2015 ABSN Application - California State University, Northridge

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CALIFONIA STATE UNIVERSITY, NORTHRIDGE
(A-BSN) ACCELERATED PROGRAM APPLICATION
DEADLINE NOVEMBER 30, 2014
Directions:
1. ATTENTION: Application to the nursing program requires the completion of the application to the
University and the application to the Department of Nursing. Admission to the nursing program is
contingent on receiving an acceptance letter form the Department of Nursing:
a. California State University Northridge online application is available by accessing:
www.csumentor.org. Available October 1 to November 30
b. The Department of Nursing application, see below, is due no later than November 30th
(postmarked)
2. Please make sure that all items on the checklist are delivered in a single packet to avoid delays in processing
your application.
Mail your application before or by the due date to:
Attention: Accelerated BSN Program
Department of Nursing, Jacaranda Hall 2210
18111 Nordhoff Street.
Northridge, CA 91330-8285
California State University, Northridge
3. Late and incomplete applications will not be accepted. Use the list below to ensure all documents are
included and submitted.
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2015 ACCELERATED BSN (A-BSN) PROGRAM
CHECKLIST FORM
Last Name
First Name
Middle Initial
Email Address
_____
Checklist form (this form)
_____
Personal information (included)
_____
Completed prerequisites checklist (included)
_____
Signed and dated Statement of Health Clearance (included)
_____
Signed and dated Self-Disclosure of Scheduling Availability form (included)
_____
Resume / CV
_____
Personal Essay (1-2 page, double spaced essay describing background, professional goal. Refer to questions 1-6 as reference)
_____
Three (3) letters of recommendation using official recommendation form (included)
_____
OFFICIAL transcripts verifying completion of Baccalaureate Degree.
_____
Courses in process to be completed in Fall 2014, must submit transcripts ASAP once grades have been posted (deadline 2/10)
_____
Foreign Graduate MUST submit an EVALUATED transcript. A copy is needed for both Nursing and Admissions & Records
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2015 ACCELERATED BSN (A-BSN) PROGRAM
PERSONAL INFORMATION FORM
I am applying for (check one):
___2015 Summer Entry
Personal Information (Please type or print clearly)
Name:
Address:
City:
State:
Zip:
California Resident? (Please circle)
Yes
No
Emergency Contact:
Phone#:
or
___2015 Fall Entry
Phone #:
Email Address:
Educational Background (List all institutions since high school)
School Name
Dates Attended
Have you previously applied to the CSUN Nursing program?
Diploma/Degree
No
Yes
Date Awarded
If yes, when? ___________
MILITARY INFORMATION:
Have you ever been on active duty in the U.S. military service?
an active duty member or a veteran of the U.S. armed forces.
Yes
No If Yes, please indicate whether you are currently
Active Duty Member
Veteran
If you select “Yes”, submit a copy of your DD214 or DD295 with this application.
Experiential Background (start with most recent)
Organization
Position Title
Specialty/Duties
Recommendations (3 are required) Name
Dates of Employment
Title
Reason for Leaving
Organization
COMPUTER SKILLS
Use email?
Internet skills? (Circle)
**You are expected to have these computer skills in the graduate program.
Proficient
Some Difficulty
None
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VOLUNTEER EXPERIENCE/Certification (Must submit documentation to validate)
Prefer 60 hours of patient care experience in a clinical setting, completed within 24 months prior to submitting your application.
Yes ____ No _____ number of hours completed: _______ documentation included? Yes _____ No _____
Institution Name/Location: ___________________________________________________________________
Explain volunteering responsibilities/duties: ________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Completed Clinical Certification? Yes: _____ No: _____
Certification
CNA Certificate
Date Completed
EMT Certificate
Other Certificate (specify):
PERSONAL ESSAY/QUESTIONNAIRE
Not to exceed 1-2 page double-spaced
Address the following questions in essay format:
1.
Describe the event or time in your life that you made a decision to pursue a career in nursing.
2.
What are your strengths in your background that will assist you as you serve the population who seek out medical care?
3.
What attributes can you bring to the program that will benefit your fellow students?
4.
Due to the time commitment for the 15 months, how do you plan to commit yourself
5.
Once you have completed your BSN, are you planning to pursue an advanced degree, if so, in what area of expertise?
6.
Have you researched the opportunities in the nursing field? If so, where do you see yourself 10 years from now?
to this intense program?
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PREREQUISITE CHECKLIST
Complete all items below based on your transcripts from EVERY school attended.
Applicant name ______________________________________________________________________
SCIENCE COURSES MUST HAVE BEEN COMPLETED AFTER SPRING 2008
Required Courses
** MUST HAVE BEEN COMPLETED WITHIN
(7) SEVEN YEARS PRIOR TO ADMISSION
EXAMPLE:
Nursing Core/Prerequisite Requirements:
Human Anatomy w/Lab**
BIO 211/212-CSUN
(3-4 Units)
Microbiology w/Lab**
BIOL 215/L –CSUN
(2/1 Units)
Human Physiology w/Lab**
BIOL 281/282-CSUN
(3/1units)
General Chemistry w/Lab**
CHEM 103-CSUN
(4 units)
Basic statistics
(3 units)
Grade
Units
A
3
Date
Completed
(Or “IP” if
in process)
FA12
Course #
HSC 123
Educational
Institution
CSUN
Critical Thinking
Oral Communication
Written Communication
DEADLINE- POST MARKED BY NOVEMBER 30
Complete Application packet must be postmarked by November 30th or delivered in person to the
Department of Nursing, Jacaranda Hall 2210 office no later than Friday, November 29th
LATE APPLICATIONS WILL NOT BE ACCEPTED. NO EXCEPTIONS.
