Montana Health Network 2021 Nursing Student/UAP Application
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Montana Health Network
2021 Nursing Student/UAP Application
In 2005, the Montana Board of Nursing adopted rules that allow nursing students to be employed as Nursing
Student Unlicensed Assistive Personnel (UAP). A Nursing Student/UAP may perform certain nursing tasks
through advanced delegation and the direct supervision of a Registered Nurse. Examples of nursing tasks that
a Nursing Student/UAP may perform are:
• Any nursing task for which the student has received instruction within the nursing program,
including but not limited to:
o Calculation of medication dose
o Administration of medications by mouth, sublingually, subcutaneous injection, intramuscular
injection, tube, aerosol/inhalation, suppository and topical
o Insertion of peripheral IV catheters
o Hanging, without additives, IV fluids and adjusting IV flow rates
Eligibility to Apply
In order to meet the eligibility requirements of a Nursing Student/UAP, the student must:
• Be currently enrolled in a state nursing board-approved nursing education program or a state
nursing commission-approved nursing education program
• In good academic standing
• Have satisfactorily completed a course in the fundamentals of nursing
• Have satisfactorily completed a pharmacology course (as a condition of receiving delegation of
medication administration)
How to Apply
1. Application packets are available at MHN or on-line at www.montanahealthnetwork.com.
2. Applications must be postmarked by April 16th for summer employment consideration.
3. Late or incomplete applications will not be considered.
4. Send completed application documents to:
Montana Health Network
Attn: Christine Williams
519 Pleasant, Miles City, MT 59301
or
registration@montanahealthnetwork.com
or
Fax: (406) 234-1423
UAP APPLICATION Pg. 1Clear Form
Recipient Selection
1. All completed Nursing Student/UAP applications will be forwarded to the student’s preferred sites for
consideration.
2. Each participating facility will determine the most qualified applicant for their facility.
3. Positions are limited. Meeting eligibility requirements does not guarantee that an applicant will be
employed.
4. Successful candidates will be notified with the expected term of employment defined. Term of
employment will generally be mid-May through late August.
5. Successful candidates will participate in each facility’s normal employment process (i.e. employment
paperwork and orientation).
Nursing Student UAP Requirements
1. The names and photos of successful candidates may be used by Montana Health Network for
marketing purposes.
2. A signed skills check-list delineating nursing skill that the student has completed is required to be
presented to facility at time of employment.
Checklist of Application Documents
All applications must include:
Completed Nursing Student/UAP Application Form
Letter of Intent (One page or less) that answers the following:
1. Discuss why you chose to go into nursing.
2. Describe what interests you about rural nursing.
3. Identify the strengths that you will bring to a healthcare facility.
4. Describe your career goals for the next five years.
5. Discuss what motivates you.
6. Identify any additional skills or talents that should be considered such as
employment background.
Completed Instructor Recommendation Form (included in packet)
Please note: Instructors may place completed recommendation form in a sealed
envelope and return to you for inclusion in application documents. However,
instructors also have the option to mail completed forms directly to Montana
Health Network. Please confirm with your instructor.
Completed Dean/Director of Nursing Program Verification Form
UAP APPLICATION Pg. 2MONTANA HEALTH NETWORK
NURSING STUDENT/UAP APPLICATION
Part I—PERSONAL INFORMATION
_______________________________________________________________________________________________
Last First Middle
_______________________________________________________________________________________________
Street Address Apt #
______________________________________________________________________________________________
City State Zip Code
_______________________________________________________________________________________________
Telephone- Cell Home
_______________________________________________________________________________________________
E-Mail Address
Part II—PROGRAM INFORMATION
__________________________________________________________________
College or University currently attending
__________________________________________________________________
Anticipated date of completion of nursing program
Part III—SITE SELECTION
Site preference for nursing student /UAP position:
(Please number top three choices: 1, 2, & 3)
Preference # 1 Preference # 2 Preference #3
Select One Select One Select One
NO SITE PREFERENCE, WILL GO TO ANY SITE AVAILABLE
LIST ANY OTHER FACILITY OF INTEREST NOT LISTED ABOVE:
Part IV—CERTIFICATION AND RELEASE
I certify that I am currently enrolled in a registered nurse educational program and that I am in good standing. To the best of my
knowledge, by the end of spring semester I will have successfully completed Fundamentals of Nursing and basic Pharmacology.
I certify that the information set forth in this application is true and complete to the best of my knowledge. I understand that if accepted
into this program, the falsification or willful omission of information on this application, shall be considered sufficient cause for my
removal from the program. I consent to and authorize MHN to request any information concerning my previous employment or
academic record as indicated on this application. I hereby release all parties and persons connected with any request for information
from all claims, liabilities, and damages for whatever reason arising out of furnishing such job or academically related information.
Signature of Applicant Date
UAP APPLICATION Pg. 3Dean/Director of Nursing Program Verification Form
_____________________________________ (Student’s name) has applied with Montana Health Network for
employment in the Nursing Student/UAP program. In our effort to consider this individual, we would
appreciate you furnishing the information requested below. Your prompt response to this inquiry will be most
helpful and will be held in strict confidence.
