Application for Admission Master of Science in Nursing Program

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					                                                          Application for Admission
                                                     Master of Science in Nursing Program
          Return with $50 application fee to Vanderbilt School of Nursing, Office of Admissions, 207 Godchaux Hall, 461 21st Ave. South, Nashville, TN 37240.


Name __________________________________________________________ Social Security Number ______ -______ - _________
             LAST                 FIRST                  MIDDLE               MAIDEN

Present Address _____________________________________________________________________________________________
City _________________________________ State ____________________ Zip ________________
Use Present Address Until _______ / _____ / ______ Proposed Entrance Date: Fall 20 _______ Spring 20_______ Summer 20____
E-Mail Address ____________________________________________ Primary Phone ( _______ ) ___________________________
Citizenship ________________________________________________ Work/Cell Phone ( _______ ) _________________________
Date of Birth ____________ /______ /________ Place of Birth ______________________________________________________
                        MONTH          DAY        YEAR                                             CITY                  STATE/COUNTRY

Gender:         Male       Female

Do you consider yourself to be Hispanic/Latino?                      Yes        No
If yes:         Puerto Rican           Cuban American              Mexican American             Other Hispanic/Latino



Please select one or more races you identify with:
  American Indian or Alaskan Native                        Asian or Asian American, including Indian subcontinent                 African American or Black
  Native Hawaiian or Other Pacific Islander                White


Please indicate which entry option best                  Proposed Specialty:
describes you:
                                                            Adult-Gerontology Acute Care Nurse                   Pediatric Primary Care Nurse Practitioner
   I have (will have) a bachelor’s or higher                Practitioner                                         Psychiatric & Mental Health NP family
   degree in a non-nursing field                            Adult-Gerontology Acute Care Nurse                   focus
   I have (will have) an ASN or Diploma in                  Practitioner and Intensivist (RNs only)              Urogynecology (Post Master’s)
   Nursing and at least 78 semester hours of                Adult-Gerontology Primary Care Nurse                 Women’s Health NP (WHNP)
   college credit                                           Practitioner                                         WHNP and Urogynecology* (RNs only)
   I have (will have) a BSN in Nursing                      Emergency Nurse Practitioner
                                                            FNP/ACNP* (RNs Only)                              Dual Majors/Degrees:
   I have a Master of Science in Nursing                    Family Nurse Practitioner (FNP)
                                                            Health Systems Management                            NMW/FNP*
Entry Status:                                               (online program RNs only)                            WHNP/ANP*
                                                            Neonatal Nurse Practitioner (RNs only)               MSN/MDiv (indicate nursing specialty
   Full-Time*                                               Nurse-Midwifery* (NMW)                               and apply to Divinity School)*
   Part-Time                                                Nursing Informatics (most courses                    MSN/MTS (indicate nursing specialty and
                                                            offered online - RNs only)                           apply to Divinity School)*
*Full-time study only begins in the fall                    Pediatric Acute Care Nurse Practitioner
semester. Pre-specialty students must be full               (RNs Only)                                        *Requires additional semester(s)
time.
NURSING LICENSURE INFORMATION

1.Have you ever been arrested or convicted of a felony, misdemeanor (other than a minor traffic violation), crime involving moral tur-
 pitude, or a crime violating federal or state law relating to controlled substances or dangerous drugs? (DWI and DUI are not minor
 traffic violations.) For purposes of this question, a “conviction” includes a finding or verdict of guilty, plea of guilty, a plea of nolo
 contendere, or first offender treatment, and also includes adjudication of guilt or sentence withheld or not entered on the charge
 (s). NOTE: The answer to this question is “YES” if an arrest or conviction has been pardoned, expunged, dismissed or deferred, you
 pled & completed probation under First offender and/or your civil rights have been restored and/or you have received legal advice
 that the offense will not appear on your criminal record        Yes    No

2. If “yes”, have you included a certified copy of the court records and final disposition in a sealed envelope from the court with your
   application? In the event the file no longer exists, you must submit documentation from the court stating that fact

3. If “yes”, have you included a personal, detailed letter explaining each incident?                  Yes     No
4. High School Graduate?          Yes      No* Date of Diploma: ____________________________________________________________
  G.E.D. Equivalency?         Yes       No* Date Test Administered:_________________________________________________________
  *As required by the Tennessee Board of Nursing, the School of Nursing only recommends graduates from high school or its equivalent who have completed our
  program for the National Council Licensure Examination for Registered Nurses.

