. The current Actively Engaged in Practice Policy can be found on the CLPNA
website. Please note that policies are subject to change at any time and it is the applicant’s responsibility to be aware
of current requirements.
 Declaration of Employment Information (For LPNs Practicing in Alberta) Type text here
This form must be completed as a requirement of registration. You are required to complete Section 1 - 3 of the
Declaration form.
 Identification Requirements
In order to meet the requirements of registration the CLPNA requires two forms of government issued ID. CLPNA
accepts passport, birth certificate, Permanent Resident card, citizenship certificate, and driver’s license. Please note
that at least one has to be photo identification and preferably both will be color copies. Do not fax identification.
 Credit Card Authorization Form

Submit payment of $340 to CLPNA in order to begin the processing of your application. The CLPNA will also accept
money orders and certified cheques made payable to CLPNA. Please do not mail cash or personal cheques.
INTERNATIONALLY EDUCATED NURSES APPLICATION FOR REGISTRATION Revised December 13, 2019
ADDITIONAL REQUIREMENTS THAT MAY BE REQUIRED BY THE CLPNA
 Jurisprudence Exam
Applicants are required to successfully complete the CLPNA Jurisprudence Exam prior to the application being
assessed. The exam reflects the legislation, standards and ethics required by the CLPNA to practice as an LPN in
Alberta. Each province has its own legislation; therefore, you will need to complete the Alberta Jurisprudence Exam in
order to practice here, even if you have completed another province’s jurisprudence exam. There is a study guide for
the exam on the CLPNA website at http://www.clpna.com/members/jurisprudence-examination/. More information
on how to access the Jurisprudence Exam will be sent to you once your application has been received.
 Verification of English Language Proficiency

All applicants to the College of Licensed Practical Nurses of Alberta (CLPNA) must be sufficiently proficient in the
English language and be able to provide professional services in English. The English Language Proficiency Standard is
applicable to all applicants requesting registration in Alberta.
The requirement for English Language Proficiency can be met through one of the following ways:
 Graduation from a Practical Nurse Program in Canada where English was the language of instruction.
 Graduation from a 4-year non-practical nurse program in Canada where English was the language of
instruction.
 Successful completion in accordance with the standard of either the Canadian English Language Benchmark
Assessment for Nurses (CELBAN) or the International English Language Testing System (IELTS) Academic
Version.
Applications for registration are not considered complete and ready for assessment until the language requirement
has been met.
FEE SCHEDULE
ADDITIONAL FINANCIAL INFORMATION
 Registration fees are not refundable, non-transferable.
 Payments are to be made payable to CLPNA and prices are subject to change. (NO personal cheques).
 Payment methods:
Visa, MasterCard (fill out form attached), Money Order, Certified Cheque, Cash or Debit (in CLPNA Office).
 Practice Permits expire annually on December 31.
INTERNATIONALLY EDUCATED NURSES
APPLICATION FOR REGISTRATION
PERSONAL (Please Print)

Domingo Jyselle Elyssa Argonza
Current Legal Surname (Last Name) Given Name (First Name) Middle Name(s)
26/01/1985
Sex  Female  Male
Maiden Name Date of Birth (dd/mm/yy)
4387 St Catherines st. Vancouver
Apartment / Box No. / Address or Street No. City / Town / Village

British Columbia Canada v5v4m4
Province/State Country Postal Code / Zip Code
778.867.2601 Tagalog
Telephone No. Cell No. Primary Language

232790
jyselled@gmail.com 8176182
E-mail Address (MANDATORY) NNAS ID Number
all information regarding patients profile and records/ chart must not be disclosed to any person unless allowed by the patient himself.
NNAS Application ID Number
PERSONAL DECLARATION (check applicable answer)

For more information on the CLPNA’s authority to request an applying member to self-declare, visit www.clpna.com; Practice Policy - Personal Declaration for
Registration Requirements which is linked to three supportive documents to enhance the LPN’s understanding of Interpretive Document-Duty to Report,
Interpretive Document-Fitness to Practice and Incapacity, and Practice Guideline-Preventing Nurse-to-Client Transmission of Blood-Borne Virus and Other
Communicable Diseases. If any circumstances change throughout the year, you are required to contact CLPNA.
1. Have you ever applied for registration in Alberta previously? Yes No
2. Have you applied for registration in any other Canadian province or territory? Yes No
3. Have you ever been denied registration/licensure or subject to conditions on a practice permit/license by a Yes No
registration/ licensing authority for nursing or any other health profession in Alberta or any other province, territory, or
country (excluding CLPNA)?
4. Have you ever been subject to any investigative proceedings with respect to unprofessional conduct, incompetence, or Yes No
incapacity in nursing or any regulatory body, in Alberta or any other province, territory, or country (excluding CLPNA)?
5. Have you ever had a judgment in a civil action against you with respect to your practice in any province, territory, or Yes No
country?
6. Are you currently under investigation or involved in any proceedings by:
a. A registration/licensing authority for nursing in any province, territory, or country? Yes No
b. Another health profession (other than nursing) in any province, territory, or country? Yes No
c. Any other profession in any province, territory, or country? Yes No
7. Are you currently charged with a criminal offense? Yes No
8. Have you pleaded guilty or been found guilty of a criminal offence for which a pardon has not been granted? Yes No
9. Do you have any physical or mental condition or disorder that may impair your ability to provide safe, competent and Yes No
ethical care? If you have answered yes to question 8, answer the questions below; otherwise leave questions (a) and
(b) blank.
a. If “Yes”, are you under the care of a physician or healthcare team? Yes No
b. If “Yes”, are you following medical advice? Yes No
Please Print: If you answered ‘YES’ to any question on the Personal Declaration, provide a brief explanation.
PROFESSIONAL REGISTRATIONS - GOOD STANDING DECLARATION

