2017 St. Luke s Foundation 2016 Scholarship Recipients St. Luke s Foundation s provides tuition assistance to St. Luke s employees pursuing a degree to expand or further their job skills. Scholarships are provided for this program through individual donations to St. Luke s Foundation. The scholarship program ensures qualified personnel for the future of St. Luke s Hospital. Dollar amounts vary depending on the scholarship awarded. 12-2016 1
APPLICATION CHECKLIST Thank you for your interest in applying to St. Luke s Foundation s. The scholarship program is a competitive process and all eligible applications will be evaluated against a standardized scoring system. All eligible applications may not receive funding. It is the applicant s responsibility to ensure all components of the application are complete and original. Below is the application checklist of required documents for your reference. TO BE ELIGIBLE YOU MUST Be employed in an eligible UnityPoint Health Cedar Rapids department. Please see pages 3 for ineligible and eligible departments. Be enrolled in an accredited college or university listed on the application for the 2017 2017 school year Continue to work for St. Luke s Hospital (one year per scholarship awarded) TIMELINE March 6, 2017 at 3 p.m.... Applications are due to St. Luke s Foundation Week of April 10, 2017... Scholarship Recipients will be notified May 11, 2017 at 4 p.m.... Patient Care Excellence Award and Scholarship Ceremony at Coe College's Sinclair Auditorium APPLICATION CHECKLIST - REQUIRED DOCUMENTS Complete all sections of the Application Form Originals Only Please Complete Applicant Information, Education, Employment, Committee Involvement, Leadership Roles, and Volunteer Activities (Pages 3-5). ( ) COMPLETE Transcripts: Check appropriate box/line and enclose: h Official transcript(s) from each of the colleges/universities you have attended. College/University Enrollment Section: Please attach your acceptance letter from the college or university you will be attending. Essay: (Page 6) In 750 words or less, please answer the following questions: 1. As you are going through your education, why is this degree important for you while caring for our patients and their families? 2. Following the completion of your degree, how will your degree assist you in your: Clinical assessment skills Independent, critical thinking skills Communication skills with physicians, co-workers as well as the patient and their family Opportunities to engage and/or lead in the hospital Applicant Section: read contract, sign and date (Page 6). Reference Forms: Enclose references in sealed envelopes with reference signature on envelope flap. Reference Form #1 Current Manager Reference From #2 Co-worker/Peer Reference Form #3 A member of the multi-disciplinary team you work with (physician, social worker, OT, PT, dietitian, care coordinator, pharmicist, spiritual care, nurse, etc. St. Luke s Foundation is located in the Medical Office Plaza at 855 A Avenue NE, Suite 105. Applications may be mailed via U.S. Post Office, hand-delivered or via inter-office mail. Scholarship Contact: Tonya Arnold Phone: (319) 369-7572 Email: Tonya.Arnold@unitypoint.org 2
IN-ELIGIBLE AND ELIGIBLE DEPARTMENTS IN-ELIGIBLE Departments: Jones Regional Medical Center (JRMC s Foundation has scholarships available for their employees) ELIGIBLE Departments: Administration & Nursing Services - Nursing Support - Performance Improvement - Nursing Float Pools - Skin Care Services (Inpatient & Outpatient) Behavioral & Mental Health - 1 West - 2 East - 3 East - Behavioral Health Access Center - Child Protection Center - Children s Day Treatment - Partial Hospitalization Breast and Bone Health Case Management Continuing Care Hospital (LTACH) Dialysis Emergency Services - Admissions Center - Emergency Department - LifeGuard Employee Health Imaging Services Infusion Center (4 East) Inpatient Units - 3 West - 3 Center - 4 Center - 4 West - 5 Center - 5 East - Intensive Care Unit - Cardiac Care Unit Living Centers East and West Medical Admissions Center Nassif Community Cancer Center Nassif Center for Women s and Children s Health - Birth Care Center - Neonatal Intensive Care Unit - Pediatrics - Pediatric Intensive Care Unit Nassif Heart Center - Diagnostic Cardiology/Heart Holding - Cardiac /Pulmonary Rehab - Cardiovascular Lab - Electrophysiology Lab - Interventional Vascular Lab Physical Medicine and Rehabilitation - 6 West - PMR Clinic Surgery Center Cedar Rapids Surgical Services - Digestive Health Center (4 East) - Operating Rooms - Post-Anesthesia - Surgicare - STAR - Pain Clinic Post-acute Services - Home Care - Hospice (Inpatient & Outpatient) - Palliative Care (Inpatient & Outpatient) UnityPoint Clinics, including Hospitalist Program Work Well Solutions 3