5. If you are a RN licensed in the State of Tennessee, please list current license number: _____________________________________
  Expiration Date: ______________________
6. Please list any states other than Tennessee in which you are licensed to practice:
   __________________________________________________________________________________________________________
7. Are you a licensed healthcare provider in another discipline (e.g. dietician, LPN, physical therapist, respiratory therapist, etc.)
    Yes      No Discipline _____________________________________ License number _________________________________
  Expiration Date: ______________________________________
8. Have you ever had your license revoked or disciplinary action taken against you?                          Yes     No
   If yes, please attach letter of explanation.

FINANCIAL AID

Are you applying for financial aid?          Yes      No

POST HIGH SCHOOL EDUCATION AND EXPERIENCE

1. Please list all post-high school educational institutions beginning with the most recent one attended.

          INSTITUTION                    LOCATION                            DATE OF ATTENDANCE                                   DEGREE AND DATE
  __________________________________________________________________________________________________________
  __________________________________________________________________________________________________________
  __________________________________________________________________________________________________________
  __________________________________________________________________________________________________________
  __________________________________________________________________________________________________________

2. Have you ever been dismissed or withdrawn from any school or college?                            Yes No
   If so, please indicate which school and attach letter of explanation.
3. Have you previously applied to Vanderbilt University School of Nursing for admission?             Yes No
   If so, when? ___________________________
4. Please list your work experience beginning with your most recent employment first (or attach resumé):
  __________________________________________________________________________________________________________
  __________________________________________________________________________________________________________

5. Do you or have you ever served in the military including the reserves?                  Yes      No
  If yes, please explain _________________________________________________________________________________________
GRADUATE RECORD EXAMINATION

When did/do you plan to take the Graduate Record Examination (GRE)? _________________________________________________

EMERGENCY CONTACT


Name ______________________________________________________________ Relationship _____________________________
Address ____________________________________________________________ Primary Phone (________) _________________
                      STREET
____________________________________________________________________ Work/Cell Phone (________) ________________
             CITY                           STATE                                       ZIP



REFERENCES             (Please list the three individuals who have supplied your recommendations* )
             NAME                                                            POSITION                                                ADDRESS
___________________________________ __________________________________                                         ___________________________________
___________________________________ __________________________________                                         ___________________________________
___________________________________ __________________________________                                         ___________________________________
*NOTE: Individuals should be genuinely qualified to evaluate your academic/professional qualifications. References from family, friends and co-workers are not ap-

propriate.



INFORMATION FOR OUR RECORDS
1. Are you currently employed by Vanderbilt University or Vanderbilt Medical Center?                               Yes       No
2. Do you currently reside in a rural community?                            Yes         No
3. Do you currently reside in a medically underserved community?                                   Yes         No
4. Upon graduation do you plan to practice in a rural community?                                  Yes         No         Undecided
5. A medically underserved community?                              Yes          No           Undecided
  If yes, please indicate the county/state of your intended practice: _______________________________________________
6. How did you hear about our program? Please check all that apply:
      Advertisement in (publication)________________________
      Current Student (please supply name) ____________________________
      Alumni (please supply name) ________________________________________________
      Current VUMC Employee (please supply name) ____________________________________________
      Faculty (please supply school) ________________________________________________
      Nursing conference/workshop______________________________________
      WWW site ______________________________________
      Other______________________________________
7. Please list any relatives who have attended or who are employed at Vanderbilt:
  Please state relationship and if the individual is a member of the alumni or an employee.
  Name ______________________________________________________________________
  Relationship _____________________________________                                 Alumni       Employee
  Name______________________________________________________________________
  Relationship _____________________________________                                 Alumni       Employee


