UNC-PrimeCare Application Final Year MSW and PMHNP Students 1. Complete student information questions and Brief Essay Questions on the following pages. Do not exceed the page limit noted for each question. 2. Check, Date, and Sign the Assurances Form and attach to your application materials. 3. Answer each question on the application. Your application will be considered incomplete if the questions are not answered, or if the Assurances Form is not attached. Social Work Students: Deadline for submitted applications is January 21st, 2018 at midnight. Submit materials to: mkanfer@unc.edu. Put PRIMECARE APPLICATION in the subject line. A hard copy of the application can also be turned into M. Kanfer at the UNC School of Social Work (office #345). Nursing Students: Deadline for submitted applications is January 29th, 2018. Submit materials to: dmoneal@email.unc.edu. Put PRIMECARE APPLICATION in the subject line. A hard copy of the application can also be turned into Ms. O'Neal or Dr. Cheryl Woods Giscombe. Student Information Full Name (First, Middle, Last) Mailing Address Home Phone and Cell Phone Email (UNC AND permanent) List proficiency in languages other than English 1
Please respond to all of the following five prompts adhering to the page limits noted. 1. What is it about intgrated behavioral health care that interests you? (1/2 page to a page) 2
2. In assessing your training to date, what areas do you want to enhance or focus on in the final year of your training? Include at least two personal goals for your enhanced training (1/2 page to a page) 3
3. What are your thoughts on challenges and rewards of working in an integrated health care setting as student? (1/2 page to a page) 4
4. What are some challenges and rewards you have, or imagine you will face, when providing culturally-sensitive care while working with underserved populations? (1/2 page to a page) 5
5. Describe a situation, personal or professional, when you were outside your comfort zone in your field practicum last year. Identify the challenges you faced and how you managed the experience. (1/2 page to a page) 6
Optional Information Is there any additional information you would like the UNC-PrimeCare team to know about your interests in integrated behavioral health care that has not been previously explained? If yes, please explain (no more than 2 paragraphs): 7
UNC-PrimeCare Application 2018/19 UNC-PrimeCare ASSURANCES FORM Please check the boxes below to indicate you have read, understand, and agree to the following: UNC-PrimeCare Selection Process The UNC-PrimeCare placement process is a collaborative partnership between the student, the placement agency/organization, the field instructor, preceptor, HRSA, the School of Social Work and the School of Nursing. A student s submission of an application does not guarantee acceptance into the UNC-Prime Care program. UNC-PrimeCare applications will be reviewed and judged for acceptance by project personnel. All students who are granted acceptance into the UNC-Prime Care program must be placed into an approved UNC-CH Prime Care field placement/practicum site. All applicable UNC-CH School of Social Work and School of Nursing placement policies and procedures apply. Required Courses, Seminars & Stipend Payment Process I understand that if accepted, I must register for SOWO 741 (Integrated Behavioral Health Care with Underserved Populations) and attend all classes. SOWO 741 is taught twice: Summer Session 1, and on three Saturdays in the fall semester. I understand that if accepted, I must attend all UNC-PrimeCare seminars and workshops held over the course of the academic year. Three will be offered in the fall, three in the spring. I understand that if accepted, I may be eligible for a stipend of up to $10,000. I further understand that my eligibility to receive this UNC-PrimeCare stipend is contingent upon my continuing satisfactory participation in the program, including but not limited to completion of all required classes, seminars, workshops and documentation completion. Participant Field Education/Internship Agreement I understand that if I am accepted into the UNC-PrimeCare program, I will be required to do the following: 1. To follow the policies, standards, and practices of the facility where I complete my clinical/field education experience (the FACILITY ), including but not limited to HIPAA. 2. To abide by the policies of The University of North Carolina at Chapel Hill and the Schools of Social Work and Nursing (the UNIVERSITY ), including but not limited to applicable Code of Conduct and honor codes. 3. To report to the FACILITY on time and to follow all established regulations of the FACILITY. 4. If requested, to undergo a health examination as required by the FACILITY, including testing to determine infectious or contagious diseases and/or to provide evidence of immunity, as may be appropriate and to meet FACILITY requirements. 5. To undergo a drug screen, and criminal background check as may be required by the FACILITY. 6. To keep confidential and private all medical, health, mental health, financial and social information pertaining to any particular client or patient that I am exposed to as part of the UNC-PrimeCare program. 7. To not publish any material related to the clinical/field education experience that identifies or uses the name of the UNIVERSITY and the FACILITY, its members, officers, clients, patients, students, or faculty, directly or indirectly, unless I have first received written permission from the UNIVERSITY and the FACILITY. 8. To comply with all federal, state and local laws regarding the use, possession, manufacture or distribution of alcohol and controlled substances. 9. To follow Center for Disease Control and Prevention (C.D.C.) Universal Precautions for Blood borne Pathogens, C.D.C./DHEC Guidelines for Tuberculosis Infection Control, and Occupational Safety and Health Administration (O.S.H.A.) Respiratory Protection Standards. 10. To wear a nametag that clearly identifies me as a student at all times while in the FACILITY if required. 11. To not present myself as an employee of the UNIVERSITY or the FACILITY.
I understand that as a UNC-PrimeCare trainee I must agree to complete administrative forms requested to help evaluate the program as required by funding from HRSA. This may include but is not limited to pre/post test surveys, individual and focus groups. I understand and agree that I may be immediately withdrawn from the FACILITY s educational training program or dismissed, suspended or expelled based upon a perceived lack of competency on my part, my failure to comply with the rules and policies of the UNIVERSITY or FACILITY, if I pose a direct threat to the health or safety of others or, for any other reason the UNIVERSITY or the FACILITY reasonably believes that it is not in the best interest of the UNIVERSITY, the FACILITY or the FACILITY s patients or clients. I further understand that potential risks of internship/field education include, but are not limited to, exposure to infectious diseases, hazardous chemicals, personal injury, illness, and even death. I also understand it is my responsibility to become informed of FACILITY policies and practices regarding the management of these issues in order to minimize the risks to me. I accept these risks. I further understand that all medical or healthcare (emergency or otherwise) that I receive at the FACILITY will be my sole responsibility and expense, unless I am eligible for Worker s Compensation coverage as determined by the UNIVERSITY. I have read, or have had read to me, the above statements, and understand them as they apply to me. I hereby certify that I am eighteen (18) years of age or older, and that I have freely and voluntarily signed this Agreement. Signature (First, Middle Initial, Last): Date: