APPLICATION FORM Please fill in all the information requested in this application form and please print clearly. Please indicate below which critical care stream you are applying for: Adult Pediatric/Neonatal Please indicate below the sponsoring institution. Applicants sponsored by the Critical Care Manager from a Community Site are pre-assigned to a tertiary institution for lab and clinical. St. Boniface Hospital Concordia Hospital Victoria General Hospital Health Sciences Centre IICU (Health Sciences Centre) Grace Hospital Seven Oaks General Hospital PART A - PERSONAL INFORMATION: Surname Given Name(s) Maiden Name Mailing Address City Province Postal Code Home Phone (include area code) Cell Phone (include area code) Work Phone (include area code) Email Address (personal): Birth date SIN # Current CRNM # (include photocopy) (day / month / year) Emergency Contact Person (relationship): Home Phone (include area code) Cell Phone (include area code) Work Phone (include area code) I declare the information to be true and complete to the best of my knowledge. Withholding information may result in my dismissal from the program at any time. If accepted, I agree to abide by the policies, procedures and working conditions established by the St. Boniface Hospital and Health Sciences Centre. I hereby authorize the St. Boniface Hospital and Health Sciences Centre to conduct a personal investigation including contacting previous employers in connection with my application to the program. Signature of applicant: Date: WCCNEP Application Form page 1
APPLICATION PROCEDURE CHECKLIST: MAILING ADDRESS: Winnipeg Critical Care Nursing Education Program (WCCNEP) c/o Health Sciences Centre Room GF201 820 Sherbrook Street Winnipeg, Manitoba R3A 1R9 Send the following information to the above mailing address: Completed WCCNEP Application Form along with the following: CRNM Registration A photocopy of your current College of Registered Nurses of Manitoba (CRNM) registration. Social Insurance Number: If SIN starts with a 9, a photocopy of both the SIN card AND work permit MUST be attached. If you are NOT an employee of Health Sciences Centre or St Boniface Hospital, you MUST provide us with the following: o photocopy of your most recent paystub o voided cheque o complete a TD1 (Personal Tax Credit Return) and a TD1MB (Manitoba Personal Tax Credit Return) * available on website www.cra-arc.gc.ca WCCNEP Rhythm Course If you have successfully completed the rhythm course, please provide a photocopy of certificate of successful completion. Starting September 2016 this course will be a pre-requisite for the WCCNEP. Basic Life Support - Applicants must present proof of having successfully completed a Basic Life Support (BLS) - Heart & Stroke Foundation of Canada - Health Care Provider (Level C). It is the applicant s responsibility to ensure that he/she has current registration. A photocopy of current registration/renewal must be submitted with the application form or prior to acceptance to the program. If you do not have current registration/renewal, please arrange to enrol in a Basic Life Support (BLS) - Heart & Stroke Foundation of Canada - Health Care Provider (Level C). Registration/Renewal must remain current for the entire program. Advanced Cardiac Life Support (ACLS) Not required, however If you have current ACLS registration, please provide a photocopy of successful completion with the application form or prior to acceptance to the program. Immunization Record Form Applicants MUST update their immunizations. A photocopy of proof of immunizations must be submitted with the application form or prior to acceptance to the program. Fit Test Card Applicants MUST have current N95 respirator fit testing. A photocopy of fit test card must be submitted with the application form or prior to acceptance to the program. If you have not been fit tested in the past year, please contact Occupational Health & Safety at your site to book an appointment. Arrange for the following to be submitted directly to the above address by the application deadline: Arrange to have your Reference Form to Support Application completed by your current or most recent supervisor. This must be forwarded DIRECTLY to the applicable address by your supervisor or it will not be accepted. NOTE: We are not responsible for any original documentation enclosed with your application. You will be contacted by the WCCNEP office for an interview. Your file will be reviewed. If accepted, you will receive an email to confirm acceptance to the Winnipeg Critical Care Nursing Education Program. WCCNEP Application Form page 2
