If you have any questions or difficulties, please dont hesitate to email Jennifer Smith at jsmith@ariachc.org

ARIA COMMUNITY HEALTH CENTER

Applications for Nurse Practitioner Residency in COMMUNITY HEALTH and PRIMARY CARE

Training the Next Generation of APRNs in Integrated and Primary Care

Aria Community Health Center (ACHC) is beginning its first chapter of the Nurse

Practitioner Residency program. A Federally Qualified Health Center (FQHC) for

10 years, excited to announce that we are now accepting applications for the Nurse Practitioner

Residency program in Family Practice and Community Health. There are five training sites across Kings County in central California. The

class of 2017/2018 will begin October 2017.

APPLICATION DEADLINE IS APRIL 30, 2017.

The mission of the Residency is:

To identify, support, train and retain qualified and

compassionate recent Nurse Practitioner

graduates, whose career goals coincide with ACHC's mission to improve the health of the

people in and around rural, underserved and

diverse communities.

The Nurse Practitioner Residency in Family Practice and Community Health has the following four goals:

ACCESS: To provide the patients and communities we serve with increased access to quality long-term primary care nurse practitioners.

CONFIDENCE: To develop the knowledge and confidence of nurse practitioner residents necessary to develop and/or sustain an efficient, effective and productive clinical practice.

HIGH QUALITY: To understand contemporary measures of quality, and as a member of an integrated health care team, assure that residents are providing high quality care.

CULTURE: To engage compassionate nurse practitioners interested in a culture of service to others, to develop leadership in their practice and profession, and to create the environment for a fulfilling long-term career at ACHC.

Application Requirements: 1. Three (3) letters of recommendation. As one of, or in addition to the three letters of recommendation that you will be supplying with the provider application, please submit one letter that specifically addresses your capabilities and interests to this Residency Program. 2. Transcripts BSN (or equivalent) and MSN (if completed) 3. CV

General InformationPlease complete all relevant fields.

Suffix

Please enter your home address in full.

City:

Other NamesPlease enter any other names by which you have been known including those appearing on professional diploma licensure.

For Non U.S. CitizensPlease provide information on your immigration status.

LanguagesPlease list all non English languages spoken and level of fluency.

Language 1: Fluency:

Language 2: Fluency:

Language 3: Fluency:

Contact Email Address Cell Phone Home Phone

ARIACOMMUNITY HEALTHCENTER APRN Residency Program Application

First Name Middle Name Last Name

Social Security NPI

State: Zip:

Home Address

Home Address Line 1:

Home Address Line 2:

Other First Name Other Middle Name Other Last Name From Date (mm/yy) To Date (mm/yy)

Other First Name Other Middle Name Other Last Name From Date (mm/yy) To Date (mm/yy)

Country or Citizenship Visa Visa Number Visa Date

Education/Work History List undergraduate and professional education and work history below.

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

ARIACOMMUNITY HEALTHCENTER APRN Residency Program Application

State: Zip:

State: Zip:

State: Zip:

Education/Work History continuedList undergraduate and professional education and work history below.

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

Education Type or Employer:

Degree Earned or Job Title:

Institution Name or functions:

Address Line 1:

Address Line 2:

City:

Phone: Fax: Country:

From (mm/yy): To: (mm/yy):

State: Zip:

State: Zip:

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

State: Zip:

Professional ReferencePlease list the names and addresses of references as follows and based upon the definition below:

Training Director Recommendation Clinical Preceptor or Coordinator Professional Reference Information: These references must have current knowledge of your clinical competence and have known you for at least one year.

Professional ReferenceName:

Institution/Relationship:

Address Line 1:

Address Line 2:

City:

Contact Phone:

Email:

Professional ReferenceName:

Institution/Relationship:

Address Line 1:

Address Line 2:

City:

Contact Phone:

Email:

Professional ReferenceName:

Institution/Relationship:

Address Line 1:

Address Line 2:

City:

Contact Phone:

Email:

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

Reference Type:

Fax:

Specialty:

State: Zip:

Reference Type:

Fax:

Specialty:

Specialty:

State: Zip:

Reference Type:

State: Zip:

Fax:

Application Attestation

Electronic Signature - Type full name Last 4 digits of SSN Date

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

I attest that all information provided in this application is true and complete to the best of my knowledge and belief. I will notify the organizations and/or their agents within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of membership and/or privileges or affiliation by the organizations, and must be submitted on-line or in writing and must be dated and signed by me.

Essay Question

ARIACOMMUNITY HEALTHCENTER APRN Residency Program Application

Please submit responses to the following question. This is an opportunity to reflect upon and communicate to ACHC your personal statement of qualifications, interest, and motivation in acceptance of this Residency. Additional space is provided at the end of this application. (please limit to 500 words or less)

A. 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? What are your aspirations for a Residency program? Please comment upon your vision and planning for your short and long-term career development.

Essay Question

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

Please submit responses to the following question. This is an opportunity to reflect upon and communicate to ACHC your personal statement of qualifications, interest, and motivation in acceptance of this Residency. Additional space is provided at the end of this application. (please limit to 500 words or less)

B. What are the goals that you are looking to accomplish during your residency at ACHC? Please identify specific areas of interest by lifecycle, age , or setting that you would like to develop increased mastery, competence, confidence in.

Essay Question

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

Please submit responses to the following question. This is an opportunity to reflect upon and communicate to ACHC your personal statement of qualifications, interest, and motivation in acceptance of this Residency. Additional space is provided at the end of this application. (please limit to 500 words or less)

C. The ACHC Residency for Nurse Practitioners is in its first year of operation. There has been a significant national interest from community health centers across the country interested in initiating nurse practitioner residency training programs. As members of the residency class, you will be asked to participate to some degree in advancing the model. Please comment on your personal qualities and strengths that you think will contribute positively to this experience. What apprehensions, concerns and hesitations might you have? Please be candid with us. We appreciate your frankness!

Essay Question

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

Use this additional space to continue your essay. Please indicate Essay Question A, B, or C.

Essay ______________

Essay Question

ARIA COMMUNITY HEALTH CENTER APRN Residency Program Application

Use this additional space to continue your essay. Please indicate Essay Question A, B, or C.

Essay ______________

Essay Question

ARIACOMMUNITY HEALTHCENTER APRN Residency Program Application

Use this additional space to continue your essay. Please indicate Essay Question A, B, or C.

Essay ______________

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