Application Portfolio Checklist: Role Specific Advancement Model
Submit this Checklist as the first page of your Application Portfolio.
The Application Portfolio provides a complete picture of your nursing practice. By assembling a collection of
documents - each with a particular point of view - you will enable others to comprehend your level of practice.
Keep in mind that no single document needs to fully describe how you meet RSAM Behaviors, but taken as a
whole, the portfolio provides a detailed, comprehensive view of your professional practice.
Name: ____________________________________
Unit: _____________________
Current Role & Level in RSAM:
Applying to Level:
Initial as
Included
________________
_________
CHECK LIST
Framework
Office Review*
Identifying Information
Professional Statement (Addresses major areas identified on website):
 Description of current practice
 Highlights particular areas of expertise/talent
 Conveys future goals
Resume (Addresses major resume headings identified on website):
 Formal Education
 Licenses/Certifications
 Professional Employment History
 UMHS Committees & Activities
 Professional Society/Organization Memberships
 CE Participation for past 2-5 years
 Presentations
 Publications and Unit-Based Tools
 Awards & Professional Honors
 Innovation, Research, and Continuous Quality Improvement
Self-Assessment Tool: Levels must be identified and examples provided in
the Comments section for each domain of how behaviors are met by applicant
Manager Voice Tool
Letters of support (2)—Note change to TWO, each addressing 2 domains
for a total of 4 different domains (Specify domains addressed)
Domain:
Domain:
Domain:
Domain:
Exemplars (2): Situations occurred within past year, in current role, on
current unit
Miscellaneous: Optional, including examples of work such as copy of poster
or other presentation, patient education/staff education materials, awards,
etc.
*If each section is not completed correctly, your Portfolio may be returned.
Assurance of Complete and Truthful Information
By signing this portfolio, I am certifying that the information stated herein is complete and accurate to the best
of my knowledge and ability. All elements were obtained and are dated within 1 year prior to the date of this
submission. Exemplars are situations that occurred within the last year in my current role.
________________________________________________________________________________________
Signature
Date