Family Nurse Practitioner Residency Application Year 2021-2022

Please submit a completed copy of this form and your CV to fnpresidency@institute.org. Application period ends 12/31/2020.

Your Contact Information

First Name Last Name

Other name used/ Preferred Name Preferred Pronouns

E-mail Address Phone

Address/ Location

Eligibility

Are you authorized to work lawfully in the United States?

Yes

No

Please note, the Institute for Family Health is not able to commence ("sponsor") an immigration case in order to employ you (for example, H-1B or other employment- based immigration case).

Is your primary speciality as a Family Nurse Practitioner?

Yes

No

If you have a secondary speciality (for example, certified nurse midwife or women's health nurse practitioner) please indicate below.

Will you be enrolled in a DNP Program while completing your residency? (To be eligible to apply, you can not be enrolled in an academic program while completing the residency.) Yes No

Will you complete your NP degree between January 2020 and July 2021? Yes No

Are you board certified?

Yes

No

If no, will you be eligible to take the board exam by May 2021?

Yes

No

Clinical training experience

Please provide four clinical training experiences below. These experiences can be both clinical rotations and employed work experience in a clinical setting.

Institution Dates of experience

Was this experience a clinical rotation or an employer?

Clinical Rotation

Employer

Neither

Type of care delivery site (outpatient, hospital, specialty care). Please be specific.

Briefly describe the clinical activities you participated in at this site.

Institution Dates of experience

Was this experience a clinical rotation or an employer?

Clinical Rotation

Employer

Neither

Type of care delivery site (outpatient, hospital, specialty care). Please be specific.

Briefly describe the clinical activities you participated in at this site.

Institution Dates of experience

Was this experience a clinical rotation or an employer?

Clinical Rotation

Employer

Neither

Type of care delivery site (outpatient, hospital, specialty care). Please be specific.

Briefly describe the clinical activities you participated in at this site.

Institution Dates of experience

Was this experience a clinical rotation or an employer?

Clinical Rotation

Employer

Neither

Type of care delivery site (outpatient, hospital, specialty care). Please be specific.

Briefly describe the clinical activities you participated in at this site.

Short Answer Questions

Please answer each question in 3-7 lines of text.

What experiences have led you to choose nursing as a profession and the role of a family nurse practitioner as a speciality practice?

Please describe your short and long term professional goals. How will completing this residency help you accomplish your goals?

Our most successful team members are self-sufficient and self-motivated and can work both independently and a part of a team. Can you describe a specific experience where you displayed these skills?

AEverettText BoxWhy are you interested in training at the Institute for Family Health? What is it about our mission statement that appeals to you?

Is there anything else you would like us to know about you?

Languages spoken (please indicate fluency)

AEverettText BoxThe Institute for Family Health's FNP Residency Program operates from two continuity sites. If selected as a resident, do you have a site you would prefer as your primary location? (We will do our best to accommodate your preference, but we consider all applicants for both sites unless noted below.)

Stevenson - 731 White Plains Road Bronx, NY 10473 Walton - 1894 Walton Avenue Bronx, NY 10453 I have no preference.

If we are unable to place you at your preferred location are you interested in being considered for your alternate selection?

Yes No Not Applicable

AEverettText BoxPlease submit your completed application and CV to fnpresidency@institute.org. In your CV please include:

1) All educational information (dates, degrees, institutions, locations)2) Work, volunteer, or community service experience3) Extracurricular activities4) Leadership experience5) Research or publications6) NP community involvement (professional organizations, conference attendance, etc.)

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