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5001 W. 41ST Street | Sioux Falls, SD | 1-605-362-0100 | www.mtmc.edu

Mount Marty College

Doctor of Nurse Anesthesia Practice Baccalaureate to DNAP Application

MMC Nurse AnesthesiaAdmission Requirements and Application Procedure

Admission RequirementsTo be accepted/admitted into the Doctor of Nurse Anesthesia Practice, the applicant must meet the following requirements: • Bachelor’s degree in nursing or associate diploma in nursing plus a baccalaureate degree in another related discipline • Graduation from an accredited (ACEN or CCNE) nursing program • Current licensure as an RN • Cumulative GPA of 3.00 on a 4.0 scale • Graduate Record Examination (GRE) with minimum scores of 150 on the verbal portion and 142 on the quantitative portion and 3.5 in analytical writing of the Revised General Test (or scores of 400 on both the verbal and quantitative portions of the General test administered prior to August 2013) • Minimum of 1 year (2 years preferred), full-time experience as a registered nurse in a critical care area within the United States, its territories, or a U.S. military hospital outside of the United States • Prerequisite courses: 2 courses in chemistry and 1 course in elementary statistics or epidemiology • Basic Life Support (BLS), Advance Cardiac Life Support (ACLS), and Pediatric Advanced Life Support(PALS)certificationsvalidthroughtheendofthefirstacademicsemester(requiredpriorto entering the program) • Completed health questionnaire, physical exam, immunization record, and criminal background check priortothestartofthefirstsemester,ifadmittedtotheprogram

Selection ProcessThe Admissions Committee will carefully review the completed application and supporting material, academic performance, nursing experience, and references. Because class size is limited, not all candidates who meet minimum requirements will be invited for an interview. Invitations to attend a personal interview will be mailed inlateOctober.InterviewsaregenerallyconductedinNovemberorDecember.Applicantswillbenotifiedof the Admissions Committee decision regarding acceptance into the program within 4 weeks of the personal interview. Applicants receiving a letter of appointment must return the Acceptance Form and a $750.00 non-refundableenrollmentfeewithinthetimespecified.Incompleteapplications,orapplicationsreceivedaftertheSeptember 15 deadline, will be reviewed only at the discretion of Admissions Committee.

Re-Application ProcessAll application materials being re-submitted must be received no later than September 15 for the class starting the following August. Incomplete applications, or applications received after the September 15 deadline, will be reviewed only at the discretion of Admissions Committee.If reapplying, application materials that MUST be resubmitted include: • STEP 1: Online Application • STEP 2: Application packet contents and checklist (except application fee)The following items DO NOT need to be resubmitted: • Application fee • Transcripts (unless a change has occurred) • GRE score reports (unless a change has occurred)

International StudentsInternational students are asked to follow the additional admissions procedures online at:http://www.mtmc.edu/admissions/app-process/international.aspx/

MMC Nurse AnesthesiaApplication Instructions and Checklist

All application materials must be received no later than September 15 for the class starting the following August. Incomplete applications, or applications received after the September 15 deadline, will be reviewed only at the discretion of Admissions Committee.

STEP 1: COMPLETE ONLINE NURSE ANESTHESIA APPLICATION Date submitted ______________A. Complete the online application before mailing the completed admission packet or forwarding materials.Supporting application materials cannot be processed unless the online application has been completedand your account established.

STEP 2: APPLICATION PACKET CONTENTS AND CHECKLISTSubmitthefollowingitemstogetherina9x13envelopetotheNurseAnesthesiaProgramOfficeinSiouxFalls,SD.

❑ Completed Checklist ❑ $35 non-refundable application fee made payable to Mount Marty College ❑ Supplemental Forms

r Critical Care Experience/RN Licensure Form r Educational Data Form

❑ Current resume ❑ Personal essay which describes your goals for doctoral study, motivations for entering the nurse anesthesiafield,whatyouhavetooffertheprofession,andreasonswhyyouchoseMountMarty College. Essay should be typed and no more than 600 words. ❑ Photocopy of your current RN license ❑ Photocopyofallcurrentcertifications

B. Three (3) professional references are required: 1 from the nursing unit director/manager, 1 from nursing unit critical care coordinator/shift supervisor, and 1 from a professional colleague (e.g. anesthesia provider, professor, colleague). Forms are provided for the unit director/manager and the coordinator/shift supervisor. The reference from the professional colleague can be in the form of a reference letter. All references must be sent directlytotheprogramoffice.Itisrecommendedthattheapplicantprovideeachreferencewithaself-addressedstamped envelope and any needed forms for direct mailing.