Other than with CLPNA, list all registrations/licenses in practical nursing or other professions (ie. registered nurse, physiotherapist, midwife,
paramedic, etc.) and check to declare whether or not you are in good standing with the other regulatory organization(s). If you are not currently
registered in another jurisdiction list the last jurisdiction in which you held registration and provide verification from that jurisdiction.
Registration Registration Conditions/Limitations on Province/State/ Registration Issued Date Expiry Date
Type (LPN, RN) Status Registration (if applicable) Country Number (dd/mm/yy) (dd/mm/yy)
I DECLARE that the active license(s) I possess to practice in other jurisdictions are in good standing.
 Yes, I am in good standing  No, I am NOT in good standing
INITIAL NURSING EDUCATION (Please Print: Provide all nursing programs taken, including both basic and refresher
programs.)
Name of Nursing Program Language of Instruction Start Date Program Credential Received (example;
(dd/mm/yy) Completion Date Degree, Diploma, Certificate)
Bachelor of Science In Nursing English 07/06/2004 (dd/mm/yy) 01/04/2008 Diploma
Name of Educational Institution Address(Street No./City/Province/Country) Phone (including area code)
University of Cagayan valley Balzain Road,Brgy Centro 12, Tuguegarao City Cagayan (078) 844 -1147
Name of Nursing Examination Language of Examination Number of Times Examination Passed
Written  Yes  No
National Licensure Exam English 1
ADDITIONAL NURSING EDUCATION (Please Print: Provide all post basic programs and/or courses completed. More
than 3 please provide on a separate piece of paper.)
Name of Credential Received Institution Name and Country Start Date and Completion Date
NURSING EMPLOYMENT HISTORY (Please Print: Provide all employers in the past 4 years. More than 4 please
provide on a separate piece of paper.)
Employer Name and Phone Address Unit/Area of Responsibility (check applicable boxes)
Callang General Hospital Judge Taguinod, Centro East Medical Mental Health/Psychiatry
Job Title/Position Status (Full-Time, Part-Time, Casual) Surgical Community
Obstetrics Gerontology/Long Term Care
Staff nurse Full-time Pediatrics
Start Date (dd/mm/yy) End date (dd/mm/yy)
01/04/2014 20/03/2019 Other___________________________________
Medical Mental Health/Psychiatry

Pediatrics
Other___________________________________

Pediatrics
Other___________________________________

Pediatrics
Other___________________________________
APPLICATION CHECKLIST
 I have included a clear copy of my birth certificate and/or passport. (Mail or Email; Do Not Fax)
 I have included a clear copy of my driver’s license, citizenship card, and/or permanent residence card. (Mail or Email; Do Not Fax)
 I have included the $340 non-refundable application fee. (Visa/Mastercard payable on the credit card authorization form, certified cheque or
money order payable to CLPNA. Please do not mail cash.
 I have included my resume, describing my education, experience, and employment history.
 I have requested my previous employer(s) to submit an original job description directly to the CLPNA.
 I have submitted the self-assessment form and provided detailed information as to where the attribute was learned.
 I understand all my documentation must be translated to English before it is submitted to the CLPNA office.
 I have completed my Criminal Record Check with myBackCheck at https://www.sterlingtalentsolutions.ca/clpna/ within the last 6 months.
PRIVACY STATEMENT
I acknowledge that the information contained in this form is being collected and will be used for the purpose of assessing my application for
registration. This information will be maintained on my file and may also be used to assess my application for renewal of my practice permit in
the future or for the purpose of a discipline proceeding under Part 4 of the Health Professions Act. The information contained in this form will
only be disclosed pursuant to the provisions in the Health Professions Act, the Licensed Practical Nurses Profession Regulation, and the Personal
Information Protection Act, as otherwise required by law, unless your consent to disclose the information has been obtained.
DENY OR DEFERRAL OF REGISTRATION ELIGIBILITY
I acknowledge that the College may immediately deny or defer registration if any information contained in this application is inaccurate or
incomplete until such time that the College has had the opportunity to reconsider my application. I agree to provide any additional information
that may be required by the College to consider my application for registration.
CONSENT TO REVOCATION/SUSPENSION OF REGISTRATION
I acknowledge and agree that the College may, at its option, immediately revoke, suspend or refuse to renew my registration if any information
contained in this application is inaccurate or incomplete until such that the College has had the opportunity to reconsider my application. I agree
to provide any additional information that may be required by the College to consider my application for registration. I also acknowledge and
agree that I may be subject to disciplinary action, irrespective of whether my registration is revoked or suspended with the College, if I fail to
provide current, correct and complete information to the College in respect to my application for registration.
REGISTRATION DECLARATION
I declare that all of the information on this form is current, correct and complete. I declare that all documents submitted with this application to
the College are authentic true originals or true copies of original documents. I declare that I am of good character and am fit to practice,
consistent with the responsibilities, ethics and standards expected of a Licensed Practical Nurse. I hereby certify that I am the person making
application for registration as a Licensed Practical Nurse in Alberta and that all statements are true and complete in every respect. I understand
that omission, inaccuracy, and falsification of information on this application may result in the cancellation of my application for registration or
cancellation of any registration, which may be issued. I understand that my application for assessment of eligibility and/or registration is
considered lapsed if required documentation is not received in the CLPNA office and I have not obtained registration within 1 year from my
application date. I understand that after 1 year has lapsed I am required to reapply.
07/06/2020
_______________________________________________________ _______________________________________________________
Applicant Signature (do not print) Date (dd/mm/yy)
Submit completed application to international@clpna.com
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT
HOURS
Complete Section 1 for all employers in the past 5 years. If you have more than 2 employers please print
additional forms. Be sure to separate hours by year for each employer.
SECTION 1 (completed by applicant)
PERSONAL (Please Print)

Domingo
_____________________________________
Jyselle Elyssa
______________________________________
Argonza
_____________________________________
Current Legal Surname (Last Name) Given Name (First Name) Middle Name(s)
26/01/1985
_____________________________________ ______________________________________ Sex  Female  Male
Maiden Name Date of Birth (dd/mm/yy)
4387 St Catherines st. Vancouver
______________________________________________________________________________ _____________________________________
Apartment / Box No. / Address or Street No. City / Town / Village
British Columbia Canada v5v4m4
_____________________________________ ______________________________________ _____________________________________
Province/State Country Postal Code / Zip Code
778.867.2601 Tagalog
_____________________________________ ______________________________________ _____________________________________
Telephone No. Cell No. Primary Language
jyselled@gmail.com
__________________________________________________________
E-mail Address
EMPLOYMENT DETAILS (Please Print)
Callang General Hospital and Medical Center

Facility Name
01/04/2014 20/03/2019 Staff nurse

__________________ __________________ ______________________________
Start Date (dd/mm/yy) End Date (dd/mm/yy) Job Title/Position
Carol kristle V. Callang Nurse Director

___________________________________ ___________________________________ Unit/Area of Responsibility (check applicable boxes)
Supervisor Name Supervisor Job Title/Position
EMPLOYMENT HOURS Medical Mental Health/Psychiatry
Surgical Community
Year Employed Total Hours Worked Obstetrics Pediatrics
2019 2305 Gerontology/Long Term Care
2018
1152 Other________________________________
2017 2304
2016 480
2015
0
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT HOURS Revised December 13, 2019
EMPLOYMENT DETAILS (Please Print)
Facility Name
__________________ __________________ ______________________________

Start Date (dd/mm/yy) End Date (dd/mm/yy) Job Title/Position
___________________________________ ___________________________________ Unit/Area of Responsibility (check applicable boxes)

Supervisor Name Supervisor Job Title/Position
EMPLOYMENT HOURS Medical Mental Health/Psychiatry
Surgical Community
Year Employed Total Hours Worked Obstetrics Pediatrics
2019 Gerontology/Long Term Care
2018
Other________________________________
2017
2016
2015
SECTION 2 - Declaration
The information contained on this Declaration of Employment Hours form is true and correct. I make this declaration
for the purpose of inducing the CLPNA to issue me a practice permit. I understand that CLPNA may request verification
from my previous or current employers at their discretion. I understand that falsification of information provided on
this application form is considered unprofessional conduct as per the Health Professions Act.
07/06/2020
Signature:________________________________________ Date:____________________________________
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT HOURS Revised December 13, 2019
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT
INFORMATION
Please check a box in each section. If you have more than one position please complete additional forms.
Section 1 – LPN Employment Information (Alberta Employers ONLY)

EMPLOYMENT INFORMATION – Complete for Each LPN Employer (Check Box):
Do you currently hold a position as an LPN in Alberta? Yes No
Facility Name: ______________________________________________________________________________________________
Supervisor Name: _____________________________________ Supervisor Phone: ____________________________________
Supervisor Email: ___________________________________________________________________________________________
Date of Last Shift Worked: ____________________________ Date of Next Scheduled Shift: ______________________________
Section 2 – Other Employment Information

OTHER EMPLOYMENT INFORMATION – (Check Box):
Do you currently hold a position in another health care role (ie. Medical Office Assistant, Health Care Aide)? Yes No
Facility Name: ______________________________________________________________________________________________
Supervisor Name: _____________________________________ Supervisor Phone: ____________________________________
Supervisor Email: ___________________________________________________________________________________________
Date of Last Shift Worked: ____________________________ Date of Next Scheduled Shift: ______________________________
Section 3 – Declaration of Licensed Practical Nurse

PLEASE CHECK ONE APPLICABLE BOX: (Mandatory)
 I attest that I have not and will not practice (this includes – orientation, “buddy” shifts, or doing any training required in the
role as an LPN) as a LPN in Alberta without an Active practice permit.
 I attest that I have practiced as a LPN (this includes – orientation, “buddy shifts, or doing any training required in the role as an
LPN) in Alberta without an Active practice permit.
- Please write date(s) worked below, and supervisor’s contact information.
- Attesting to having practiced without a practice permit will result in a review by the CLPNA Complaints Director.
- Employers will be contacted to verify this information.
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT INFORMATION Revised December 13, 2019
Section 3 (continued) – Declaration of Licensed Practical Nurse
I am requesting registration with the CLPNA. Any of the information submitted in the above declaration is subject to verification
by the CLPNA in accordance with the Health Professions Act (HPA), Licensed Practical Nurses Profession Regulation, CLPNA
Bylaws and CLPNA policies. Working in certain positions within the health care sector and not holding a valid practice permit
may be subject to review under Section 46(1) of the HPA. Additionally, it is considered an offence under the HPA to practice as
an LPN without a valid practice permit in a position designated as an LPN position or to use the protected title as an LPN while
not registered with the CLPNA. Contravention of the HPA may result in charges of unprofessional conduct and sanctions,
including a fine.
I understand my responsibilities as a regulated member of the CLPNA and if I did have any questions or concerns they were
addressed prior to signing this Declaration of Employment Information.
SIGNATURE OF DECLARATION (Mandatory):

Jyselle Elyssa Domingo
Applicant Name:_____________________________________________________________________________________
Applicant Signature:__________________________________________________________________________________
07 JUNE
2020
Dated this _________ (day) of _____________________ (month) __________________ (year)
Section 4 – Office Use Only
Verification Required:  YES  NO
Employer Contacted (1st Attempt):________________________ Date:_____________________ By: _______________________
Employer Contacted (2nd Attempt):________________________ Date:_____________________ By: _______________________
Information Confirmation Date: _______________________________________ By:_____________________________________
Referred to Conduct Department:  YES  NO Date:____________________
Action Taken:______________________________________________________________________________________________
Notes:____________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
INTERNATIONALLY EDUCATED NURSES DECLARATION OF EMPLOYMENT INFORMATION Revised December 13, 2019
INTERNATIONALLY EDUCATED NURSES SELF-ASSESSMENT OF PRACTICE
Jyselle Elyssa Domingo

