Application for Advanced Nursing Education - Nurse Practitioner Residency in Family Practice
On behalf of the University of South Alabama College of Nursing (USA CON) Advanced Nursing Education / Nurse Practitioner Residency (ANE-NPR) project, we are privileged to invite your application to participate in one of the educational programs currently supported by a $2.6 million grant funded by the Health Resources and Services Administration (HRSA) aimed at providing training for primary care FNPs in community-based settings to support placement of the residents in rural and underserved settings in the Mobile, AL area and to retain the FNPs in these primary care settings upon completion of the residency.

This program is intended for recent (within 18 months) graduates of the Nurse Practitioner (MSN) programs who are interested in obtaining additional training and experience working in community-based settings in diverse patient populations.  Upon completion of this residency, you will have the skills, expertise and professional values required to function independently and collaboratively with confidence.

Please answer all questions to the best of your ability.  If there is a question that does not apply to you, please enter N/A.  Thank you so much for your interest in this program.
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Email *
Last Name *
First Name *
Middle Name/Initial *
Phone Number *
Address Line 1 *
Address Line 2 *
City *
State *
Zip Code *
Date of Birth *
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DD
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Gender *
Race *
Ethnicity *
According to the Health Resources and Services Administration (HRSA), "environmentally disadvantaged" means "an individual's environment inhibited him/her from obtaining the knowledge, skills, and abilities to enroll in and graduate from a health professions school."  Do you consider yourself to be environmentally disadvantaged? *
According to HRSA, "economically disadvantaged" means "an individual from a family with an annual income below a level based on the low-income thresholds, according to family size established by the U.S. Census Bureau...A family is a group of two or more individuals."  Do you consider yourself to be economically disadvantaged? *
According to HRSA, "educationally disadvantaged" means "an individual who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program."  Do you consider yourself to be educationally disadvantaged? *
According to HRSA, "rural" means "a geographical area located in a metropolitan county designated by the Federal Office of Rural Health Policy as being considered rural."  Do you consider yourself to have a rural residential background (where you have an established residence)? *
According to HRSA, a "veteran" is "any person who served in one of the seven uniformed services of the United States.  The seven uninformed services include:  The United States Army, Navy, Air Force, Marines, Coast Guard, Public Health Service, and National Oceanic & Atmospheric Administration Commissioned Officers Corps."  Are you a veteran? *
In what month did you complete the Family Nurse Practitioner Program *
In what year did you complete the Family Nurse Practitioner Program *
Institution Name (where you earned your degree) *
Institution Address Line 1 *
Institution Address Line 2 *
City *
State *
Zip Code *
Have you ever received discipline on your RN or APRN license in any state? *
Are you currently being investigated for an RN or APRN licensure matter? *
Have you ever defaulted on a Federal Student Loan or other federally-funded loan? *
Have you worked in any of the following areas?  (optional)
Please select all certifications you currently hold as a Nurse Practitioner at the time of this application. *
Required
Name of certifying board? *
Please list the name, address, and contact information of references as follows:  Specialty Coordinator (FNP Specialty), Clinical Preceptor, and Professional Reference (APRN or RN)                                                             *
What personal, professional, educational and clinical experiences have led you to choose nursing as a profession and the role of a family nurse practitioner as a specialty practice?  (Limit 500 words) *
Please describe your desire to train in a community health center setting as well, as your long term commitment to practicing as a primary care provider.  (Limit 500 words) *
What are your goals for a NP Residency Program, including your aspirations for your short and long term career development?  (List 2-5 goals) *
In what specific areas of interest would you like to develop an increased mastery, competence and confidence?  (List 5-10 areas of interest) *
Thank you for completing this application.  You will be contacted soon to further discuss the program.  Note that submission of this application does not guarantee your enrollment in the Advanced Nursing Education Nurse Practitioner Residency program.  This residency is fully funded by HRSA and the number of applicants we can accept is contingent on the availability of funds we receive each year.
If you are offered a position in the program, are you  committed to completing a 12 month residency in the Mobile, AL area serving the underrepresented and rural population? *
I attest that all information provided in this application is true and complete to the best of my knowledge and belief.  Please provide your electronic signature and date below. *
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