Please type or print 2017 St. Luke s Foundation Application Deadline Due by March 6, 2017 All documents submitted must be ORIGINAL. If you have requested an institution to submit a form on your behalf, it is your responsibility to ensure school officials are aware of the application deadline. PROGRAM TYPE Indicate the program in which you are currently enrolled or to which you have been accepted. h Bachelor of Arts (BA) h Clinical Laboratory Scientist/Medical Technologist h Clinical Laboratory Technician/ Medical Lab Technician h Dental Assistant h Dental Hygienist h Master of Business Administration (MBA) h Master of Arts in Marriage and Family Therapy h Mt. Mercy - St Luke's BSN Program h Nursing (RN) h Nursing (BSN) APPLICANT INFORMATION (please print) NAME (LAST, FIRST, MIDDLE INITIAL) h Nursing (Masters MSN) h Nurse Practitioner (NP) h Certified Nurse Anesthetist (CRNA) h Clinical Nurse Specialist (CNS) h Nurse Administrator h Occupational Therapist h Pharmacist h Pharmacy Technician h Physical Therapist h Physician Assistant h Radiation Sciences h Diagnostic Medical Sonography (DMS) in General and Vascular (GV) h Diagnostic Medical Sonography (DMS) in Cardiac and Vascular (CV) h Radiologic Technology (RT) and Cardiovascular Interventional (CVI) h Radiologic Technology (RT) and Computed Tomography (CT) h Radiologic Technology (RT) and Magnetic Resonance Imaging (MRI) h Respiratory Therapist h Social Worker (LISW or MSW) h Speech Pathologist h Other: MAIDEN NAME/OTHER NAMES USED TELEPHONE NUMBER CURRENT MAILING ADDRESS CITY STATE ZIP E-MAIL ADDRESS PERMANENT MAILING ADDRESS CITY STATE ZIP EDUCATION Please submit all original official transcripts (no copies) for each secondary and post-secondary academic institution attended. Note: If you have a GED, include the original transcript with signature. High School transcripts are not needed if proof of 60 college credit hours with grades and GPA are sent. Circle the highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED College: 1 2 3 4 High School Attended and Location Graduation Date College/University Attended and Location Dates Attended GPA Graduation Date Degree Earned College/University Attended and Location Dates Attended GPA Graduation Date Degree Earned College/University Attended and Location Dates Attended GPA Graduation Date Degree Earned 4
EMPLOYMENT NAME OF EMPLOYER YEARS OF EMPLOYMENT DEPARTMENT MANAGER JOB TITLE NAME OF EMPLOYER YEARS OF EMPLOYMENT DEPARTMENT MANAGER JOB TITLE NAME OF EMPLOYER YEARS OF EMPLOYMENT DEPARTMENT MANAGER JOB TITLE NAME OF EMPLOYER YEARS OF EMPLOYMENT DEPARTMENT MANAGER JOB TITLE NAME OF EMPLOYER YEARS OF EMPLOYMENT DEPARTMENT MANAGER JOB TITLE 5
COMMITTEE INVOLVEMENT For Organizational Committees, please define your role/involvement, projects completed and how often you meet. Please DO NOT use acronyms! Unit/Department (Example: Unit Practice Council, SuperUser, NICU Evidence Based Practice Committee) Hospital-Wide (Example: Skin Care Committee, Patient Care Council, Patient Throughput Committee) System-Wide (Example: UnityPoint Health Cardiac Affinity Group, UnityPoint Health Professional Nurse Practice Council) LEADERSHIP ROLES Please list and define your responsibilities in leadership roles throughout he hospital (Examples: Charge Nurse, Preceptor for New Nurses, Students, BCLS Instructor, CPI Instructor). Do not use acronyms. 6