NAME: ____________________________________________ STAKEHOLDER NUMBER:____________
SELF-ASSESSMENT
RATING SCALE
1 - Always 2 - Sometimes 3 - Never
I performed this task daily in my I occasionally performed this task in I never performed this task in my
previous position. I am comfortable my previous position. I am somewhat previous position. I am not comfortable
with my knowledge, skills and abilities comfortable with my knowledge, skills with my knowledge, skills and abilities
as related to this task/requirement. and abilities as related to this as related to this task/requirement.
task/requirement.
Rate each of the following on a scale of 1-3 as per the rating scale above.
Rating
Competency
(1-3)
Demonstrates knowledge of therapeutic communication.
1
Where, when and how I demonstrated this skill:
Most of my floor assignment during my first year at Callang genral Hospital was in the medical ward. During my rounds, I noticed that the patient was anxious. based from her records, she is due
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for explore laparotomy. when a patient cries,my natural instinct as a nurse and human is to relieve their sufferings. What a patient needs during this time is to acknowledge their feelings. I told the
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patient " I see you frightened "? and the patient needed a support. i also assured her that the whole team will be there throughout her surgery and doctors will do evrything for the sucess of the
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opeartion. i also asked the patient if i can hold her hand or touch her while giving her my time and listen to her concerns and worries.
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Initiate and maintain a therapeutic environment, including use of therapeutic

communication techniques. 1
three years ago when i was assigned at pediatric floor unit. one of the patients was scheduled for IV reinsrtion. the patient was afraid of needle and she was terrified and scared. In order for me to
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do the procedure, it is necesarry for me to have patients cooperation.Iv therapy in children presents many challenges.i have to deal with squirming infants, anxious parents and smaller veins.
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first thing i did was to explain the procedure based on her developmental stage, i also let the child fell the soft catheter that will go inside his vein.I also told the parent to distract the child with some
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video games.the most important thing is i told the patient that " Iv therapy will sting but it will only last for a short time" and i also gave her treats like candies for being brave
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Page 1 of 13
Utilize the nursing process (assessment, planning, implementation and evaluation) to
apply knowledge and theory in the provision of care. 1
2 years ago, when i was assigned by my Head nurse to float at pediatric ward. one of the patient in the aisle develop a fever. I took her vital signs. check her Intravenous sites for redness or
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infiltrations and also doing head to toe assesment. I did tepid sponge bath to lower the temperature and also loosen the clothings. afterwards i called the attending physician to inform about my
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patients fever. The doctor ordered antipyretic every 4 hours as needed.After giving the medication, i came back to asses from time to time to evaluate for any improvements in the patients condition.
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The patients temperature after giving her medication and doing spiongebath. the patient also felt comfortable at was able to sleep the whole night.
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Uses a theory-based approach.

1
It was 2 years ago. i had an admission at medical ward who has an asthma attack. as a nurse, i had to implement a plan of care puposefully,inorder for me to have better outcomes. by using the
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assesement, diagnosis, planning, intervention and evaluation method. this way i can assess better my patient efficiently and in a systematic way and also to help better communicate with other
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of heath care team
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Demonstrates knowledge in nursing, health and social sciences.

1
during my exposure at the hospital that i previously worked, Most of the patients that were admitted came from far flung areas wherein they dont have an easy acces to medical help. One of the
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patient came to seek for treatment due to his uncontrolled hypertension. During my rounds, I saw the patients table next to her bed a different plants inside the bottle with water on it. I asked
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politely the patient saying " those plants look interesting" what are they for? The patient replied " that is the one that im taking to controll my hypertension.As a nurse, I had to educate the patient
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about the use of any plants not approved by the food and drug administration or plants that may have a negative inetraction to some drugs that the patient is taking.I was also being respectful of his
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beliefs and approach the patient in a non judgemental and non threatening way.
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Complete assessments using a systematic approach in a holistic (bio-psycho-social and

spiritual) manner. 1
It happend 3 years ago, where i was assigned at emergency department. One female client arrived due to Increased Blood pressure. The patient appears anxious.As a nurse before beginning to
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examine the patient,I had to make her feel relax by building rapport and asking questions like " how are you today"? could you please tell me the reason what brought you here in the hospital?
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i also asked her how is she doing. These are the few questiones that i asked to make the patient feel comfortable. With her permission i also asked her lifestyle as well as religious belief inorder
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for us to be aware of and sensitive to her beliefs.
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Implements identified health teaching strategies into clients’ learning.
1
it was 2 years ago, when i was assigned at medical ward. Most of our clients has undergone surgery or operations. One patient who was a 1 day post-op appendectomy refused to get up in bed
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or even turned to her side. I asked her " what makes you not to make any movements or even get up"? the patient replied that she was afraid the the wound might open, sho she opt to stay flat in
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bed. I told the patient that" it is necessary for you to start walking to improves blood flow and speed wound healing. In addition, I told her that failure to get up from bed may cause increased
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constipation and gas, and puts her to highest risk of infection. bloodclots and lung problems such as pneumonia, i also told her to get up slowly from bed.
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Make clinical judgments based on different ways of knowing, including critical thinking
and intuition. 1
it was 3 years ago, when my patient at medical ward was found unconscious. Upon assesment, i did not just rely on what the monitor was showing but rather i did some critical thinking
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and proper assesment which is vital to a better managemnt of a patient.Moreover, i checked the patient if he is responsive by calling his attention such as " sir can you hear? i tapped him but no
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response, he has no pulse rate and no rise and fall of the chest.The patient appears to be cold and pale.based on my cliitnical judgement, i know that i need to perform what need sto be done at that
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moment and no second must be wasted.By having critical thinking and intuition, i immediately flatten the bed, performed cardiopulomonary resuscitation while telling my colleagues to call for code
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and to make sure that the doctor was made aware of the situatuion.
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Incorporates the determinants of health and health disparities/inequities into all

aspects of care. 1
majority of our patients in the hospital i previosly worked have specific determinants or disparities. one classic example was, most of our patients in the medical ward belongs to lower income
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familes. despite their socio economic status and their education level, We still deliver optimum care that we could render without bias and discrimination.we provide health teachings, and information
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about their concerns in a way that can be easily understood by the patient. we extend our undesrtanding by explaining the procedures that they will undergo like, xrays,ultrasound and ct scan.
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we give them options in case they are undecive. We try not to use medical terms and rather speak with them in our own dialect.In addition, for the low income earners, we encourage them to avail
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the Philippine health insurance, a government owned and controlled corporation. its main goal is to ensure the health of evry filipino through social insurance regardless of social status.In the
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philippines, it is more respectfully if we adress the them like " maam" or Sir and not by their first them.
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Considers the determinants of health during all aspects of care.

