STRIVING TO ACHIEVE LITERACY VIA EDUCATION, RESEARCH AND ENGAGEMENT (SALVERE)

Hello Applicants! Thank you for your interest in the SALVERE Pre-Nursing Public Health Program. If chosen, you will shadow home health nurses that are employed by Universal Nursing Services. In order to be a qualified applicant, you must meet the following requirements: 1) 2) 3) 4) 5) 6) 7) Must have a minimum of 24 credit hours. Submit a resume and cover letter. Copy of unofficial transcript. Be able to dedicate a minimum of 4 hours per week to the program. Completed application must be turned in by OCTOBER 10, 2012 by 8:00 PM. TB test must be complete by the time applicants begin shadowing. Turn in completed documents via email by scanning them to salvereglobal@gmail.com.

If you need help with your resume or cover letter, contact UTSA Career Center. Hours are: Monday Thursday: 7:30 am to 5:30 pm Friday: 8:00 am to 5:00 pm Walk Ins: Wednesday from 1:00 pm to 4:00pm TB Skin test can be completed at Student Health Services on the UTSA campus for a cost of $5. Main Campus Clinic: RWC 1.500 Phone Number: (210) 458- 4142 Downtown Campus Clinic: BV 1.308 Phone Number: (210) 458-2930

Updated September 26, 2012

STRIVING TO ACHIEVE LITERACY VIA EDUCATION, RESEARCH AND ENGAGEMENT (SALVERE)

PLEASE PRINT CLEARLY. TYPED APPLICATIONS ARE HIGHLY RECOMMENDED AND PREFERRED. Name:________________________________________________________________________________ If chosen, how would you like your name to appear on your scrubs (first, last):_____________________ Address: _____________________________________________________________________________ City:________________________ State: _________________________ ZIP:_______________________ Phone Number: (_____)__________________ Date of Birth: _____/______/ _______ Sex: M or F

Email: _______________________________________________________________________________ Emergency Contact: Name:______________________ Relationship:_________________ Phone Number: (____)_________ Name:______________________ Relationship:_________________ Phone Number: (____)_________ Do you have a dependable mode of transportation: When do you plan on applying to Nursing School: YES or NO Fall or Spring 20______

What Nursing Programs are you applying to: _____________________________________________________________________________________ _____________________________________________________________________________________ What Nursing Field interests you (check all the apply): Acute Advanced Practice Cardiac Chronic Research Diabetes Oncology Geriatrics Pediatrics

Maternal & Child Health Womens Health

Mental Health

Other: ___________________________

Have you taken your TB test: YES or NO Do you have other commitments (i.e. work or involvement in other organizations): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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Are you an officer in any organizations? If so, please identify: _____________________________________________________________________________________

How many hours will you be taking in Fall 2012: ______________________________________________ Please mark the box the times you will be present in class. If you have work or any other weekly commitments, please color in those times as well.

Updated September 26, 2012

Short Answer: Please type the responses to the following questions and attach it to the application. Question 1: Please list examples of work, volunteer activities, or organizational involvement that relate to the nursing profession. Question 2: Describe the characteristics and traits that show your suitability in the nursing field. Question 3: What was your motivation for choosing to pursue a career in nursing?

Updated September 26, 2012

CONFIDENTIALITY All job/career shadows have an ethical and legal duty to treat all patient information as confidential. It is the legal right of each patient to expect privacy regarding his or her care. This includes any information on a medical record, the computer system, overheard conversation or visual contact with a patient you may recognize. HIPAA Our Commitment To Do The Right Thing HIPAA (Health Insurance Portability and Accountability Act of 1996) establishes guidelines about who can access patient information. Much of it is plain common sense. Access to certain information is dependent on what type of job you are doing. Some basics to keep in mind are: If information is overheard in passing, it must be kept in confidence. Do not access more information than is necessary to perform your duties. Patient information must be carefully guarded. ALWAYS keep papers containing patient information face down on the work surface to maintain confidentiality. Never throw paperwork that contains patient information in open trashcans. Always use approved containers as directed by your supervisor. There ARE penalties for noncompliance, which can include fines, criminal sanctions and even imprisonment in the most severe cases.

I understand that I am not to access any patient records unless that patient has a valid clinical registration at the clinic or department where I am employed or stationed, and/or I have a job-related need to access it. I further understand that I am not to access my own patient record or that of an immediate family member. I also understand that the law and the policies of this facility prohibit the accessing and disclosure of other confidential information, including but not limited to information about members of the medical staff, the facilitys employees, and the facilitys finances. I understand it is my duty and obligation to maintain confidentiality of all such information, and I shall do so throughout and after the tenure of my services at this facility.

I further understand that any accidental or intentional violation of confidentiality may lead to serious consequences, up to and including term discontinuance of my shadowing at this facility, legal action, or other appropriate action as deemed necessary by the employer.

__________________________________________________ Signature To be complete, this application must be accompanied by: cover letter resume short answer responses unofficial or official transcript

_____________________________ Date

Updated September 26, 2012

Please scan and email your applications to saIvereglobal@gmail.com. I understand that if I fail to meet any portion of the requirements, my application is not acceptable to be reviewed and I cannot qualify for a spot in the shadowing program. I also agree to permit review of this application and my records by anyone representing Pre-Nursing Society/SALVERE Pre-Nursing Public Health Program.

__________________________________________________ Signature

_____________________________ Date

Updated September 26, 2012