application form part a - personal information - Winnipeg Regional ...

APPLICATION FORMPlease fill in all the information requested in this application form and please print clearly.Please indicate below which critical care stream you are applying for: Adult Pediatric/NeonatalPlease indicate below the sponsoring institution. Applicants sponsored by the Critical Care Managerfrom a Community Site are pre-assigned to a tertiary institution for lab and clinical. St. Boniface Hospital Concordia Hospital Victoria General Hospital Health Sciences Centre IICU (Health Sciences Centre) Grace Hospital Seven Oaks General HospitalPART A - PERSONAL INFORMATION:Surname Given Name(s) Maiden NameMailing Address City Province Postal CodeHome Phone (include area code) Cell Phone (include area code) Work Phone (include area code)Email Address (personal):Birth date(day / month / year)SIN #Current CRNM # (include photocopy)Emergency Contact Person (relationship):Home Phone(include area code)Cell Phone(include area code)Work Phone(include area code)I declare the information to be true and complete to the best of my knowledge. Withholding information mayresult in my dismissal from the program at any time. If accepted, I agree to abide by the policies, proceduresand working conditions established by the St. Boniface Hospital and Health Sciences Centre. I hereby authorizethe St. Boniface Hospital and Health Sciences Centre to conduct a personal investigation including contactingprevious employers in connection with my application to the program.Signature of applicant:Date:WCCNEP Application Form – page 1

APPLICATION PROCEDURE CHECKLIST:MAILING ADDRESS:Winnipeg Critical Care Nursing Education Programc/o Health Sciences Centre – Room GF201820 Sherbrook StreetWinnipeg, ManitobaR3A 1R9Send the following information to the above mailing address: Completed Winnipeg Critical Care Nursing Education Program Application along with thefollowing: CRNM Registration – A photocopy of your current College of Registered Nurses ofManitoba (CRNM) registration. Social Insurance Number: If SIN starts with a “9”, a photocopy of both the SIN cardAND work permit MUST be attached. If you are NOT an employee of Health Sciences Centre or St Boniface Hospital, you MUSTprovide us with a photocopy of your most recent paystub and a voided cheque. Basic Life Support - Applicants must present proof of having successfully completed aBasic Life Support (BLS) - Heart & Stroke Foundation of Canada - Health Care Provider(Level C). It is the applicant’s responsibility to ensure that he/she has current registration. Aphotocopy of current registration/renewal must be submitted with the application form orprior to acceptance to the program. If you do not have current registration/renewal, please arrange to enrol in a Basic LifeSupport (BLS) - Heart & Stroke Foundation of Canada - Health Care Provider (Level C).Registration/Renewal must remain current for the entire program. Advanced Cardiac Life Support (ACLS) – If you have current ACLS registration, pleaseprovide a photocopy of successful completion with the application form or prior toacceptance to the program. Immunization Record Form – Applicants MUST update their immunizations. A photocopyof proof of immunizations must be submitted with the application form or prior to acceptanceto the program.Arrange for the following to be submitted directly to the above address by the applicationdeadline: Arrange to have your “Reference Form to Support Application” completed by yourcurrent or most recent supervisor. This must be forwarded DIRECTLY to the applicableaddress by your supervisor or it will not be accepted.NOTE: We are not responsible for any original documentation enclosed with your application.You will be contacted by the WCCNEP office for an interview.Your file will be reviewed. If accepted, you will receive an email to confirm acceptance tothe Winnipeg Critical Care Nursing Education Program.WCCNEP Application Form – page 2

