Thank you for your interest in the Summer Nursing Intern Program at Redwood Area Hospital.

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1 Name: Thank you for your interest in the Summer Nursing Intern Program at Redwood Area Hospital. Please complete the application packet. Interns must be enrolled in a summer internship course through a Minnesota college or university and be supervised by a nursing faculty member licensed in Minnesota. In addition, applicants must have acute care clinical experience and reach senior nursing student status by fall school term of To apply, you will need to submit: (Please use the following checklist for completing your application.) 1. A completed application for employment form. 2. Professional Resume including experiences, skills, and community activities. 3. Your nursing course summary. 4. Verification of your GPA (copy of a transcript). 5. Your goals for the summer program. 6. Two clinical instructor references. It is important to use the correct forms for references. 7. One employer reference (if none, one personal reference). Use the form titled Employer Reference Form. 8. A photocopy of your current CPR certification card (American Heart Association or Red Cross). You will need to be certified in CPR prior to your first day of employment at Redwood Area Hospital 9. Interviews will take place between December 15, 2014 and February 1, If selected, you must be able to interview in person between these dates. 10. Home phone # Cell phone # 11. address: 12. Mailing address: Please return this letter and the above requested forms to me. Application materials need to be in by Friday, December 5, Interns are accepted into the Summer Nursing Intern Program based upon the submitted application materials and the interview. I look forward to receiving your application. Sincerely, Jody Rindfleisch, SPHR Human Resource Manager Phone:

2 NURSE INTERN 2015 INFORMATION SHEET 1. Completed application packets must be returned by Friday, December 5, Dates of the program: June 1, 2015, through August 7, Nurse Interns must: Have completed their Junior year in a baccalaureate nursing program Have at least a 3.0 GPA in their nursing courses Be enrolled in a summer internship course through a participating Minnesota college or university; and Have current Basic Life Support certification from the American Heart Association 4. Students attending a college or university outside the State of Minnesota will need to enroll in a Minnesota college or university for credits. The Minnesota Board of Nursing requires that in order for a person to practice nursing in the state, they either have to be licensed as an RN or LPN or be under the supervision of an instructor licensed in the state. 5. This program requires your participation for the entire 10 weeks. Any exceptions or special circumstances should be discussed during the interview process 6. Interns will be scheduled hours per week. They will work the same hours as their preceptor(s), including rotating shifts and weekends. Shifts may be 8 or 12 hours. 7. Interviews will take place between December 15, 2014, and February 1, Selected applicants must be able to interview in person between those dates. 8. In addition to an application and resume, applicants must complete all application materials. This includes obtaining 3 references or letters of recommendation. One reference must be from a clinical instructor The second reference can be from a clinical instructor or other faculty member The third reference should be from a work experience. If no employer reference is available, a personal reference can be obtained (use the employer reference form). 9. The Nurse Intern program will be a paid internship. Salary will be competitive with market. 10. Offers for nurse intern positions will be extended the week of February 9, Students must confirm offers by February 21, If you have any questions, please contact: Jody Rindfleisch, SPHR Human Resource Manager Phone:

