Capella University NHS Doctoral Capstone DNP/DrPH/DHA 9971 Capella University

Capella University NHS Doctoral Capstone DNP/DrPH/DHA 9971 Capella University NHS Capstone Project Application Checklist NHS Practicum Contact Data Form NHS Learner Practicum Application NHS Learner Site Application NHS Practicum Preceptor Application NHS DPP Form (Part I completed) Preceptor CV/ Résumé Learner CV/ Résumé NHS Practice Access Agreement or verification of Site Affiliation Agreement V1 January 2017

NHS Practicum Contact Data Form Learner Contact Information Name Address Email Address - Capella Email Address secondary (personal) Telephone (xxx)xxx-xxxx Time zone Employer Preceptor Information Preceptor s Name Preceptor s Credentials Highest degree in nursing (DNP Mentors only) Highest academic degree and field of study Preceptor s Position Email Address Telephone Time zone Agency Name and Address Capella affiliation? Yes/No Explain *Preceptor may not be a current Capella learner. Is preceptor direct supervisor to learner? *Preceptor may not be a direct supervisor to learner. Site Information Name Address MINNEAPOLIS, MN 55402-3389 I 1.888.CAPELLA (227.3552) I WWW.CAPELLA.EDU

NHS Practicum Learner Application Complete this form and include in it as part of your NHS application packet, which will be submitted to your mentor in DNP/DrPH/DHA 9971. Only complete packets will be accepted for review. NAME LEARNER ID STREET ADDRESS, CITY, STATE, ZIP PRIMARY PHONE SECONDARY PHONE EMAIL (this email address should be the primary email address on file with Capella) OF APPLICATION It is understood that the site and preceptor will remain the same unless otherwise noted by the learner. If at any time either should change, it is your responsibility to notify your Capstone Mentor within 3 business days. Practicum hours will not be accrued unless under the direction of an approved preceptor. For DNP Learners Only - It is also understood that an unrestricted registered nurse s license is required for this experience in the state where the practice experience will take place. If for any reason the status of this nursing license changes during the course of the practice experience, Capella University is to be notified within three (3) business days of the status change. Your complete application will be submitted in your first DNP/DrPH/DHA 9971 Doctoral Capstone course in your program. The chosen preceptor and practice plan will be subject to your Capstone Mentor s review and changes could be necessary. Please note: learners will be required to submit their project to the Capella IRB and any required institutional committees prior to gathering data or initiating their doctoral capstone project in the practice setting. MINNEAPOLIS, MN 55402-3389 I 1.888.CAPELLA (227.3552) I WWW.CAPELLA.EDU

NHS Learner: Site Application Form Complete this form and include in it as part of your NHS application packet, which will be submitted to your Capstone Mentor in DNP/DrPH/DHA 9971. Only complete packets will be accepted for review. LEARNER NAME As a Doctoral Capstone learner, it is your responsibility to match the practicum experience with your overall goals for Capstone Project. It is important that you choose a preceptor who can assist you in meeting these goals. All placements are subject to approval by your Capstone Mentor and School Reviewer. PRECEPTOR NAME PRECEPTOR TITLE PRECEPTOR CREDENTIALS PRECEPTOR PHONE PRECEPTOR EMAIL PRACTICE SITE ORGANIZATION NAME PRACTICE SITE ORGANIZATION PHONE PRACTICE SITE ORGANIZATION ADDRESS For what reasons have you selected this individual to supervise your practicum? How will this preceptor serve to foster your overall practicum experience? Is the individual you have selected your immediate supervisor, boss, or manager? yes no LEARNER SIGNATURE MINNEAPOLIS, MN 55402-3389 I 1.888.CAPELLA (227.3552) I WWW.CAPELLA.EDU

NHS Practicum Preceptor Application Complete this form and include in it as part of your NHS application packet, which will be submitted to your Captsone Mentor in DNP/DrPH/DHA 9971. Only complete packets will be accepted for review. LEARNER NAME Preceptor Contact information: PRECEPTOR NAME PRECEPTOR POSITION SITE ADDRESS PRECEPTOR PHONE PRECEPTOR EMAIL Note: Your CV/resume must be included to complete this preceptor application. Highest degree earned (indicate academic discipline): Current licenses/certification: Are you authorized to approve practice experiences within your organization? yes no If the answer is no, please indicate the name of the administrator within your organization who is authorized to approve field experiences. NAME POSITION PHONE EMAIL Are you the immediate supervisor, boss, or administrator for the learner applicant? yes no PRECEPTOR SIGNATURE MINNEAPOLIS, MN 55402-3389 I 1.888.CAPELLA (227.3552) I WWW.CAPELLA.EDU

