Application for Admission Pre-Nursing Post-Baccalaureate Program Cohort Δ (Delta) to begin Summer 2015

The California State University does not discriminate on the basis of race, color, national origin, gender, sexual orientation or physical handicap in the educational programs or activities it conducts.

Instructions

Complete this pdf application and e-mail it to NurseAdmit.SFSU@gmail.com. Two Letters of Reference, signed and on letterhead, may be sent as an e-mail attachment, or by fax, US mail or carrier to the

address below. Each letter must be accompanied by a Reference Form, downloadable from our web page. Letters and Forms must be received with 2 weeks of the application deadline.

Unofficial transcripts, usually downloadable from the internet, must be e-mailed as an attachment to NurseAdmit.SFSU@gmail.com at the time you submit your application. Official transcripts must be received within 4 weeks of submitting your application. These should be sent directly by the school issuing them, via e-mail attachment to NurseAdmit.SFSU@gmail.com or by US mail or carrier in sealed envelopes to the address below.

$60 application fee, in the form of a check or money order payable to “SFSU Trust Funds”, must be submitted at the time you submit your application. Sorry, we cannot accept payments by credit card.

Dr. Barry S. Rothman Department of Biology, College of Science and Engineering San Francisco State University, 1600 Holloway Avenue San Francisco, CA 94132

Phone: 415-338-2410 Fax: 415-338-2295 (Attn: B. Rothman) E-Mail: NurseAdmit.SFSU@gmail.com

Deadlines: Each year we will admit a new cohort of no more than 60 students each summer (start date, June 08, 2015, for Cohort Δ), and allow a few transfers during the following fall and spring semesters. If all seats in our Program have not been filled by applicants submitting by the deadline, February 15, 2015, late applications may be considered. Because applicants do not have much control over their letter-writers, we will observe a 2-week grace period after the deadline for letters to arrive. However, the application itself must be submitted by the deadline. To speed the completion of applications, we only require unofficial transcripts to be submitted with the application. However, official transcripts must arrive within 4 weeks of the deadline.

Admission Requirements: Applicants must have graduated from an accredited institution of higher learning with a baccalaureate or higher degree and a final GPA of 2.5 or above, or they must earn a GPA of 2.5 or above in their most recent 60 semester-units or 90 quarter-units of course work. Because of the limited number of students that can be accommodated by the Program, applicants with considerably higher GPAs will have an advantage in being admitted. However, GPA will be only one of many factors in evaluating applicants. You must have a Bachelor’s degree from a regionally accredited (http://www.chea.org/Directories/regional.asp) university conferred by the time you begin the Program.

Application Process: Processing of a file will begin only after a complete application and a $60 application fee have been received. Those that pass our initial screening will be invited for an interview. Those who pass our interview screening will receive an official offer of admission. Holding a seat in the Program will require payment of a $500 non-refundable admissions processing fee, usually within 2-3 weeks of the offer of admission.

Immigration Status: US citizens, both in-state and out-of-state, and those with Resident Status (Green Card) are welcome to apply to the Program. There is no preference nor quotas for any types of applicants; all applicants are treated equally and pay the same fees. However, at present, we are unable to enroll international students.

See Checklist (last page) for more details.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 2

Personal Information Please fill all requested information below. Do not leave blanks; if an item does not apply to you, enter “N/A”.

Last Name First Name Middle Name

Maiden Name (if applicable) Other Names (if applicable)

Gender (M/F) Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country)

Are you a U.S. Citizen? Yes No Social Security Number: ______—____—________ Ethnicity (optional)

Present US Visa Status if not a Citizen: Country(ies) of Citizenship:

Native Language: Fluency: Native Language: Fluency:

Other Language: Fluency: Other Language: Fluency:

Other Language: Fluency: Other Language: Fluency:

Mother’s Level of Education: Native Language:

Country of Birth: Language spoken at home:

Current Occupation:

Father’s Level of Education: Native Language:

Country of Birth: Language spoken at home:

Current Occupation:

Current Address

Street 1 Street 2

City State Zip Code Country

Permanent Address

□ Check here if same as Current Address (above). If different, enter a new address below.

