Frontier School of Midwifery & Family Nursing 195 School Street PO Box 528 Hyden, KY (606) FAX: (606)

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1 195 School Street PO Box 528 Hyden, KY (606) FAX: (606)

2 Contents Frontier School of Midwifery & Family Nursing Application Packet MSN Checklists for Application Process Student Application Form Professional Reference Form (3 copies) Instructions for Portfolio (Only for those with a Baccalaureate degree in a discipline other than nursing.) Please visit our website for the complete FSMFN information, including the most current Admissions Calendar and Deadlines. Admissions Criteria Candidates are expected to meet the following criteria for admission to the FSMFN: Be a registered nurse with educational preparation from a nationally (CCNE or NLNAC) accredited nursing program offered by a regionally accredited educational institution. Registered nurses with a baccalaureate or higher degree in nursing will be considered for admission to the MSN Program. Registered nurses without a baccalaureate or higher degree in nursing, who have completed a diploma or associate degree nursing program and have a bachelor s degree in another discipline, will be considered for admission to the MSN Program with the additional requirement of a portfolio of relevant employment and academic experience. Registered nurses with an associate degree in nursing, who do not have a baccalaureate degree in any discipline, will be considered for admission via the ADN to MSN Bridge Program. Have a grade point average (GPA) of 3.0 from the most recent degree earned. If GPA is less than a 3.0, the applicant must take either the Graduate Record Examination (GRE) or the Miller Analogy Test (MAT) and obtain a satisfactory score. Click here for GRE Website and here for the MAT website. Please note that an applicant with a GPA less than 2.7 will not be considered for admission. Be a registered nurse currently licensed in the state in which s/he works. If assignment to a clinical practice site requires that the student practice in another jurisdiction, then the student is required to meet licensing (requirements according to statutes in place at the site. One year of nursing experience. The admissions committee may consider other significant experience in health care. Submit three professional references on FSMFN-supplied forms. Telephone Interview with the Coordinator of Student Services (606) A health examination that includes documentation of immunity to Rubella and Hepatitis B, and freedom from tuberculosis in a communicable stage. For Admissions to the Master s program, applicants must present evidence of satisfactory completion of a college level statistics course within the past ten years (not applicable for Bridge Program admission). Each applicant is evaluated individually. FSMFN faculty Admissions Committee makes all admission decisions.!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 2 of 12

3 Checklist for Applicants Place a check mark in the provided box next to each item as you complete it and enclose it in your application packet. You must return this Checklist with your Application Packet. If you have any questions, feel free to contact: Chair of Admissions Committee, Suzan Ulrich, (November April (954) ) (May - October (716) ) or Chair of Family Nursing, Julie Marfell, (859) or Chair of Midwifery & Women s Health, Suzan Ulrich, (November April (954) ) (May - October (716) ) or Director, ADN to MSN Bridge Program, Trish Voss, (440) or 1 Complete the entire Application Packet and send to: Frontier School of Midwifery & Family Nursing, P.O. Box 528, 195 School St., Hyden, KY Student Application Form Your answers to the two questions on the last page of the Student Application form Copy of wallet-size RN license showing current expiration date Check for $100 made out to FSMFN Inc. This Checklist Your Curriculum Vitae (CV) or resume A Snapshot is helpful to get to know you (optional) 3 References Arrange for three professional references. Complete Section A of each Professional Reference Form which are included in the application and give or send the forms to your three professional references. Have them return the forms to you in a sealed envelope. PLEASE do not open the envelopes Transcripts Request official transcripts from all institutions of higher learning previously attended to be sent to you in sealed envelopes. PLEASE do not open the envelopes doing so will result in your transcripts becoming unofficial which will delay your application process. Portfolio If your baccalaureate degree is in a discipline other than Nursing you will need to submit a portfolio (Instructions for the Portfolio are at the end of the Application form.) Applications are not considered complete if any of these items are missing. Incomplete applications will not be reviewed for admission to FSMFN. 2 If undergraduate Grade Point (GPA) is less than 3.0, take the GRE or the MAT. Click here to go to the GRE website or MAT website. Note: The FSMFN GRE graduate code is Once you have sent your completed application to the FSMFN, contact the Student Services Coordinator to schedule a telephone interview appointment. This interview is to get to know you and your plans for graduate school. Student Services Coordinator: Debra Turner or (606) , ext Signed: Date:!FSMFN Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 3 of 12

