EHS Nurse Residency Program: Nurse Resident Interest Form

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EHS Nurse Residency Program: Nurse Resident Interest Form

Welcome to the Vizient/AACN Nurse Residency Program (TM) (NRP) at St. John’s Episcopal Hospital!

You may enter your demographics via this digital form.

Please note the following:

Google requires a Gmail account in order to submit this form. Your Gmail account information (whether personal or otherwise) is not collected or stored by EHS.

Employee ID# (Skip if not currently employed at EHS)

Hire Date (Skip if not currently employed or hired at EHS):

YYYY

First Name: *

Last Name: *

Email Address: *

Phone Number (XXX-XXX-XXXX) *

Best way to contact you (Select all that apply) *

Phone

Day

Evening

Required

Basic nursing education completed at (School Name): *

Adelphi University

Molloy University

Nassau Community College

Plaza College

St. John's University

Other:

Degree received, or expected within 6 months (Select one): *

Accelerated BSN

ADN

BA in Nursing

BSN

Diploma

LPN/LVN

Masters

MSN

Other:

Currently enrolled in Nursing Program and expected to graduate beyond 6 months (Skip if not currently enrolled)

Accelerated BSN

ADN

BA in Nursing

BSN

Diploma

LPN/LVN

Masters

MSN

Other:

Clear selection

Expected Date of Graduation (Skip if already graduated)

YYYY

Nursing Specialty Interest (1st preference) *

Medical-Surgical (Telemetry, Post-operative, Pulmonary)

Critical Care

Emergency Department

Maternal-Child Health

Behavioral Health

Perioperative Care (OR, PACU, Ambulatory Surgery)

Ambulatory Clinic

Other:

Nursing Specialty Interest (2nd preference) - optional

Medical-Surgical (Telemetry, Post-operative, Pulmonary)

Critical Care

Emergency Department

Maternal-Child Health

Behavioral Health

Perioperative Care (OR, PACU, Ambulatory Surgery)

Ambulatory Clinic

Other:

Clear selection

Nursing Specialty Interest (3rd preference) - optional

Medical-Surgical (Telemetry, Post-operative, Pulmonary)

Critical Care

Emergency Department

Maternal-Child Health

Behavioral Health

Perioperative Care (OR, PACU, Ambulatory Surgery)

Ambulatory Clinic

Other:

Clear selection

Submit

Clear form

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