VOLUNTEER ACTIVITIES Please list your current volunteer activities (Examples: church, schools, community, organization). Indicate the scope of each activity and your level of participation. Note: It is important for the selection committee to have this information from all applicants. I. ESSAY In 750 words or less, please answer the following questions: 1. As you are going through your education, why is this degree important for you while caring for our patients and their families? 2. Following the completion of your degree, how will your degree assist you in your: Clinical assessment skills Independent, critical thinking skills Communication skills with physicians, co-workers as well as the patient and their family Opportunities to engage and/or lead in the hospital II. TO BE COMPLETED BY APPLICANT Applications must be received by 3 p.m. on March 6, 2017. Completed applications, transcripts, enrollment information or other scholarship information received after the due date will result in the application being deemed ineligible. Questions regarding the application and selection process should be directed to Tonya Arnold at St. Luke s Foundation. While this signature on this application is not a legal document, if you are selected as a scholarship recipient, you will be required to sign a Retention Agreement with St. Luke s Hospital, that you will work for St. Luke's Hospital for at least one year from the date you were awarded a scholarship from St. Luke's Foundation. I certify the information contained in this application is true, complete and correct to the best of my knowledge and that all funds will be used for tuition expenses and academic fees in the current year. I hereby authorize the release of personal, scholastic and financial information related to my education status from any academic institution I have attended in the past. PRINTED APPLICANT NAME PRINTED NAME OF REFERENCE 7
REFERENCE FORM #1 - Current Manager I. TO BE COMPLETED BY APPLICANT Please use this form for submitting references. Three (3) references (separate forms are attached) are required. References should not include family members or friends. Please remind your references to return this form to you or to mail the reference (in a sealed and signed envelope) to: St. Luke s Foundation 855 A Avenue NE, Suite 105 Cedar Rapids, IA 52402 To meet the deadline all documents must be received by March 6, 2017. Complete this portion of the form and then provide it to your reference for completion and return to you or directly to St. Luke s Foundation. You may want to provide your reference with a self-addressed envelope. Enclose the returned reference form in its sealed envelope with your application. PRINTED APPLICANT NAME PRINTED NAME OF REFERENCE II. RELEASE OF ACCESS TO THIS LETTER OF RECOMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L. 93-380 (Family Educator Rights and Privacy Act of 1974). h I waive my right to access this letter of recommendation. h I do not waive my right to access this letter of recommendation. SIGNATURE OF APPLICANT III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for the person making the recommendation: Review Sections I and II to ensure applicant has provided the necessary information. Complete the remainder of the form. Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. The applicant will return the sealed envelope with his or her application. 8
REFERENCE FORM #1 - Current Manager Please rate the applicant s achievement and potential by entering an X in the appropriate spaces below. Skill Decision-making ability Organizational skills Communication skills: Written Oral Adaptability to stress Integrity Interpersonal sensitivity Leadership ability Ability to commit to Goals Team Exceptional Above Below Not Able to Respond In addition to the rating, please give your evaluation of the applicant. It is important you complete this section. You may want to indicate your perceptions of the applicant s strengths and limitations. Please ( ) check one: My recommendation is: M Highly Recommend M Recommend M Do not recommend SIGNATURE OF THE REVIEWER MAKING THE RECOMMENDATION DATE PRINTED NAME BUSINESS AND POSITION (IF APPLICABLE) ADDRESS WORK TELEPHONE NUMBER All information is confidential and for programmatic purposes only. 9
REFERENCE FORM #2 - Co-Worker/Peer I. TO BE COMPLETED BY APPLICANT Please use this form for submitting references. Three (3) references (separate forms are attached) are required. References should not include family members or friends. Please remind your references to return this form to you or to mail the reference (in a sealed and signed envelope) to: St. Luke s Foundation 855 A Avenue NE, Suite 105 Cedar Rapids, IA 52402 To meet the deadline all documents must be received by March 6, 2017. Complete this portion of the form and then provide it to your reference for completion and return to you or directly to St. Luke s Foundation. You may want to provide your reference with