1
during my last year at callang general hospital, where i was assigned to medical ward, patient was admitted for appendectomy. upon assesment, it reveals that the patient doesnt have enough funds
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for the said procedure. the patient also doesnt understand any " Tagalog word " whcih is the main language in my place. as a nurse advocates, i referred the patient to department of social welfare
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to assess the patients situation. Furthermore with regards to his pending surgery. i helped him process his application to Philippines charity organization wherein they provide funds for health
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programs and medical assistance. also i asked for the help of our supervisor to look for an interpreter to communicate better to the client.the hospital also provides assistance in case the patient
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doesnt have any funds to settle the bill if they are discharged from the hospital.
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Page 3 of 13
Care for clients at any point in the life cycle employing a systematic approach and 1
holistic (biological, psychological, spiritual, developmental and sociocultural needs)
perspective in the completion of nursing care.
it was my first year at the hospital where i previously worked and was assisgned to pediatric ward. Upon arounds, i always greet them and introduced my self sayin " My Name is Jyselle and will be
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your nurse for today", After building a good interaction, i assessed the patient from head to toe prioritizing the airway, breathing and circulation. it is also necessary to assess the the kind of
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environment the child has by simply observing how the child was being treated by the parents, the way the care giver act and speak towards the patient, checking for some unhygienic ways that
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may expose the child to further infection.upon these assesment, we plan our actions basing from the untoward signs and symptoms. one classic example was asking the significant other ' I noticed
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that the baby has a diaper rash since yesterday? did she sleep well?does she cry a lot during diaper change? also we include in the assesment the biological approach and holistic. In my practise,
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we often do health teachings to the significant others or to the caregiver present at the time because it is very common in the philippines that the caregivers rely on the school old teachings that
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may create a negative effects on the growing child.
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Sensitive to client cultural diversity (eg age, socio-economic, cultural, ethnic, gender
ability) in assessment, planning, implementation and evaluation of nursing care. 1
People with different background have different perspective. For health workers like me, i must not be judgemental and must be open minded for the changes that might help in the healing process
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of our patients so as not to have miscommunication. upon assesment at my patient at the emergency room 2 years ago, i oveheard my patient speaking a distinct language which i am somewhat
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familiar. I approached him by saying " sir' or " mr" or we ask them how they want to be adressed. we approach them by greeting like ' Hello , good morning, i will be your nurse for today, how would
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you like me to call you?.Furthermore,asking some series of questions such as, how are you feeling right now?are you in any pain right now? i will attend to you throughout the shift.after making
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the client feel at ease, He then comfortable responded to all my questions. Making feel the patient welcome and not presuured. another example is, when a male patient chooses another male nurse
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for foley reinsertion. It is his right to ask another male to do the procedure and to consider the patients sexual orientation and protect his right to privacy.
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Collaborates with clients across the lifespan to perform a holistic nursing assessment.
1
during my first year in the hospital i last worked, most of our patients belongs to lower income family. as a nurse i am not only focused on medical aspect but rather the person as a whole. upon
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assesment of a client, we also take note the kind of environment the client has in their home, in preparation also for their discharge.when caring for a client, we encourage the client and the family
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members to work closely with us. one classic example would be, a stroke patient with left sided body weakness, about to be discharge from the hospital. Couple of days prior to their discharge,
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we gradually incorporate/ train the family on how to care for the client at home.care at home includes: turning patient side to side, oral care, peri care, bed bath and feeding. moreover, before
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the family caregiver, we as a nurse must asses the readiness and willingness of the family caregiver. like for example " it was great that Mr. X hd made progress everyday, and it wont be possible
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without your presence. additionaly, now the he is able to be discharge 3 days from now, have you thought about what will be your set up at home?what i would suggest is, discuss this situation
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amongst family member, and we will guide you all throughout. would the be ok? do you have any concerns so far?
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Page 4 of 13
Adhere to Code of Ethics.
1
It happened during my 3rd year at Callang general Hospital. I was working with my bestfriend and colleague at the same time.My bestFriend was incharge of the medication, while i was doing all
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the paper works.i was shocked when she reluctantly admitted that she overdosed a certain medication to patient X. as one of the senior staff, I immediately checked the ptaient and assessed for
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any untoward signs and symptoms. I also checked the vital signs.It was a very challenging moment at that time since my friend doesnt want it to report to our supervisor for the reason that the
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patient wasnt showing any signs of adverse reaction.It was a very difficult time when your torn between your relationship and your job. However my reposnibilties to my patients prevails over my
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emotions. I immediately informed the supervisor and the attending physician of what happened. i also wrote an incident report.
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Respects and preserves clients’ rights based on a code of ethics or ethical framework.
1
It happened last year here in Canada when i had my first client as home support worker. Ive been with my client nearly 1 year before she decided to have Medical assisted in dying. I was unsure
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how to deal with her request ar first considering that this kind of situation is not accepted in the place where i came from.My patient had a fall and from that incident she experienced unrelenting
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pain for couple of weeks. My patient lost her appetite and became weak and thereafter she decided to inform her physician about her request to end her life. I know the situation is quite different
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from what i used to but i have to respect client wish with dignity.
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Recognizes and reports situations within the practice environment that are potentially
unsafe. 11
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I was assigned at pediatric unit during my 3rd year year at callang general hospital, i was doing my rounds when i noticed a a non functioning nebulizer, and the bed rails of the patient was not
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working. as a nurse this kind of incident must be reported and have it replaced or repaired. it is definitely unsafe and and might cause accidents. some instances also include whenever giving
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medication,we have been avoiding not recappin the needles to avoid needle stick injury. i myself experienced needle stick as wel. all i did was, wash my hands immediately with running water
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and soap and not scrubbing vigorously. afterwards, i reported it to my headnurse. i was advised to have prophylaxis, hepa B testing and was asked to write a report about it.another instances,
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was when my colleague suddenly had latex allergy. Her hands got swollen and had abrasions due to excessive itching. Nurses wear gloves most of the time and its already part of all the
procedures. My colleague reported it to my headnurse and it was resolved by replacing the hosptal gloves with the latex free.
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Page 5 of 13
Demonstrates behaviours that contribute to an effective and therapeutic nurse-client
relationship. 1
A patient came to emergency room at Cgh hospital 2 years ago, she is looking pale and weak and has a cough. I ushered her to seat in a chair and said " Hi my name is Jyselle, How are you feeling
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right now?Before taking her vital signs, i asked her if she has any pain.and it seems that she is worried and anxious.the Patient mentioned she has muscle aches from time to time. In addition, she
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also said about having a lot of pressure from work and lately she hasnt spent enough timewith her daughter.Being a widowed of two, she really tries really hard to cope with the situation since her
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husband dies a year ago. I just listend to her attentively while she opens up, giving her time to talk about her situation not just the physical symptoms but her situation as a whole.when she burst into
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tears, i held her hands ansd stayed with her.I then told her" Ma'am i understand how difficult you situation. I can see that you have been going through a lot lately. I aslo mentioned about her
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needing to inform her workplace inorder to have some flexible schedule to allow her self to re energized and have time spent with her daughters
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Engages in relational practice through a variety of approaches that demonstrates caring

