College of Nursing Student Services Office 985330 Nebraska Medical Center Omaha, NE 68198-5330 phn: (402) 559-4110 fax: (402) 559-6379 Dear Applicant, Congratulations on your decision to apply to the University of Nebraska Medical Center, College of Nursing. The application procedure is a very systematic step-by-step process. The following information should make the process easier to understand. 1. The application file on which admission decisions are made consist of: - Application Form Two Letters of Recommendation High School Transcript All College Transcripts Campus Preference Sheet Application Fee of $45.00 (No fee for those who have previously attended UNO, UNL, UNMC or UNK) NOTE: Submit the application form before the supporting material. Send to: University of Nebraska Medical Center Office of Academic Records Student Life Center 984230 Nebraska Medical Center Omaha, NE 68198-4230 2: When your application is received at UNMC Academic Records, they will send you a letter explaining what is needed to complete your file. It will be your responsibility to follow-up to ensure that any missing items are received in the Academic Records Office. 3. When all of the above items for your application are received at UNMC Academic Records your file will be sent to the College of Nursing for review. You will receive a letter from your (first Choice) campus Student Services Advisor explaining your status in the reviewing process. 4. Application to the College can be made for fall or spring admission. The deadline for Fall Admission is February 1st and August 1st for Spring Admission. All applications are processed through the Omaha Division. 5. You will need to have updated transcripts sent to Academic Records as soon as possible. Grade reports will work if the institution cannot get the transcript to us by the deadline. However, before final acceptance an official transcript of all college work is required. (Over) 6. When you have been offered a position you will receive a letter of notification. You should send your letter of acceptance within 10 days. Those not accepting within the specified time period will lose their position. 7. Upon receipt of the acceptance letter you will receive information from the UNMC Financial Aid Office. It is essential that you respond immediately to the Financial Aid Office if you wish to be eligible for financial aid and/or scholarships. 8. You will be notified by your campus Student Services Advisor about your status in the admission process. 9. The following are the Student Services Advisors for each division of the College of Nursing: Michele Saucier (402) 472-7343 Lincoln Division 1230 O Street, Suite 131/ P.O. Box 880220 Lincoln NE 68588-0220 Larry Hewitt (402) 559-5102 Omaha Division 985330 Nebraska Medical Center Omaha NE 68198-5330 Hilary Christo (308) 865-8322 Kearney Division 1917 West 24th Street Kearney NE 68849-4510 Karen Schledewitz (308) 632-0413 Scottsbluff Division Panhandle Research and Extension Division 4502 Avenue I Scottsbluff NE 69361-4939 Or you may dial toll-free: 1-800-626-8431 Ext. 4110 Thank you, UNMC College of Nursing Admissions Committee LPH/lph Revised 1/09 ________________________________________________________ NAME (Please Print) OFFICE OF ACADEMIC RECORDS THE UNIVERSITY OF NEBRASKA MEDICAL CENTER 984230 Nebraska Medical Center, Omaha, NE 68198-4230 APPLICATION FOR ADMISSION 1. Please check program for which application is made: Deadline for All Program Application Material Begins November 1 end of May November 1 end of August (Check applicable program box) Radiography Nuclear Medicine Technology January 15 January 15 end of August end of August For those applicants who have completed required college courses plus an accredited radiography or nuclear medicine technology program by the enrollment date and are nationally certified or candidates for certification: Nuclear Medicine Technology Radiation Therapy Technology Diagnostic Medical Sonography Radiography — CT / MRI Radiography — CVIT January January January January January end end end end end School of Allied Health Professions Programs Division of Clinical Laboratory Science — B.S. (combined program of UNMC at NHS Hospital & Clinic and Nebraska Methodist Hospital) Division of Physical Therapy Education — D.P.T. Division of Radiation Science Technology Education — B.S. Division of Clinical Perfusion Education — M.P.S. Division of Medical Nutrition Education — Certificate 15 15 15 15 15 of of of of of August August August August August January 1 end of August February 15 mid August March 1 end of August (for applicants who have completed an accredited baccalaureate program in dietetics by the enrollment date) Division of Cytotechnology — Certificate College of Nursing Programs (Recommend early application) Nursing — B.S.N. for all Divisions FALL Term February 1 SPRING Term August 1 For applicants who have a Bachelor’s degree from an accredited institution Accelerated BSN- Lincoln Campus Only May 15 Accelerated BSN- Omaha Campus Only May 15 Accelerated BSN- Scottsbluff Campus Only May 15 end of August January January January January College of Pharmacy Doctor of Pharmacy — Pharm.D. January 1 end of August 2. HAVE YOU APPLIED PREVIOUSLY TO UNMC? YES NO If Yes, indicate: Year(s)___________ Program(s) ________________ When do you expect to enroll? ________ _______ Note:You will be considered for only the immediate next class and must reapply if month year not accepted. 