Application Instructions

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1 Application Instructions The 2014 DNP 2014 Application cycle is closed ecept for the Neonatal/Pediatric Nursing program, which will be open until April 15, The program is accepting paper applications for the remainder of the application cycle. Applications for the DNP Nurse Anesthesia (Entry) Program for Summer 2015 admission will be accepted May 1, 2014 through September 1, Applications for all other DNP programs for 2015 admission will be accepted through NursingCAS beginning June 1, DNP applicants ecept for nurses applying to the Nurse Anesthesia program apply through NursingCAS, a national centralized application service sponsored by AACN. DNP Neonatal/Pediatric Nurse Practitioner Application Instructions 1. Complete the brief paper application. 2. Acquire an official copy of ALL higher education transcripts -- DO NOT open the envelopes! 3. Send a copy of the Recommendation Form to three persons who know you well enough to evaluate your ability for successful completion of the Neonatal/Pediatric Nursing program. Two (2) references should be from former nursing professors and one (1) should be from a current or recent nursing supervisor/mentor. In your cover letter, request that they return their completed evaluation to YOU. 4. Submit a brief essay (300 words or less) regarding how a DNP will affect your practice as a Neonatal/Pediatric Nurse Practitioner. 5. Photocopy your nursing license(s), BCLS and NRP certifications, and any other certifications that you may hold. 6. Place all of the above documents in one (1) large envelope. Personally deliver or mail the envelope to: UTHSC College of Nursing 920 Madison Avenue, Suite 1020 Memphis, TN Attention: Ms. Roylynn Germain You will be contacted and given further instruction regarding your application within five to seven business days from the receipt of your documents.

2 Legal Name College of Nursing 920 Madison Ave. Suite 1020 Memphis, TN (901) College of Nursing Admissions Application Last First Middle Maiden/Other Previous Name Address Street Name and Number Preferred First Name City State _ Zip Code County _ State of Legal Residence _ County of Legal Residence _ Telephone Home ( ) - Work ( ) - Cell ( ) - Additional Identification Information Se Male Female Date of Birth /_ / City/State of Birth US Citizen Permanent Resident/Resident Alien 1 PLEASE CHOOSE ONE OF THE FOLLOWING 2 : Hispanic Non-Hispanic Country of Citizenship _ Race 3 CHOOSE ANY OF THE FOLLOWING: American Indian or Alaska Native Asian Black or African American Native American or Other Pacific Islander White 1 Military Service None Active Veteran Are you eligible for Veteran s educational benefit? Yes No Employment History Present/Most Recent Position Employer Supervisor _ Address Name Title Number and Street City State Zip Code Phone ( ) - Dates of Employment to Job Description: List all other post-high school positions beginning with most recent. Eplain lapses in time. Note that all DNP Nurse Anesthesia applicants must have a minimum of one (1) full year of recent ICU eperience at the time of interview. EMPLOYER LOCATION POSITION EMPLOYMENT DATES List any lapses in employment with reason: _

3 College of Nursing 920 Madison Ave. Suite 1020 Memphis, TN (901) APPLICANT NAME: _ Education Desired Entry: FALL (August) SUMMER-Nurse Anesthesia only (June) Program of Study: DNP -- Nurse Anesthesia DNP Neonatal Nurse Practitioner DNP-Pediatric Nursing RN - BSN Test Scores Please enter test scores and request submission of official test scores to UTHSC code GRE (required for DNP Nurse Anesthesia and PhD Applicants) Date Taken Date Taken Date Taken Verbal Verbal Verbal Quantitative Quantitative Quantitative Analytical Analytical Analytical List all Higher Educational Institutions attended in reverse chronological order Begin with most current. NAME OF SCHOOL DATES ATTENDED (MO/YR TO MO/YR) CITY AND STATE DEGREE/CERTIFICATION/ LICENSE/DIPLOMA Professional Licensure and Certifications LIST ALL PROFESSIONAL NURSE LICENSE(s) and CERTIFICATION(S); SUBMIT PHOTOCOPY OF EACH WITH THE APPLICATION PACKET. Required: RN License, BCLS, ACLS and PALS. Optional: CCRN Certification License/Certification State Number or ID DATE OF EXPIRATION

