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 obtained through Attorney General s office Graduate of a bachelor s degree nurse (BSN), associate s degree nurse (ADN), or diploma nurse program o ADN or diploma nurse applicants must be accepted to a BSN program or, if not already completed, enrolled in a BSN bridge/transition to practice course for the Fall 2014 semester. To complete the program, ADN or diploma nurse applicants will have to enroll in a BSN program by the Spring 2015 semester. 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 (see attached) Two original letters of recommendation on institutional letterhead with author s signature o 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 my clinical practice as a nurse? o One page maximum, 12-point font, 1 margins Original, sealed copy of official college transcripts Proof of active, unencumbered Registered Nurse license or that you are sitting for the NCLEX- RN exam by no later than June 30, 2014 (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: Preference will be given to applicants that supply proof of acceptance into a BSN program with their application. Otherwise, you must have completed the Bridge/Transitions to Practice course or be enrolled in the course for Fall 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 June 30, 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 For more specific questions, call Revised 2/2014

2 1. Demographics Last Name First Name Middle Name Previous/Maiden Name Street Address Apt # or PO Box # City State Zip Code Mailing Address (If different) Date of Birth (MM/DD/YYYY) Age Social Security Number 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 Stepping Up participant? 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 Previous Employer on the next page. Employer Job Title Job Department Supervisor Name Supervisor Phone Number Supervisor Which benefits, if any, do you receive directly from your employer? Check all that apply. Medical Dental Vision Employment Start Date (MM/DD/YYYY) Average Hourly Wage (XX.XX) Average Hours Worked Per Week 2 Revised 2/2014

3 4. Most Recent Previous Employer (Only Fill Out if Unemployed or t in Labor Market) Employer Job Title Job Department Supervisor Name Supervisor Phone Number Supervisor Which benefits, if any, did you receive directly from your employer? Check all that apply. Medical Dental Vision Average Hourly Wage (XX.XX) Average Hours Worked Per Week Employment Start Date (MM/DD/YYYY) Employment End Date (MM/DD/YYYY) Household Size (i.e. three) If you are under the age of 24 as of January 1, 2014, living with parent(s), and your parents declare you as a dependent, then your parents must be included in your household. Income will not impact eligibility, will remain confidential, and is used only for reporting purposes. 5. Household Monthly Household Income (Gross) Do you have health insurance -Includes employer insurance, private insurance, RIte Care and Medicaid? (Circle) 6. Insurance and Assistance 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) SSDI (Social Security Disability Insurance) TANF (Cash Assistance for Families) RSDI (Retirement, Survivors, Disability Insurance) GPA (General Public Assistance) RI Works SSI (Supplemental Security Income) Other Public Assistance (Specify) 7. Ethnicity (Circle all that apply) Black/African American Asian Hispanic/Latino American Indian/Alaskan Native White Native Hawaiian/Other Pacific Islander Unknown Other (please explain): 8. Veteran s Status (Circle one) Decline to disclose Veteran t a veteran Decline to disclose 3 Revised 2/2014

4 9. Language What is your native/first language? English Fluency (Circle one): Basic Read only Speak only Did you complete high school? Check the circle that best applies to you. o I graduated with my high school diploma. o I completed my GED. o I completed an EDP. o I completed a Work Readiness Certificate. o I did none of the above. 10. High School Education Intermediate (speak/read/write) Fluent Did you attend high school in another country? (Circle one) If yes, where? What is the last full grade of school you completed? (e.g., 10th) 11. College or Post-Secondary Technical Training What college or post-graduate training program did you attend? In which month and year did you graduate with your Nursing degree? Do you have a second degree or any other certificates? If so, please list. What Nursing degree did you earn? (i.e., ADN, BSN, Diploma nurse) 12. How You Learned About Nurse Residency (Check 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) Smart Phone/iPhone Cellular Phone Texting Internet Access Computer 4 Revised 2/2014

5 14. Physical Demands The physical demands and work environment described here are representative of those that must be met by a Nurse Resident 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 Nurse Resident may be required to push, pull, lift, and/or carry up to 20 pounds or more. The Nurse Resident 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 program. 15. n-discrimination Policy It is the policy of the RI Nurse Residency Passport to Practice program to not discriminate on the basis of race, color, national origin, religion, sex, disability, age, citizenship status, genetic information, veteran status, sexual orientation, gender identity or expression in its educational programs, activities, and employment practices in accordance with applicable laws and regulations. Additionally, a lack of English language skills will not be a barrier to admission into the program. By signing below, I acknowledge that I have read and understand the above policy of non-discrimination. Applicant Signature: Date: For Office Use Only Participant ID #: Cluster: Data Entry Person: Enrollment Date: Optional: With your application, you are welcome to submit a résumé. (For Office Use Only) tes: 5 Revised 2/2014

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