PART B - ACADEMIC INFORMATION:List below only those programs that have been completed.Formal EducationCompletedDiploma of NursingInstitution Name & AddressSite & Unit SeniorExperience completedGraduatingYearGPA/AverageUndergraduate Degree inNursingSite & Unit SeniorExperience completedUndergraduate Degree(other) – specify FacultyMasters – specify FacultyCertificate - specifyList below any university/college courses** taken (and not applied toward a university/collegedegree listed in the previous table). The university/college course(s) must have been taken before orafter your basic nursing education (ie. Diploma in Nursing Certificate or Baccalaureate Nursing Degree).Those courses such as Introductory Psychology, Introductory Sociology, or Anatomy and Physiology, thatwere needed to complete your basic nursing certificate or degree, are not to be included in this table.List University/College CoursestakenInstitution Name & AddressCreditHoursGradeYearWCCNEP Application Form – page 3

PART C - CONTINUING EDUCATION:List courses, workshops, seminars, conferences, etc. for the last five years.CourseAdvanced Cardiac Life Support(ACLS, PALS)Trauma Nursing Core Course(TNCC)Institution / Personproviding workshop, seminar,course, conferenceLength inhoursDate TakenEmergency Nursing CourseECG Monitoring CourseWorkshop, Seminar,ConferencePART D - OTHER INFORMATION:Please describe any volunteer activities, awards, professional association membership, committeeparticipation, etc.WCCNEP Application Form – page 4

INSTRUCTIONS FOR COMPLETING THE EMPLOYMENT RECORD FORM - Please use the codes (on the next page) when completing theEmployment Record Form.PART E - EMPLOYMENT RECORDThis form must be completed. A resume will not be accepted as a substitute.EMPLOYMENTHOURS and employment category.List number of hours worked in each of the following categories:1.PLACE OFEMPLOYMENT(Address)Please list all yournursing experiencefrom the last sevenyears in orderbeginning with thelast position.2.EmploymentCode(indicate T,COM, RUR,etc.)3.EFT4.DatesStartDateEndDate5.Rotation6.ICU7.Telemetry/MonitoredUnit8.ER9.Peds10.Acute CareMed/Surg /Float11.OTHER(please bespecific)REASONFORLEAVINGTotal hours (columns 6 to 10)WCCNEP Application Form – page 5

INSTRUCTIONS FOR COMPLETING EMPLOYMENT RECORDPlease use the following codes when completing the Employment Record Form.2. EMPLOYMENT CODET = Tertiary Centre – a teaching centre within a large city (e.g. St. Boniface Hospital orHealth Sciences Centre)COM = Community Hospital – a centre within a large city (e.g. Concordia Hospital,Misericordia General Hospital, etc.)RUR = Rural Hospital – a centre outside the city (e.g. outside the perimeter of the City ofWinnipeg)LTC/PCH =Care Facility where the patient population is dependent on health care providersAG = Nursing employment agency (e.g. Drake Medox, Olsten Kimberley, etc.) in whichnurses work in a variety of settings that include hospitals and patients’ homes.3. EFT4. DATE OF EMPLOYMENT – STARTED AND ENDED5. ROTATIOND12 = 12 hour day shift onlyN12 = 12 hour night shift onlyDN12 = 12 hour day and night shiftD8 = 8 hour day shift onlyE8 = 8 hour evening shift onlyN8 = 8 hour night shift onlyDE8 = 8 hour day and evening shiftDN8 = 8 hour day and night shiftNE8 = 8 hour night and evening shiftCAS = CasualEXPLANATION OF CODING FOR HOURS AND EMPLOYMENT CATEGORIES6. ICU = An intensive care unit (ICU) where patient monitoring (ECG)is common practice. The ICU must be able to care formechanically ventilated patients.7. Telemetry/Monitored Unit = An acute care unit with a minimum of ECGMonitoring/Telemetry. Indicate the type of unit.8. ER = Emergency Room.9. Peds = A pediatric and neonatal intensive care unit.10. Acute Care Med/Surg / Float = An adult acute care medical/surgical unit.11. Other = The following is a partial list of practice areas that would beincluded in the “Other” category:Rehabilitation, Geriatrics, Psychiatry, Community Health,Long Term Care.* When completing this column, please indicate thespecific unit.WCCNEP Application Form – page 6