STUDENTS WHO LIVE AT A DISTANCE:
All non-RN pre-specialty students must take coursework on site at Vanderbilt University School of Nursing in the first year. Clinical in
the specialty year may be pursued at your home location in certain specialties. Due to certain restrictions, the School of Nursing is
not able to accommodate clinical placements in all locations. RN experience restrictions may apply. See
http://www.nursing.vanderbilt.edu/msn/distlearn.html for details or call 1-615-343-0939 for more information.
     I will take specialty year classes via distributed learning methods and high-speed internet connection. I will do my specialty year
     clinical practice in my home site of_________________________________ (subject to approval of Vanderbilt School of Nursing).
      I will take specialty year classes on site at Vanderbilt University School of Nursing (all non-RN students must take pre-specialty
      year classes on site)

STUDENT AFFIDAVIT
I certify that the information given herein is true to the best of my knowledge and hereby agree to be bound by all policies,
procedures, and regulations of Vanderbilt University, both those presently existing and those subsequently amended or adopted.

___________________________________________________________                                        _______________________________
                      APPLICANT’S SIGNATURE                                                                               DATE



RELEASE OF INFORMATION
I authorize the release of information contained in this application to be used for the purpose of considering me for scholarship funds
and so that aggregate data concerning the School of Nursing may be compiled.

_____________________________________________________________                                      _______________________________
                      APPLICANT’S SIGNATURE                                                                               DATE



                                             GOAL STATEMENT AND INTERVIEW SURVEY INSTRUCTIONS

GENERAL: Both the writing style (i.e., grammar, spelling, word use) and content will be used in the overall evaluation of your re-
sponses. Please type your goal statement and interview responses on separate pieces of paper and include them with your applica-
tion materials.

STATEMENT OF CAREER GOALS
Please use this as an opportunity to tell us (as specifically as you can at this time) what you are planning to do with your nursing
career in your specialty area after you complete the Master of Science in Nursing (MSN) degree. For example, what do you
see as the role of the advanced practice nurse in your specialty?

INTERVIEW SURVEY*
1. What is your concept of nursing? Why do you want to become an advanced practice nurse?
2. Describe talents, aptitudes, gifts and personal strengths you possess and how these could contribute to a career in nursing?
3. How will you apply your personal strengths to assure success in Vanderbilt University School of Nursing’s intense
   accelerated program?
4. What has influenced your decision on a specialty? Describe any life experiences that have contributed to your interest in
   your selected specialty.
5. What is your understanding of the responsibility of an adult learner in graduate level education?
6. How will your acceptance into this program impact your current living and working situations?
   What challenges do you anticipate if accepted and how will you manage these anticipated challenges?

*Note: An interview in person or by telephone is required in Psychiatric-Mental Health Nurse Practitioner program and may be required in other specialties. Applicants
are also welcome to request a personal interview and a visit to the campus to meet with faculty and students, attend classes and tour the facilities.


NON-DISCRIMINATION POLICY
In compliance with federal law, including the provisions of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amend-
ment of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, the ADA
Amendments Act of 2008, Executive Order 11246,, and the Uniformed Services Employment and Reemployment Rights Act, as
amended, and the Genetic Information Nondiscrimination Act of 2008 , Vanderbilt University does not discriminate against individu-
als on the basis of their race, sex, religion, color, national or ethnic origin, age, disability, or military service, applicable veteran status,
or genetic information in its administration of educational policies, programs, or activities; admissions policies; scholarship and loan
programs; athletic or other University-administered programs; or employment. In addition, the University does not discriminate
against individuals on the basis of their sexual orientation, gender identity, or gender expression consistent with the University’s
nondiscrimination policy. Inquiries or complaints should be directed to Anita J. Jenious, J.D., Director; the Equal Opportunity, Affir-
mative Action, and Disability Services Department; Baker Building; PMB 401809, 2301 Vanderbilt Place; Nashville, TN 37240-1809.
Telephone 615-32(2-4705) (V/TDD); FAX 615-34(3-4969.)
                                                    Recommendation Form
                                              Master of Science in Nursing Program
                                                                                                                  PROPOSED SPECIALITY