PART B - ACADEMIC INFORMATION: List below only those programs that have been completed. Formal Education Completed Diploma of Nursing Institution Name & Address Site & Unit Senior Experience completed Graduating Year GPA/ Average Undergraduate Degree in Nursing Site & Unit Senior Experience completed Undergraduate Degree (other) specify Faculty Masters specify Faculty Certificate - specify List below any university/college courses** taken (and not applied toward a university/college degree listed in the previous table). The university/college course(s) must have been taken before or after your basic nursing education (ie. Diploma in Nursing Certificate or Baccalaureate Nursing Degree). Those courses such as Introductory Psychology, Introductory Sociology, or Anatomy and Physiology, that were needed to complete your basic nursing certificate or degree, are not to be included in this table. List University/College Courses taken Institution Name & Address Credit Hours Grade Year WCCNEP Application Form page 3
PART C - CONTINUING EDUCATION: List courses, workshops, seminars, conferences, etc. for the last five years. Course Advanced Cardiac Life Support (ACLS, PALS) Trauma Nursing Core Course (TNCC) Institution / Person providing workshop, seminar, course, conference Length in hours Date Taken Emergency Nursing Course ECG Monitoring Course Workshop, Seminar, Conference PART D - OTHER INFORMATION: Please describe any volunteer activities, awards, professional association membership, committee participation, etc. WCCNEP Application Form page 4
INSTRUCTIONS FOR COMPLETING THE EMPLOYMENT RECORD FORM - Please use the codes (on the next page) when completing the Employment Record Form. PART E - EMPLOYMENT RECORD This form must be completed. A resume will not be accepted as a substitute. EMPLOYMENT HOURS and employment category. List number of hours worked in each of the following categories: 1. PLACE OF EMPLOYMENT (Address) Please list all your nursing experience from the last seven years in order beginning with the last position. 2. Employment Code (indicate T, COM, RUR, etc.) 3. EFT 4. Dates Start Date End Date 5. Rotation 6. ICU 7. Telemetry/ Monitored Unit 8. ER 9. Peds 10. Acute Care Med/Surg / Float 11. OTHER (please be specific) REASON FOR LEAVING Total hours (columns 6 to 10) WCCNEP Application Form page 5
INSTRUCTIONS FOR COMPLETING EMPLOYMENT RECORD Please use the following codes when completing the Employment Record Form. 2. EMPLOYMENT CODE T = Tertiary Centre a teaching centre within a large city (e.g. St. Boniface Hospital or Health Sciences Centre) COM = Community Hospital a centre within a large city (e.g. Concordia Hospital, Misericordia General Hospital, etc.) RUR = Rural Hospital a centre outside the city (e.g. outside the perimeter of the City of Winnipeg) LTC/PCH = Care Facility where the patient population is dependent on health care providers AG = Nursing employment agency (e.g. Drake Medox, Olsten Kimberley, etc.) in which nurses work in a variety of settings that include hospitals and patients homes. 3. EFT 4. DATE OF EMPLOYMENT STARTED AND ENDED 5. ROTATION D12 = 12 hour day shift only N12 = 12 hour night shift only DN12 = 12 hour day and night shift D8 = 8 hour day shift only E8 = 8 hour evening shift only N8 = 8 hour night shift only DE8 = 8 hour day and evening shift DN8 = 8 hour day and night shift NE8 = 8 hour night and evening shift CAS = Casual EXPLANATION OF CODING FOR HOURS AND EMPLOYMENT CATEGORIES 6. ICU = An intensive care unit (ICU) where patient monitoring (ECG) is common practice. The ICU must be able to care for mechanically ventilated patients. 7. Telemetry/Monitored Unit = An acute care unit with a minimum of ECG Monitoring/Telemetry. Indicate the type of unit. 8. ER = Emergency Room. 9. Peds = A pediatric and neonatal intensive care unit. 10. Acute Care Med/Surg / Float = An adult acute care medical/surgical unit. 11. Other = The following is a partial list of practice areas that would be included in the Other category: Rehabilitation, Geriatrics, Psychiatry, Community Health, Long Term Care. * When completing this column, please indicate the specific unit. WCCNEP Application Form page 6