In 2005, the Montana Board of Nursing adopted rules that allow nursing students to be employed as Nursing
Student Unlicensed Assistive Personnel (UAPs). Generally speaking, a Nursing Student/UAP may perform
certain nursing tasks through advanced delegation and the direct supervision of a Registered Nurse. Examples
of nursing tasks that a Nursing Student/UAP may perform are:
• Any nursing task for which the student has received instruction within the nursing program,
including but not limited to:
o Calculation of medication dose
o Administration of medications by mouth, sublingually, subcutaneous injection, intramuscular
injection, tube, aerosol/inhalation, suppository and topical
o Insertion of peripheral IV catheters
o Hanging, without additives, IV fluids and adjusting IV flow rates
In order to meet the eligibility requirements of a Nursing Student UAP, the student must:
• Be currently enrolled in a state nursing board-approved nursing education program or a state
nursing commission-approved nursing education program
• In good academic standing
• Have satisfactorily completed a course in the fundamentals of nursing
• Have satisfactorily completed a pharmacology course (as a condition of receiving delegation of
medication administration)
I hereby verify that ______________________________________________________________
Student’s Name
(Please check all that apply)
Is currently enrolled in our Registered Nursing Program and is in good standing.
Has completed or is currently enrolled in a Fundamentals of Nursing Course
Has completed or is currently enrolled in a Introductory Pharmacology Course
Is projected to enter their final year of nursing education this coming fall semester
Your name ___________________________________ _____________________________
(printed name) (signature and title)
College/University ____________________________________________________________
Date _____________________________
THANK YOU FOR YOUR COOPERATION
PLEASE RETURN TO STUDENT
UAP APPLICATION Pg. 4Instructor Recommendation Form
_____________________________________ (Student’s name) has applied with Montana Health Network for
employment in the Nursing Student UAP program. In our effort to consider this individual, we would
appreciate you furnishing the information requested below. Your prompt response to this inquiry will be most
helpful and will be held in strict confidence.
Please rate this student in the following areas using this rating grid:
5 = Outstanding
4 = Highly Competent/Strongly Present
3 = Competent/Moderately Present
2 = Needs Improvement
1 = Unacceptable
NA = Unable to assess
Attendance
• No more than 2 absences per semester 1 2 3 4 5 NA
• No more than 2 times arrived late for school 1 2 3 4 5 NA
Positive Work Habits
• Demonstrates mature and professional attitude 1 2 3 4 5 NA
• Flexible – modifies course of action as needs or priorities change 1 2 3 4 5 NA
• Completes assigned work on time without asking for extensions or
1 2 3 4 5 NA
exceptions
• Demonstrates responsibility and accountability 1 2 3 4 5 NA
• Demonstrates pride in work setting 1 2 3 4 5 NA
• Complies with policies 1 2 3 4 5 NA
• Demonstrates dependability 1 2 3 4 5 NA
Interpersonal Relationships
• Works well in teams 1 2 3 4 5 NA
• Willing to consider a variety of viewpoints 1 2 3 4 5 NA
• Demonstrates tact and sensitivity when dealing with others 1 2 3 4 5 NA
• Shares credit for team accomplishments 1 2 3 4 5 NA
Communication Skills
• Articulates views in a concise and understandable manner 1 2 3 4 5 NA
• Is a receptive listener; shows interest and understanding 1 2 3 4 5 NA
• Asks questions which clearly define the information being sought 1 2 3 4 5 NA
• Communicates clearly in writing 1 2 3 4 5 NA
• Demonstrates congruent verbal and non-verbal communication 1 2 3 4 5 NA
• Expresses abstract ideas in concise and understandable terms 1 2 3 4 5 NA
Critical Thinking Skills
• Demonstrates an ability to use problem-solving techniques 1 2 3 4 5 NA
• Uses available resources to aid in solving problems; seeks other
1 2 3 4 5 NA
opinions
• Generates more than one alternative to solving a problem 1 2 3 4 5 NA
• Gathers data and asks questions to avoid making assumptions
1 2 3 4 5 NA
about situations
UAP APPLICATION Pg. 5• Follows up on outcomes of chosen solutions to provide feedback for
1 2 3 4 5 NA
future decisions
Clinical Competence
• Demonstrates clinical competence consistent with educational
1 2 3 4 5 NA
standards for this level
Additional Comments:
Based on my observations of ____________________________________ in a clinical setting, the following
statement is true: (student’s name)
(check one)
I recommend that this student be considered for employment as a Nursing Student UAP.
I do not recommend that this student be considered for employment as a Nursing Student
UAP.
Instructor: _________________________________________________________________________________
(Printed name) (Signature)
Nursing Program: ___________________________________________________________________________
Date: __________________________
THANK YOU FOR YOUR COOPERATION
PLEASE RETURN TO STUDENT IN SEALED ENVELOPE OR MAIL DIRECTLY TO:
Montana Health Network
Attn: Christine Williams
519 Pleasant, Miles City, MT 59301
or
registration@montanahealthnetwork.com
or
Fax: (406) 234-1423
UAP APPLICATION Pg. 6You can also read