Street 1 Street 2

City State Country Zip Code

Contact Information

( ) ( ) (Area Code) Home Telephone Number (Area Code) Work Telephone Number

( ) (Area Code) Cellular Telephone Number E-Mail Address (often checked)

Person who will always know your current address and contact information

( ) Name Relationship (Area Code) Home Telephone Number

( ) (Area Code) Cellular Telephone Number E-Mail Address

Application for Admission to Cohort Δ (Delta)Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 3

College Education

Please provide information on universities/colleges attended in reverse chronological order, based on date of completion (most recent to least recent). If you are currently attending a university or college, write the expected date of completion as the graduation date.

University/College 1

Name: City: State:

Dates Attended => from: to:

Major: Degree: Overall GPA: Total Units: Semester (S) or Quarter (Q):

University/College 2

Name: City: State:

Dates Attended => from: to:

Major: Degree: Overall GPA: Total Units: Semester (S) or Quarter (Q):

University/College 3

Name: City: State:

Dates Attended => from: to:

Major: Degree: Overall GPA: Total Units: Semester (S) or Quarter (Q):

University/College 4

Name: City: State:

Dates Attended => from: to:

Major: Degree: Overall GPA: Total Units: Semester (S) or Quarter (Q):

University/College 5

Name: City: State:

Dates Attended => from: to:

Major: Degree: Overall GPA: Total Units: Semester (S) or Quarter (Q):

Applications to US Nursing Schools

Have you previously applied to a US nursing schools? If you answered yes, please answer the following questions.

How many times have you applied?

During which application cycles did you apply (e.g., 2010-2011)

1.

2.

3.

4.

How many US nursing schools did you apply to during the most recent cycle?

Were you invited for interviews at US nursing schools? If so, how many?

During which application cycles were you invited for these interviews? Have you previously applied to a health profession school other than a nursing school? If you answered yes, please explain

outcome below.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 4

Prerequisites for Nursing School If lecture and lab were combined for a course, fill out the lecture line, leave the lab line blank, and indicate that it was a combined course by

checking the box . Indicate to the best of your ability whether each course was at the major’s (M) or non-major’s (N) level. Note repeated courses by indicating the total number of times the class was taken. A course that has not been repeated has been taken 1 time. Indicate semester units with S and quarter units with Q. Those who took major’s level courses may have taken 2 semesters or 2-3 quarters of certain subjects, for example General Chemistry I and II,

or General Chemistry I, II and III. In such cases, use “Other” for the additional semesters or quarters. If more space is needed, use the Other

Courses Relevant to Pre-Nursing table on the following page. For courses in progress, use i.p. for the grade. Example:

Introductory Biology Lecture M 2 Diablo Valley Coll, UCI F’2010,

W’2011 C-, B+ 3, 4 S, Q

Course

If combined lect/lab, check the box =>

Level (Major’s

or Non-

Major’s)

Times

Taken School(s)

Sem or Qtr &

Year (e.g., Fall, 2010)

Grades Units

Sem

or

Qtr

Science and Math Prerequisites

Introductory Biology Lecture Introductory Biology Lab Introductory Chemistry Lecture Introductory Chemistry Lab Anatomy Lecture Anatomy Lab Physiology Lecture Physiology Lab Microbiology Lecture Microbiology Lab Statistics Other: Other: Other: Other: Other: Other: Other: Other: Other: Other:

Other: Other:

Social Science Prerequisites

English Composition Oral Communication (Speech) Sociology Cultural Anthropology Introductory Psychology Nutrition Other: Other:

Other:

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 5

Other Courses of Interest to our Admissions Committee:

Enter all other Math, Science and Public Health Courses taken.

Course Title, Dept and Number

Level (Major’s

or Non-

Major’s)

School

Sem or Qtr &

Year (e.g., Fall,

2010)

Grade Units S or Q

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 6

Standardized Tests

TEAS Scores – If Taken

Date of Test

(mm/yyyy) Total Score Reading Math Science

English &

Language

Usage

1st Attempt 2nd Attempt

3rd Attempt

Advanced Placements (AP) Test Scores – If Taken

Test Description Date of Test (mm/yyyy) Score

Other Standardized Test Scores; e.g., SAT, ACT, GRE, MCAT, DAT, PCAT, etc.

Test Name

Date of Test

(mm/yyyy)

Total

Section

Description (e.g., Verbal)

Score Section

Description Score

Section

Description Score

English Proficiency Requirement All students who received degrees from outside the United States who do not speak English as a first language, or those with international educational backgrounds, must complete the Test of English as a Foreign Language (TOEFL) and provide the Program with official documentation of the results.

