Millikin University Decatur, Illinois Nursing Internship Application for Summer 2016 Applicant s Anticipated Graduation Date (Circle Response) December 2016 OR May 2017 * Please complete this application for consideration for a summer internship course (June-July) offered at Millikin University in collaboration with HSHS St. Mary s Hospital, Decatur, IL. Please include a personal essay and 2 references. The deadline for applications is January 9, 2016. PERSONAL DATA Name SSN Last First MI Present Address Street City State Zip Permanent Address Street City State Zip Phone (Home) (Cell) Email Address EDUCATION DATA * Start with most recent college/school of Nursing. Name of School City & State Major/Degree Note: If your school or employment records are under another name, please indicate that name: Last First MI
EMPLOYMENT HISTORY 1.) Present or Last Employer Address City State Zip Code Telephone Number From (Mo./Yr.) to (Mo./Yr.) Job Title Supervisor s Name Reason for Leaving Salary Description of Duties May we contact? 2.) Previous Employer Address City State Zip Code Telephone Number From (Mo./Yr.) to (Mo./Yr.) Job Title Supervisor s Name Reason for Leaving Salary Description of Duties May we contact? Are you a current employee of HSHS St. Mary s Hospital? Are you a previous employee of HSHS St. Mary s Hospital? Dates Employed To Month / Year Month / Year A current CPR certification is required. Date of CPR expiration?
AREAS OF INTEREST for CLINICAL ROTATIONS indicate your #1, 2, 3, and 4 choice Behavioral Health Adolescent Adult Geriatric Cardiovascular Emergency Room General Medical General Surgical Write-in Home Health Intensive Care Units Neurology Orthopedics Pediatrics Post Partum/Nursery Postoperative Anesthesia Care Rehabilitation (Inpatient)/Gerontology AREAS OF INTEREST for SPECIAL EXPERIENCES indicate your #1, 2, 3, and 4 choice (we will try to fulfill your interest choices to the best our ability) Adult Day Care Interventional Radiology Cancer Care Midwife Cardiac Catheterization Lab Nursing Informatics Case Management Operating Room Clinical Initiatives Nurse (heart failure, sepsis, hospital to home clinic) CRNA Outpatient Procedural Area Dialysis Nurse Practitioner Ear/Nose/Throat Surgery Cardiovascular focus Emergency Room Emergency Med focus Gastroenterology Pediatric focus Home Health Pain Center House Supervisor Physician s Office-specify Infection Control/Prevention Pre-op Area/Same Day Services Postoperative Anesthesia Care Wound Care Med Pass (do a morning med pass for a group of patients with an instructor) Write-in Unit Manager/Director SCHEDULING INTERESTS (it is preferred that all participants work 2 shifts on an alternate shift from their base schedule) Day/Evening Rotation Day/Night Rotation Evenings Nights 8 hour work shifts 8 hour/12 hour work shifts (mix) 12 hour work shifts PERSONAL ESSAY Please submit a1-2 page written essay addressing the following: 1) Why you are interested in the summer nurse internship program. 2) What you expect to achieve from the nurse internship program. 3) What you expect the internship program to provide. 4) Describe a difficult/challenging situation you had to deal with in clinical and how you dealt with it. 5) Your future career and educational aspirations.
CLINICAL EXPERIENCE-this is a self-evaluation Basic Skills Blood Pressure T./P./R. Patient mobilization & Transfers Adult Assessment No knowledge Learned in class only Minimal Moderate Feel Competent Recording I &O Emptying and Measuring suction containers Emptying and measuring drainage systems Bowel and Bladder Hygiene Specimen collection: Stool Sputum 24 hr urine Urinalysis Isolation Techniques IV therapy: Calculate Rate Needle Insertion Discontinue needle Assist in admitting & discharging patients Caring for patients with drainage tubes
CLINICAL EXPERIENCE (cont.) Basic Skills No knowledge Learned in class only End of Life Care Blood glucose monitoring Oxygen Administration & Airway Management Pain Management OB Assessment Pediatric Assessment Minimal Moderate Feel Competent Additional Comments/Learning Needs: Signature Date (May be electronically signed) Checklist: Application Transcript (does not need to be official) Skills list from school Copy of CPR card Essay 2 Reference forms given to faculty Names of faculty: 1) 2) Submit all application forms by mail or email to: Millikin University School of Nursing 1184 West Main Street Decatur, Illinois 62522 Attn: Charlotte Bivens MS, RN cbivens@millikin.edu