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A-BSN APPLICANT RECOMMENDATION FORM
TO THE APPLICANT: This section must be completed before sending to recommender.
WAIVER OF ACCESS TO CONFIDENTIAL REFERENCES
In accordance with Family Education Rights and Privacy Acts of 1974 (Public Law 93-380), I
understand that at my option, I may waive the right to review this letter of recommendation.
(Please check your choice below.)
I waive my right to inspect this letter
I do NOT waive my right to inspect this letter
Applicant’s Name____________________________________________
Address____________________________________________________
Signature __________________________________________________
If you do not check one of the above actions or do not authorize this waiver by signature, then
the program will assume you have not waived access.
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TO THE RECOMMENDER:
Name (please print) ___________________________________________ Date____________
How well do you know the candidate:
Very well
fairly well
slightly
How long have you known the applicant? __________________________
Relationship to applicant?
Advisor
Professor
Employer
Physician
Other _____
Please refer to the following table and indicate your impression of this applicant regarding the following factors:
Applicant Characteristics
Critical Thinking: effective problem-solving & decision-making
taking into account available information
Communication: Oral expression
Communication: Written expression
Interpersonal Relations: ability to get along with others, rapport,
cooperation
Integrity: ethical standards, honesty, trustworthiness
Advocacy: Represents the needs of others effectively
Life long learner: Seeks personal learning opportunities
Respect for others: Collaborates, respects values & beliefs of others, &
culturally sensitive
Competence: Quality of work is consistently accurate, thorough &
timely.
Motivation: genuineness and depth of commitment.
Maturity: personal development, accepts constructive criticism and
demonstrates good judgment
Perseverance: commitment to finishing difficult tasks
Empathy: sensitivity to needs of others
Resourcefulness: demonstrates skillful management of available
resources.
Creativity: demonstrates originality
Ability to organize work: Reliable and prompt
Collaboration: Exhibits teamwork and works well with peers and
upper management.
Self-Confidence: assuredness, capacity to achieve with awareness of
own strengths and weaknesses
Outstanding
Very
Good
Good
Average
Poor
Unable
to Judge
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*Questions may be addressed on a separate sheet.
1.
Are there any circumstances, which you think might affect this candidate’s ability to complete an academically rigorous
Yes
No
If Yes, please explain:
nursing program?
2.
Considering this candidate’s interests, work habits, personality, and career goals. Does this person display the moral and
Yes
No Additional Comments:
ethical attributes necessary to be a health care professional?
3.
Please discuss the characteristics of the applicant that you feel will make him/her a competitive candidate for our professional
program.
This applicant receives my highest recommendation
I recommend this applicant with confidence.
I recommend this applicant.
I recommend this applicant with some reservations.
I would not recommend this candidate for admission.
RECOMMENDER:
Signature ________________________________________________________
Title/Occupation __________________________________________________
Institution ________________________________________________________
Address _________________________________________________________
City _____________________________ State _____________ Zip __________
Telephone (______) _____________________________________
RETURN THIS FORM IN A SEALED ENVELOPE TO APPLICANT. THANK YOU.
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CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
DEPARTMENT OF NURSING ABSN PROGRAM
CLASS AND CLINICAL TIME SCHEDULING
SELF-DISCLOSURE OF AVAILABILITY
For admission to and progression in the CSUN pre-licensure A-BSN pathway, all students must be able to
attend classes and clinical training as scheduled each semester. Clinical training is offered on any of the
seven days of the week and during any portion of these days as negotiated with and as offered by the
clinical agencies. The Nursing Program must schedule clinical times in collaboration with clinical agencies.
The clinical agencies are constrained by patient census, presence of other students in their facility, and other
variables not under the control of the University.
Students are required to obtain and maintain at their sole cost the following clinical requirements: health exams
and immunizations, evidence of TB test, titers or other required tests, background check, drug screening,
nursing liability insurance, CPR certification, fire safety card, HIPPA and Blood Borne Pathogen training, and
any other requirements deemed necessary by the clinical agencies.
Students must complete a pre-clinical checklist and provide proof that requirements are met 4 weeks prior to the
start of their first clinical course. If an affiliating clinical agency notifies faculty that they are refusing clinical
placement to a student based on background check or drug screen, the student will be unable to complete
required clinical laboratory coursework, be unable to progress in the program and thus be unable to meet
Degree requirements.
Scheduled clinical dates, times and hours cannot be modified to meet students’ personal needs. Clinical
rotations may however change each academic semester or year according to changes in clinical agencies’
schedule.
Students are required to demonstrate professional maturity and physical, emotional, ethical and moral fitness for
clinical practice.
Student must be able to provide transportation to CSUN and to the various clinical sites assigned for the clinical
rotation.
I certify that I have read, understood, and agree to the above statements and I certify that I am able to meet
classes and clinical assignments during any of the seven days of the week and during any time of day. I
understand that if for any reason I choose not to sign, date and submit this form, and then my application for the
A-BSN track cannot be considered.
Signature
Date
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DEPARTMENT OF NURSING
STATEMENT OF HEALTH CLEARANCE
STATEMENT OF PHYSICIAN OR HEALTHCARE PROVIDER:
I hereby certify that _______________________________ was examined by me on
_______________, 20 ____, and was found to be fit to function in a nursing program, without limitations or
accommodations related to:
(Please circle area that is applicable)
Lifting patients
Yes
No, needs accommodations
Pulling patients
Yes
No, needs accommodations
Turning patients
Yes
No, needs accommodations
Physical mobility
Yes
No, needs accommodations
Pushing heavy medical equipment
Yes
No, needs accommodations
Mental disability
Yes
No, needs accommodations
If you answered “No, needs accommodations” to any of the above, please explain.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________
Signature of Physician or Healthcare Provider
____________________________________
Stamp of Physician or Healthcare Provider

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