SoNHS Practice Access Agreement Instructions Read this agreement carefully. Print a copy, sign it, and obtain the necessary signatures as indicated on page 3. Fill in all blanks if any area is left blank, the agreement will not be valid. Include this form as part of your Practice Immersion/Practicum application packet and submit it as part of your CORE ELMS requirements. Purpose of Agreement This agreement is established between Capella University (hereafter referred to as Capella or Capella University ),, (hereafter referred to as the SoNHS learner ), and (hereafter referred to as the site ) for the purpose of establishing guidelines for the cooperative provision of practice within health care settings for learners enrolled in a Capella University School of Nursing and Health Sciences (SoNHS) degree program. General Provisions Definitions: A. Practice Immersion/Practicum consists of defined activities required for completion of the SoNHS learner s course of study. This experience gives the SoNHS learner the opportunity to practice skills and utilize the competencies necessary for degree completion. B. University supervisor is the instructor serving the SoNHS learner for course work in which he/she is enrolled simultaneously during the practice immersion/practicum experience. The university supervisor serves as a liaison with the preceptor and with the site for practice coordination. C. The preceptor is the cooperating site employee who provides supervision to the SoNHS learner. D. The SoNHS learner, as the term is used in this agreement, is a learner enrolled in a School of Nursing and Health Sciences degree program at Capella University. ACCREDITATION: Capella University is an online university based in Minneapolis, Minnesota. Since 1997, Capella has been accredited by The Higher Learning Commission and is a member of the North Central Association of Colleges and Schools (NCA), www.ncahlc.org. CAPELLA UNIVERSITY: Capella Tower, 225 South Sixth Street, Ninth Floor, Minneapolis, MN 55402, 1.888.Capella (227.3552), www.capella.edu. The parties mutually acknowledge and agree as follows: A. Each party to this agreement agrees to hold the other parties harmless for any losses, injuries or other damages incurred as a result of activity undertaken pursuant to the practice immersion/practicum experience described herein. It is recognized that this waiver of liability does not in any way affect the rights to remediation afforded under any policy of insurance. The SoNHS learner understands that he/she is expected to obtain and maintain his/her own personal professional liability (malpractice) insurance at the $1,000,000 incidental and $3,000,000 aggregate levels for the full duration of his/her practice immersion/practicum experience. SoNHS learner also agrees to provide the preceptor with a copy of the personal professional liability insurance policy, as requested. B. To exchange all information needed for review and approval of the SoNHS learner outcomes, professional activities and experiences linked to the SoNHS practice immersion. In addition all professional materials that are necessary for participation and evaluation of the practice immersion/practicum experience are to be completed and provided in a timely manner. C. Capella, in cooperation with the site, will be permitted to contact the site for the purpose of obtaining agreement of the site s employed professional(s) to serve as preceptor(s). The preceptor shall provide supervision of the activities performed by the SoNHS learner. D. Data collection, if applicable and related activities will begin only upon approval of the practice objectives and proposal by an assigned university supervisor. E. The site has the authority to terminate a SoNHS learner s practice immersion/practicum experience for cause, including violation of site rules of professional conduct by the SoNHS learner. F. All communication should be sent to the university supervisor directly using the contact information provided. MINNEAPOLIS, MN 55402-3389 1.888.CAPELLA (227.3552) WWW.CAPELLA.EDU SoNHS PRACTICE ACCESS AGREEMENT 1/3

