Accelerated Bachelors in Science Nursing (ABSN) Program Application

Deadline: Postmark on or before November 30, 2015

Instructions:

1. Application to the nursing program requires completion of 2 separate applications. One tothe University (online: CSUMentor.edu) and the second to the Department of Nursing.Admission to the Nursing program is contingent on receiving an acceptance letter from theDepartment of Nursing:

1st Application: California State University Northridge online application is available October 1 to November 30 by accessing: www.csumentor.edu

2nd Application: The Department of Nursing application must be postmarked no later than November 30th.

2. Please make sure that all items on the checklist are delivered in a single packet to avoiddelays in processing your application.

Mail your application on or before November 30, 2015 to:

Attention: Accelerated BSN Program Department of Nursing, Jacaranda Hall 2210 California State University, Northridge 18111 Nordhoff Street. Northridge, CA 91330-8285

*Must be postmarked no later than November 30, 2015*

3. Late and incomplete applications will not be accepted. Use the list below to ensure alldocuments are included and submitted.

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Checklist Form

I am applying for (check): Summer 2016 or Fall 2016

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 2015, must submit transcripts ASAP once grades have been posted (deadline 2/15/16)

Foreign Graduate MUST submit an EVALUATED transcript. A copy is needed for both Nursing and Admissions & Records

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Personal Information

Name: (Last/First/Intl)

Address:

Phone: Home Cell:

E-mail:

Name of Emergency Contact:

Phone #:

Educational Background(List all institutions since high school)

School Name Dates Attended Diploma/Degree Date Awarded

Have you previously applied to the CSUN Nursing program? No Yes

If yes, when

Military Information Have you ever been on active duty in the U.S. military service? No Yes

If Yes, please indicate whether you are currently an active duty member or a veteran of the U.S. armed forces.

Active Member Veteran

If you select “Yes”, submit a copy of your DD214 or DD295 with this application.

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Experiential Background(begin with most recent)

Clinical Experience (Must submit documentation to validate)

1. Completed Clinical Certification? Yes Hours _______

No

2. Attach copy of certification

✓ Certification Date Completed ✓ Certification Date Completed LVN Phlebotomy CNA EKG/Monitor Tech EMT Other

Volunteer Hours

The Department of Nursing prefers 100 volunteer hours or more of patient care experience in a clinical setting, completed within 24 months prior to submitting your application.

*Please note: CNA/EMT etc. school training/clinical hours will not be considered as volunteerhours.

1. Please attach a letter validating hours. The letter must include job description and hourscompleted.

Organization Position/Title Specialty/Duties Dates of Employment

Reason for Leaving

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Personal Statement

Write a 1-2 page double-spaced personal statement addressing all of the following 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

to this intense program?

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?

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Prerequisite Checklist

Name: CSUN ID #______________

Science Courses Must Have Been Completed After Spring 2009

Course Grade Units

Q=Quarters S= Semester

Date Completed

(Or “IP” if in progress)

Course # Educational Institution

Microbiology BIOL 215/L (CSUN)

Microbiology Lab

Human Anat. BIO 211/212 (CSUN)

Human Anat. Lab

Human Physiol. BIOL 281/282 (CSUN)

Hum. Phys.Lab

Gen.Chem.1 CHEM 103/103L (CSUN)

Gen.Chem.1 Lab

Statistics

Critical Thinking

Oral Communication

Written Communication

Courses in progress are to be completed in Fall 2015, must submit transcripts ASAP once grades have been posted.

The deadline to submit final transcripts is February 15, 2016.

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ABSN Applicant Recommendation Form 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.

Print Name Signature Date

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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Letter of Recommendation Form Student Name

Name ___________________________________________ 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 Supervisor Other, _________

Please refer to the following table and indicate your impression of this applicant regarding the following factors:

Applicant Characteristics Out-

standing Very Good Good Average Poor

Unable to

Judge

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 Lifelong 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

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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 anacademically rigorous nursing program? Yes No If Yes, please explain:

2. Considering this candidate’s interests, work habits, personality, and career goals. Does this persondisplay the moral and ethical attributes necessary to be a health care professional? Yes No Additional Comments:

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3. Please discuss the characteristics of the applicant that you feel will make him/her a competitivecandidate 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:

Name:

First Last

Address:

Phone: Work: Cell:

E-mail:

Signature:

RETURN THIS FORM IN A SEALED ENVELOPE TO APPLICANT.

THANK YOU.

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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 BSN 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.

Print Name Signature Date

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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 check the appropriate boxes)

TASKS Able to Perform Needs Accommodations

Lifting patients

Pulling patients

Turning patients

Physical mobility

Pushing heavy medical equipment

If you answered “Needs Accommodations” to any of the above, please explain.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Print Name Signature/ Stamp Date