**KEEP THIS PAGE FOR YOUR REFERENCE. RN RESIDENCY PROGRAM 2015 TIMELINE Application Deadline. 03/31/2015 August, 2015

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1 **KEEP THIS PAGE FOR YOUR REFERENCE RN RESIDENCY PROGRAM 2015 TIMELINE Application Deadline Cohort Start Date 03/31/2015 August, 2015 In order to complete the online application for the RN Residency, please visit and search for the Nurse Clinician I / RN Residency position at Illinois Masonic. Select "Apply" and complete the online application. Within 5-7 business days of submitting your online application, you will receive a Patient Experience Profile (PEP) questionnaire via , which you must complete prior to moving forward in the interviewing process. Successful completion of the PEP is required for advancing in the application process. The online application and PEP must be completed before submission of this packet. Please do not use staples or paper clips with application.

2 () Complete Advocate Illinois Masonic Medical Center Components RN Residency Program Application Checklist This application packet is designed to be printed, completed and mailed by the applicant. Please complete the following checklist to ensure processing of your application packet and return to the address indicated below by the indicated application deadline date. Please submit single sided in the order indicated below and on plain printer paper with no staples. Transcripts and reference forms should be in sealed envelopes. It is recommended the applicant retain a copy for your records. Please mail or drop off to Attn: Johanna Lemke, Nursing Office, Adovcate Illinois Masonic Medical Center, 836 W. Wellington, Chicago, IL Employment Application signed and dated Résumé outlining your work experiences, extracurricular, community, and health care activities. Please include your address on your resume. Completed Division Preference Sheet One page personal statement enclosed reflecting personal reason(s) for choosing health care as a profession, including professional goals, area of interest, and five year career plan All official college transcript(s) enclosed (PREFERRED METHOD), OR institution(s) have agreed to submit transcript(s) separately by the application deadline date Three (two-page) reference forms enclosed in sealed envelopes, with the envelope flap signed by the reference (1 faculty, 1 professional colleague or co-worker and 1 personal) Education Verification form License and Vacation Statement signed and dated Background Investigation Authorization (2 pages) The following is not part of the application packet, but also needs to be completed: Apply online to Nurse Clinician I/RNResidency Program position and complete Patient Experience Profile (PEP) This application will be considered for the Cohort starting August 2015 ONLY if all of the above items are received by 4pm on March 31st, 2015 Program Requirement: Must have proof of RN licensure and Education Verification prior to 4:00pm CST the Friday before the start of the Residency. It is the applicant's responsibility to ensure that all components of the RN Residency Program Application are complete. This checklist is provided to assist the applicant. Failure to submit a complete application may result in the application being deemed ineligible. Sign, date and return the completed checklist with the application. Printed Name of Applicant Applicant Signature Date updated 2/26/2015

3 Division Preference Sheet Name: In the boxes provided, rank your top three division choices overall with 1&2&3 Please only mark a TOTAL of 3 boxes on this sheet. MEDICAL/SURGICAL UNITS 9 Stone: This 14 bed short stay unit cares for patients recovering from a variety of surgical procedures. Some of the specialties include EENT (Eyes, Ears, Nose, and Throat), gynecological and urological procedures. This is a fast paced unit with a strong emphasis on patient education and preparation for home care. 8 Stone: 8 Stone is the largest unit in the medical surgical division. It is a 32 bed unit with a concentration of surgical, trauma, orthopedic, and neurosurgical patients. The unit serves a diverse patient population encompassing all aspects of recovery from unexpected trauma to any surgical procedure. Frequently seen on the unit are extensive general surgical conditions, multiple trauma, multiple fractures, joint replacement surgeries, and neurosurgical conditions. The unit is fast paced with the average length of stay for patients being between 2-4 days. Medical-Gerontology/Oncology Unit: This 25 bed unit focuses primarily on the care of medical, geriatric and oncology patients. Frequent procedures/services include the following: Chemotherapy administration, management of chemo side effects, care of the patient receiving radiation therapy (external beam, brachytherapy), palliative and hospice care. Inpatient Rehabilitation Unit: This unit is a partnership between Illinois Masonic and the Rehabilitation Institute of Chicago. The rehab unit serves a diverse patient population with a variety of diagnoses and age groups who are working to overcome barriers to their ability to perform everyday activities. This highly collaborative unit builds on the skills of the nurse, physiatrist, physical and occupational therapist, and speech and language pathologists. CRITICAL CARE UNITS SICU Surgical Intensive Care Unit: The 16 bed surgical trauma ICU serves a diverse population of critically ill adults. The patient population is comprised of Level One Trauma, Neurosurgical, Complicated General Surgical, Cardiac, Vascular, and Thoracic Surgical patients. This unit also has particular expertise caring for the complicated, high risk ENT patients in addition to patients recovering from open heart procedures. MICCU Medical Intensive Coronary Care Unit: The 14 bed MICCU delivers exceptional care to a population consisting of cardiac, sepsis, respiratory, and renal patients. CSU/SSU Cardiac/Surgical Surveillance Unit: The 35 bed CSU/SSU cares for patients who are post open hearts surgical patients, and post Cardiac interventional procedures such as cardiac electrophysiology and catheterization. The unit also cares for pre and post stroke patients who due to their cardiac status may need extensive neuro/cardiac work ups and possible Carotid endarectomies. CSU/SSU also cares for cardiac patients who have a variety of complex co morbidities such as COPD, Cancer and Trauma. WOMEN S AND CHILDREN UNITS Labor and Delivery: Our fast-paced L&D is a Level III Co-Perinatal Center with Rush University. With an OB triage, expanding L&D, 2 OR suites, and our Alternative Birthing Center for low-risk patients desiring a more natural experience, we are able to meet the needs of our diverse patient population. Mother/Baby & PSU (Perinatal Surveillance Unit): This combination unit provides care for mothers across the pregnancy continuum, from high-risk antepartum to postpartum. On the journey to Baby Friendly designation, our postpartum care is focused on the bond between the family and new baby, emphasizing education to ease the transition home, breastfeeding, and rooming in. PEDIATRICS: The Pediatric department is comprised of 14 Pediatric floor status beds (5 intermediate care beds and 9 general care beds). In addition, there are 8 neonatal intermediate status beds. There are 5 pediatric hospitalists who cover the unit 24 hours a day. NEONATAL INTENSIVE CARE UNIT: The Neonatal Intensive Care Unit (NICU) is a Level III, 29 bed unit comprised of 10 ICU beds and 19 intermediate status beds in the NICU. In addition, there are 8 intermediate status beds located on the pediatric unit. The majority of the patients are premature infants with Respiratory Distress Syndrome. The unit can accommodate severely premature infants who require ventilator management, chest tubes, central lines, and surgical care. Updated