Mail materials to: Mount Marty College, Nurse Anesthesia Program Office, 5001 West 41st Street, Sioux Falls, SD 57106

STEP 3: DOCUMENTS SENT DIRECTLY TO ADMISSIONS PleasehavethefollowingitemssentdirectlytotheNurseAnesthesiaProgramOffice,SiouxFalls,SD.

❑ Oneofficialtranscriptfromeachcollege/universityattended ❑ Officialtranscriptverificationofclassesinwhichyouarecurrentlyenrolled ❑ OneofficialGREscoretranscript.RegisterfortheRevisedGeneralGREtestonlineatwww.gre.org.

The GRE code for Mount Marty College is 6416. Please allow 4-8 weeks for the GRE scores to be reported to the College.

MMC Nurse AnesthesiaEducational Data Form

Educational Data:Applicants must possess an appropriate baccalaureate degree from a regionally accredited college or university andhavemaintainedanoverallGPAof3.0on4.0scale.Degreesmustbecompletedwithfinaltranscriptssubmitted prior to enrollment in August. Appropriate degrees include a baccalaureate degree in nursing or an associate/diploma in nursing plus a baccalaureate degree in another related discipline.

Nursing Education Institution Date Conferred GPADiploma in NursingAssociate Degree in NursingBachelor of Science in Nursing

Other Degrees Institution Date Conferred GPA

Graduate Record Examination (GRE):Date taken/scheduled _______ Scores: Verbal _______ Quantitative _______

Course Prerequisites:Courses must be completed at a college or university level with a minimum grade of C. (2 points on 4 point scale)

CHEMISTRY: 2 courses of chemistry (minimum total of 6 semester hours) are required. Acceptable chemistry courses include: general, organic, inorganic or biochemistry. Please list chemistry courses taken.Chemistry: List two courses. If you have taken more than two chemistry courses, list the two with best grades.Note: labs are not required.Chemistry Course Title# Completion Date Institution Letter Grade # of hours

STATISTICS: 1 statistics or epidemiology course will satisfy the prerequisite. Please list statistics or epidemiology course taken.Course Title# Completion Date Institution Letter Grade # of hours

Missing Prerequisites:Applicants who have not met all prerequisites by the application deadline must submit a plan with their application for completing any missing prerequisites.

r Yes r No Have you ever attended another anesthesia school? If yes, use a separate sheet to fully explain.

If yes: Name: _____________________________ Address: ________________________________________

Dates of Attendance: _______________________ Reason for Leaving: ______________________________

MMC Nurse AnesthesiaCritical Care Experience/RN Licensure Form

Nursing Procedure/Skills Frequency of ExperienceDaily Weekly Monthly Rarely/

NeverNever /NA to my unit

Basic heart rhythm interpretationArterial pressure monitoringArterial blood gas interpretationMechanical ventilation / weaningTitration of IV vasoactive drugsCVP monitoring12-lead EKG interpretationInvasive cardiac outputPA pressure monitoringRecovery of immediate postoperative heartsCode blue team leader / rapid response nurseContinuous renal replacement therapyCardioversion/defibrillationIntra- aortic balloon pumpVentricular assist device (LVAD)ICP monitoringPreceptor RoleShift charge nurse / leadership role# of times spent shadowing/learning role of a nurse anesthetist: 0 1 2 3 4 5 6

Hospital Type of Unit # of Beds Dates of Employment

Hours worked/week

Total months/years of experience

Total months/years an RN Total months/years in critical care as an RN:

Applicant: _________________________________________________________________________________ Last First Middle Other

At least one year (2 preferred) of recent full-time critical care nursing experience as a RN is required prior toAugust 1 in the year of program enrollment. Acceptable critical care nursing experience includes: ICU, CCU,SICU, MICU, NICU and PICU. Please indicate critical care experience below.

