ST. ELIZABETH HEALTH CENTER SCHOOL FOR NURSE ANESTHETISTS, INC. P.O. Box 1790 1044 Belmont Avenue Youngstown, OH 44501-1790 (330) 480-3444

ST. ELIZABETH HEALTH CENTER SCHOOL FOR NURSE ANESTHETISTS, INC. P.O. Box 1790 1044 Belmont Avenue Youngstown, OH 44501-1790 (330) 480-3444 Dear Applicant: Thank you for your interest in St. Elizabeth Health Center School for Nurse Anesthetists, Inc. Currently the program for student registered nurse anesthetists is 27 months in length. New students are accepted annually with no discrimination or preferred treatment relative to age, race, creed, sex, color, national origin, or marital status. The program is accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs, 222 South Prospect Avenue, Park Ridge, IL 60068-4010, (847)692-7050, a specialized accrediting body recognized by both the United States Department of Education and the Council for Higher Education Accreditation (CHEA). A Certified Registered Nurse Anesthetist directs the program. The program has an academic affiliation with Youngstown State University, One University Plaza, Youngstown, OH 44555, (330)941-3092, which is accredited by North Central Association of Colleges and Schools, 30 N. LaSalle Street, Suite 2400, Chicago, IL 60602-2504, (800)621-7040, and upon successful completion of the program, a Master of Science in Nursing is awarded. Students who have already earned a Master of Science in Nursing from Youngstown State University will not be awarded a second MSN from YSU. All core nursing courses do not need repeated; however, all courses specific to the MSN Nurse Anesthesia track must be successfully completed. Additional clinical experience will be gained during the times classmates are attending class for core nursing courses. Your experience will include the use of many anesthetic agents and techniques. You will have the opportunity to gain experience in major cardiac, thoracic, peripheral vascular, and neurosurgical procedures, as well as general surgery, obstetrics, pediatrics, and outpatient procedures. Constant supervision of all students is maintained by Certified Registered Nurse Anesthetists and/or Staff Anesthesiologists from Bel-Park Anesthesia Associates, Inc. Enclosed is an application form. Please submit the following materials with your application by December 31, 2012: a. Curriculum Vitae (resume) b. Nursing School transcript - sent directly from your School of Nursing c. College transcripts - sent directly from your college(s) d. Letters of recommendation from the director of your school of nursing, your current nursing supervisor or employer, and a personal character reference e. Current A.C.L.S. and P.A.L.S. certification f. Non-refundable application fee of $50.00 made payable to: ST. ELIZABETH HEALTH CENTER SCHOOL FOR NURSE ANESTHETISTS, INC. g. Verification of unencumbered RN licensure (according to State Law) h. GRE scores sent directly to St. Elizabeth Health Center School for Nurse Anesthetists, Inc. i. Copies of specialty certifications

Applicant Letter Page 2 Applicants must have graduated from an approved baccalaureate program of nursing. A minimum of at least one year of experience as a Registered Nurse in an ADULT CRITICAL CARE SETTING during which the Registered Nurse has developed as an independent decisionmaker capable of using and interpreting advanced monitoring techniques based on knowledge of physiological and pharmacological principles is required. Advanced monitoring techniques include but are not limited to: Arterial Lines Swan-Ganz Catheters Ventilators Intravenous Drips for Cardiopulmonary Support The Admissions Committee will review your file based on the following criteria: a. G.P.A. of 3.0 or above on nursing and/or college transcripts preferred b. Satisfactory scores on GRE. c. Quality of recent clinical experience d. Positive letters of recommendation e. Evidence of post-graduate continuing education f. Current A.C.L.S. and P.A.L.S certification g. Acceptance into the graduate program at Youngstown State University h. Personal interview i. CCRN (preferred) j. Current unencumbered nursing license A personal interview is part of the admissions procedure. Applicants who meet admission requirements will be considered for invitation for the personal interview. Applicants with incomplete files will not be reviewed by the committee. If approval for acceptance is granted by the admissions committee and you choose to enter the program, a letter of commitment and non-refundable retainer fee must be submitted. In addition to tuition at the University, a clinical tuition is charged. Tuition, fees, room and board, and health insurance remain the responsibility of the student. Please feel free to contact the School for Nurse Anesthetists if you have any further questions regarding our program. Sincerely, Beverly A. Rodgers, CRNA, M.Ed. Program Administrator Adjunct Professor Youngstown State University BAR:eam Enclosures

St. Elizabeth Health Center School for Nurse Anesthetists, Inc. Academic Affiliation with Youngstown State University APPLICATION FOR ADMISSION Application for the Year Beginning Fall 2013 NAME: Last First Middle ADDRESS: CITY: STATE: ZIP: HOME TELEPHONE: ( ) E-MAIL ADDRESS: MAY WE CONTACT WORK TELEPHONE: ( ) YOU AT WORK: YES NO SOCIAL SECURITY NUMBER: / / R.N. LICENSE(S): STATE YEAR REG. NUMBER R.N. LICENSE(S): STATE YEAR REG. NUMBER Educational Background: SCHOOL NO. OF YEARS YEAR NAME AND LOCATION DEGREE ATTENDED GRADUATED OF SCHOOL High School University Professional Technical Degree Held: Major: Minor: Have you previously been enrolled in a graduate program? Yes No If yes, where, date of graduation, and degree obtained:

When have you taken (or when will you take) the GRE Test? Do you have CCRN? Yes No Submit copy if yes. CLINICAL EXPERIENCE (Begin with Current Employer) Name of Firm Position & Unit Address Employment Dates Reason for leaving Name of Firm Position & Unit Address Employment Dates Reason for leaving Name of Firm Position & Unit Address Employment Dates Reason for leaving WERE YOU EVER DISMISSED FROM A COLLEGE, UNIVERSITY, PROGRAM OF NURSE ANESTHESIA, OR PROFESSIONAL SCHOOL DUE TO DEFICIENCIES IN SCHOLARSHIP OR CONDUCT? YES NO IF YES, PLEASE EXPLAIN: HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO IF YES, PLEASE EXPLAIN:

