Page 1 Updated 08/14/2015
TRANSFER STUDENT APPLICATION CHECKLIST
Keep for your own records. Do not send with application.
University Application Deadlines:
On Campus Students: Winter – October 1st
Spring/Fall – February 1st
Online Students: Allow 8 weeks for processing
Department of Nursing Application Deadlines: Winter – October 1st
Summer – February 1st
Fall – June 1st
*Note: Letters of Acceptance/Denial will be sent the 1st week of
the following month
Application Steps
☐ Apply to Brigham Young University-Idaho. If you were previously admitted, but have not attended, or have fallen out of your admission sequence, please check with the Admissions Office (208-496-1300) regarding your current status. Please apply by following the directions at www.besmart.com. Your application will be considered incomplete without acceptance to the University.
Complete prior to applying for the RN-BSN program
☐ Personal Information Page 2
☐ 2 References and 2 Letters of Recommendation (references and letters can be from different educators or employers). Follow directions for Letters of Recommendation on forms provided
Page 2, 9-10
☐ Qualifying Questions Page 3
☐ Provide a brief Description of your purpose behind pursuing your BSN Page 4
☐ Provide Unofficial Transcripts from all colleges attended Submit w/ Pkt
☐ Choose a sequence (3- or 6-semester) *sequence is for RN-BSN courses and more semesters may be required prior to (pre-reqs) or after this sequence to obtain a Bachelor’s degree from the University. Please visit the RN-BSN website http://www.byui.edu/nursing/rn-to-bsn and then contact the Advising Office if you have further questions regarding needed courses: [email protected]
Page 5
☐ Declare credits from Affiliated Schools (if applicable) Page 5
☐ Resume – please include total years of RN experience at top and only relevant experience Submit w/ Pkt
☐ Online Residency Information Page 6-8
☐ Order your Background Check through TrueScreen. Please go to http://www.byui.edu/nursing/rn-to-bsn/application# and click on the “Background Check” button. Due to personal information made available through the background check, Do Not send a copy of your background check through the mail.
☐ If you are unsure or do not understand anything within the application, please note it on the application
Please do not submit this sheet with your application. Keep these instructions for your use.
To submit your application: Mail to:
BYU-Idaho Nursing Outreach 251 Hart Bldg.
525 S Center St. Stop 0910 Rexburg, Idaho 83460-0910
The B.S.N. Program at BYU-Idaho is accredited by the Accreditation Commission for Education in Nursing
Page 2 Updated 08/14/2015
Please indicate the Semester that you are applying for:
☐ FALL ☐ WINTER ☐ SPRING
Application Date _______________, 201_____ BYU-I #, if known __ __ - __ __ __ - __ __ __ __ RN License Number: _____________________
State: __________
BYU-I email address,
if known: @byui.edu Permanent email address:
1. Have you applied for the RN to BSN program in the past? (circle one) Yes / No
2. Print or type in full: ,
Last Name First Name Middle/Maiden Name
3. Home Phone: ( ) Cell Phone: ( )
4.
Mailing Address for Selection Decision:
PO Box/ Number & Street City State Zip code
5.
Permanent Address:
PO Box/ Number & Street City State Zip code
6. Person to notify in case of emergency:
Relationship: Phone Number: ( )
Address:
Number & Street City State Zip code
7. Information concerning School of Nursing (RN Degree):
Name of School City/State Date of Entrance Date of
Grad
Degree Received (AS/AAS/ADN) 8. Give the names of the two persons (educators or employers) you have selected as references and follow the
directions for the Letter of Recommendation forms provided at the end of the packet. The Recommendation forms can be from the two individuals listed below or two other individuals.
Page 3 Updated 08/14/2015
PLEASE ANSWER THE FOLLOWING QUESTIONS ACCURATELY:
Qualifying Questions Yes No
1. Have you ever applied for a license or received a license to practice under any name other than the name
listed on this application?
2. Have you ever been denied the right to sit for a licensure exam?
3. Have you ever had a license, certificate, permit, or registration to practice a licensed profession denied,
conditioned, curtailed, limited, restricted, suspended, or revoked in any way?
4. Have you ever been permitted to resign or surrender your license, certificate, permit, or registration to
practice in regulated profession while under investigation or while action was pending against you by any professional licensing agency, criminal, or administrative jurisdiction?
5. Are you currently under investigation or is any disciplinary action pending against you now by any
professional licensing agency?
6. Is any action related to your conduct or patient care pending against you now at any hospital or health care
facility?
7. Have you ever had office monitoring, practice curtailments, individual surcharge assessments based upon
specific claims history, or other limitations, restrictions, or conditions imposed by any malpractice carrier?