Name _________________________________________________________________________________                              Adult-Gerontology Acute Care Nurse
                        FIRST           MIDDLE              MAIDEN              LAST
                                                                                                                    Practitioner
Present Address _________________________________________________________________
                                                                                                                    Adult-Gerontology Acute Care NP
_________________________________________________________________________________________________                   Intensivist (RNs Only)
         CITY              COUNTY            STATE                      ZIP                                         Adult-Gerontology Primary Care
                                                                                                                    Nurse Practitioner
Name of Evaluator________________________________________________________________
                                                                                                                    Emergency Nurse Practitioner FNP/
                                LAST              FIRST                         MIDDLE
                                                                                                                    ACNP* (RNs Only)
                          Academic                  Employer                                                        Family Nurse Practitioner (FNP)
APPLICANT
                                                                                                                    Health Systems Management (RNs
1. Please complete the information above.                                                                           Only)
                                                                                                                    Neonatal Nurse Practitioner (RNs
2. Read the statement below and, if you choose, sign it where indicated. The Family Education Rights and            Only)
Privacy Act of 1974 entitles School of Nursing graduate students to have access to letters of evaluation in         Nurse-Midwifery *
their records at the School. The applicant may waive the right of access to letters of evaluation in which case     Nursing Informatics (RNs Only)
letters of evaluation will be considered confidential by the School of Nursing and will not be available to the     Pediatric Acute Care Nurse
student. If you wish to waive your right to access this letter of evaluation, please sign your name on the line     Practitioner (RNs Only)
below the following statement.                                                                                      Pediatric Primary Care Nurse
                                                                                                                    Practitioner
I, the undersigned, hereby waive all rights or privileges provided by Public Law 93-380 to inspect or challenge     Psychiatric and Mental Health Nurse
the content and comments appearing in this letter of evaluation.                                                    Practitioner -family focus
                                                                                                                    Urogynecology (Post Master’s)
Applicant’s Signature _________________________________ Date _______________
                                                                                                                    Women’s Health Nurse Practitioner
3. Please use legal-sized envelopes. Please type or print your name and address on the front of the envelope        (WHNP)
and mail it with this form to the evaluator you have identified above.                                              WHNP and Urogynecology* (RNs
                                                                                                                    Only)
RECOMMENDER
                                                                                                                  Dual Degrees: On Campus Online
Please complete the information requested on both sides of this form. If you need additional sheets of paper
                                                                                                                    NMW/FNP*
please staple them to this form. Your comments will be held completely confidential if the applicant has
                                                                                                                    WHNP/Adult Gerontology Primary
signed the statement above. Please enclose this form and any attachments in the envelope addressed to the
                                                                                                                    Care NP
applicant. Please sign the back of the envelope, writing your signature across the seal of the envelope flap
                                                                                                                    MSN/MDiv & MSN/MTS
and return sealed envelope to the applicant.
                                                                                                                  *Additional semester(s) required
Please evaluate the applicant’s qualifications by checking the appropriate spaces below.

 QUALIFICATIONS                                     EXCELLENT               GOOD              AVERAGE               BELOW            NO BASIS FOR
                                                                                                                   AVERAGE           JUDGEMENT
 Intellectual Ability
 Critical thinking
 Inquisitiveness
 Knowledge in subject of proposed study
 Verbal communication of ideas
 Written communication of ideas
 Industry and perseverance
 Emotional stability
 Self-image
 Independence
 Creativity-Imagination
 Leader ability
2. Please describe your relationship to the applicant and how long you have known her/him.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. The School of Nursing appreciates your statement concerning this applicant. Please comment on the following: Estimate of char-
   acter, and how well qualified he/she is for advanced study in nursing.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