4 Student Application Form A non-refundable $ Application Fee, made payable to FSMFN Inc., must accompany this application. Select Specialty Track CNEP (Nurse-Midwifery) CFNP (Family Nurse Practitioner) CWHCNP (Women s Health Care Nurse Practitioner) Select Program Entry Post Baccalaureate MSN Post-Master s certificate ADN to MSN Bridge Select Timeframe For Completion Full time Part time (Not available for ADN to MSN Bridge course sequence) Enter desired enrollment date: Visit our website for most current enrollment calendar. Please type or print on this form. Name: S.S. # Home Address: Name of Employer: Work Address: Phone: ( ) Zip: Phone: ( ) Zip: Citizenship: address: Place of Birth: Maiden Name: Other previously used names: Educational Experience List in chronological order Universities, Colleges, and Professional Schools attended. Please have each institution send your official transcripts directly to the Registrar at FSMFN. Institution Attended Major Date of Graduation Degree!FSMFN Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 4 of 12

5 What is your highest degree? Are you currently applying to any other education programs? Yes No If yes, please list the program. Physical Assessment Course School Where Taken Course Name and Number Date Taken Statistics School School Where Taken Course Name and Number Date Taken The following four items are optional. Answers will be used only for statistical and government analysis. 1. Ethnic origin (Check one) Caucasian African-American Hispanic Asian Native American 2. Veteran/Military Status: 3. List any physical limitations you may have: 4a. Size of your community (check one) 4b. Name of the county you reside in. 5,000 or less 5,000-10,000 10,000-50,000 50,000 or more Other. Please list size 4c. Gender: Female Male 4d. Date of Birth: Professional Licenses or Certificates List below and enclose copies of current licenses, or letter of verification from your State Board of Nursing and certification credentials with application. Type License Number State or Organization!FSMFN Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 5 of 12

6 List the most recent first with most applicable experience only. Employment Record Agency Name/Address Dates Employed (M/Y to M/Y) Area of Service (Employment setting - ie. hospital, L&D, Office Practice, etc.) Position Title Professional Work Experience Midwifery Applicants List Years worked as a Professional Nurse Birth Center or with CNM Maternal Newborn/Perinatal Other years years years years Describe the areas that most prepared you for nurse-midwifery practice: WHCNP Applicants List Years worked as a Professional Nurse Birth Center or with CNM Maternal Newborn/Perinatal Other years years years years Describe the areas that most prepared you for advanced practice nursing: FNP Applicants List Years worked as a Professional Nurse Birth Center or with CNM Maternal Newborn/Perinatal Other years years years years Describe the areas that most prepared you for advanced practice nursing:!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 6 of 12

7 List Membership and Activity in Academic, Professional or Community Organizations Organization Name # Years Member Your Activity Completed Research or Publications Title Date Published in what Journal Co-Authors List TWO professional supervisors and ONE professional peer who can discuss your capabilities and qualifications. (CNM or NP reference encouraged, as applicable.) (Complete Section A on the enclosed Applicant Reference Forms and distribute them to the individuals you have listed below. Please have them return the completed references to you in sealed envelopes to be added to your Admission Packet.) Name Address Telephone Relationship Have you ever been convicted of a felony? Yes No If yes, attach a description of the circumstances.!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 7 of 12

8 Please type responses to the following on a separate sheet of paper Please write a well-crafted statement about your desire to become a nurse-midwife or a nurse practitioner. Include information about yourself and your professional goals as a nurse-midwife or nurse practitioner. Please type separately and limit yourself to words. Graduate education is rigorous and from the experiences of Frontier students it is clear that full time study requires a commitment of 40 hours a week while part time study requires 30 hours per week. This will require adjustments to your current work and family life. It is important that you take time to consider how you will integrate graduate school into your current situation. Please write a well crafted statement about how you plan to fit the rigors and time commitment of graduate education into your life situation of work and family. I agree to adhere to the rules and regulations of the Frontier School of Midwifery and Family Nursing, and certify that all statements in this application are true. I also understand that any misrepresentation of information will make me ineligible for admission to the Frontier School of Midwifery and Family Nursing or subject to dismissal after admission has been granted. Signed: Date:!FSMFN Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 8 of 12

9 Professional Reference Form Section A - To Be Completed By The Applicant The Family Educational Rights and Privacy Act of 1974 and its amendments guarantee students access to their educational records. Students may, however, waive their right of access to recommendations. The choice of the applicant regarding this recommendation is to be indicated below. Failure by applicant to sign constitutes a waiver of applicant s right to review this reference. I waive my right to inspect the contents of the following recommendation. I do not waive my right to inspect the contents of the following recommendations. Signed: Date: Name of Applicant: Last First Middle Maiden Applying to which program: Nurse-Midwifery Family Nurse Practitioner WHNP Section B - To Be Completed By The Person Serving As The Applicant s Reference The above named person has made application to the Frontier School of Midwifery and Family nursing and is requesting you to serve as a reference. Please comment on the following. Length of time you have known the applicant Capacity in which you know applicant Please rate the applicant in each of the attributes listed below. Personal 4 Outstanding 3 Above 2 1 Below N Not Observed Intellectual Curiosity Raises meaningful questions and seeks answers Dependability Follows through on commitments Performance under Stress Accomplishes goals in stressful situations Open Mindedness Gives thoughtful consideration to new ideas Assertiveness Expresses own beliefs and acts on them without hurting others Self-confidence Carries out actions with assuredness Integrity Functions on the basis of accepted ethical standards Flexibility Changes or modifies behavior when appropriate!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 9 of 12

