UCHealth Northern Colorado Region Intent to Credential Application UEXCEL Level III and Level IV vone, Calton allan smvoyeorm S540 wome address: MOS Kelaldin Drive vunivenne PLC DWAR YR pate,__ 10-26-9016 . Current UEXCEL Level: Ie Level Applying to Credentiat:_/// Pid Manager/Director: Krvtl A te, 1 Manager/Director Mail Stop: On eration Ros ae UEXCEL hasa mandatory advisor program. Please review the Certified Advisor liston the UEXCEL Website, as well as Manager/Director Signature;_\_> the UEXCEL Board member list, select an advisor, then write the advisor preference below, Please remember your advisor must have already recently advanced to Level III or Level IV, the same level you desire to credential YX simeorasioe flee — Llanarne¥ ADVISORCOMMITMENT STATEMENT: agree to be a UEXCEL Advisor. I understand this commitment means | am currently knowledgeable about the UEXCEL requfrements and [ will s{pport the advancement process, [attest to having completed an Advisor Certificat Tagree to may 1e portfolio and the advancement criteria with this applicant prior to vie LO-P0-LG Signature: (]_thave read the Annual UEXCEL Nursing Requirements and the UEXCEL Standards for the Level 1 am applying toadvance. Ihave completed the ULearn courses titled UEXCEL: E-Learning Part I Intro and UEXCEL: E-Learning Part It Credentialing. Please print and attach your transcript from ULearn showing completion of the two courses, and attach to this application, o Thave reviewed the written material on the Credentialing Procedure: 2016-2017 Level II & Level lV, Deadline Your Intent to Credential form must be scanned and emailed to the UEXCEL Board Secretary at UEXCELNorth@uchealth.org no later than November 1, 2016. You will receive a confirmation email. Updated 972016Transcript Page | of 1 Transcript Course Name: UExcel E-Learning Part | - Intro User Name: Cathleen Allan Passing Assessment Type of Attempt Score g2600 Passed Date Scored Name ee ement 9 Monday, October 3, 2016 1 90% 80 Yes tpv6:t4 PM UExcel Part! Post-Assessment Note: The Course Score assessment type is calculated based on the scores from multiple modules. Click the view score breakdown link to see the scores from these modules. hutps://uchealth.certpointsystems.com/Portal/MyInformation/My TranscriptHistory.aspx?ve.... 10/3/2016‘Transcript Page 1 of 1 Transcript Course Name: UExcel E-Learning Part II - Credentialing : User Name: Cathleen Allan Passing Assessment Type of Attempt Score Ge0n."9_—PassedDate Scored Name pecesoment Not Not Not Monday, October 3, ; Available Available Available Y®* 2016 10:07:27 Pm | Not Available Course Credit Note: The Course Score assessment type is calculated based on the scores from multiple modules. Glick the view score breakdown link to see the scores from these modules. https://uchealth.certpointsystems.com/Portal/MyInformation/MyTranscriptHlistory.aspxve.... 10/3/2016