4. Do you know of any special circumstances in the applicant’s social or academic background or emotional makeup that should
  be considered in the evaluation of this applicant for graduate studies?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Signature____________________________________________________ Date ____________________________________________

Name (please print) ___________________________________________________________________________________________

Position or Title_______________________________________________ Daytime phone number ____________________________

Full Address __________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
                   CITY                                                                STATE                        ZIP




NON-DISCRIMINATION POLICY

In compliance with federal law, including the provisions of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amend-
ment of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, the ADA
Amendments Act of 2008, Executive Order 11246,, and the Uniformed Services Employment and Reemployment Rights Act, as
amended, and the Genetic Information Nondiscrimination Act of 2008 , Vanderbilt University does not discriminate against individu-
als on the basis of their race, sex, religion, color, national or ethnic origin, age, disability, or military service, applicable veteran status,
or genetic information in its administration of educational policies, programs, or activities; admissions policies; scholarship and loan
programs; athletic or other University-administered programs; or employment. In addition, the University does not discriminate
against individuals on the basis of their sexual orientation, gender identity, or gender expression consistent with the University’s
nondiscrimination policy. Inquiries or complaints should be directed to Anita J. Jenious, J.D., Director; the Equal Opportunity, Affir-
mative Action, and Disability Services Department; Baker Building; PMB 401809, 2301 Vanderbilt Place; Nashville, TN 37240-1809.
Telephone 615-32(2-4705) (V/TDD); FAX 615-34(3-4969.)
                                                    Recommendation Form
                                              Master of Science in Nursing Program
                                                                                                                  PROPOSED SPECIALITY
Name _________________________________________________________________________________
                        FIRST           MIDDLE              MAIDEN              LAST                                Adult-Gerontology Acute Care
Present Address _________________________________________________________________                                   Nurse Practitioner
                                                                                                                    Adult-Gerontology Acute Care NP
_________________________________________________________________________________________________
         CITY              COUNTY            STATE                      ZIP                                         Intensivist (RNs Only)
                                                                                                                    Adult-Gerontology Primary Care
Name of Evaluator________________________________________________________________                                   Nurse Practitioner
                                LAST              FIRST                         MIDDLE                              Emergency Nurse Practitioner FNP/
                          Academic                  Employer                                                        ACNP* (RNs Only)
APPLICANT                                                                                                           Family Nurse Practitioner (FNP)
                                                                                                                    Health Systems Management (RNs
1. Please complete the information above.
                                                                                                                    Only)
                                                                                                                    Neonatal Nurse Practitioner (RNs
2. Read the statement below and, if you choose, sign it where indicated. The Family Education Rights and
                                                                                                                    Only)
Privacy Act of 1974 entitles School of Nursing graduate students to have access to letters of evaluation in
                                                                                                                    Nurse-Midwifery *
their records at the School. The applicant may waive the right of access to letters of evaluation in which case
                                                                                                                    Nursing Informatics (RNs Only)
letters of evaluation will be considered confidential by the School of Nursing and will not be available to the
                                                                                                                    Pediatric Acute Care Nurse
student. If you wish to waive your right to access this letter of evaluation, please sign your name on the line
                                                                                                                    Practitioner (RNs Only)
below the following statement.
                                                                                                                    Pediatric Primary Care Nurse
I, the undersigned, hereby waive all rights or privileges provided by Public Law 93-380 to inspect or challenge     Practitioner
the content and comments appearing in this letter of evaluation.                                                    Psychiatric and Mental Health
                                                                                                                    Nurse Practitioner -family focus
Applicant’s Signature _________________________________ Date _______________                                        Urogynecology (Post Master’s)
                                                                                                                    Women’s Health Nurse Practitioner
3. Please use legal-sized envelopes. Please type or print your name and address on the front of the envelope
                                                                                                                    (WHNP)
and mail it with this form to the evaluator you have identified above.
                                                                                                                    WHNP and Urogynecology* (RNs
RECOMMENDER                                                                                                         Only)
                                                                                                                  Dual Degrees: On Campus Online
Please complete the information requested on both sides of this form. If you need additional sheets of paper        NMW/FNP*
please staple them to this form. Your comments will be held completely confidential if the applicant has            WHNP/Adult Gerontology Primary
signed the statement above. Please enclose this form and any attachments in the envelope addressed to the           Care NP
applicant. Please sign the back of the envelope, writing your signature across the seal of the envelope flap        MSN/MDiv & MSN/MTS
and return sealed envelope to the applicant.                                                                      *Additional semester(s) required
Please evaluate the applicant’s qualifications by checking the appropriate spaces below.