3. FEE: If you have previously attended UNO, UNL, UNK, or UNMC campus, DO NOT submit a fee with this application. If you have never been enrolled at any of the University of Nebraska system campuses, enclose a check or money order for $45.00 payable to UNMC. The fee is non-refundable and not applicable toward tuition. This fee is subject to change upon review by the Board of Regents. 4. TRANSCRIPTS: Applicants must request official transcripts from each institution previously attended, regardless of credit earned. Transcripts must be sent from the Registrar to the UNMC Office of Academic Records. If you are applying to multiple UNMC programs, official transcripts must be submitted for each program application. High school transcripts are required from applicants to the College of Nursing, Division of Clinical Laboratory Sciences, and Division of Radiation Science Technology. 5. CHANGE OF CAMPUS FORM: Applicants from UNO, UNK and UNL can request a "Change of Campus" form from their current campus Registrar. Request the Change of Campus be sent directly to the UNMC Office of Academic Records. If applying to Medical Nutrition Education, send official transcripts and all application material directly to the Program Director. 6. REFERENCES: Applicants are to distribute the enclosed forms with stamped envelopes to the referent for completion and return directly to the address on the form. Three (3) references are required except for Nursing (two references). References should not be submitted from relatives. Cytotechnology references letters need to be sent directly to Program Director. 7. PHOTOGRAPH: Required from applicants to College of Pharmacy. Attach one billfold size recent photograph with date taken and your signature written on the back. 8. Mail completed application and fee (if required) to the UNMC Office of Academic Records. All materials submitted in support of your application become the property of the University and cannot be returned or forwarded. Medical Nutrition Education applications and fee (if required) should be sent to the Program Director for nationwide computer match processing. 9. Scholarship and Financial Aid applications will be mailed to applicants accepted for admission. SSD-40 (Rev. 11//08) 2 UNMC APPLICATION FOR ADMISSION Please Type or Print in Ink ______ Female ______ Male SOCIAL SECURITY # Name _____________________________________________________________________________ Last First Middle Former Name(s) __________________________ (if any appear on records) Current Address ________________________________________________________________________________________________________ Street City County State ZIP Code Permanent Address _____________________________________________________________________________________________________ Street City County State ZIP Code Current Phone _________ ________________ area code local Birthdate ______/______/______ ____ Parent(s) Work Phone _________ ________________ area code local Birthplace ________________________________________ City/State ____ Guardian(s) Permanent Phone ______ ____________ area code local Hometown ___________________________ City/State Name _____________________________________________________________________________ Last First Middle Address of Parent or Guardian ____________________________________________________________________________________________ Street City County State ZIP Code Person most helpful in my selection of a UNMC educational program: ____ High School Counselor ____ College Advisor ____ UNMC Faculty/Staff Your e-mail address: _____________________ ____ Other _______________________________ NON-U.S. CITIZENS — Please complete the following: Country of Citizenship __________________________________ Last Visa Classification _______________________________________ Arrival Date in U.S. _____________________________________ Permanent Residents, please list Alien Card number (Form I-151) __ *UNITED STATES CITIZEN: PREDOMINANT ETHNIC BACKGROUND _____ CAUCASIAN _____ ASIAN OR PACIFIC ISLANDER. Check Subcatetgory (A person of ____ Chinese, ____ Filipino, ____ Hawaiian, ____ Korean, ____ Vietnamese, ____ Japanese, ____ Indian or Pakistani, ____ Other Pacific Islander or Asian.) _____ BLACK. Not of Hispanic Origin (A person having origins in any of the Black Racial Groups.) _____ HISPANIC. Check Subcategory (A person of ____ Mexican, ____ Puerto Rican, ____ Cuban, ____ Central or South American or other Spanish Culture or Origin, regardless of race.) _____ AMERICAN INDIAN or ____ ALASKAN NATIVE. Check appropriate category. (A person having origin in any of the original peoples of North America.) *Supplying this information is optional with the applicant and is not a requirement for admission. The data is used by the U.S. Departments of Health ahd Human Services and Education for statistical purposes. These questions are related to residency and are to be completed by: a. Each applicant over 18 years of age OR b. Parent/guardian of applicant less than 19 years Midwest Student Exchange Program (MSEP) status is desired if admitted Yes No (Open to residents in the states of Kansas, Michigan, Minnesota, Missouri, and North Dakota) Do you claim to be a resident of Nebraska? Yes No If Yes, Nebraska County of Legal Residence ________________________________ If Yes, date you began living in Nebraska ___________________________________ Month Day Year If No, state of legal residence ______________________________________________ Do you have a Nebraska driver/s license? Yes No Are you registered to vote in Nebraska? Yes No If employed, have you filed a Nebraska income tax return? Yes No Note: You may be required to verify your Nebraska residency by filing an application with the UNMC Office of Academic Records and showing proof of above items. SSD-40 (Rev. 07/08) 3 Give chronological record of previous part-time or full-time employment: Name of Employer Address Type of Position Held Inclusive Dates ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ NAME ALL EDUCATIONAL INSTITUTIONS ATTENDED List in chronological order the ALL colleges, universities, professional, technical or business schools you currently attend or have attended (even if no credit has been earned) on either correspondence, evening or daytime schedules. Begin with high school and date of graduation. High School _____________________________________ Location _________________________________________________________ City State County Date Graduated: ___________________________________________________ Month Year College, University, Professional, Technical or Business Schools Attended Dates City State or County Entered Left Mo. Yr. Mo. Yr. No. of Hours Earned Cumulative Grade Point Average (college only) Program Degree or Certificate Received or Expected Date Received or Expected Mo. Yr. If your education has been interrupted, list in detail your activities during the intervening period. Also, indicate if you have been suspended or dismissed from a collegiate institution. WORK IN PROGRESS Instructions:Please list all courses currently in progress and those which you plan to complete prior to your enrollment at University of Nebraska Medical Center. 1. CURRENT 2. FUTURE Fall Fall Winter Winter Spring Semester Quarter Year__________ Spring Semester Quarter Year__________ Summer Summer Name of Institution: ___________________________________ Name of Institution: _____________________________________ Dept. Name SSD-40 (Rev.07/08) Name of Course Credit Hrs. Dept. Name Name of Course Credit Hrs. 4 List extra-curricular interests and give number of years of participation in each. List honors, awards (i.e., scholarships, etc.). Specify high school (HS) or college (C). ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Please provide a narrative describing your interest in the selected area of study, particularly stressing your professional career goals. Radiation Science applicants need to submit separate narratives for each program. Clinical Perfusion applicants need to provide typed (double-spaced) narrative on separate sheet. Pharmacy applicants should complete the Personal Questionnaire and one page essay in place of this narrative. NOTE: Should you desire to arrange for a disability accommodation in conjunction with completing the application process, please contact Ms. Ronda Stevens, Coordinator, Counseling and Student Development Center, at the address on the front of this application. Her phone is (402) 559-5553. FOR ALL APPLICANTS: One of the objectives of the University of Nebraska Medical Center is to recruit and retain persons of high moral and ethical character. In accordance with this objective, the University of Nebraska Medical Center reserves the right to review a candidate’s suitability for admission. I certify that information on this application is complete, accurate and true; and I understand that any information given falsely or withheld may make me ineligible for admission and/or enrollment. I agree to abide by the policies