RI Nurse Residency PASSPORT to PRACTICE Application

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1 RI Nurse Residency PASSPORT to PRACTICE Application Eligibility requirements: Active unencumbered Rhode Island Registered Nurse license Rhode Island resident Current Federal background check Graduate of a bachelor s degree nurse (BSN), associate s degree nurse (ADN), or diploma nurse program ADN or diploma nurse applicants must be accepted and actively enrolled in a BSN program Unemployed or underemployed (See RI Nurse Residency PASSPORT to PRACTICE Frequently Asked Questions) To apply to the RI Nurse Residency PASSPORT to PRACTICE program, you must submit the following materials: Completed application form Two letters of recommendation o At least one of these letters must be from a faculty member, current employer, or previous employer Clinical narrative that answers the following question: How would this residency program improve your clinical practice as a nurse? o One page maximum, 12-point font, 1 margins Copy of most recent transcript from your nursing degree program Proof of active, unencumbered Registered Nurse license or that you are sitting for the NCLEX- RN exam (Proof of active, unencumbered Registered Nurse will be required by start of the residency program) Original copy of a clean Federal background check Proof of Rhode Island residency o One document indicating your current address (i.e. utility bill, bank statement, etc.) ADN or diploma nurse applicants only: Letter or of acceptance to a BSN program Completed applications can be submitted by mail or in person to: Stepping Up Attention: Nurse Residency Coordinator 375 Branch Ave. Providence, RI All materials must be received by July 15, Late applications will not be accepted. Applicants that have supplied all of the above materials and meet the program s eligibility requirements will be contacted for an interview with the selection committee. For more information about the program: Visit Stepping Up s website at and click on the RI Nurse Residency page. Rhode Island Action Coalition 1 Revised

2 1. Demographics Last Name Maiden Name First Name Middle Name Street Address Apt #- PO Box # City State Zip Code Mailing Address (If different) Date of Birth (MM/DD/YYYY) Age Social Security Number (XXX-XX-XXXX) Address Gender (Circle) Marital Status (Circle) Male Female Married Single Divorced Widowed Home Phone Number (XXX-XXX-XXXX) Work Phone Number (XXX-XXX-XXXX) Cell Phone Number (XXX-XXX-XXXX) Have you ever been a participant in Stepping Up? If yes, explain: Emergency Contact Name Current Employment Status (Circle) 2. Emergency Contact Emergency Contact Phone Number 3. Current Employer Full-time Part-time Per Diem t in Labor Market Unemployed If you circled t in Labor Market or Unemployed, please skip to section 4 Most Recent Employer. Employer Job Title Job Department Supervisor Name Supervisor Phone Number Supervisor Which employer benefits do you receive? (Circle all that apply) Medical Dental Vision Employment Start Date (MM/DD/YYYY) Average Current Hourly Wage (XX.XX) Average Hours Worked Per Week 4. Most Recent Employer (Only Fill Out if Unemployed or t in Labor Market) Employer Job Title Job Department Supervisor Name Supervisor Phone Number Supervisor Which employer benefits did you receive? (Circle all that apply) Average Current Hourly Wage (XX.XX) Medical Dental Vision Average Hours Worked Per Week Employment Start Date (MM/DD/YYYY) Employment End Date (MM/DD/YYYY) 2 Revised

3 Household Size (i.e. three) 5. Household Information Monthly Household Income (Gross) Do you have health insurance - Includes employer insurance, private insurance, RIte Care and Medicaid? (Circle) 6. Insurance and Assistance Information Are you currently receiving unemployment benefits? (Circle) Are you or anyone in your household receiving public assistance? (Circle) If your household is receiving public assistance, what type of assistance are you receiving and how much do you receive per month? SNAP (Food Support) TANF (Cash Assistance for Families) GPA (General Public Assistance) SSI (Supplemental Security Income) RI Works Have you ever been arrested? (Circle) Have you ever been convicted? (Circle) If yes, please explain: If yes, please explain: 7. Ethnicity (Circle all the apply) Black/African American Asian Hispanic/Latino American Indian/Alaskan Native White Native Hawaiian/Other Pacific Islander Unknown Other (please explain): Decline to disclose 8. Veteran s Status (Circle one) Veteran t a veteran Decline to disclose Native Language (Circle) 9. Language English n-english If non-english, what is your native language? English Fluency (Circle one) Basic Read only Speak only Intermediate (speak/read/write) Fluent 3 Revised

4 Did you attend high school in another country? (Circle one) 10. High School Education If yes, where? Did you receive a high school diploma? (Circle one) Have you completed a GED, EDP or Work Readiness Certificate? (Circle one) 11. College or Post-Secondary Technical Training What is the last grade you completed Include college equivalent? (i.e. 11 th ) Last year you attended college? (i.e. 2011) From which college is your nursing degree? Which nursing degree did/will you earn? ADN BSN Diploma nurse Did you graduate from college? When did/will you graduate? (MM/YYYY) 12. I learned about the RI Nurse Residency PASSPORT to PRACTICE program from: (Circle all that apply) Brochure/Flier Network RI Salve Regina University Website Community College of Rhode Island (CCRI) New England Institute of Technology (NEIT) St. Joseph School of Nursing Workforce Partnership of Greater Rhode Island Friend/Family Newspaper//Magazine Student Nurses Association of Rhode Island (SNARI) Workforce Solutions of Providence-Cranston Governor s Workforce Board RI Rhode Island College (RIC) TV/Radio University of Rhode Island (URI) Healthcare Employer Labor Union Other 13. Access to Technology at Home (Circle all that apply) Cell Phone MP3 Player/iPod VCR/DVR Internet Access Computer CD Player DVD Player 4 Revised

5 14. Physical Demands The physical demands and work environment described here are representative of those that must be met by an intern to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work involves sitting, walking, talking, hearing, using hands and fingers to handle, feel or operate objects, tools, or controls, and reaching with hands and arms, driving a vehicle. The intern may be required to push, pull, lift, and/or carry up to 20 pounds or more. The intern may also work in an environment where there are chemicals. Vision abilities required by this job include close vision and the ability to adjust focus. The noise level in the work environment is usually moderately quiet. Ability to read, write and understand English. Some travel may be required. In signing this form, I authorize the RI Nurse Residency PASSPORT to PRACTICE program to use the information collected in this application for data matching, research and evaluation purposes as long as my application materials are kept private and confidential. Also, in signing this form, I authorize Human Resources to release my salary information to the RI Nurse Residency PASSPORT to PRACTICE program. 15. n-discrimination Policy It is the policy of the RI Nurse Residency PASSPORT to PRACTICE program not to discriminate on the basis of age, sex, race, religion, national origin, color, or handicap in its educational program, activities, and employment practices in accordance with applicable laws and regulations. Additionally, the lack of English language skills will not be a barrier to admission into the program. I have read and understand the above policy of non-discrimination. Applicant Signature: For Office Use Only Date: Participant ID #: Nurse Residency Coordinator: _ Data Entry Person: Enrollment Date: 5 Revised

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