 QUALIFICATIONS                                     EXCELLENT               GOOD              AVERAGE               BELOW            NO BASIS FOR
                                                                                                                   AVERAGE           JUDGEMENT
 Intellectual Ability
 Critical thinking
 Inquisitiveness
 Knowledge in subject of proposed study
 Verbal communication of ideas
 Written communication of ideas
 Industry and perseverance
 Emotional stability
 Self-image
 Independence
 Creativity-Imagination
 Leader ability
2. Please describe your relationship to the applicant and how long you have known her/him.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. The School of Nursing appreciates your statement concerning this applicant. Please comment on the following: Estimate of char-
   acter, and how well qualified he/she is for advanced study in nursing.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

4. Do you know of any special circumstances in the applicant’s social or academic background or emotional makeup that should
  be considered in the evaluation of this applicant for graduate studies?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Signature____________________________________________________ Date ____________________________________________

Name (please print) ___________________________________________________________________________________________

Position or Title_______________________________________________ Daytime phone number ____________________________

Full Address __________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
                   CITY                                                                STATE                        ZIP




NON-DISCRIMINATION POLICY

In compliance with federal law, including the provisions of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amend-
ment of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, the ADA
Amendments Act of 2008, Executive Order 11246,, and the Uniformed Services Employment and Reemployment Rights Act, as
amended, and the Genetic Information Nondiscrimination Act of 2008 , Vanderbilt University does not discriminate against individu-
als on the basis of their race, sex, religion, color, national or ethnic origin, age, disability, or military service, applicable veteran status,
or genetic information in its administration of educational policies, programs, or activities; admissions policies; scholarship and loan
programs; athletic or other University-administered programs; or employment. In addition, the University does not discriminate
against individuals on the basis of their sexual orientation, gender identity, or gender expression consistent with the University’s
nondiscrimination policy. Inquiries or complaints should be directed to Anita J. Jenious, J.D., Director; the Equal Opportunity, Affir-
mative Action, and Disability Services Department; Baker Building; PMB 401809, 2301 Vanderbilt Place; Nashville, TN 37240-1809.
Telephone 615-32(2-4705) (V/TDD); FAX 615-34(3-4969.)
                                                    Recommendation Form
                                              Master of Science in Nursing Program
                                                                                                                  PROPOSED SPECIALITY
Name _________________________________________________________________________________
                        FIRST           MIDDLE              MAIDEN              LAST                                Adult-Gerontology Acute Care
Present Address _________________________________________________________________                                   Nurse Practitioner
                                                                                                                    Adult-Gerontology Acute Care NP
_________________________________________________________________________________________________
         CITY              COUNTY            STATE                      ZIP                                         Intensivist (RNs Only)
                                                                                                                    Adult-Gerontology Primary Care
Name of Evaluator________________________________________________________________                                   Nurse Practitioner
                                LAST              FIRST                         MIDDLE                              Emergency Nurse Practitioner FNP/
                          Academic                  Employer                                                        ACNP* (RNs Only)
APPLICANT                                                                                                           Family Nurse Practitioner (FNP)
                                                                                                                    Health Systems Management (RNs
1. Please complete the information above.
                                                                                                                    Only)
                                                                                                                    Neonatal Nurse Practitioner (RNs
2. Read the statement below and, if you choose, sign it where indicated. The Family Education Rights and
                                                                                                                    Only)
Privacy Act of 1974 entitles School of Nursing graduate students to have access to letters of evaluation in
                                                                                                                    Nurse-Midwifery *
their records at the School. The applicant may waive the right of access to letters of evaluation in which case
                                                                                                                    Nursing Informatics (RNs Only)
letters of evaluation will be considered confidential by the School of Nursing and will not be available to the
                                                                                                                    Pediatric Acute Care Nurse
student. If you wish to waive your right to access this letter of evaluation, please sign your name on the line
                                                                                                                    Practitioner (RNs Only)
below the following statement.
                                                                                                                    Pediatric Primary Care Nurse
I, the undersigned, hereby waive all rights or privileges provided by Public Law 93-380 to inspect or challenge     Practitioner
the content and comments appearing in this letter of evaluation.                                                    Psychiatric and Mental Health
                                                                                                                    Nurse Practitioner -family focus
Applicant’s Signature _________________________________ Date _______________                                        Urogynecology (Post Master’s)
                                                                                                                    Women’s Health Nurse Practitioner
3. Please use legal-sized envelopes. Please type or print your name and address on the front of the envelope
                                                                                                                    (WHNP)
and mail it with this form to the evaluator you have identified above.
                                                                                                                    WHNP and Urogynecology* (RNs
RECOMMENDER                                                                                                         Only)
                                                                                                                  Dual Degrees: On Campus Online
Please complete the information requested on both sides of this form. If you need additional sheets of paper        NMW/FNP*
please staple them to this form. Your comments will be held completely confidential if the applicant has            WHNP/Adult Gerontology Primary
signed the statement above. Please enclose this form and any attachments in the envelope addressed to the           Care NP
applicant. Please sign the back of the envelope, writing your signature across the seal of the envelope flap        MSN/MDiv & MSN/MTS
and return sealed envelope to the applicant.                                                                      *Additional semester(s) required
Please evaluate the applicant’s qualifications by checking the appropriate spaces below.