State Status License # if active Expiration Date

r Active r Inactive

r Active r Inactive

r Active r Inactive

r Active r Inactive

r Active r Inactive

r Yes r No Have you ever had a nursing license suspended or revoke? If so submit a letter of explanation.

r Yes r No Have you ever been the subject of a Nursing Board disciplinary action? If yes, submit a letter of explanation.

r Yes r No Have you ever been refused a nursing license? If yes, submit a letter of explanation.

r Yes r No Are you aware of any disciplinary action pending on your nursing license?

List the state in which you were originally licensed as an RN:

Answer the following questions. If yes, submit a letter of explanation.r Yes r No Have you ever been on probation or suspended from any place of employment?r Yes r No Within the last three years, have you ever experienced a physical, emotional or mental condition

that endangered the health or safety of persons entrusted in your care?

CERTIFICATES/PROFESSIONAL ORGANIZATIONS:Pleaseincludephotocopiesofallcertificationsheld.

BLSCertification r Yes r No Expiration Date: __________________ACLSCertification r Yes r No Expiration Date: __________________PALSCertification r Yes r No Expiration Date: __________________CCRNCertification r Yes r No Expiration Date: __________________OtherCertifications: ________________________________________________________________________

List the professional organizations you are a member of: ____________________________________________________________________________________________________________________________________

RN PROFESSIONAL LICENSE:Applicants must provide proof of licensure as a professional Registered Nurse (RN). Please complete the requested information below. Include a photocopy of your current nursing license(s).

List all states where you have licensure as a professional Registered Nurse (RN)

I attest that the information provided in this application is accurate.

Signature: ______________________________________________________ Date: ____________________

To be completed by applicant. Please type or print.

Applicant ________________________________________________________________________________ Last First Middle Other

I have read and approved this request for information. I voluntarily waive any right of access to this confidentialletterofevaluation.

Applicant Signature _____________________________________Date _________________________

To be completed by current Nursing Unit Director/Manager.The Admissions Committee appreciates your cooperation in determining the applicant’s potential for success,both as a graduate student and in an advanced practice role as a nurse anesthetist. Your candid opinion willbeappreciated.Thisinformationwillbeheldinconfidenceiftheapplicanthassignedtheabovewaiver.Please complete your evaluation using the MMC Recommendation Form provided. Place the completedevaluation in the business size envelope provided by the applicant and send directly to the program. This recommendation is an essential part of the application. The deadline for completed applications is September 15 for fall admission.

Applicant’s General InformationHospital/Medical Center where employed: _______________________________________________________Primary Unit: ______________________ # of beds ____________ Average hours worked/week __________Secondary Unit (if any): ______________ # of beds ___________ Average hours worked/week __________How long have you known the applicant professionally? ___________________________________________

Applicant’s Personal AttributesPlease evaluate the applicant in each of the following categories by checking the appropriate column.Personal Attributes Excellent Above Average Average Below AverageIntegrityEmotional maturityMotivationSocial valuesIntellectual abilityAbility to organizeInterpersonal skillsLeadership qualitiesProfessional mannerPerformance in critical situationsEnthusiasm for learningAcceptance of criticismCommunication skillsReliabilityClinical/professional competenceCritical thinking/analytic abilitiesSelf-confidencePotential for advanced practice nursingPotential for graduate studyParticipation as mentor/preceptorParticipation Unit Meetings/Committees

MMC Nurse AnesthesiaRecommendations by Nursing Director/Manager

What are the applicant’s strengths?

What are the applicant’s weaknesses?

Do you believe the applicant has adequate critical care experience to move on to an advanced practice nursing role?

CommentsPlease provide any additional comments that would be of value to the Admission Committee. Feel free to usethe space below or attach a letterhead bearing your signature.

