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SUU LPN/PARAMEDIC TO BSN DEGREE application

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SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
1
NURSING APPLICATIONS ARE DATE SPECIFIC. BE SURE THAT THE APPLICATION YOU SUBMIT IS CURRENT.
Dear Applicant:
We are pleased to hear of your interest in the Southern Utah University Baccalaureate Nursing Program. To support you in
the admissions process, Ms. Vikki Robertson, SUU Department of Nursing Administrative Assistant, is available to answer any
questions you may have concerning the Nursing Program. She can be reached at (435)586-1906 or e-mail at
RobertsonV@suu.edu
. If you have questions regarding transfer credits or advisement, please contact an SUU Student Success
Advisor for the College of Science and Engineering, SUU Student Success Advisors contact information is, (435)586-5420:
• Jared Wilcken ~ Advising Science students with the last name A-C ~ wilcken@suu.edu
• Rachel Abramson ~ Advising Science students with the last name D-J ~ rachelabramson@suu.edu
• Sharon Brown ~ Advising Science students with the last name K-Q ~ brownsh@suu.edu
• Sam LaGrone ~ Advising Science students with the last name R-Z ~ samuellagrone@suu.edu
We look forward to working with you in completing your admissions application and offer the following guidelines to
insure proper processing. Students just finishing their LPN or Paramedic program and anticipate direct entry into the
LPN/Paramedic to BSN program, please use alternate application available here:
https://www.suu.edu/cose/nursing/admission.html
SUU Department of Nursing admission is competitive and based on review of all application materials. Minimum
requirements to apply for admission include the following:
• Completed admission application packet for LPN/Paramedic to BSN option.
• Completion of ALL pre-requisites; including Core Course Requirements, Knowledge Area Requirements, & Required
Support Courses.
1
• Undergraduate cumulative GPA of 3.0 on a 4.0 scale.
• A cumulative GPA of 3.0 on a 4.0 scale on all “Required Support Courses” with no course grade less than a C (C- is not
acceptable).
• Completed “Department of Nursing Advisement Sheet" signed by applicant and adviser. Consult with SUU, Walter
Maxwell Gibson, College of Science and Engineering Student Success Advisor (as listed above) prior to submitting your
application.
• Copy of your LPN license or Paramedic Certificate by first Friday of September.
• $20.00 non-refundable nursing application fee; checks made payable to “SUU Nursing (NURS2)” & Paid to SUU Cashiers
Office, include copy of your receipt in application packet. (Use attached deposit form). Or pay on-line at
http://suu.edu/cose/nursing/
and select “Application On-line Payment Option”, include a copy of your receipt in your
application packet.
1
Students who are finishing pre-requisite courses during the semester they apply to the Nursing Program will need to submit their final grade report to the
Department of Nursing by 4:00 pm, on Friday of the week grades are posted.
Please note that meeting the above requirements does not guarantee admission. From the applicants who meet minimum
requirements, those who appear to be best qualified will be admitted. The goal of the Admissions and Advancement
Committee is to select the most capable students. GPA and course grades are carefully scrutinized and are an important part of
the application process. The application package assists us in evaluating these qualities. We expect applicants to be courteous,
respectful, truthful, and professional at all times.
Applications and all required documentation need to be submitted to the Department of Nursing ON or BEFORE 4:00PM,
December 13, 2019, to be considered for the 2020 program (Applications postmarked/received after this deadline will NOT be
considered for admission to the program). Please mail or hand deliver to:
Southern Utah University Department of Nursing
Attn: Vikki Robertson
351 West University Blvd., SCA 108 A
Cedar City, UT 84720
The selective admission process for LPN/Paramedic (BSN) students is once per year, Summer semester. Applicants are
notified of the committee decision by mail. All decisions by the Nursing Admissions and Advancement Committee are final
and may not be appealed. If the applicant pool exceeds the maximum number of positions available for the specified semester,
several students will be considered as alternates for admission. If accepted applicants decline their acceptance or are not
admitted for any reason, alternates will be notified of acceptance. The Nursing Program does not keep a waiting list from year
to year.
