Nursing Application Forms

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					          Arizona State University
   College of Nursing & Health Innovation

Required Application
  Forms Packet

                  Updated 4/8/11
                                  College of Nursing & Health Innovation
                             500 North 3 Street, Phoenix, Arizona 85004-0698
                                              Mail Code 3020

                        Required Application Forms Instructions:


Please be aware that because of the changes in the health care system, certain nursing roles are in great
demand and admission is highly competitive. Therefore, completed applications (including transcripts,
GRE Analytical writing score, letters of recommendation, all required paperwork) must be received
no later than the posted deadline for priority review. Applications that are late will be reviewed only if
there is space available after the admission process (interviews and review) has been completed. Late
applications that are not reviewed will not be processed for the next application cycle; those applicants
will need to reapply for the following admission term.
                1. Apply to the ASU Graduate College:
                        See web site:
                        An official transcript from each institution attended must be sent directly to
                         the Graduate College Admissions Office (see address below)
                        GRE (Graduate Record Examination) - Analytical Writing Score from the
                         General Test– request that scores be sent electronically to ASU. See web site:
                (Note: post-Masters students are not required to
                         provide a GRE score.)
                    Send transcripts to:
                         Arizona State University
                         Graduate College, Interdisciplinary Bldg, B-Wing, Room 170
                         P.O. Box 871003
                         Tempe, Arizona 85287-1003
                2. Apply to your desired degree program by completing the supplemental section
                   of the Graduate College’s application, and download the Required Application
                   Forms Packet from the link within this section of the application.
                        Upload a current, detailed resume or curriculum vitae
                        Upload your Statement of Purpose, per the below instructions:

                         Prepare a statement reflecting your goals and purposes for pursuing graduate
                         study. For admission purposes, goals will be judged for clarity and congruity
                         with graduate education, congruity with selected nursing role in the DNP and
                         congruity with past and current work experience. Please limit to no more than
                         500 words. Include the following in your statement:

                             Relationship of your identified area of study, your career goals, and
                              specific outcomes you want to accomplish from graduate study

                                                Updated 4/8/11
                           Relationship between your career goals and past and current clinical
                            experience including work experience or future plans to work in rural areas
                            and/or with medically underserved populations.
                           Ideas for your Doctoral Applied Project in your planned area of clinical

                       Upload materials on creative/research activities in which you have participated

                3. Submit Self-Evaluation Form (in this packet) and other required documents
                        Please complete and submit your self evaluation form and other documents to:
                        Arizona State University
                        College of Nursing & Health Innovation
                        Graduate Academic Advisor-DNP
                        500 North 3 Street, Mail Code 3020
                        Phoenix, Arizona 85004-0698

                4. Advisement/Information
                   Applicants who wish to discuss the application process, or explore career choices
                   and graduate program options, can contact our Graduate Academic Advisors at (602)
                   496-0937 (DNP programs) or (602) 496-0703 (Masters and Certificate programs.)
                5. Interview
                   All applicants are required to have an interview with a faculty representative from the
                   clinical area of interest in which the student plans to study. Only applicants with
                   complete application files will be scheduled for an interview with College of
                   Nursing & Health Innovation faculty.

The current University Tuition and Fees Schedules are published on the ASU Web site at: . Tuition and fees are subject to annual review and
possible change upon approval by the Arizona Board of Regents. Additional fees may be attached to
practice courses.

Financial Assistance for graduate study is available in the form of scholarships, traineeships,
assistantships and loans. Scholarships, some traineeships and assistantships are awarded to full-time
students with regular admission status and satisfactory academic standing. Students are advised to
consult the Graduate College Bulletin, Arizona State University Office of Student Financial Assistance, or
the College of Nursing & Health Innovation website for additional information.

           Please visit our website at for more information
                                  and links to University resources.

                                              Updated 4/8/11
                                     SELF EVALUATION FORM
Applicant’s Name (to be completed by applicant)           Address (to be completed by applicant)

Applying to:      Master of Science, Nursing Degree __ Nurse Educator __Community & Public Health
                  Master of Healthcare Innovation        Master of Science, Clinical Research Management
                  DNP: Post- Baccalaureate to Doctor of Nursing Practice Degree
                  List desired specialty: ________________________________________
                  DNP: Post Master to Doctor of Nursing Practice Degree w/ Advanced Practice Specialty
                  List your current specialty:__________________________________
                  DNP: Post Master to Doctor of Nursing Practice w/out Specialty or Adding Specialty
                 Please list desired Specialty to Add:________________________
                 Certificate Programs:
                     Child and Adolescent Mental Health Intervention Specialist Certificate
                  Child Family Mental Health NP Certificate       Clinical Research Management Certificate
Community and Public Health Certificate                    EBP (Evidence-based Practice) Certificate
                   Family NP CertificateInternational Health for Health Professionals Certificate
                  Nurse Educator Certificate