4 APPLICANT NAME: College of Nursing 920 Madison Ave. Suite 1020 Memphis, TN (901) Have you ever been admitted into another Nursing Program and not completed the program? YES NO If yes, please eplain to which Program you were accepted and reason(s) for non-completion. 3 Have you ever been convicted of a misdemeanor or felony? YES NO Have you ever had any certification, registration, license, or clinical privileges revoked, suspended, or in any way restricted by an institution, state, or locally? YES NO If you answered yes to any of the above questions, please provide a brief eplanation. Additional Questions Are you first generation of your family to enroll in an institution of higher education? YES NO If no, are your grandparents or parents graduates of the University of Tennessee (Knoville, Memphis, Martin, or Chattanooga campus) YES NO I certify that all answers I have given on this application are complete and accurate to the best of my knowledge. I understand that admission to the College of Nursing does not imply acceptance as a candidate for an advanced degree. I understand that any misrepresentation of facts on this application will be cause for refusal of admission, cancellation of admission, or suspension from the University. The University of Tennessee Health Science Center (UTHSC) reserves the right to perform background checks on all applicants. Although it is my responsibility to provide official documents, I grant UTHSC permission to request transcripts from all schools that I have attended. Signature Date 1 TOEFL may be required. 2 Information related to your ethnic background is requested for reporting to the Department of Education. The data reques ted will be used only for the required reports to this agency and will not be used in any way in the admissions process. 3 Information related to your ethnic background is requested for reporting to the Department of Education. The data requested w ill be used only for the required reports to this agency and will not be used in any way in the admissions process.

5 University of Tennessee Health Science Center College of Nursing Internal Use Only BANNER ID UTHSC COLLEGE OF NURSING RECOMMENDATION FORM Applicant Name (Last, First) Degree Sought (BSN, MSN, DNP, or PhD) Date Program (i.e. Nurse Anesthesia) ****APPLICANT: Please provide each recommender with a stamped (if U.S. mail) self-addressed envelope along with instructions for the recommender to sign the return envelope after it has been sealed. Recommender enters the information from this point forward. Name (Last, First) Position Work RECOMMENDER INFORMATION Highest Degree Earned Telephone - Work Employer Work Please provide brief statements for the questions below. APPLICANT OVERVIEW How long and in what capacity have you known the applicant? What do you consider to be the applicant s outstanding talents or strengths? What do you consider to be the applicant s major liabilities or weaknesses? Are there any other comments you believe might be helpful to the Admissions Committee? Recommender s Initials

6 University of Tennessee Health Science Center College of Nursing Internal Use Only BANNER ID Applicant Name (Last, First) COMPARATIVE ASSESSMENT In making your assessment, rate the applicant in comparison to other individuals you have known who have similar levels of eperience and education. Applicant Qualities Ecellent Good Average Below Average Poor Not Observed Intellectual ability Ability to analyze a problem and formulate a solution Oral communication skills Written communication skills Competency Leadership Critical thinking skills Creativity/innovation Interpersonal skills Team skills Adaptability Reaction to criticism Conflict resolution Patient interaction Dependability Motivation Self-discipline Initiative Integrity Awareness of limitations OVERALL ASSESSMENT Your overall assessment of the applicant s ability to complete an advanced academic degree: Recommend without reservation Recommend with reservation Do not recommend Signature Date PLEASE MAIL THE COMPLETED RECOMMATION FORM IN THE ENVELOPE PROVIDED BY THE APPLICANT AND SIGN THE BACK OF THE ENVELOPE AFTER IT IS SEALED. FOR QUESTIONS, CONTACT UTHSC COLLEGE OF NURSING OFFICE OF STUDENT AFFAIRS AT (901)

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