and regulations of the University of Nebraska Medical Center. I will inform the UNMC Office of Academic Records of any change in my plans to attend. _________________________________________________________ Month Day Year _________________________________________________________ APPLICANT’S SIGNATURE Admission to the University of Nebraska Medical Center shall not be denied to any person because of age, sex, race, color, national origin, religion, political beliefs, or disability (as defined in The Rehabilitation Act of 1973). SSD-40 (Rev. 07/08) University of Nebraska Medical Center College of Nursing Campus Preference Sheet Name SSN List below the College/University you have completed or working on your Pre-Nursing Admission Courses: A. FIRST CHOICE: Please indicate the campus you would like to attend below: CHOOSE ONLY ONE PLEASE PRINT CLEARLY: • • • • Omaha Division Lincoln Division Scottsbluff Division Kearney Division B. CAMPUS PREFERENCE: The College of Nursing is administered by the University of Nebraska Medical Center in Omaha with the nursing program being offered at four locations; in Omaha (on the UNMC campus), in Lincoln (on the UNL Campus), the West Nebraska Division (in Scottsbluff) and in Kearney (on the UNK Campus). PLEASE NOTE: If you indicate that you will attend a campus (even if it might not be your first choice), you will be expected to enroll at that campus if offered a position. Also, you do not need to list more than one campus unless you have an interest in attending more than one of the available campus choices. Please list all campuses you wish to be considered for. Listing more than one campus only increases your chances of being placed at one of the four campuses; it doesn’t increase your chances of being placed on your first choice campus. C. REGISTERED NURSES with a current license wishing to complete the BSN program should make a campus selection to complete the clinical component of Community Health and the Lab component of Health Assessment. Your campus selection should be a choice which is convenient to travel to at least once a week. PLEASE PRINT CLEARLY (Remember; second, third and/or fourth choices are NOT required) • Omaha Division • Lincoln Division • Scottsbluff Division • Kearney Division PLEASE PRINT CLEARLY: SECOND CHOICE THIRD CHOICE FOURTH CHOICE D. If we cannot offer you admission to your first or second choice campus you will be placed on your first choice alternate list, if you are qualified. I affirm that the above statements are true and fully intend to abide with the commitments. Signature Return this form with your Application to: Date Office of Academic Records University of Nebraska Medical Center 984230 Nebraska Medical Center Omaha, NE 68198-4230 Revised: 8/06 College of Nursing Letter of Recommendation Applicant Instructions: Two references are required to complete your application. We recommend you consider requesting references from individuals who know you well and can comment on your suitability and preparation for a health care career and/or your academic preparation. Name of Applicant: (Please Print) (Last) (First) (Middle) (Maiden) RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to inspect their files upon request. In order to inform the person you have requested to write a letter of recommendation whether the letter will be held in confidence or if the letter will be open to your inspection, please check [¥] one of the following statements. Waiving your rights to see this letter of recommendation is not a requirement for admission. [ ] I hereby do waive my rights to access this letter of recommendation. or [ ] I hereby do not waive my rights to access this letter of recommendation. ____________ (Date) ___________________________ (Applicant’s Signature) ______--_____--______ Soc. Security Number =============================================================== 1. In what capacity have you been associated with this student? Please check one or more of the following choices: [ ] Instructing Lecture or Laboratory ____________________ (specify courses) [ ] Academic Advising [ ] Other _________________________________ (specify) 2. How long have you known the applicant? 3. How well do you know the applicant? [ ] Very well [ ] Somewhat [ ] Not very well 4. What major strengths do you believe this applicant exhibits? 5. What weaknesses or issues might interfere with this applicant’s success in college course work? 6. What experiences has this candidate had that you believe would serve them well as a professional nursing student? 7. Do you have any additional comments relevant to the applicant’s suitability to the nursing profession? 