4 OTHER OPERATING ROOM The unit has 13 OR suites and 3 additional eye surgery rooms in the eye surgical suites and completes an average of 32 cases a day. The OR performs all specialty surgeries except transplants, and offers state-of-the-art equipment and services. The surgery department is staffed 24 hours during the week and shifts include 8, 10 and 12 hours. INPATIENT BEHAVIORAL HEALTH UNIT The Psychiatric Services Unit is a 35 bed acute care adult psychiatric unit which utilizes a combination of medication, skill building, and supportive and structured care for treatment. The interdisciplinary staff consists of nurses, social workers, mental health counselors, expressive therapists, and psychiatrists and focuses on providing individualized treatment to help people return to caring for themselves. Connection to outpatient resources is a high priority in order to ensure patient health after discharge. EMERGENCY DEPARTMENT More than 42,000 people a year come to Illinois Masonic for emergency care. AIMMC is a Level I Trauma Center which includes a trauma bay in addition to general emergency and behavioral health emergency designated beds. RNs are required to become verified as a Trauma Nurse by attending a Trauma Nurse Core Course (TNCC). AIMMC s Emergency Department serves as the lead agency in pre hospital disaster preparedness for the City of Chicago. Our growing fast track area that is staffed by Nurse Practitioners and helps to facilitate faster, more streamlined patient care.

5 Advocate Illinois Masonic Medical Center RN Residency Program X Faculty Professional Personal Reference Form Faculty I. TO BE COMPLETED BY APPLICANT Please use this form for submitting your references. Three references are required, including at least one reference from an instructor or an employer/supervisor. References should not include family members. Please remind your references to return this form to you in a sealed and signed envelope as soon as possible. Complete this portion of the form and then provide it to your reference for completion and return to you. You may want to provide your reference with a self-addressed envelope. Enclose the sealed envelope with your application. Printed Applicant Name Printed Name of Reference Reference Address City State ZIP Phone II. RELEASE OF ACCESS TO THIS LETTER OF RECOMMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L (Family Educator Rights and Privacy Acts of 1974) I waive my right to access this letter of recommendation. I do not waive my right to access this letter of recommendation. Signature of Applicant III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for person making the recommendation: * Review sections I & II to ensure the applicant has provided the necessary information. * Complete the remainder of the form. *Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. How well do you know the applicant? Very Well Fairly Well Minimally Unknown How long have you known the applicant? Identify the associations you have had with the applicant. Check all that apply. Instructor Employer/Supervisor Friend Community Organization Academic Advisor Other Name of Applicant

6 Please rate the applicant's achievement and potential by entering an "X" in the appropriate spaces below. Above Below Not able to respond Skill Exceptional Exceptional Average Average Average Decision-Making ability Organizational skills Communication skill: Written Communication skill: Oral Adaptability to stress Positive Attitude Professional Behavior Integrity Interpersonal sensitivity Leadership ability Ability to commit to a goal In addition to the ratings, please give your evaluation of the applicant. You may want to indicate your perceptions of the applicant's strengths and limitations. Please indicate some activity or association that illustrates the candidate's desire and ability to impact the nursing profession. My recommendation is: highly recommend recommend do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number ( ) ( )