3 APPLICATION FOR EMPLOYMENT REDWOOD AREA HOSPITAL 100 FALLWOOD ROAD REDWOOD FALLS, MN Redwood Area Hospital is an Equal Opportunity Employer and does not discriminate in hiring or any other decisions on the basis of race, color, creed, religion, national origin, sex, marital status, age, or disability. PERSONAL INFORMATION NAME LAST FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER PRESENT ADDRESS STREET CITY STATE ZIP PHONE PERMANENT ADDRESS STREET CITY STATE ZIP PHONE CELL PHONE ALTERNATE CONTACT EMPLOYMENT DESIRED PRIMARY POSITION DESIRED WILL YOU ACCEPT ANOTHER POSITION? NO YES-SPECIFY: ARE YOU AVAILABLE TO WORK: SHIFT(s) DESIRED STATUS DESIRED WEEKENDS ROTATING SHIFTS DAYS NIGHTS FULL-TIME TEMPORARY HOLIDAYS ON-CALL EVENINGS OPEN PART-TIME CASUAL SALARY DESIRED DO YOU LIMIT YOUR EARNINGS DUE TO SOCIAL SECURITY OR OTHER REASONS? NO YES-SPECIFY EARNING LIMIT ARE YOU EITHER A US CITIZEN OR LEGALLY ELIGIBLE TO HOLD EMPLOYMENT IN THE UNITED STATES? YES NO EDUCATION/TRAINING SCHOOL NAME & ADDRESS OF SCHOOL COURSES TAKEN DID YOU GRADUATE? High School / GED YES NO GED Post-Secondary Education / College Graduate or Other Special Training OTHER CLASSES/TRAINING YES Date: / / YES Date: / / NO NO DIPLOMA, DEGREE, OR CERTIFICATE RECEIVED Diploma Other AREAS OF SPECIALIZATION OR INTEREST PROFESSIONAL MEMBERSHIPS, HONORS RECEIVED, VOLUNTEER OR COMMUNITY SERVICE, OR OTHER QUALIFICATIONS YOU HAVE WHICH YOU FEEL ARE RELEVANT TO THE POSITION FOR WHICH YOU ARE APPLYING PROFESSIONAL LICENSES, REGISTRATIONS, OR CERTIFICATIONS TYPE ISSUING STATE OR ORGANIZATION DATE ISSUED NUMBER EXPIRATION DATE

4 MILITARY EXPERIENCE MILITARY BRANCH MILITARY OCCUPATIONAL SPECIALTY SPECIALIZED TRAINING: ARE YOU AN HONORABLY DISCHARGED VETERAN OF THE ARMED FORCES OR ARE YOU OTHERWISE ELIGIBLE TO CLAIM VETERAN'S PREFERENCE POINTS? YES NO DO YOU WISH TO CLAIM VETERANS' PREFERENCE POINTS? YES NO PROOF OF APPLICABLE MILITARY STATUS/ELIGIBILITY (IE, DD214 FORM) WILL BE REQUIRED TO CLAIM CREDITS. EMPLOYMENT HISTORY - PLEASE LIST CURRENT EMPLOYER(S) FIRST EMPLOYER NAME DATES OF EMPLOYMENT FROM: / / TO / / ADDRESS -- STREET, CITY, STATE, & ZIP SALARY STARTING: ENDING: SUPERVISOR'S NAME AND TITLE PHONE REASON FOR LEAVING POSITION TITLE DUTIES EMPLOYER NAME DATES OF EMPLOYMENT FROM: / / TO / / ADDRESS -- STREET, CITY, STATE, & ZIP SALARY STARTING: ENDING: SUPERVISOR'S NAME AND TITLE PHONE REASON FOR LEAVING POSITION TITLE DUTIES EMPLOYER NAME DATES OF EMPLOYMENT FROM: / / TO / / ADDRESS -- STREET, CITY, STATE, & ZIP SALARY STARTING: ENDING: SUPERVISOR'S NAME AND TITLE PHONE REASON FOR LEAVING POSITION TITLE DUTIES EMPLOYER NAME DATES OF EMPLOYMENT FROM: / / TO / / ADDRESS -- STREET, CITY, STATE, & ZIP SALARY STARTING: ENDING: SUPERVISOR'S NAME AND TITLE PHONE REASON FOR LEAVING POSITION TITLE DUTIES EMPLOYER NAME DATES OF EMPLOYMENT FROM: / / TO / / ADDRESS -- STREET, CITY, STATE, & ZIP SALARY STARTING: ENDING: SUPERVISOR'S NAME AND TITLE PHONE REASON FOR LEAVING POSITION TITLE DUTIES