TOEFL Score Type of Test

(paper/computer)

Date of Test

(mm/yyyy) Comments or other information

1.

2.

3.

4.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 7

Financial Aid Please fill out the chart below, indicating the types of financial aid you have received since entering college

Name of Financial Aid Type of Financial Aid Dollar Amount

of Aid

Period Aid was Given

(mm/yyyy to mm/yyyy)

1. 2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

If accepted into our Program, will you be applying for financial aid from SFSU? Yes No

Please note that applications for financial aid can be initiated immediately after an admission offer has been made.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 8

Disadvantaged Status

Do you come from an educationally and/or economically disadvantaged* background? Yes No *The definition of “disadvantaged” is that which is currently in use for health professions programs (42 CFR 57.1804(c)) and includes both

economic and social factors that are barriers to an individual’s participation in a health professions program. This means an individual who

qualifies as a low income student (see chart below) or an individual who comes from an environment that has inhibited the individual from

obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school, or from a program

providing education or training in an allied health profession.

Some of the factors that we take into account in considering disadvantaged status: Growing up in a neighborhood and schools that had gang activity, frequent violence, drug use, and/or high teenage pregnancy

rates, etc. Growing up in a family that at the time had low income. Growing up homeless. Attending elementary, middle and/or high schools that provided poor educations. Having parents with low levels of education. Growing up in a single-parent home or in the foster care system. Having to care for siblings and/or disabled relatives while growing up. Having to work during high school and/or college. Helping to financially support parents and/or siblings during high school and college. Being the target of repeated racial and/or religious discrimination. Speaking English as a second language.

2012 HHS Poverty Guidelines

Number of Persons in Family or Household

48 Contiguous States and D.C. Alaska Hawaii

1

2

3

4

5

6

7

8

For each additional person, add

SOURCE: Federal Register, Vol. 77, No. 17, January 26, 2012, pp. 4034-4035 http://aspe.hhs.gov/poverty/12poverty.shtml

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 9

Statement of Disadvantage

If you selected No above for your Disadvantaged Status, skip to the next page.

If you selected Yes for your Disadvantaged Status, please complete the Statement of Disadvantage below.

1. What personal hardships have you encountered in preparing for a career in nursing? Which have you overcome and how did you do so?

2. What educational hardships have you encountered in preparing for a career in nursing? Which have you overcome and how

did you do so? 3. What economic hardships have you encountered in preparing for a career in nursing? Which have you overcome and how did

you do so?

Free Application For Federal Student Aid (FAFSA) All applicants that claimed to be socioeconomically disadvantaged are required to file a current FAFSA application (http://www.fafsa.ed.gov/) with the SFSU Financial Aid Office. All information entered will be held in the strictest confidence. Not filing a FAFSA application will be considered equivalent to having not coming from a socioeconomically disadvantaged

background.

Have you ever filed a FAFSA application? __________ If "Yes", Please provide the dates: _________________

Have you ever sent a FAFSA application to SFSU? ______ If "Yes", Please provide the dates: _________________

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 10

Work/Experiences Please indicate below employment history and the relevant experiences you have had regarding your pursuit of a career as a nurse.You are not obligated to fill out all 12 experiences. Limit: 1,000 characters for each Experience Description. Experience 1

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 2

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 3

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 4

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 11

Experience 5

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 6

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 7

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 8

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 12

Experience 9

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 10

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 11

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Experience 12

Experience Type: Start Date: End Date:

Experience Name: Average Hours/Week:

Organization Name: Country: City:

Supervisor/Contact Person’s Name:

Title: Phone Number: Email Address: Experience Description:

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 13

Personal Statement

Please complete all eight of the following prompts below. Note that responses are limited to 2,500 characters each. 1. Why have you chosen to pursue a career in nursing?

2. What is your present preparedness and suitability for entering the nursing field? Use this section to address any

academic problems you have incurred and how you have dealt with them.

3. How have you used the resources available to you to help others?

4. What is the nature and type of nursing practice you hope to enter after your professional training has been completed,

including demographics of patient population and location?