8. How would you rank this student in the following categories relative to other nursing students or nursing professionals you know?: Characteristics Top 10% Top 25% Average Below 25% Below 10% No basis to judge Intellectual Curiosity: their pursuit of available resources inside/outside the classroom. Self-Reliance: Sense of responsibility: dependability: promptness: conscientiousness: selfconfidence. Maturity: Personal development: ability to cope with life situations: awareness of own strengths and weaknesses: self-confidence. Judgment: Ability to analyze a problem: common sense: decisiveness. Interpersonal Interactions: rapport: cheerfulness: tact: cooperation: empathy. Commitment/Motivation: genuineness: depth of commitment: goals set for themselves: reason for choosing nursing as a career. 9. Based on the information that you have provided throughout this recommendation, how comfortable would you be with this student being your nurse or taking care of a loved one?: [ ] Very Comfortable [ ] Somewhat Comfortable [ ] Somewhat Uncomfortable [ ] Very Uncomfortable [ ] Don’t Know 10. Personal references are a valued and an integral part of the admissions process. Our nursing program seeks individuals who have the potential for success in a rigorous educational program and possess the personal attributes required to become a competent and compassionate health care provider. If would like to provide some additional insight on this student, please attach an additional narrative statement on professional letterhead and provide comments about the student’s developing maturity, problem-solving ability, originality, unique skills, cultural sensitivity, attributes, or future potential. Your candid evaluation of the applicant will be of significant value and is appreciated. (Please type or print) (Printed Name) (Date) (Signature) (Mailing Address) (Phone) (Institution/Company) (Position) ================================================================ Return to: University of Nebraska Medical Center, Office of Academic Records Student Life Center, 984230 Nebraska Medical Center Omaha, NE 68198-4230 College of Nursing Letter of Recommendation Applicant Instructions: Two references are required to complete your application. We recommend you consider requesting references from individuals who know you well and can comment on your suitability and preparation for a health care career and/or your academic preparation. Name of Applicant: (Please Print) (Last) (First) (Middle) (Maiden) RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to inspect their files upon request. In order to inform the person you have requested to write a letter of recommendation whether the letter will be held in confidence or if the letter will be open to your inspection, please check [¥] one of the following statements. Waiving your rights to see this letter of recommendation is not a requirement for admission. [ ] I hereby do waive my rights to access this letter of recommendation. or [ ] I hereby do not waive my rights to access this letter of recommendation. ____________ (Date) ___________________________ (Applicant’s Signature) ______--_____--______ Soc. Security Number =============================================================== 1. In what capacity have you been associated with this student? Please check one or more of the following choices: [ ] Instructing Lecture or Laboratory ____________________ (specify courses) [ ] Academic Advising [ ] Other _________________________________ (specify) 2. How long have you known the applicant? 3. How well do you know the applicant? [ ] Very well [ ] Somewhat [ ] Not very well 4. What major strengths do you believe this applicant exhibits? 5. What weaknesses or issues might interfere with this applicant’s success in college course work? 6. What experiences has this candidate had that you believe would serve them well as a professional nursing student? 7. Do you have any additional comments relevant to the applicant’s suitability to the nursing profession? 8. How would you rank this student in the following categories relative to other nursing students or nursing professionals you know?: Characteristics Top 10% Top 25% Average Below 25% Below 10% No basis to judge Intellectual Curiosity: their pursuit of available resources inside/outside the classroom. Self-Reliance: Sense of responsibility: dependability: promptness: conscientiousness: selfconfidence. Maturity: Personal development: ability to cope with life situations: awareness of own strengths and weaknesses: self-confidence. Judgment: Ability to analyze a problem: common sense: decisiveness. Interpersonal Interactions: rapport: cheerfulness: tact: cooperation: empathy. Commitment/Motivation: genuineness: depth of commitment: goals set for themselves: reason for choosing nursing as a career. 