HRHCare Family Nurse Practitioner Residency Training Program Application

Transcription

1 HRHCare Family Nurse Practitioner Residency Training Program Alication HRHCare of Peekskill, New York, is leased to announce that it is acceting alications for the Family Nurse Practitioner Residency Program with a focus on rural/migrant health. The class of will begin in Setember Alication deadline is May 31, HRHCare is committed to leadershi, transformation, and innovation in health care. This residency is designed for new nurse ractitioners with a commitment to develoing career ractices in the challenging setting of the FQHC and/or secial oulations. There is a one-year emloyment commitment after comletion of the rogram. The Family Nurse Practitioner Residency Program has the following three goals: Preares Nurse Practitioners to assume full resonsibility for rimary care of comlex underserved oulations across all life cycles and in multile settings, but focusing on rural communities and migrant workers Building uon the education and ractice base acquired in the educational rogram leading to certification as a Nurse Practitioner, the residency will develo the clinical and oerational confidence necessary for efficient, effective and roductive ractice as a member of the health care team in a FQHC Increase the number of Nurse Practitioners choosing to build long-term careers in FQHCs, and their caability for leadershi ositions within those organizations and within the healthcare system of the future Alication Requirements: 1. All alicants are required to fill out the attached HRHCare Alication for Family Nurse Practitioners. All Personal Statement Questions found at the end of attached alication (# 1-4) must be comleted for consideration. 2. Current CV 3. Three letters of recommendation. Letters should be from any of the following individuals; Graduate Program Director (1), Clinical Precetor (2), and Manager from a current or revious osition (3). All letters of recommendation MUST be on formal letterhead. As one of, or in addition to the three letters of recommendation that you will be sulying with the alication, lease submit at least one letter that secifically addresses your caabilities and interests related to this Residency Program focused on rural/migrant health. For more information, lease contact nresidency@hrhcare.org hrhcare.org

2 Alication Requirements: HRHCare Family Nurse Practitioner Residency Training Program Alication Tye or legibly rint all resonses and comlete the alication in its entirety. COMPLETE ADDRESS AND TELEPHONE NUMBERS ARE REQUIRED WHERE INDICATED. ALL DATES MUST BE INCLUSIVE (MONTH & YEAR). All questions must be answered and you may not indicate SEE CV, etc., for a resonse. If a question is not alicable note N/A. Attach additional sheets if there is insufficient sace on the alication for your resonse. As indicated by the below, current coies of the following documents must accomany your alication. Please make sure all coies are legible. CV with MONTH & YEAR for WORK & EDUCATION history sections CV must show a five (5) year work history MONTH & YEAR format If alicable, written and signed exlanation of any gas in work history over three (3) months Coy of New York RN license Coy of New York APRN license Coies of license(s) from any other state Federal DEA certificate ANCC/AANP certification or evidence of eligibility for certification Coy of driver s license Professional diloma (BSN, MSN) AND official graduate school transcrits Three (3) letters of recommendation from rofessional references (suervisor, rogram director, chairman of deartment, CMO). If alicable, non U.S. residents must rovide a coy of their ermanent resident card/visa/roof of eligibility to work in U.S. Electronic alications should be ed to nresidency@hrhcare.org. Simly download the PDF, comlete all fields, save, and attach to the . Alication deadline is May 31, Licensure and credentialing materials (i.e. Board Certification, NY licenses, and DEA license) are not required when alying, simly write ending. They are required rior to the start of residency on Setember 5, 2018.

3 General Information Please comlete all relevant fields. First Name Middle Name Last Name Suffix Contact Address Cell Phone Home Phone Gender: Male: Female: Birth Date: Birth Place: Social Security: NPI: Ethnicity (otional): Home Address Please enter your home address in full. Home Address Line 1: Home Address Line 2: City: State: Zi: Other Names Please enter any other names by which you have been known (including those aearing on rofessional diloma and licensure.) Other First Name Other Middle Name Other Last Name From Date (mm/yy) To Date (mm/yy) Other First Name Other Middle Name Other Last Name From Date (mm/yy) To Date (mm/yy) For Non U.S. Citizens Please rovide information on your immigration status. Country or Citizenshi Visa Visa Number Visa Date Language(s) Please list all non-english languages soken and level of fluency. Language 1: Language 2: Language 3: Fluency: Fluency: Fluency:

4 Education List undergraduate, graduate and rofessional education below. Education Tye: Degree Earned: Institution Name: Address Line 1: Address Line 2: City: State: Zi: Phone: From (mm/yy): Fax: To: (mm/yy): Country: Education Tye: Degree Earned: Institution Name: Address Line 1: Address Line 2: City: State: Zi: Phone: From (mm/yy): Fax: To: (mm/yy): Country: Education Tye: Degree Earned: Institution Name: Address Line 1: Address Line 2: City: State: Zi: Phone: From (mm/yy): Fax: To: (mm/yy): Country:

5 Professional References Please list the names and addresses of three rofessional references (I.E. rogram director, direct suervisor, medical director, CMO) who can attest to your clinical cometence currently and over the ast three to five years. Professional Reference Name: Institution/Relationshi: Address Line 1: Address Line 2: Years Known: Secialty: From: / To: / City: State: Zi: Contact Phone: Fax: Professional Reference Name: Institution/Relationshi: Address Line 1: Address Line 2: Years Known: Secialty: From: / To: / City: State: Zi: Contact Phone: Fax: Professional Reference Name: Institution/Relationshi: Address Line 1: Address Line 2: Years Known: Secialty: From: / To: / City: State: Zi: Contact Phone: Fax:

6 Alication Attestation I attest that all information rovided in this Alication is true and comlete to the best of my knowledge and belief. I will notify the Organizations and/or their agents within 10 days of any material changes to the information I have rovided in my alication or authorized to be released ursuant to the credentialing rocess. I understand that corrections to the alication are ermitted at any time rior to a determination of membershi and/or rivileges or affiliation by the Organizations, and must be submitted on-line or in writing, and must be dated and signed by me. Electronic Signature Tye full name Last 4 digits of SSN Date

7 Personal Statement Questions - Personal Statement question #1 of 4 (All four of the following questions are required for comletion of this alication).

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