8. Have you been named a defendant in a malpractice suit during the past 10 years? The filing date of the
complaint naming you as a defendant should be considered to be the date of the malpractice suit for purposes of responding to this question.
9. Have you ever had any malpractice insurance coverage denied, conditioned, curtailed, limited, suspended,
or revoked in any way?
10. Is any action pending against you now by the Federal Drug Enforcement administration or any state drug
enforcement agency?
11. Are you currently using or have you recently (within 90 days) used any drugs (including recreational
drugs) without a valid prescription, the possession, or distribution of which is unlawful under the Idaho Controlled Substances Act or other applicable state or federal law?
12. Have you ever used drugs without a prescription, possession, or distribution of which is unlawful under
the Idaho Controlled substances Act or other applicable state or federal law, for which you have not successfully completed or are not now participating in a supervised drug rehabilitation program or for which you have not otherwise been successfully rehabilitated?
13. Have you been arrested for or charged with a misdemeanor or felony charge in any jurisdiction during the
last 10 years? Motor vehicle offenses such as driving while impaired or intoxicated must be disclosed, but minor traffic offenses such as parking or speeding violation need not be listed.
14. Have you ever pleaded guilty to, no contest to, or been convicted of any felony or misdemeanor in any
jurisdiction?
15. Have you ever been involved as the abuser in any incident of verbal, physical, mental, or sexual abuse?
16. Have you ever been terminated from a position because of drug use or abuse?
17. Would you pose a direct threat to yourself, to your patients or clients, or to the public safety, or welfare
because of any circumstances or condition?
18. Have you ever been incarcerated for any reason in any Federal, State or County Correctional Facility?
If you answered “yes” to questions 2-9, please attach to this application a full disclosure of all of the circumstances and any resolution reached. If you have answered “Yes” to questions 10 – 18, please also specifically provide the following
information:
1. The nature and extent of any past or present use of dependency on a drug, controlled substance,
alcohol or chemical.
2. The disposition of any related criminal action
3. The disposition of the matter with appropriate ecclesiastical authorities.
4. If you were formally enrolled or employed at Brigham Young University-Idaho, the disposition of
the matter in relationship to your enrollment or employment.
5. The details of your involvement in any supervised drug rehabilitation program.
6. Any evidence of your complete rehabilitation from past use of dependency on drugs, controlled
substances, alcohol, or chemicals.
In addition, if you answered “Yes” to questions 13 and 14, you must include with your application a court docket for each and every arrest and/or conviction within the past ten (10) years. If you are currently on probation or parole, you must also include a probation/parole officer report.
I have read the above questions and have answered them correctly.
Page 4 Updated 08/14/2015
ESSAY
Instructions:
Please provide a brief description of your purpose behind pursuing your BSN.
TRANSCRIPTS
While applying to Brigham Young University Idaho, you were required to submit Official Transcripts. We
require that you submit Unofficial Transcripts from all colleges attended as part of your application packet.
BACCALAUREATE DEGREE COMPLETION PLAN INSTRUCTION (BDCP)
In an effort to help you plan the BSN degree and finish in a timely manner, we have provided two options for
you. You are required to select either the 3-Semester or 6-Semester sequence. Keep in mind that NURS 338 has
Statistics (MATH 221B preferred) as a prerequisite. For the 3-Semester sequence, this prerequisite must be
completed prior to your first semester in the RN to BSN Program.
NURSING CLASS SEQUENCE
Preference Required:
I prefer the following course sequence* (check one)
☐ 3-Semester ☐ 6-Semester
* 3 or 6 semester sequence timeline is only for the RN-BSN courses. University required courses for a
Bachelor’s degree may be completed before, during, or after the RN-BSN courses
You are expected to remain in your chosen sequence throughout the duration of the program. If circumstances
change, you can petition a change through the Nursing Outreach Office via the RN-BSN website petition link.
3- Semester Sequence
1
stSemester
2
ndSemester
3
rdSemester
NURS 316 Professional Seminar NURS 327 Physical Assessment
NURS 400 Adv. Nursing Concepts
NURS 338 Nursing Research
NURS 449 Community Nursing
NURS 450 Nursing Leadership
5 Credits
9 Credits
10 Credits
6-Semester Sequence
1
stSemester
2
ndSemester
3
rdSemester
4
thSemester
5
thSemester
6
thSemester
NURS 316
NURS 338
NURS 327
NURS 449
NURS 400
NURS 450
2 Credits
3 Credits
4 Credits
5 Credits
5 Credits
5 Credits
• (Stats) MATH 221A, 221B, or 221C at BYU-I, or a transferable statistics course for one of the listed courses, is a prerequisite to NURS 338.