a self-addressed envelope. Enclose the returned reference form in its sealed envelope with your application. PRINTED APPLICANT NAME PRINTED NAME OF REFERENCE II. RELEASE OF ACCESS TO THIS LETTER OF RECOMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L. 93-380 (Family Educator Rights and Privacy Act of 1974). h I waive my right to access this letter of recommendation. h I do not waive my right to access this letter of recommendation. SIGNATURE OF APPLICANT III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for the person making the recommendation: Review Sections I and II to ensure applicant has provided the necessary information. Complete the remainder of the form. Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. The applicant will return the sealed envelope with his or her application. 10
REFERENCE FORM #2 - Co-Worker/Peer Please rate the applicant s achievement and potential by entering an X in the appropriate spaces below. Skill Decision-making ability Organizational skills Communication skills: Written Oral Adaptability to stress Integrity Interpersonal sensitivity Leadership ability Ability to commit to Goals Team Exceptional Above Below Not Able to Respond In addition to the rating, please give your evaluation of the applicant. It is important you complete this section. You may want to indicate your perceptions of the applicant s strengths and limitations. Please ( ) check one: My recommendation is: M Highly Recommend M Recommend M Do not recommend SIGNATURE OF THE REVIEWER MAKING THE RECOMMENDATION DATE PRINTED NAME BUSINESS AND POSITION (IF APPLICABLE) ADDRESS WORK TELEPHONE NUMBER All information is confidential and for programmatic purposes only. 11
REFERENCE FORM #3 A Member of the Multi-Disciplinary Team you Work With (see page 2 for examples) I. TO BE COMPLETED BY APPLICANT Please use this form for submitting references. Three (3) references (separate forms are attached) are required. References should not include family members or friends. Please remind your references to return this form to you or to mail the reference (in a sealed and signed envelope) to: St. Luke s Foundation 855 A Avenue NE, Suite 105 Cedar Rapids, IA 52402 To meet the deadline all documents must be received by March 6, 2017. Complete this portion of the form and then provide it to your reference for completion and return to you or directly to St. Luke s Foundation. You may want to provide your reference with a self-addressed envelope. Enclose the returned reference form in its sealed envelope with your application. PRINTED APPLICANT NAME PRINTED NAME OF REFERENCE II. RELEASE OF ACCESS TO THIS LETTER OF RECOMENDATION The applicant must complete and sign the following statement before submitting this form to the reference. This request is in compliance with Federal Law P.L. 93-380 (Family Educator Rights and Privacy Act of 1974). h I waive my right to access this letter of recommendation. h I do not waive my right to access this letter of recommendation. SIGNATURE OF APPLICANT III. SUMMARY SHEET TO BE COMPLETED BY THE REFERENCE Instructions for the person making the recommendation: Review Sections I and II to ensure applicant has provided the necessary information. Complete the remainder of the form. Place the completed recommendation in an envelope, seal and sign your name across the seal of the envelope. Return the form to the applicant. The applicant will return the sealed envelope with his or her application. 12
REFERENCE FORM #3 A Member of the Multi-Disciplinary Team you Work With Please rate the applicant s achievement and potential by entering an X in the appropriate spaces below. Skill Decision-making ability Organizational skills Communication skills: Written Oral Adaptability to stress Integrity Interpersonal sensitivity Leadership ability Ability to commit to Goals Team Exceptional Above Below Not Able to Respond In addition to the rating, please give your evaluation of the applicant. It is important you complete this section. You may want to indicate your perceptions of the applicant s strengths and limitations. Please ( ) check one: My recommendation is: M Highly Recommend M Recommend M Do not recommend SIGNATURE OF THE REVIEWER MAKING THE RECOMMENDATION DATE PRINTED NAME BUSINESS AND POSITION (IF APPLICABLE) ADDRESS WORK TELEPHONE NUMBER All information is confidential and for programmatic purposes only. 13