Again, we are pleased that you are interested in the SUU Nursing Program; remember it is REQUIRED that you meet with an
SUU Student Success Advisor prior to submitting your application.
Donna J. A. Lister, PhD, APRN, FNP-BC, CNE
Chair, Department of Nursing
LPN/Paramedic to BSN
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
2
PLEASE TYPE OR PRINT NEATLY IN INK YOUR RESPONSES. SUBMIT THIS FORM WITH ALL ACCOMPANYING DOCUMENTS.
Are you a previous/current Southern
Utah University student?
Yes No
Last semester and year enrolled at SUU SUU Student (T) Number.
A. PERSONAL INFORMATION
Legal Name (Last) (First)
(Middle)
Preferred Name
Former Name(s)—List all former names
Date of Birth (Mo./Day./Yr.)
Gender (optional)
Male Female
B. CONTACT INFORMATION
Mailing Address House/Street Number
Daytime Telephone
Mailing Address City, State, Zip
Evening Telephone
Permanent Address House/Street Number
Applicant Cell Phone (if applicable)
Permanent Address City, State, Zip
Home Town (City & State) (where you
grew up):
Applicant Email Address
Relationship
Emergency Contact Telephone
Emergency Contact Address House/Street No., City, State, Zip
C. APPLICANT INFORMATION
Please select one of the following:
U.S. Citizen U.S. Permanent Resident
Immigrant International Applicant
Country of Citizenship? _________________
State reside?
_______________
How long? ______
Have you ever served in the Armed Forces?
Yes No
Branch: _____________________
I am a re-applicant to the SUU Nursing
Program.
Yes No
Ethnic Background (select one, optional):
Black Non-Hispanic Asian Pacific Islander Hispanic Alaskan American Indian White Non-Hispanic (Caucasian) Other
__________________
D. ACADEMIC BACKGROUND (Include ALL colleges and universities you have attended, including Southern Utah University, use additional pages if needed)
Name of Institution – List schools in
order attended with most recent first.
Location
(City, State)
Indicate
2-yr/4yr.
Beg. Date
mm/yy
End Date
mm/yy
Degree
Obtained
(yes/no)
Degree Date
mm/dd/yy
Study Field
If attended more than three (3) colleges/universities, explain (use a separate sheet of paper if needed):
E. HEALTHCARE CERTIFICATIONS (use additional pages if needed, attach accompanying copies/documentation as indicated, if available)
Certification can include but is not limited to CNA, LPN, EMT, MA, CPR, First Aid, Paramedic, etc. (not all certification will have a #)
Type: _________________________ Number: ____________________________ Year Received: ____________ Included Copy
Type: _________________________ Number: ____________________________ Year Received: ____________ Included Copy
Type: _________________________ Number: ____________________________ Year Received: ____________ Included Copy
Type: _________________________ Number: ____________________________ Year Received: ____________ Included Copy
✔
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
3
F. HEALTH CARE EXPERIENCE Include all, most recent first. Include any/all potential health care experiences. Attach additional pages as needed.
Company Name-List in order with most
recent first.
Location
(City, State,)
Position
Beg. Date
mm/yy
End Date
mm/yy
Ttl. Hours
Completed
Reason Left
G. WORK EXPERIENCE Include all employment, most recent first. Attach additional pages as needed.
Name of Firm/Employer – List in order
with most recent first.