Page 5 Updated 08/14/2015
FOUNDATIONS / GENERAL EDUCATION PLAN
Selection of courses and timeline for completing baccalaureate degree requirements:
Courses Required for Graduation
Credits
Course Completion Plan
List “Completed” or semester planned
Pathophysiology*
3
Foundation Religion Courses**
8
Statistics
3
*Please see prerequisites listed in the BYU-Idaho University catalog.
**Beginning Fall 2015: FDREL 200, 225, 250, and 275 are required; REL 121 & 122 will waive FDREL 275
It is the student’s responsibility to meet all University requirements as outlined in their designated catalog.
Note: These are the minimum Foundations / General Education requirements. Your required courses may differ
from those listed and is determined by your BYU-I catalog year and what courses transfer from other colleges /
universities. Consult with the College of Agriculture and Life Sciences Academic Discovery Center at (208)
496-9839 if you have any questions.
RESIDENCY CREDITS FROM CHURCH UNIVERSITIES AND COLLEGES
Please indicate how many credits you have earned at any of the following educational institutions:
Institution
Credits Institution CreditsBYU
BYU-Idaho/Ricks CollegeBYU-Hawaii
LDS Business CollegePlanned BSN graduation month/year: __________________
My Application to BYU-I is complete: ☐ Yes ☐ No
It is strongly encouraged that you maintain contact with the Admissions Office to ensure your acceptance to the
University. Students who have not been admitted to the University 7 days after the application deadline will not
be considered for the program.
I declare that during the duration as a student at BYU-I Nursing: I will live by the BYU-I honor code. I will maintain personal health insurance. I will also keep my RN license, CPR, and my immunizations records current and updated with the Department of Nursing. This includes an annual TB. My CPR card must be on file at BYU-I and show a current expiration date. I understand that it is my responsibility to renew and re-submit the items listed to the Department of Nursing/TruScreen before they expire. Any default of these items may cause me to be placed on
suspension or removed from the program. I give permission to the Department of Nursing to release personal
information requested by a hospital or health care partner to secure clinical placements.
Page 6 Updated 08/14/2015
Online Residency Survey for RN to BSN Applicants
We welcome applications from all qualified candidates regardless of where they earned their ASN degree. All
applicants in Groups 2 and 3 are required to fill out this survey.
Students are prioritized for admission into the following three groups.
Group 1.
BYU-Idaho/Ricks College ASN alumni: From the most recent graduates to the least
recent are considered for admission first.
Group 2.
Applicants who have completed a combination of 15 or more credits from the following
institutions: BYU-Idaho/Ricks College, BYU-Hawaii, LDS business College and LDS
Institute of Religion (limited to 15 credits) are considered for admission second.
Group 3.
All other applicants are considered for admission third.
Instructions:
If you fall into Group 2 or 3 above, provide the following information:
Applicant’s Full Name: ______________________________________
1.
Please list the last 5 years of your involvement in any organizations, programs or activities that provide
voluntary service to the community:
Date (year only) Organization / Program / Activity
Position / Title / Function
Describe the duties and/or accomplishments of the above position:
Date (year only) Organization / Program / Activity
Position / Title / Function
Describe the duties and/or accomplishments of the above position:
Date (year only) Organization / Program / Activity
Position / Title / Function
Page 7 Updated 08/14/2015
Continued from Item 1 on page above
Date (year only)
Organization / Program / Activity
Position / Title / Function
Describe the duties and/or accomplishments of the above position:
Date (year only)
Organization / Program / Activity
Position / Title / Function
Describe the duties and/or accomplishments of the above position:
2.
Please list any certifications you have earned in nursing specialties:
Date (year only) Certifying Organization
Certification
3.
Please list any professional associations you are a member of, or active in:
Page 8 Updated 08/14/2015
4.
Have you attended LDS Institute of Religion? _____ Yes _____ No
If “Yes,” please provide the following information:
Institute Location
Start Year
End Year
Total Credits
Please list the institute courses you’ve taken. In the appropriate column, please check whether the course was
taken for credit or non-credit.
Course Name
Credit
Non-Credit
1
st.
2
nd.
3
rd.
4
th.
5
th6
th.
7
th.
8
th.
9
th.
10
th.
6.
If you have served a religious mission, please indicate where and when you served below:
Religious Affiliation
Name / Location of Mission
Start Year End Year
7.
Please list the last 5 – 10 years of your service/calling history with the LDS church (or other
denomination, if applicable).
Page 9 Updated 08/14/2015
BRIGHAM YOUNG UNIVERSITY-IDAHO, DEPARTMENT OF NURSING
LETTER OF RECOMMENDATION
Note: After completing the recommendation, please place in an envelope and sign across the seal, give it back to the applicant so it can be included as part of the application packet.