7 Advocate Illinois Masonic Medical Center RN Residency Program Faculty x Professional Personal Reference Form Professional I. TO BE COMPLETED BY APPLICANT Please use this form for submitting your references. Three references are required, including at least one reference from an instructor or an employer/supervisor. References should not include family members. Please remind your references to return this form to you in a sealed and signed envelope as soon as possible. Complete this portion of the form and then provide it to your reference for completion and return to you. You may want to provide your reference with a self-addressed envelope. Enclose the sealed envelope with your application. Printed Applicant Name Printed Name of Reference Reference Address City State ZIP Phone II. RELEASE OF ACCESS TO THIS LETTER OF RECOMMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L (Family Educator Rights and Privacy Acts of 1974) I waive my right to access this letter of recommendation. I do not waive my right to access this letter of recommendation. Signature of Applicant III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for person making the recommendation: * Review sections I & II to ensure the applicant has provided the necessary information. * Complete the remainder of the form. *Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. How well do you know the applicant? Very Well Fairly Well Minimally Unknown How long have you known the applicant? Identify the associations you have had with the applicant. Check all that apply. Instructor Employer/Supervisor Friend Community Organization Academic Advisor Other Name of Applicant

8 Please rate the applicant's achievement and potential by entering an "X" in the appropriate spaces below. Above Below Not able to respond Skill Exceptional Exceptional Average Average Average Decision-Making ability Organizational skills Communication skill: Written Communication skill: Oral Adaptability to stress Professional Behavior Positive Attitude Integrity Interpersonal sensitivity Leadership ability Ability to commit to a goal In addition to the ratings, please give your evaluation of the applicant. You may want to indicate your perceptions of the applicant's strengths and limitations. Please indicate some activity or association that illustrates the candidate's desire and ability to impact the nursing profession. My recommendation is: highly recommend recommend do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number ( ) ( )

9 Advocate Illinois Masonic Medical Center RN Residency Program Faculty Professional X Personal Reference Form Personal I. TO BE COMPLETED BY APPLICANT Please use this form for submitting your references. Three references are required, including at least one reference from an instructor or an employer/supervisor. References should not include family members. Please remind your references to return this form to you as soon as possible. Complete this portion of the form and then provide it to your reference for completion and return to you. You may want to provide your reference with a self-addressed envelope. Enclose the sealed envelope with your application. Printed Applicant Name Printed Name of Reference Reference Address City State ZIP Phone II. RELEASE OF ACCESS TO THIS LETTER OF RECOMMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L (Family Educator Rights and Privacy Acts of 1974) I waive my right to access this letter of recommendation. I do not waive my right to access this letter of recommendation. Signature of Applicant III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for person making the recommendation: * Review sections I & II to ensure the applicant has provided the necessary information. * Complete the remainder of the form. *Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. How well do you know the applicant? Very Well Fairly Well Minimally Unknown How long have you known the applicant? Identify the associations you have had with the applicant. Check all that apply. Instructor Employer/Supervisor Friend Community Organization Academic Advisor Other Name of Applicant

10 Please rate the applicant's achievement and potential by entering an "X" in the appropriate spaces below. Above Below Not able to respond Skill Exceptional Exceptional Average Average Average Decision-Making ability Organizational skills Communication skill: Written Communication skill: Oral Adaptability to stress Professional Behavior Positive Attitude Integrity Interpersonal sensitivity Leadership ability Ability to commit to a goal In addition to the ratings, please give your evaluation of the applicant. You may want to indicate your perceptions of the applicant's strengths and limitations. Please indicate some activity or association that illustrates the candidate's desire and ability to impact the nursing profession. My recommendation is: highly recommend recommend do not recommend Signature of Person Making Recommendation Date Printed Name Business and Position (if applicable) Address Work Telephone Number Home Telephone Number ( ) ( )

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12 RN RESIDENCY LICENSURE AND VACATION STATEMENT Independent verification of your Illinois nursing license is required prior to the cohort start date. You will not be able to start the RN Residency program if you have failed the NCLEX or you do not have an Illinois nursing license. Additionally, an education verification must also be completed prior to your start date. The precepted portion of the RN Residency program about 3 months in length and requires full-time employment without vacation or other activities. An excess of two absences, planned or unplanned will require mediation with the Residency Coordinator. Adherence to the designated schedule, including every other weekend is also required. Any scheduled time off will necessitate approval of the hiring manager prior to start of the residency. Scheduled time off will not be granted for designated monthly seminar days, dates to be provided prior to the start of the residency. I have read the above statements. PLEASE PRINT NAME SIGNATURE DATE

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