Location
(City, State,)
Position
Beg. Date
mm/yy
End Date
mm/yy
Reason Left Employment
H. List extracurricular activities, awards, honors, scholarships, student government, etc.
--PLEASE COMPLETE SECTION “H” BY ATTACHING A TYPED PAGE IN BULLETED FORMAT (1-page maximum) --
I. Complete the sentence and expand to two (2) paragraphs (1-page maximum): A good nurse …
--PLEASE COMPLETE SECTION “I” BY ATTACHING A TYPED PAGE (1-page maximum) --
J. In essay format, answer the following by selecting two from numbers 1-3 and one from numbers 4 or 5. Be specific as to which
question(s) you are selecting:
1. Describe a time in your life when you experienced a significant challenge, difficulty, or failure. What did you learn about yourself
through facing this situation?
2. Describe a time when you had a conflict with another individual. How did you respond to/manage that conflict?
3. Tell us what strengths you will bring to the nursing program and what you believe will be your biggest challenge or obstacle?
4. Tell us how your investment in your education at SUU contributes to your desired future.
5. Connect the dots as to how your previous work experience contributes to your future career in healthcare.
--PLEASE COMPLETE SECTION “J” BY ATTACHING 2 TYPED PAGEs (2-page maximum) --
K. LETTER OF RECOMMENDATION
List the names of the three (3) persons you have selected as references (make sure you have a total of three (3) copies of the structured recommendation form
included with this application). Each evaluator should be instructed to complete the form, place it in the envelope provided by you, seal the envelope, sign
his/her name across the seal of the envelope, and return the sealed envelope to you to include with your application, or the evaluator can mail the letter of
recommendation directly to the Department of Nursing. You, the applicant, are to provide an addressed envelope with your name on front of envelope, and IT
IS YOUR RESPONSIBILITY TO VERIFY IT HAS BEEN RECEIVED AND INCLUDED WITH YOUR APPLICATION.
AT LEAST ONE FROM A PROFESSIONAL (WORK) REFERENCE.
AT LEAST ONE FROM AN ACADEMIC (COLLEGE/UNIVERSITY) REFERENCE.
THIRD REFERENCE IS APPLICANTS CHOICE (OTHER).
1. Name of Recommender:
Recommendation Type:
Professional Academic Other
Email:
Phone Number:
Return to applicant:
Y or N
Mail to Dept.:
Y or N
How do you, the applicant, know this recommender?
2. Name of Recommender:
Recommendation Type:
Professional Academic Other
Email:
Phone Number:
Return to applicant:
Y or N
Mail to Dept.:
Y or N
How do you, the applicant, know this recommender?
3. Name of Recommender:
Recommendation Type:
Professional Academic Other
Email:
Phone Number:
Return to applicant:
Y or N
Mail to Dept.:
Y or N
How do you, the applicant, know this recommender?
2
1
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
4
L. NURSING DEPARTMENT ADVISEMENT SHEET ~ To be completed by the SUU COSE Student Success Advisor and signed by the
student (applicant) and said advisor. An appointment to complete this form must be made no less than one week prior to the application
deadline date. Student Success Advisor contact information is available on the cover sheet of this application.
Student Name: .
SUU STUDENT Number (T#):
Pre-requisites: (Gen Ed and Core Requirements):
Core Course Requirements below must be completed with a “C” or
better, a “C-” grade will not be accepted and must be repeated.