Part 1. To be completed by Applicant: CONFIDENTIALITY (Check one)
I waive my right of access to this confidential report
☐
. I do not waive my right of access to this confidential report☐
. Applicant’s Signature: ______________________________________ Date:
_________________________ Applicant’s Name (printed): ______________________________________Please print the recommender’s name here (first and last):
Part II. (To be completed by Recommender): The individual named above has applied for acceptance in the Brigham Young University – Idaho
Nursing Department RN to BSN Program
and is requesting arecommendation from you. Please assist us in evaluating this applicant’s potential. We appreciate your honest and confidential evaluation of his or her abilities and attitudes.
Length of time you have known the applicant?
How would you evaluate yourself giving ratings of this kind to
students? Generous Average Very conservative
Please use the scale shown below to compare the applicant with a representative group of students whom you have known during your career.
Trait Superior Top 2% Outstanding Top 10% Excellent Top 20% Good Top 50% Avg/Poor Lower 50% No basis for judgment Ability to exhibit Professional
Behavior
☐
☐
☐
☐
☐
☐
Ability to demonstrate Respect
☐
☐
☐
☐
☐
☐
Ability to exhibit Confidence in
actions and learn from mistakes
☐
☐
☐
☐
☐
☐
Their Emotional Stability
☐
☐
☐
☐
☐
☐
Ability to Manage Stress
☐
☐
☐
☐
☐
☐
Ability to display Integrity
☐
☐
☐
☐
☐
☐
Ability to display compassion
☐
☐
☐
☐
☐
☐
Ability to engage in good
Interpersonal Relationships
☐
☐
☐
☐
☐
☐
Ability to make Sound Judgments
☐
☐
☐
☐
☐
☐
Ability to Problem Solve
☐
☐
☐
☐
☐
☐
Overall competence and potential
☐
☐
☐
☐
☐
☐
The Nursing Department assumes that in all likelihood the applicant is a competent person. We will be most appreciative if instead of describing his or her general excellence, you would tell us what makes this candidate especially promising when compared to other applicants who may appear equally well qualified. If or any reason you have substantial reservations about the candidate’s potential for success, please explain why. (Write your comments either on this form or on a separate page.)
Signature of Recommender Name of Recommender (Please print) Date
Page 10 Updated 08/14/2015
BRIGHAM YOUNG UNIVERSITY-IDAHO, DEPARTMENT OF NURSING
LETTER OF RECOMMENDATION
Note: After completing the recommendation, please place in an envelope and sign across the seal, give it back to the applicant so it can be included as part of the application packet.
Part 1. To be completed by Applicant: CONFIDENTIALITY (Check one)
I waive my right of access to this confidential report
☐
. I do not waive my right of access to this confidential report☐
. Applicant’s Signature: ______________________________________ Date:
_________________________ Applicant’s Name (printed): ______________________________________Please print the recommender’s name here (first and last):
Part II. (To be completed by Recommender): The individual named above has applied for acceptance in the Brigham Young University – Idaho
Nursing Department RN to BSN Program
and is requesting arecommendation from you. Please assist us in evaluating this applicant’s potential. We appreciate your honest and confidential evaluation of his or her abilities and attitudes.
Length of time you have known the applicant?
How would you evaluate yourself giving ratings of this kind to
students? Generous Average Very conservative
Please use the scale shown below to compare the applicant with a representative group of students whom you have known during your career.
Trait Superior Top 2% Outstanding Top 10% Excellent Top 20% Good Top 50% Avg/Poor Lower 50% No basis for judgment Ability to exhibit Professional
Behavior
☐
☐
☐
☐
☐
☐
Ability to demonstrate Respect
☐
☐
☐
☐
☐
☐
Ability to exhibit Confidence in
actions and learn from mistakes
☐
☐
☐
☐
☐
☐
Their Emotional Stability
☐
☐
☐
☐
☐
☐
Ability to Manage Stress
☐
☐
☐
☐
☐
☐
Ability to display Integrity
☐
☐
☐
☐
☐
☐
Ability to display compassion
☐
☐
☐
☐
☐
☐
Ability to engage in good
Interpersonal Relationships
☐
☐
☐
☐
☐
☐
Ability to make Sound Judgments
☐
☐
☐
☐
☐
☐
Ability to Problem Solve
☐
☐
☐
☐
☐
☐
Overall competence and potential
☐
☐
☐
☐
☐
☐
The Nursing Department assumes that in all likelihood the applicant is a competent person. We will be most appreciative if instead of describing his or her general excellence, you would tell us what makes this candidate especially promising when compared to other applicants who may appear equally well qualified. If or any reason you have substantial reservations about the candidate’s potential for success, please explain why. (Write your comments either on this form or on a separate page.)
Signature of Recommender Name of Recommender (Please print) Date