5 BACKGROUND INFORMATION PURSUANT TO MINNESOTA STAT (B) AND (C), APPLICANTS ARE NOTIFIED THEY MAY BE DISQUALIFIED FROM EMPLOYMENT IN CERTAIN POSITIONS WITH A PARTICULAR CRIMINAL HISTORY. FURTHER, PURSUANT TO MINNESOTA STATUTE 245C, EMPLOYMENT OFFERS ARE CONDITIONAL UPON THE APPLICANT BEING SUBJECT TO A CRIMINAL HISTORY BACKGROUND CHECK. USE THIS SPACE TO MAKE ANY FURTHER COMMENTS THAT YOU FEEL MAY BE HELPFUL TO US. REFERENCES PLEASE LIST INDIVIDUALS WHO CAN DISCUSS YOUR QUALIFICATIONS AND SUITABILITY FOR THE POSITION FOR WHICH YOU ARE APPLYING. REDWOOD AREA HOSPITAL RESERVES THE RIGHT TO CONTACT ALL PRIOR EMPLOYERS AND EDUCATIONAL INSTITUTIONS IN ADDITION TO THE REFERENCES LISTED BELOW. NAME & TITLE RELATIONSHIP ADDRESS - STREET, CITY, STATE, ZIP CONTACT TELEPHONE NAME & TITLE RELATIONSHIP ADDRESS - STREET, CITY, STATE, ZIP CONTACT TELEPHONE NAME & TITLE RELATIONSHIP ADDRESS - STREET, CITY, STATE, ZIP CONTACT TELEPHONE ATTESTATION I certify that the information I have provided on this application is true and correct to the best of my knowledge. I understand that any false or misleading information provided, or any ommission or concealment of fact(s) will disqualify me from consideration of employment and constitutes immediate dismissal should I be employed by Redwood Area Hospital. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I understand that upon making a contingent job offer, Redwood Area Hospital may conduct a criminal background check, post-offer health exam and drug screening. Future employment is also contingent upon satisfactory verification of any applicable licenses and/or education qualification requirements and reference verifications. I understand that if employed, I will be required to complete an Employment Verification Form (I-9), and within three days must show satisfactory evidence of my identity and eligibility for employment. Signature Date AUTHORIZATION AND RELEASE I hereby authorize any and all current and former employers, volunteer organizations, and references named in this application or any agent of such a current or former employer or organization, to release to Redwood Area Hospital and its agents any and all information regarding my job performance and qualifications to perform the position I am presently seeking and any other employment related information, both public and private. I understand that Redwood Area Hospital will use this information to determine suitability for the position for which I am applying. This authorization expires one year from the date of my signature. I also hereby release Redwood Area Hospital and all current and former employers, volunteer organizations, and references named in this application or any agent of such employer or organization, of any and all liability of whatever nature by reason of requesting or providing such information. Signature Date APPLICATION PROCESS Please return completed application to: Redwood Area Hospital, Attention Human Resource Dept, 100 Fallwood Rd, Redwood Falls, MN or by fax to (507) Visit our website at for information about career opportunities at Redwood Area Hospital.

6 NAME NURSING COURSE SUMMARY Please list in sequence all nursing courses completed by December Course Title and Brief Description Number of Hours in Clinical Component of Course Per Week Type of Institution Where Clinical Experience Was Conducted Please list nursing courses to be completed January 2015 through May Course Title and Brief Description Number of Hours in Clinical Component of Course Type of Institution Where Clinical Experience Will Be Held Redwood Area Hospital 100 Fallwood Road Redwood Falls, MN 56283

7 NAME SUMMER NURSING INTERN PROGRAM GOALS List three goals that you would like to achieve during your summer internship. 1. GOAL METHOD TO ACHIEVE These goals will be shared with your preceptor and periodically reviewed throughout your experience. Redwood Area Hospital 100 Fallwood Road Redwood Falls MN 56283

8 NAME SUMMER NURSING INTERN PROGRAM LETTERS OF RECOMMENDATION I have requested letters of recommendation from the following nursing instructors: 1. Name Title Address Street City, State and Zip Code 2. Name Title Address Street City, State and Zip Code I have requested a letter of recommendation from my previous work place/experience: 1. Name Title Address Street City, State and Zip Code Redwood Area Hospital 100 Fallwood Road Redwood Falls MN 56283