10 Personal Sensitivity to Change Alert to and considerate of needs of clients and colleagues Tolerance of Ambiguity Functions without rigidly defined, externally imposed structure 4 Outstanding 3 Above 2 1 Below N Not Observed Comments: Please rate the applicant in each of the attributes listed below. Professional 4 Outstanding 3 Above 2 1 Below N Not Observed Problem-Solving Ability Uses a systematic approach to the identification and solution of problems Accountability Accepts responsibility for own decisions and actions Leadership Potential Able to motivate and direct others Decision Making Ability Considers alternatives and takes appropriate actions Self-Directness Plans and executes actions independently Understands Limitation Sets self-expectations congruent with own capabilities Seeks Help Appropriately When situation exceeds capabilities Communication with Others Establishes ideas succinctly and logically in writing and when speaking Comments:!FSMFN Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 10 of 12

11 In your experience with other nurses, please evaluate the applicant s professional competence: 4 - Most Least Would you seek out this individual to care for you or your family? If no, why not? Clients Please comment on applicant s ability to work collaboratively with: Peers Other Professionals Please comment on applicant s ability to work collaboratively with: The nature of the Community-Based Education Programs for CNMs and NPs require that the applicant have the ability to be a selfdirected, independent learner who will seek faculty to help and support as needed by telephone or written correspondence. Please comment on the applicant s potential for successful completion of the Community-Based Education Programs for CNMs and NPs. Feel free to use the back of this page. Name Position Agency Address Signature: Date: Thank you for giving your time and careful consideration to this reference. Please return to the applicant in a sealed envelope.!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 11 of 12

12 Instructions for Portfolio Applicants with and RN and a bachelor s degree in a field other than Nursing ONLY If your baccalaureate degree is in a discipline other than nursing you must submit a portfolio detailing you employment and academic experiences. Applicants are expected to provide the information/meet the requirements listed below. It is important that you carefully respond in detail to all of the items. Admission depends on a clear description of your achievements. Applicants who do not meet all performance requirements but whose credentials reveal potential ability for graduate study may be referred to a committee for recommendations pertaining to their acceptance. In some instances, applicants may be required to fulfill prerequisites designated by the committee. When assembling your portfolio the following information should be included in a notebook or folder. 1. Curriculum Vitae including: a. Formal education, degree(s) obtained and major, school attended, dates b. All nursing and other positions held c. Any relevant CE programs/courses taken d. Any published professional articles (in journals, hospital/agency publications, school newspapers, etc.) e. Presentations before staff, patient/family and other groups including educational seminars presented to peers as part of job responsibilities) date, title, location f. Honors/awards received g. Membership in professional and other organizations offices held, dates of membership h. Community service: name of organization, description of activities 2. A formal paper divided into six sections. This paper is an essential aspect of the admission process and will be carefully evaluated in order to make a decision on your direct entry into the MSN program. Follow the guidelines carefully, speaking to all items. The paper will be evaluated on content, clarity of presentation, grammar, punctuation, etc. Section 1. Description of the theoretical basis of your practice This description may be eclectic drawing on knowledge from behavioral, biologic and other theories, including one of a nurse theorist. Give two examples of application in practice. Section 2. Description of teaching and counseling aspects of your practice Give three principles of teaching and describe how these have been applied using three examples of patient, family, or group teaching activities. Give three principles of counseling and describe how they have been applied in your work with patients/clinics or staff, or groups. Give at least three examples. Section 3. Description of collaborative activities, with all members of the health team Define collaboration. Describe how collaboration is applied in your practice using three examples. Section 4. Description of leadership and change Define and describe leadership. Give three examples of how you have functioned as a leader in your position (you do not need to have had a formal leadership position, a staff nurse can be a leader). Describe inhibitors and facilitators of change. Describe how you have participated in change giving two examples. Section 5. Description of research knowledge/activities Describe content related to research that you have had in your nursing program and in your other collegiate programs. This can include courses in research or content related to reading and evaluating research that was incorporated into the courses such as sociology, biology, etc. Identify courses and content specifically. Describe how you incorporate research findings into your practice. Give one example. Describe any clinical research activities in which you have participated or which you have facilitated. Section 6. Personal philosophy of nursing Describe your personal philosophy of nursing. Include an analysis of how nursing and general education in the baccalaureate or higher degree program has influenced this philosophy.!fsmfn Common\Forms\Application Process\Application.pdf 01/13/09 -- bsf Page 12 of 12

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