9. Based on the information that you have provided throughout this recommendation, how comfortable would you be with this student being your nurse or taking care of a loved one?: [ ] Very Comfortable [ ] Somewhat Comfortable [ ] Somewhat Uncomfortable [ ] Very Uncomfortable [ ] Don’t Know 10. Personal references are a valued and an integral part of the admissions process. Our nursing program seeks individuals who have the potential for success in a rigorous educational program and possess the personal attributes required to become a competent and compassionate health care provider. If would like to provide some additional insight on this student, please attach an additional narrative statement on professional letterhead and provide comments about the student’s developing maturity, problem-solving ability, originality, unique skills, cultural sensitivity, attributes, or future potential. Your candid evaluation of the applicant will be of significant value and is appreciated. (Please type or print) (Printed Name) (Date) (Signature) (Mailing Address) (Phone) (Institution/Company) (Position) ================================================================ Return to: University of Nebraska Medical Center, Office of Academic Records Student Life Center, 984230 Nebraska Medical Center Omaha, NE 68198-4230 UNIVERSITY OF NEBRASKA MEDICAL CENTER DISCLOSURE STATEMENT Completion of this form is a formal part of the application process. This form must be completed and submitted before any offer of admission can be made. A positive response to any of the questions below will not necessarily result in denial of admission. Information on this form will be available ONLY to the Associate Dean or his/her designee for evaluation of your suitability for full admission. This information will be held CONFIDENTIAL. Which College of Nursing campus is listed as number (1) on your campus preference? Omaha Lincoln Kearney Scottsbluff 1. Have you ever had a health care license canceled, limited, suspended, revoked or denied for any reason? YES NO 2. Have you ever been subject to proceedings by a licensing agency to cancel, limit, suspend or revoke a license for any reason? 3. Have you ever been convicted of any criminal offense (including misdemeanors and felonies) other than a minor traffic violation or been the defendant in a civil suit? 4. Are you currently using alcohol or a controlled substance(s) that would affect your ability to participate in, or prevent you from successfully completing, an academic program in a reasonable period of time? (Please be aware that you may be subject to a drug screen before some agencies will allow clinical experiences.) 5. Have you ever had any substantiated referrals for child or adult maltreatment that would be on file with the Nebraska Child or Adult Abuse/Neglect registry? (You may be required to give authorization For a release of information for this registry.) 6. Have you been issued a dishonorable discharge from the US Military ? YES NO YES NO YES NO YES NO YES NO *FOR ANY YES RESPONSES TO THE ABOVE QUESTIONS, APPEND DETAILS ON A SEPARATE SHEET(S) In evaluating conviction records, the University of Nebraska Medical Center considers the following factors: 1. The relative relationship of the conviction to the program to which you are being considered for admission 2. Circumstances surrounding the conviction 3. The time interval from the conviction to submission of an application for admission. 4. Other relevant history 5. Degree of rehabilitation Read this statement carefully: I certify that the information contained in this University of Nebraska Medical Center College of Nursing disclosure is true to the best of my knowledge and belief. Because of the high ethical and professional standards to which nurses are held, the failure to provide pertinent information regarding an act or event, such as the ones outlined in this document, may result in revocation of my admission, or if admitted, dismissal from the College of Nursing, regardless of when discovered. I agree to promptly inform the College of Nursing of any changes in any matters covered herein, even if such changes occur after I have submitted my application or enrolled as a student. I grant permission to the University of Nebraska Medical Center College of Nursing to investigate my employment record, educational record, criminal record, and other records to verify the information I have provided throughout the application process and any additional information I have provided and release the University from any liability resulting from such investigation. If you understand the statement printed above, please complete the information below: _________________________________________ Print Your Name ______________________ Date _________________________________________ Signature _______________________ Social Security Number Mail this form in a separate envelope to: UNMC Academic Records - Attn: Crystal 984230 Nebraska Medical Center Omaha, NE 68198-4230