9 Nursing Student Internship Faculty Reference Form Greetings, I am applying to a Nursing Student Internship Program. As part of the application process applicants must obtain 2 references, one should be from a clinical instructor and the other can be from a clinical instructor, other nursing faculty, or a supervisor of a health-related job. Please complete the attached Evaluation and Faculty Reference Form and it directly to the Redwood Area Hospital Human Resource Manager at Applications with recommendations must be submitted by December 5, 2014 Thank you in advance for your assistance. To Be Completed By the Nursing Student Student s Authorization to Release Clinical/Faculty Reference I have applied to a Nursing Student Internship Program and I authorize you to release the information requested within this Faculty Reference Form. This page (p. 1) of this document should remain with the school/faculty as evidence of student s permission to provide the reference. Page 2 document of this document should be directed to the specific clinical agency as requested by the student. Printed Name Signature Today s Date Educational Institution Daytime Phone Other Contact 1

10 To Be Completed By the Clinical or Faculty Reference (submit to clinical agency as directed by student). Signature Title Relationship to Student Educational Institution Daytime Phone Address Check those which apply: Clinical judgment/ critical thinking Appropriately responds to stressful situations Exceeds Expectations Meets Expectations Does Not Meet Expectations Cannot Evaluate Organizational ability Technical skills Initiative Consistent Performance Interpersonal & communication skills Flexibility/Ability to adjust to new situations Integrity Preparation for clinical, labs or classroom. Attendance/punctuality N/A N/A Meets Deadlines N/A N/A Please comment on the student s talents and strengths: Please comment on the student s weaknesses and areas for improvement: Overall Evaluation: Strongly recommend Recommend Do not recommend 2

11 Nursing Student Internship Faculty Reference Form Greetings, I am applying to a Nursing Student Internship Program. As part of the application process applicants must obtain 2 references, one should be from a clinical instructor and the other can be from a clinical instructor, other nursing faculty, or a supervisor of a health-related job. Please complete the attached Evaluation and Faculty Reference Form and it directly to the Redwood Area Hospital Human Resource Manager at Applications with recommendations must be submitted by December 5, 2014 Thank you in advance for your assistance. To Be Completed By the Nursing Student Student s Authorization to Release Clinical/Faculty Reference I have applied to a Nursing Student Internship Program and I authorize you to release the information requested within this Faculty Reference Form. This page (p. 1) of this document should remain with the school/faculty as evidence of student s permission to provide the reference. Page 2 document of this document should be directed to the specific clinical agency as requested by the student. Printed Name Signature Today s Date Educational Institution Daytime Phone Other Contact 1

12 To Be Completed By the Clinical or Faculty Reference (submit to clinical agency as directed by student). Signature Title Relationship to Student Educational Institution Daytime Phone Address Check those which apply: Clinical judgment/ critical thinking Appropriately responds to stressful situations Exceeds Expectations Meets Expectations Does Not Meet Expectations Cannot Evaluate Organizational ability Technical skills Initiative Consistent Performance Interpersonal & communication skills Flexibility/Ability to adjust to new situations Integrity Preparation for clinical, labs or classroom. Attendance/punctuality N/A N/A Meets Deadlines N/A N/A Please comment on the student s talents and strengths: Please comment on the student s weaknesses and areas for improvement: Overall Evaluation: Strongly recommend Recommend Do not recommend 2

13 EMPLOYER REFERENCE FORM Letter of Reference for: Thank you for agreeing to reference this student for Redwood Area Hospital. Please comment on this student in the areas listed. Your reference provides valuable assistance to us in considering this person for the Summer Nursing Intern Program. Please return it to the applicant in a sealed envelope. Reference forms need to be submitted as part of the application packet. Completed packets must be in by December 5, Initiative: Below Average Average Above Average Superior Comments: Dependability: Below Average Average Above Average Superior Comments: Ability to Work Independently: Below Average Average Above Average Superior Comments: Quality of Work: Below Average Average Above Average Superior Comments: Communication Skills: Below Average Average Above Average Superior Comments: Ability to Accept Authority and Work With Others: Below Average Average Above Average Superior Comments: Please summarize three (3) of the student s positive characteristics: Discuss one area of growth/need for improvement for this student: (Please add additional sheets if necessary) Signature Place of Employment Title Relationship to Applicant

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