behaviours appropriate for clients. 1
During my exposure to pediatric ward I've seen a lot of patients who cries everytime they see nurses who are wearing white uniform, I suggested to my supervisor that we should wear scrub suits
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in variety of color and is appealing patients eye. In addition, during procedure, like blood extraction,I used a puppet or doll to show to my patients what will happen during the procedure, i also used
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aged appropriate term.this way i could build rapport and trust between my patient and health care team.
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Demonstrates support for clients making informed decisions about their health care,
and respects those decisions. 1
An in- patient 38 years old female, was advised to have laparascopic cholecystectomy due to having gallstone.The doctor explained that a diet regimen can be given to the patient and some
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medications.when the doctor left, the patient was in awe.additionaly ,i asked the patient if she needs something and or if she's ok.When the patient patient looked at me, she asked " Nurse, if
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your're in my shoes, What will you do?. As a nurse, I know she is quite confused about the situation and needs someont to talk to. I replied by saying "It seems that you are bothered about the
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situation at hand. Are you afraid in the operation in ANy way? I also said that Whatever will be her her decisions rest assured it will be respected.I explained her options rewgarding what the doctor
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said. Additionally, I told the patient that i will give her titime to decide and have it discuss with the family. allowing the patient decide with regard to her current condition and nit pressuring them at
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all makes a better result.
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Page 6 of 13
Respects clients’ diversity and decisions.
1
one of the very challenging situation i encountered was when my 5 years old patient requires a blood transfusion due to Dengue hemorrhagic fever. the client was jehovah witness, and they are
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known for their refusal to blood transfusion which may lead to various challenges for medical practitioners. as part of the heath care team involved with his care. what i did was talk to the parents
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and told that " I respect you decisio howeveryou must be counselled regarding the risk and and likely consequences of not receiving the blood transfusion.in addition, i asked the
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mother to sign a release form absolving the medical practitioner from all liability flowing from a failure to administer blood products.With the decision of the Parents i still approached them in a non
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judgemtal manner.
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Provides care for clients while being respectful of diversity. 1

while working here in Canada as support home worker, I learned a lot of things about dealing with clients with different culture background and diversity. It was quite
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challenging and i also had to consider my Own values and beliefs to refrain from biases.One of my client who decided to have an assisted medical dying. It may not be
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practised in the philippines this kind of procedure, nonetheless i still respect clients decison without being judgemental.
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Uses self-awareness to support compassionate and culturally safe client care.

1
people with different cultures have diffrent background, one client of mine 2 years ago at medical ward was scheduled to have abdominal surgery. the clients requested to have a small pray over
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for him by a pastor, as a nurse, I also need to listen and also understand, respect my patients choice. By integrating this values and their beliefs into my plan of care will also help and support
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the patients specific goal. I also asked the patient if there is something that i can do, like getting someone to call a pastor. the patients request for pray over did not affect the kind of care i provided
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. the patient also reassured that their small group pray over wont create a noise enough to bother other patients next to them,
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Page 7 of 13
Demonstrates knowledge of the distinction between ethical responsibilities and legal
rights and their relevance when providing nursing care. 1
It happened last year when i was working as home support worker for client x.The client refuses to use her Wheelchair when going or using the washroom, the client prefers to walk with
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assistance eventhough the client already had two near missfall due to her insistence of not using the wheelchair.My clients Gait became more unsteady. I mentioned to my client why it is necessary
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for her to use the wheelchair, I also told her that I am concerned about her safety. The client still insisted of not using the wheelchair because it makes her feel invalid.
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Respect clients’ directives, right to self-determination and right to informed decision-