Indicate your preference for program of study:     Full time       Part time

    DIRECTIONS TO THE APPLICANT: Please complete all three pages of this form, sign at the end, and mail
    to the address indicated. Early receipt of the evaluation will be advantageous.
    Place an “X” through the box that best reflects your assessment of yourself on each of the attributes listed


      1 Outdated; scattered and irregular knowledge of nursing
      2 Possesses limited current information
      3 Familiar with most general information
      4 Keeps abreast
      5 Thorough systematic understanding of nursing
         CANNOT JUDGE


      1 Fails to incorporate new information
      2 Maintains status quo; requires assistance with new information
      3 Supports the development of new ideas; deals adequately with information
      4 Contributes to development of new ideas; grasps new information
      5 Generates new ideas; grasps new information easily
        CANNOT JUDGE

                                                   Updated 4/8/11

1 Requires detailed instruction; dependent on others
2 Frequent supervision required; relies on others
3 Routine worker; requires supervision on new tasks
4 Resourceful; independent; paces self
5 A self-starter; seeks additional tasks


1 Makes frequent avoidable errors
2 Work is inaccurate
3 Adequate level of accuracy; occasional errors
4 Seldom makes an error; careful
5 Always accurate; work shows great attention to detail


1 Difficulty communicating ideas and intentions to others
2 Acceptable communication within nursing under normal circumstances
3 Communicates clearly within nursing under unusual circumstances
4 Communicates clearly to multiple audiences under unusual circumstances
5 Clearly expresses ideas even under stress; can translate communication of others (negotiator)


1 Changes objectives; unable to complete tasks without direction
2 Not well focused; rarely completes tasks without direction
3 Usually focused; completes most tasks; requires some direction
4 Focused; completes tasks with only appropriate direction
5 Focused on objectives; completes tasks; overcomes obstacles


1 Unable to prioritize tasks; disorganized work habits
2 Variable efficiency in managing tasks
3 Reorganizes efficient ways of accomplishing tasks with some direction
4 Organizes work and accomplishes tasks with minimal direction
5 Prioritizes and accomplishes tasks independently


1 Insufficient; needs prodding
2 Does only required minimum
3 Good, average output
4 Usually does more than required
5 Energetic; highly productive


1 Does not understand how to get cooperation; poor discipline, too lax or severe
2 Frequent difficulty in obtaining cooperation; difficulty getting job done
3 Receives routine cooperation; gets satisfactory job done
4 Influences and inspires others; get job done well
5 Very strong leader; promotes top performance from others

                                             Updated 4/8/11

1 Poor judgment; likely to make illogical decisions
2 Fair judgment under normal circumstances; sometimes acts before thinking
3 Judgment good on routine matters
4 Thinks clearly and positively under unusual circumstances
5 Logical; sound judgment


1 Has considerable difficulty in adjusting to any assignments
2 Has some difficulty when shifted to new/different assignments
3 Average amount of guidance needed to learn variety of duties
4 Usually learns new assignments with normal supervision
5 Highly flexible; can handle many varied assignments


1 Easily irritated; finds pressures intolerable
2 Occasionally goes to pieces under pressure; is “jumpy” and nervous
3 Has average tolerance for crises; usually remains calm
4 Tolerates pressures; tolerates crises better than most
5 Thrives under pressure; enjoys challenges and problems


1 Unreliable; needs detailed supervision and follow-up
2 Somewhat unreliable; requires occasional check on routine tasks
3 Usually can be depended on, but must be checked on important matters
4 Usually meets responsibilities carefully and correctly
5 Merits utmost confidence


1 Unlikely to be successful in graduate studies
2 Likely to have some difficulties in graduate studies
3 Has potential for success in graduate studies
4 Likely to be successful in graduate studies
5 Highly likely to be successful in graduate studies

                                              Updated 4/8/11
Additional comments:

If possible, please list the names, addresses, and phone numbers for five potential Clinical Sites / Preceptors in your
area (this is especially important if you are outside the Phoenix area, or are an out-of-state applicant):





Printed Name:                                             Your Signature:


Reference forms received by the College of Nursing & Health Innovation are the property of Arizona State
University. They are confidential and not shared with the applicant or persons other than the faculty on the
ASU College of Nursing & Health Innovation Standards Committee or in an advisement position.