 QUALIFICATIONS                                     EXCELLENT               GOOD              AVERAGE               BELOW            NO BASIS FOR
                                                                                                                   AVERAGE           JUDGEMENT
 Intellectual Ability
 Critical thinking
 Inquisitiveness
 Knowledge in subject of proposed study
 Verbal communication of ideas
 Written communication of ideas
 Industry and perseverance
 Emotional stability
 Self-image
 Independence
 Creativity-Imagination
 Leader ability
2. Please describe your relationship to the applicant and how long you have known her/him.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. The School of Nursing appreciates your statement concerning this applicant. Please comment on the following: Estimate of char-
   acter, and how well qualified he/she is for advanced study in nursing.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

4. Do you know of any special circumstances in the applicant’s social or academic background or emotional makeup that should
  be considered in the evaluation of this applicant for graduate studies?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Signature____________________________________________________ Date ____________________________________________

Name (please print) ___________________________________________________________________________________________

Position or Title_______________________________________________ Daytime phone number ____________________________

Full Address __________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
                   CITY                                                                STATE                        ZIP




NON-DISCRIMINATION POLICY

In compliance with federal law, including the provisions of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amend-
ment of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, the ADA
Amendments Act of 2008, Executive Order 11246,, and the Uniformed Services Employment and Reemployment Rights Act, as
amended, and the Genetic Information Nondiscrimination Act of 2008 , Vanderbilt University does not discriminate against individu-
als on the basis of their race, sex, religion, color, national or ethnic origin, age, disability, or military service, applicable veteran status,
or genetic information in its administration of educational policies, programs, or activities; admissions policies; scholarship and loan
programs; athletic or other University-administered programs; or employment. In addition, the University does not discriminate
against individuals on the basis of their sexual orientation, gender identity, or gender expression consistent with the University’s
nondiscrimination policy. Inquiries or complaints should be directed to Anita J. Jenious, J.D., Director; the Equal Opportunity, Affir-
mative Action, and Disability Services Department; Baker Building; PMB 401809, 2301 Vanderbilt Place; Nashville, TN 37240-1809.
Telephone 615-32(2-4705) (V/TDD); FAX 615-34(3-4969.)

				
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