Overall Recommendation: Check one☐ I highly recommend this applicant ☐ I recommend this applicant with reservations☐ I recommend this applicant ☐ I do not recommend this applicant (please explain under comments)

What is the applicant’s ability compared to others with similar ICU experience?☐ Top 10% ☐ Top 25% ☐ Top 50% ☐ Bottom 50%

Evaluator’s InformationName: ___________________________________Title: ___________________________________________Signature: ________________________________________________________________________________Maywecontactyouforadditionalinformation/clarification?☐ Yes ☐ NoIf yes, phone number where you can be reached _________________________________________________

MMC Nurse AnesthesiaRecommendations by Nursing Unit Director/Manager (Continued)

To be completed by applicant. Please type or print.

Applicant ________________________________________________________________________________ Last First Middle Other

I have read and approved this request for information. I voluntarily waive any right of access to this confidentialletterofevaluation.

Applicant Signature _____________________________________Date _________________________

To be completed by current Clinical Care Coordinator/Shift Supervisor.The Admissions Committee appreciates your cooperation in determining the applicant’s potential for success,both as a graduate student and in an advanced practice role as a nurse anesthetist. Your candid opinion willbeappreciated.Thisinformationwillbeheldinconfidenceiftheapplicanthassignedtheabovewaiver.Please complete your evaluation using the MMC Recommendation Form provided. Place the completedevaluation in the business size envelope provided by the applicant and send directly to the program. This recommendation is an essential part of the application. The deadline for completed applications is September 15 for fall admission.

Applicant’s General InformationHospital/Medical Center where employed: _______________________________________________________Primary Unit: ______________________ # of beds ____________ Average hours worked/week __________Secondary Unit (if any): ______________ # of beds ___________ Average hours worked/week __________How long have you known the applicant professionally? ___________________________________________

Applicant’s Personal AttributesPlease evaluate the applicant in each of the following categories by checking the appropriate column.Personal Attributes Excellent Above Average Average Below AverageIntegrityEmotional maturityMotivationSocial valuesIntellectual abilityAbility to organizeInterpersonal skillsLeadership qualitiesProfessional mannerPerformance in critical situationsEnthusiasm for learningAcceptance of criticismCommunication skillsReliabilityClinical/professional competenceCritical thinking/analytic abilitiesSelf-confidencePotential for advanced practice nursingPotential for graduate studyParticipation as mentor/preceptorParticipation Unit Meetings/Committees

MMC Nurse AnesthesiaRecommendations by Clinical Care Coordinator/Shift Supervisor

Applicant’s Clinical ExperiencePlease evaluate the applicant with respect to the following clinical procedures and skills by checking the appropriate column. The Admissions Committee is seeking information about the applicant’s critical care nursing experience and level of competence. We do not expect that applicants will possess experience in or be an expert in every procedure or skill listed below. Indicate clinical experience not offered in your area as NA.

Nursing Procedures/Skills Frequency of Experience Level of CompetenceDaily Weekly Monthly Rarely/

NeverExpert Competent Novice

Basic heart rhythm interpretationArterial pressure monitoringArterial blood gas interpretationMechanical ventilation / weaningTitration of IV vasoactive drugsCVP monitoring12-lead EKG interpretationInvasive cardiac outputPA pressure monitoringRecovery of immediate postoperative heartsCode blue team leader/ rapid response nurseContinuous renal replacement therapyCardioversion/defibrillationIntra-aortic balloon pumpVentricular assist device (LVAD)ICP monitoringPreceptor Shirft charge nurse / leadership role

CommentsPlease provide any additional comments that would be of value to the Admission Committee. Feel free to usethe space below or attach a letterhead bearing your signature.

Overall Recommendation: Check one☐ I highly recommend this applicant ☐ I recommend this applicant with reservations☐ I recommend this applicant ☐ I do not recommend this applicant (please explain under comments)

What is the applicant’s ability compared to others with similar ICU experience?☐ Top 10% ☐ Top 25% ☐ Top 50% ☐ Bottom 50%

Evaluator’s InformationName: ___________________________________Title: ___________________________________________Signature: ________________________________________________________________________________Maywecontactyouforadditionalinformation/clarification?☐ Yes ☐ NoIf yes, phone number where you can be reached ___________________________________________________

MMC Nurse AnesthesiaRecommendations by Clinical Care Coordinator/Shift Supervisor (Continued)