making. 1
Two years ago, when my client was admitted to the hospital due to vehicualr accident now requires a blood transfusion. The client refused owing it to his religion. as part of a health care team
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we have to repect his wishes however we must informed him about the risk of not receiving the blood transfusuion. In addition all the discussion that were betweem the patient and the healt
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care team were documented.
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Advocate for equitable access, treatment and allocation of appropriate resources within
the community for all clients. 1
When i did a volunteer job at the local community 5 years ago, i was part of a medical team who gives free medicall chekup, vitamins, consultation and as well as minor surgery. The main
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goal of the program is to reach those people who doesnt have enoiugh funds to seek treatment and also underserved communities. We also give free food and snacks and small
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entertainment program for them not to be fearful or anxious while lined up for consultations.
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Uses an ethical reasoning and decision making process to address situations of ethical
distress and dilemmas. 1
One of my most unforgettable and controversial client was when i was assigned at OB ward. Patient X was admiited to our ward and delivered a baby boy and the baby is currently in PICU,
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althroughout the patients hospiralization nobody was with her except her bestfriend. I was also curious why was the surname of the baby was different with the baby"s father. I read the chart and
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patient X is married and have 2 children. One morning the patient had a visitor and it was her sister in law, at the same time the doctor came for visit. I accompanied the doctor inside and the
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doctor told the patient " you baby is doing good and nay transfer to regular room tomorrow" all of a sudden the patient hysterically said, I dont have a baby and what are you saying doc? u must have
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mistaken me for another patient. the doctor and myself stepped out of the room puzzled. then eventually we learned that the patient had an affair and kept the pregnancy secret to her family,
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she decided th have the baby for adoption,
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Page 8 of 13
Recognize and fulfill the professional obligation of the duty to provide care.
1
I was assisgned at private ward of medical surgical ward while the other side of the floor was pediatric ward.Two nurses who was assisgned on the pediatric ward was new nurses. I walked
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past a room going to the washroom which is located in the pediatric floor, and surprisingly, I noticed the boy on the room was having difficulty of breathing a nonstop productive cough.What i did
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was, inform the nurses on duty that their patient needs further assesment.the 2 newly hired nurses requested my help because they dont have enough experiences in pediatric cases. I also, asked
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my supervisors permission if i can float at pediatric ward. The patient had a decreasing oxygen level and hewas gasping for breath.I also informed the doctor and carried all his orders
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i know i was not assisgned on the pediatric floor but my responsibilities and my will to help those nurses in the pediatric ward prevais.
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Advocate for client autonomy, respect, dignity and access to information, especially
when they are unable to advocate for themselves. 1
One of our role, is not just delivering care but patient advocacy as well.one claasic example was, when i had an Elderly patientand she is due for foley catheter insertion. SImple procedure can be
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frightening to some patients, they are vulnerable and and exposed.Simple act like pulling a curtain closed, Holding a gown together in the back or offering a drape to the patient as well as
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explaining the procedure.In addiditon, even with those cognitive impairment have a right to make choices and have their wishes honored like what clothes to wear for today.
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Advocates for clients’ rights especially when they are unable to advocate for
themselves. 1
Most of my client or patients in the hospital paritcularly the medical ward, belongs to Low income earner. One of the most common problem experienced by our patient was the cost of medication
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after prolonged stay in the hospital. during their hospitalization,most of the expenses are covered by goverment insurance up to some extent. should the Philhealth benefits has been used up,
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patients are left no choice but to purchase the medication out of their pocket.As a nurse advocate, to help clients with their situation, we have a variety of resources to help those who has
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difficulty paying prescriptions such as, senior citizen benefits, also comparing drug over another, or even communicating to the doctor to find ways to lower the cost..
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Page 9 of 13
Establishes and maintain respect, empathy, trust and integrity in interactions with
clients. 1
During my shift two years ago at medical ward.Patient was admitted due to emergency appendectomy. I noticed that the patient appeared anxious and uncomfortable. I approaced the patient
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and asked " you looked tensed " The patient just nod and didnt say nothing.afterwards, i asked her if i can sit beside her and asked her permision to hold her hand to make her feel that she can
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trust me, patients are more likely to open upand diclose information and a better quality of interaction.Eventually, The Patient eventually slowly open up about her worries.which is her fear of
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surgeries.
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Establishes and maintains a caring environment that supports clients in achieving

optimal health outcomes, goals to manage illness or a peaceful death. 1
my last year at CGH hospoital whwn Patient X was trasferred from ICU to regukar room, the patient was unconscious and was on DNR as requested by the family. As part of the health care team
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incolved the patients care, we still provide optimum care such as medication, repostioning, spongebath and medication. wes still expain to the patient all the procedures that we are about to do.we
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still deliver the best care, including the nutrition, combing hair and oral care.
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Document and maintain clear, concise, accurate and timely records using both paper- 1
based and electronic methods, in accordance with nursing standards and the practice
setting’s policies.
BAc k when my my first year at medical surgical ward, one of my patient during my rounds, she vomitted nonstop, I had to inform the resident on duty and document in the chart the time when
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the patient vomitted.The doctor ordered anti emetic drug. I also recorded the time when i gave the medication, and documented it both in the patients chart and the computer,
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front the time that the patient vomitted up until the patient was feeling better was recorded both in paper and computer.
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Maintains clear, concise, accurate and timely records of clients’ care.

1
It is practise in my home country that evrytime the doctors visit we have to accompany then to the patients room, we also bring the chart and hand them to the doctor during their visits, after the
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doctor writes his order, we have to carry out the doctord order write any medication to medication sheet and also fill out the Kardex, we also update during nights shift the patients record both
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in paper and in computer in preparation for tomorrows shift.
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Page 10 of 13
Adhere to legal requirements regarding documentation: complete occurrence reports as
required. 1
2 years ago during my last month at the callang general hospital, one unforgettable incident happened at private medical surgical ward. i was working with a colleague who is in charge of the
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medication, i was the senior staff that moment so i was doing all the paper works and carrying the doctore order, two of our patient was due for blood transfusion, my co worker went to the
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laboratory to pick up the blood, surprisingly , she hooked the blood without checking it twice with me. 5 minutes later she approached me shakingly and told me that she mixed up the blood, she
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hooked the wrong blood. i immediately stopped the blood transfusion, informed the supervisor, called the physician. The family was aware the patient received the wrong blood. proper
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investigation was made starting from the laboratory up until to the occurence of the event.
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Practise according to relevant mandatory reporting legislation and other reporting 1

requirements under legislation, regulation, by-laws and policies applicable to licensed
practical nurses.
i was working as Home support care nurse when i noticed that my patient has a bruises and a lump on her underam, which was not there when i had my duty the before it happened. my patient
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was non verbal. so the first thing that i did was inform the agency that i am currently working with. i gave them the details of what i saw, how the bruises looks like.and the status of the patient.
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the patients family is not present as well so i immediately informed the agency.I also wrote in the communication book what happened.
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Initiate contact and receive, transcribe and verify orders.