SoNHS Practice Access Form Responsibilities Capella University agrees: 1. To review and approve all practice immersion/practicum experiences and related objectives prior to the start of any practice immersion/practicum activities at the site. 2. To prepare SoNHS learners for practice immersion/practicum by means of course work designed to familiarize them with methods and protocol for a practice experience. 3. To assign a Capella University supervisor to facilitate communication between the university, the SoNHS learner, and the preceptor. 4. To provide the preceptor the following materials: A copy of the agreement between the learner, site, preceptor, and Capella University. All evaluation forms required at the end of the supervised practice immersion/practicum experience. Contact information for the university supervisor. 5. To assign each SoNHS learner to a university supervisor/ mentor in each course. Preceptor agrees: 1. The preceptor will notify Capella University within three (3) business days if he or she becomes aware of any status change to the learner s registered nurse s license during the practice experience. 2. To maintain regular communication with the university supervisor, including any concerns in a timely manner. 3. To provide necessary paperwork and evaluation forms on time. 4. To maintain regular contact with the university supervisor, to consist of at least electronic contact at the beginning, middle, and end of the practice immersion experience. 5. To notify the SoNHS learner that he/she is responsible for complying with all policies and procedures governing practice learners at the site, and that he/she is required to conduct him/herself according to the professional and ethical standards of a health care professional. 6. To provide immediate consultation with the university supervisor should disagreements arise with the SoNHS learner (acknowledging that the preceptor has primary authority for all activities of the practice learner at the site). 7. To notify the university supervisor immediately if there are any changes to the agreement including dates, hours, supervision, etc. The Site agrees: 1. To verify the chosen preceptor(s) has the appropriate credentials, time, and commitment to supervise the SoNHS learner. 2. To provide opportunities for the SoNHS learner to engage in activities necessary to complete the SoNHS practice immersion/practicum experience. 3. To provide the SoNHS learner with adequate workspace to carry out the practice immersion/practicum. The Learner agrees: 1. To immediately notify the university supervisor of any changes to the practice immersion agreement, including dates, hours, supervision, etc. 2. To abide by Capella University learner Code of Conduct (policy 4.02.02) and all appropriate protocols relating to their practice immersion/practicum. 3. To conduct oneself according to community standards as a health care professional at all times during the practice immersion/practicum experience, and to adhere to the rules, policies, regulations, and standards of the site. 4 To notify the preceptor(s) and the university supervisor of any relevant impairment of competence to perform as expected during the practice immersion/practicum, whether the impairment arises from physical, psychological, or other causes. 5. To obtain any additional training deemed necessary by the preceptor(s), Capella University SoNHS faculty, or the university supervisor, in order to conduct the activities at a minimum standard of competence. 6. To represent oneself as a SoNHS learner at appropriate times during the practice immersion/practicum placement. 7. To submit his/her project to the Capella IRB and any required institutional committees prior to gathering data or initiating the capstone project in the practice setting (SoNHS doctoral learners only). 8. That a current, unrestricted registered nurse s license is a requirement for participating in the MSN or DNP program. If for any reason the status of the registered nurse s license changes, notification will be made to Capella University within three (3) business days. MINNEAPOLIS, MN 55402-3389 1.888.CAPELLA (227.3552) WWW.CAPELLA.EDU SoNHS PRACTICE ACCESS AGREEMENT 2/3

SoNHS Practice Access Form Term of the Agreement This agreement shall be effective from / / to / /, and may be extended through the mutual agreement of the parties. Waiver of Liability Each party to this agreement agrees to hold the other parties harmless for any losses, injuries, or other damages incurred as a result of activity undertaken pursuant to the practice immersion/practicum described herein. It is recognized that this waiver of liability does not in any way affect the rights to remediation afforded under any policy of insurance. Waiver of Rights under the Family Education Rights and Privacy Act (FERPA) The parties understand that all activities are undertaken as an educational experience required for completion of DNP learner s program of study at Capella University. As such, proper evaluation of performance and development is required. The SoNHS learner agrees that it is necessary for the university supervisor and preceptor to openly communicate regarding the SoNHS learner s activities, competencies, and other matters relating to the practice immersion. The SoNHS learner agrees to this communication and waives any rights as they pertain to FERPA restricting this exchange of information. Right to Counsel In executing this agreement, each party acknowledges that they have read the document and have had the opportunity to consult with legal counsel. Jurisdiction and Venue This agreement shall be subject to the laws of the state of Minnesota and all action in relation to the terms hereunder shall be venued in the Federal district Court located in Hennepin County, Minnesota. Severability Any portion of this agreement that is deemed to be unenforceable may be severed from the agreement with the effect of the remaining portions of the agreement being fully enforceable by the parties. Entire Agreement This agreement reflects the entire agreement between the parties and supersedes all other agreements, whether oral or written. No part of this agreement may be amended except by written agreement signed by the parties. Execution This agreement may be executed in counterparts and via facsimile/email with each part being considered an original and all parts being recognized as one and the same document. Executed this day of, 20. Signature Page Preceptor Agreement I,, the preceptor assigned to this learner, agree to provide professional supervision for this practice immersion/practicum experience. I agree to submit all required forms by the end of the quarter in which the practice immersion/ practicum is completed. Signatures LEARNER SIGNATURE PRECEPTOR SIGNATURE CAPELLA UNIVERSITY SUPERVISOR MINNEAPOLIS, MN 55402-3389 1.888.CAPELLA (227.3552) WWW.CAPELLA.EDU SoNHS PRACTICE ACCESS AGREEMENT 3/3