Please submit an essay clearly stating your philosophy of nursing, reasons for pursuing a career in nurse anesthesia, and your expectations of Master s level education. Also include your career goals, community activities, and memberships in professional organizations. (If typed, please use 12 or larger Font) I CERTIFY THAT: My nursing license has never been revoked, restricted, suspended or limited by any state, and is not a subject of a pending action or investigation. I do not currently suffer from a physical or mental condition which might interfere with the practice of nurse anesthesia. I do not currently suffer from drug or alcohol addiction or abuse. I have not been convicted of and am not currently under indictment for any felony; and I have not been the subject of any documented allegations of misconduct, incompetent practice, or unethical behavior. I CERTIFY THAT: The above answers are true to the best of my knowledge. Any falsification or omissions of this application provides grounds for disqualification or dismissal. DATE: SIGNATURE:

Academic Reference LETTER OF REFERENCE Fall 2013 St. Elizabeth Health Center School for Nurse Anesthetists, Inc. P.O. Box 1790 1044 Belmont Avenue Youngstown, OH 44501-1790 APPLICANT: Please read the paragraph below very carefully and check off either confidential or non-confidential in the appropriate space prior to giving this form to the individual writing the recommendation. This letter of reference must be completed by the director of your school of nursing or a professor and sent to the above address. Name of Applicant: The applicant has chosen this statement be confidential or non-confidential, according to the Family Education Rights and Privacy Act of 1974. Confidential references are prepared for the use of the director of graduate admissions only, and should not be shown to the candidate. Non-confidential references may be viewed by the candidate. The following information will be used in making an evaluation of the applicant s strengths and weaknesses as related to graduate study. Please use additional paper if necessary. 1. In what professional and/or personal capacity and for how long have you known the applicant? 2. How well does the applicant express himself/herself verbally? In written forms? 3. Please comment on the applicant s analytical ability and research skills. 4. Please discuss any special factors in the applicant s background which demonstrate motivation and preparation for graduate work.

5. Please make any additional comments you may have about the applicant s record, personal qualities, academic ability, critical thinking, and ability to apply research findings in clinical practice. Please indicate your evaluation of each of the criteria using the following rating scale: 4 = Excellent 3 = Above average 2 = Average 1 = Below average N/A = Not applicable Criteria 4 3 2 1 N/A A. Clinical Judgment: does the individual Exhibit sound clinical judgment? Exhibit technical competency? Perform well under stress? Adapt well to various types of equipment? Synthesize and apply knowledge to total patient care? Demonstrate initiative? Function well alone? Function well with others? Use consultation advantageously? Follow established policies and procedures? B. Personal Attributes: does the individual Exhibit ethical behavior? Exhibit self-direction? Meet your standards of dependability and punctuality? Assume responsibilities willingly? Exhibit habits of personal hygiene and professional appearance? C. Educational Activities: does the individual Participate in departmental programs? Participate in institutional programs? Contribute to community health programs? Attend professional meetings, lectures, and symposiums? Appreciate the value of continuing education? Please Check One: I strongly recommend I recommend I do not recommend this applicant for admission to graduate study Name Position; relationship to applicant Employer Business Address Signature Date Phone #

Nursing Supervisor Reference LETTER OF REFERENCE Fall 2013 St. Elizabeth Health Center School for Nurse Anesthetists, Inc. P.O. Box 1790 1044 Belmont Avenue Youngstown, OH 44501-1790 APPLICANT: Please read the paragraph below very carefully and check off either confidential or non-confidential in the appropriate space prior to giving this form to the individual writing the recommendation. This letter of reference must be completed by your current nursing supervisor or employer and sent to the above address. Name of Applicant: The applicant has chosen this statement be confidential or non-confidential, according to the Family Education Rights and Privacy Act of 1974. Confidential references are prepared for the use of the director of graduate admissions only, and should not be shown to the candidate. Non-confidential references may be viewed by the candidate. The following information will be used in making an evaluation of the applicant s strengths and weaknesses as related to graduate study. Please use additional paper if necessary. 1. In what professional and/or personal capacity and for how long have you known the applicant? 2. How well does the applicant express himself/herself verbally? In written forms? 3. Please comment on the applicant s analytical ability and research skills. 4. Please discuss any special factors in the applicant s background which demonstrate motivation and preparation for graduate work.

Non-Family Personal Character Reference LETTER OF REFERENCE Fall 2013 St. Elizabeth Health Center School for Nurse Anesthetists, Inc. P.O. Box 1790 1044 Belmont Avenue Youngstown, OH 44501-1790 APPLICANT: Please read the paragraph below very carefully and check off either confidential or non-confidential in the appropriate space prior to giving this form to the individual writing the recommendation. This personal character reference must be completed by a non-family member and sent to the above address. Name of Applicant: The applicant has chosen this statement be confidential or non-confidential, according to the Family Education Rights and Privacy Act of 1974. Confidential references are prepared for the use of the director of graduate admissions only, and should not be shown to the candidate. Non-confidential references may be viewed by the candidate. The following information will be used in making an evaluation of the applicant s strengths and weaknesses as related to graduate study. Please use additional paper if necessary. 1. In what professional and/or personal capacity and for how long have you known the applicant? 2. How well does the applicant express himself/herself verbally? In written forms? 3. Please comment on the applicant s analytical ability and research skills. 4. Please discuss any special factors in the applicant s background which demonstrate motivation and preparation for graduate work.