5. What potential setbacks or problems do you think may prevent you from gaining admission to a nursing school?

6. To the best of your knowledge, why were you previously not admitted to a nursing school (if applicable)?

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 14

7. Why have you chosen to apply to the SFSU Pre-Nursing Post-Bac Program?

8. Use this space to include any additional information you would like to bring to the Admission Committee’s attention.

How did you hear about us? Check all that apply.

SFSU School of Nursing website

AADSAS post-bac website

StudentDoctor.net

Health professions adviser

Peer group - fellow pre-health students

Web-based search

Public advertisement (buses, student newspapers, etc.)

Other (please specify):

Certification

I hereby certify that all the information I have submitted in this application and in support of my candidacy for admission

to the San Francisco State University Pre-Nursing Post-Bac Program is complete and true to the best of my knowledge

and belief. I understand that knowingly providing false, incomplete or misleading information may be grounds for denial

of admission or, if discovered after an offer of admission has been made, for withdrawal of the offer of admission or

dismissal from the Pre-Nursing Post-Bac Program and San Francisco State University.

Applicant’s Electronic Signature Date

This Certification must be signed electronically (type in your name) for your application to be considered.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 15

List of References Two professional references are required; at least one is preferred from a university faculty member. If no faculty member is available as a reference, explain why at the bottom of this page. Download and e-mail a Reference Form to each of your referees after you have completed and signed the waiver section at the top of the form. The referee must include a signed Written Statement on letterhead with the Reference Form. Be sure to check in with your referees to make sure that your form and letter have been submitted.

Ask your referees to convey the Reference Form and a signed, Written Statement on letterhead, in one of the following ways:

As an e-mail attachment sent to NurseAdmit.SFSU@gmail.com, or

By fax at 415-338-2295 (Attn: Barry S. Rothman), or

By US mail: Place the letter and form in an envelope, seal it and sign across the back flap. Either give the envelope to the applicant or mail it to: Dr. Barry S. Rothman, Department of Biology, College of Science and Engineering, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132.

Reference 1 Last Name: Institution/Organization:

First Name: Telephone:

Title: Email:

Relationship to you: Comments?

Reference 2 Last Name: Institution/Organization:

First Name: Telephone:

Title: Email:

Relationship to you: Comments?

Reference 3 Last Name: Institution/Organization:

First Name: Telephone:

Title: Email:

Relationship to you: Comments?

If a university faculty member is not writing a letter for you, please explain in the space provided below.

Application for Admission to Cohort Δ (Delta) Pre-Nursing Post-Bac Program

Version 1.2, 11/30/12 16

Application Checklist

Personal Information (on application) College Education (on application)

Applications to Nursing Schools (on application) Pre-Requisites for Nursing School (on application)

Other Courses of Interest to Committee (on application)

Standardized Tests (on application)

English Proficiency Requirement (if applicable, complete table and send as an e-mail attachment official documentation of TOEFL scores).

Financial Aid Chart (on application). Financial Aid Intention (on application). Disadvantaged Status? (Yes/No on application).

Disadvantaged Statement (on application; complete if you answered “Yes” to question above). Experiences (on application). Personal Statement (on application).

SFSU ID Number (on application).

How Did You Hear About Us? (on application; this information is very helpful to us).

Certification (application must be electronically signed to be considered). List of References (on application).

Two Professional References. (We prefer at least one reference from a university faculty member. Letters must be signed and on letterhead. Letter and completed Reference Form may be sent by e-mail, fax, US mail or carrier. See address and fax number below.

Transcripts Unofficial transcripts, usually downloadable from the internet, should be e-mailed to NurseAdmit.SFSU@gmail.com at the time you submit your application; this will considerably speed processing.

In addition, Official transcripts must be received within 4 weeks of the application deadline. They must be sent directly from the school issuing them, via e-mail to NurseAdmit.SFSU@gmail.com or by US mail or carrier in sealed envelopes to the address shown below).

$60 Application Fee (Send by US mail or carrier a check or money order payable to “SFSU Trust Funds”, to the address below. Do not send cash. Your application will not be considered without our having received this fee).

Dr. Barry S. Rothman Department of Biology, College of Science and Engineering San Francisco State University, 1600 Holloway Avenue San Francisco, CA 94132

E-Mail: NurseAdmit.SFSU@gmail.com Phone: 415-405-4239 Fax: 415-338-2295 (Attn: B. Rothman)