1
It happened 3 years ago, when I am doing a night shift at medical surgical ward. all My patient was doing fine until one of the significant other from the second room asked for help. The ptient who
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was admiited due to COPD was having difficulty of breathing.I immediately hooked the oxygen to 2 lpm. I took his vital signs and oxygen level. I called the physician , relayed what was the patient
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was experiencing, The doctor gave some ordere like nebulization,. Those ordered was carried out I also informed the doctor about the patients progress after dping all the nursing interventions.
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Page 11 of 13
Recognize, respond and appropriately report questionable orders, actions or decisions
made by other healthcare workers. 1
It happened 2 years ago at Medical ward ehen my Co worker who is in charge of medication gave the wrong dose of medicatio. The doctors order 6 unit of inuslin subq. My co worker gave
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60 units of insulin instead.I immediately went rush to check and assess the patient then head back to phone the doctor immediately because it was very high dose of insulin. I also asked my co
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worker to report it the supervisor while I rectify the situation. The doctor requested a blood sugar monitoring evry 1 hour. Since the patient diesnt have any funds to buy or pay the glucose hourly,
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what ended up happening was, my co wroker has to pay the amount of the hourly glucoe monitoring. i wrote an incident report about what happened and continuosly monitor the patient.
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Based on ethical and legal considerations, maintains client confidentiality in all forms of
communication. 1
all data or record must be made available only to thiose health care teams that are directly involves with patients care. Any informationregarding the patient must be kept confidential to nurses and
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health worker not directly involved with patients care.one instances was, during my first year at my previous work, one colleague of mine asked " what disease does your patient X has, because i
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know the patients family. I smiled back to my colleague and replied about patients confidentialty and told her that im not in the position to dsiclose such matters with her.
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Effectively communicates appropriate information about clients’ care with the inter-
professional healthcare team while respecting confidentiality. 1
a 16 year old patient was admitted at medical surgical ward where i worked due to vehicular accident. The attending physician referred the patient to the pediatrician on deck because the patient
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was just 16 years old, and also to neuro surgeon for collabiorative care. Series of test and laboratory exam was made by each Doctors, and as a nurse it is my responsibilty to communicate
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to all health teams involved with my patients. any lab results must be relayed to all the doctors while maintaning confidentiality.
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Page 12 of 13
Recognize and respond to the clients’ right to healthcare information.
1
A patient has the right to be given the information regarding the care that she receives, The treatment that is given her and the facts regarding her diseases/ ilness in a manner that she can fully
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undesrtand.one example was when my patients x- ray result came in, she asked me if does she have a serious problems, back in my home, nurses are not allowed to explain test result to patient,
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we leave it to the doctors, However we can provide information what was the result was but we rely further explanation about their conditon to the doctors.
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Knowledge about personal health information legislation and privacy legislation.

1
all information regarding patients profile and records/ chart must not be disclosed to any person unless allowed by the patient himself.
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One patient of mine at the medical surgical ward had a missed abortion, she doesnt want her Father to know about her condition.Dilatation and curettage was done. The patient doesnt evan want
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her father to know the she is in the hospital. Her decision and request was respected by the health care team involved and was not disclosed to the patients father while maintaining a non
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judgemental way.
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Page 13 of 13

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INTERNATIONALLY EDUCATED NURSES

IEN APPLICATION PACKAGE

 Criminal Record Check

 Declaration of Hours Form

 Credit Card Authorization Form

 Verification of English Language Proficiency

PERSONAL (Please Print)

Apartment / Box No. / Address or Street No. City / Town / Village

Telephone No. Cell No. Primary Language

PERSONAL DECLARATION (check applicable answer)

PROFESSIONAL REGISTRATIONS - GOOD STANDING DECLARATION

Medical Mental Health/Psychiatry

Medical Mental Health/Psychiatry

Medical Mental Health/Psychiatry

Submit completed application to international@clpna.com

SECTION 1 (completed by applicant)

PERSONAL (Please Print)

EMPLOYMENT DETAILS (Please Print)

Callang General Hospital and Medical Center

01/04/2014 20/03/2019 Staff nurse

Carol kristle V. Callang Nurse Director

__________________ __________________ ______________________________

___________________________________ ___________________________________ Unit/Area of Responsibility (check applicable boxes)

Section 1 – LPN Employment Information (Alberta Employers ONLY)

Facility Name: ______________________________________________________________________________________________

Supervisor Name: _____________________________________ Supervisor Phone: ____________________________________

Supervisor Email: ___________________________________________________________________________________________

Section 2 – Other Employment Information

Facility Name: ______________________________________________________________________________________________

Supervisor Name: _____________________________________ Supervisor Phone: ____________________________________

Supervisor Email: ___________________________________________________________________________________________

Section 3 – Declaration of Licensed Practical Nurse

SIGNATURE OF DECLARATION (Mandatory):

Section 4 – Office Use Only

Verification Required:  YES  NO

Employer Contacted (1st Attempt):________________________ Date:_____________________ By: _______________________

Employer Contacted (2nd Attempt):________________________ Date:_____________________ By: _______________________

Information Confirmation Date: _______________________________________ By:_____________________________________

Referred to Conduct Department:  YES  NO Date:____________________

Jyselle Elyssa Domingo

Initiate and maintain a therapeutic environment, including use of therapeutic

Uses a theory-based approach.

Demonstrates knowledge in nursing, health and social sciences.

Complete assessments using a systematic approach in a holistic (bio-psycho-social and

Incorporates the determinants of health and health disparities/inequities into all

Considers the determinants of health during all aspects of care.

Engages in relational practice through a variety of approaches that demonstrates caring

Provides care for clients while being respectful of diversity. 1

Uses self-awareness to support compassionate and culturally safe client care.

Respect clients’ directives, right to self-determination and right to informed decision-

Establishes and maintains a caring environment that supports clients in achieving

Maintains clear, concise, accurate and timely records of clients’ care.

Practise according to relevant mandatory reporting legislation and other reporting 1

Initiate contact and receive, transcribe and verify orders.

Knowledge about personal health information legislation and privacy legislation.

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______________

_ _ Unit/Area of Responsibility (check applicable boxes)

Supervisor Name: _ Supervisor Phone:

Supervisor Name: _ Supervisor Phone:

Employer Contacted (1st Attempt):______________ Date:_ By: _____________

Employer Contacted (2nd Attempt):______________ Date:_ By: _____________

Information Confirmation Date: ___ By:_