Catalog Year:
Course
Completed
(Grade) (Credit hours)
Course
Completed
(Grade) (Credit hours)
ENGL 1010 (3)
BIOL 2420
PHYSIOLOGY (3)
ENGL 2010 (3)
BIOL 2425
PHYSIOLOGY LAB (1)
AMERICAN INST (3)
BIOL 2060
MICROBIOLOGY (3)
FINE ARTS (3)
BIOL 2065 (1)
MICROBIOLOGY LAB
LM 1010 (1)
Information Literacy
BIOL 2320
ANATOMY (3)
COMM 1310/HUM (3)
BIOL 2325
ANATOMY LAB (1)
CHEM 1110 (3)
ELEMENTARY CHEM
CHEM 1115 (1)
ELEM CHEM LAB
CHEM 1120 (5)
BIO ORGANIC CHEM
CHEM 1125 (1)
BIO ORG CHEM LAB
BIOL 2170
PATHOPHYSIOLOGY (3)
NFS 1020 (3)
Human Nutrition
FLHD 1500/PSY1110 (3)
Lifespan Development
PSY 1010 (3)
General Psychology
MATH 1040 (4)
Statistics
□ Overall Cumulative GPA
(all college):
□ Current 30 Credits:
Total:
Total:
CORE GPA:
Total:
Total:
Gen Ed requirement met with Associate of Science/Arts (AS/AA)
Degree from (list when & where):
Gen Ed grades verified by:
Signing below, signifies that student has met with a Southern Utah University Student Success Advisor for the College of Science and
Engineering. Student and advisor agree that the pre-requisite requirements have been met to apply to the Southern Utah University
Nursing Program.
Academic Advisor Signature: Date:
Student Signature: Date:
Important: Include a completed and signed copy of this form with your Nursing Admission Application.
Points toward your application are awarded based on the grades above. If you have had to re-take any classes it will be to your benefit to attach a short
letter of explanation concerning any retakes.
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
5
M. Functional Requirements for Student Success
Southern Utah University’s Nursing faculty members value diversity in the students who wish to enter the
profession of nursing. Students interested in entering nursing must be aware of functional requirements,
environmental factors, and psychosocial demands that must be met to be considered as a candidate for entry into the
nursing profession.
Functional requirements include, but are not limited to:
• Must be able to independently push, pull, and lift a medically fragile adult when positioning or transferring.
• Must have the ability to palpate body structures and be able to differentiate and report subtle variation in
temperature, consistency, texture and structure.
• Must be able to identify and distinguish subtle variations in body sounds such as breathing.
• Must be able to read, understand, and apply printed material which may include instructions printed on
medical devices, equipment and supplies.
• Must be able to visually distinguish subtle diagnostic variations in physical appearance of persons served.
An example would be “pale color”.
• Must be able to distinguish subtle olfactory changes in physical characteristics of persons served.
• Must be able to walk and stand for extended periods of time.
• Must possess the ability to simultaneously and rapidly coordinate mental and muscular coordination when
performing nursing tasks.
Environmental factors include, but are not limited to:
• Protracted or irregular hours of work.
• Ability to work in confined and/or crowded spaces.
• Ability to work independently as well as with coordinated teams.
• Potential exposure to harmful substances and/or hazards.
Psycho social demands include, but are not limited to:
• Ability to maintain emotional stability during periods of high stress.
• Ability to work in an emotionally charged and stressful environment.
I am aware of the functional requirements, environmental factors, and psycho social demands that
must be met to be considered as a candidate for entry into the nursing program. __________
Initial
I understand that any personal body alterations (tattoos, gauges, piercings-other than one conservative
earring per ear, et.) must be completely covered and/or removed for all clinical experiences. __________
Initial
Signing below signifies that I have read, understand, and that I agree and meet all of the requirements stated above.
_________________________________________________ __________________________
Signature Date
________________________________________________
Print Name
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
6
N. APPLICATION CHECKLIST AND SIGNATURE. Complete the following checklist before signing and dating your
application. Applicants are responsible to send their COMPLETE and signed application for the SUU Department of Nursing
Bachelor of Science program in one envelope to:
Southern Utah University
Department of Nursing
Attn: Vikki Robertson
351 W. University Boulevard, SCA 108 A
Cedar City, UT 84720
CHECKLIST FOR SUU DEPARTMENT OF NURSING BSN APPLICANTS
Be sure to submit a complete and SIGNED application. Incomplete or unsigned applications will NOT be considered for admission
to the Nursing Program!
Completed, signed and dated Department of Nursing application.
Receipt for the $20.00 Nursing Application Processing Fee; checks made payable to “SUU Nursing (NURS2)” (see cover letter &
deposit form).