Please send completed reference form to:                Graduate Academic Advisor-DNP
                                                        College of Nursing & Health Innovation
                                                        Arizona State University
                                                        500 North 3 Street, Mail Code 3020
                                                        Phoenix, AZ 85004-0698

                                                      Updated 4/8/11
                    ARIZONA STATE UNIVERSITY
                       GRADUATE PROGRAMS
     Immunizations, Health and Fingerprint Information - Required Documents
Submit to: Graduate Academic Advisor-DNP, College of Nursing & Health Innovation, 500 N. 3
              Street, Phoenix, AZ 85004-0698, prior to the application deadline :

     Proof of required two doses of MMR, Measles (Rubeola), Mumps, and Rubella vaccine (second
      MMR must be given after 12/31/79). If the student chooses not to have the second MMR, the
      student must have a titer that demonstrates immunity for Measles (Rubeola) and Rubella.
      *Required of all students applying to ASU. Therefore, you must also submit MMR
      information separately to the ASU Health Services office; please download the form from
      the following website:
      If this is not in place, you will be unable to register for classes. Students who have had
      organ transplants should notify the Graduate Program Office to request a permanent

     Proof of completion of Hepatitis B vaccine (a series of three inoculations or titer)

     Proof of Tetanus/Diphtheria (Td) immunization within the past 10 years.

     Proof of Chicken Pox (Varicella) immunity by titer. If titer is negative, a series of two
      vaccinations (at least 8 weeks apart) is required.

     Proof of a negative TB Skin Test that will be current at the beginning of the time of admission.
      Follow-up treatment is required if the TB Skin Test is positive. Documentation of BCG does not
      mean you do not have to meet this requirement. BCG does not give a true positive TB test and
      therefore does prevent you from being required to demonstrate a negative TB skin test or proof of
      treatment for latent TB infection. . Treatment must be initiated prior to enrollment in any clinical
      course. A TB Skin Test (or evidence of follow-up treatment) is required every 12 months while
      students are participating in clinical courses.

     Copy of active RN license (and copy of advanced practice license if applicable); copy of
      current CPR “Level C” Certification (Health Care Provider) that will not expire in the next 12

     Fingerprint Clearance Card (AZ residents.) (Xerox copy must be submitted; student responsible
      for retaining the original card and showing it to agencies upon request). “Restricted” fingerprint
      card requires a Petition submitted to the College of Nursing & Healthcare Innovation Standards
      Committee. See website: . Out-of-state
      applicants: please submit similar verification of clearance of a fingerprint/background

The following items will need to be submitted to the College of Nursing and Health Innovation
                 Graduate Program Office, upon admission to your program:

     Proof of negative drug screen. Applicants will be notified by the Graduate Education and
      Advanced Practice Program Office about the procedure for the drug screen. Due to changes in
      contracts with clinical agencies this requirement may need to repeated annually.
     Additional laboratory tests, and/or immunizations, or documentation may be required for
      practicum courses by certain health care agencies.
                                             Updated 4/8/11
NOTE: Students are responsible for maintaining the current status of their health records in their
student file located in the Graduate Program Office. Only photocopies of all documentation of health
related materials will be accepted, and may be faxed to 602-496-0545. Students are responsible for
maintaining their own records of current CPR certification, proof of negative TB skin tests and current
fingerprint card until graduation. Copies of proof of these updates must be submitted to the Graduate
Program Office when due.

                          APPLICATION CHECKLIST

 A complete application MUST be submitted prior to the application deadline for
  priority review. Please ensure you have submitted all of the following items:

       Complete the Application for Graduate Admissions through the Graduate College
       at and pay the appropriate fees.
       Be sure to upload your Statement of Purpose, your Resume, and any creative
       and/or research activity materials as part of this application.

       Have your transcripts from every college and university from which a Bachelors
       degree or higher was earned, sent to:

                Arizona State University
                Graduate College
                Interdisciplinary Building, B-Wing, Room 170
                PO Box 871003
                Tempe, AZ 85287-1003

    Click on the link within the application to download the Required Application Forms
    Packet and submit all required forms.

       Complete and submit all supplemental materials to the DNP Academic Advisor:

               Self-Evaluation Form
               GRE Score (Analytical Writing score only is required) **NOT required
                                                             of post-Masters applicants
               Copy of active RN License
               Copy of active Advanced Practice license (required for post- Masters with
                                                              advanced practice ONLY)
               Health and Immunization Documentation (complete all requirements
               specified on the information page)
               Copy of AZ DPS Fingerprint Clearance Card (or similar documentation for
               out-of-state residents proving clearance of fingerprint/background check)
               International students: all additional Graduate College requirements

                                              Updated 4/8/11

Description: Nursing Application Forms document sample