One (1) transcript (unofficial is acceptable) from EACH community college, college, and university you have attended (this includes
SUU transcripts).
Completed Bulleted List of extracurricular activities, awards, honors, scholarships, student government, etc. (Item H)
Completed Essays (Item I & J).
A minimum of three (3) recommendations in sealed, signed envelopes or noted that the evaluator is mailing recommendation. IT IS
THE APPLICANT/STUDENT RESPONSIBILITY TO MAKE SURE ALL THREE (3) RECOMMENDATIONS ARE
RECEIVED BY THE DEPARTMENT OF NURSING BY THE APPLICATION DEADLINE DATE, if they are not included
with the completed application packet (item K).
Completed Nursing Department Advisement Sheet (item L) signed by both SUU Academic Advisor and student/applicant.
Signed Functional Requirement for Student Success Form (item M).
Other important things to remember/check-off:
Non-SUU Students: I have submitted my SUU application to the Office of Admissions, with the required documentation
and fees. _________
(Initial)
All applicants: I understand that if I am offered admission to the program without having all required pre-requisites
completed at time of application, I must submit an unofficial copy of my transcripts by 4:00 pm, on Friday of the
week grades are posted.
__________
(Initial)
All applicants: I understand that if I am offered admission to the program, that my admission is contingent on the following:
Successful completion of any remaining pre-requisite courses and maintaining my application GPA.
Submission of a clean/clear background report with the acceptance form. __________
(Initial)
Incomplete applications will not be considered.
NOTE: In order to be licensed as a registered nurse in the state of Utah, the application must be in conformity with the Utah Nurse Practice Act.
Applicants who have been convicted of a felony, treated for mental illness or substance abuse should discuss their eligibility status for licensure with
the Utah State Board of Nursing. Acceptance and completion of the nursing program does not assure eligibility to take the RN licensure exam. The
Utah State Board of Nursing makes the final decision as to whether a license will be issued to practice nursing in the State of Utah. If you have
questions regarding this, please contact the State Board of Nursing, 160 East 300 South, Salt Lake City, Utah 84111; Phone Number (801) 530-6628
or Toll Free in Utah (866) 275-3675.
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
7
O. SIGN YOUR APPLICATION BELOW. APPLICATION WITHOUT A SIGNATURE WILL NOT BE CONSIDERED FOR
ADMISSION!
Please read closely the text below before signing application.
It is understood that in applying to Southern Utah University’s Nursing Program the applicant has read, understands and signed
the “Functional Requirements for Student Success” (document can be downloaded with other application materials, item “M”). The
Department of Nursing reserves the right to deny admission or to recommend dismissal of an admitted student whose academic record or
performance in clinical instruction does not meet minimal expectations or whose performance is not consistent with these essential
qualifications.
The Bachelor of Science in Nursing (BSN) program is an upper-division course of study requiring students to communicate effectively on
their own behalf. Students in this program are expected to demonstrate skill in independent decision making, professional communication,
critical thinking and problem solving.
Accordingly, the manner in which an applicant/prospective student communicates with the Department of Nursing may be considered as a
potential indicator of the applicant/prospective student’s ability to succeed in the BSN program. The Department of Nursing seeks to foster
the reciprocal benefits of direct communication, which provides an opportunity for the communicator/applicant to identify and articulate his
or her thoughts, and for the Department of Nursing to consider and respond directly to both, words and tone of applicant/student. The
Department of Nursing generally views indirect communication through a third party, whether parent, friend or other party as
diminishing the effectiveness of that communication. (In situations involving a student or applicant with a disability affecting his or her
ability to communicate, the Department does not consider needed third party assistance as “indirect” communications, and will provide all
reasonable accommodations for that disability.)
Although individuals applying for entry into the BSN program should understand that admissions decisions are final, the Department of
Nursing may discuss some information about an application, but only with the applicant. At the Department’s sole discretion, information
may be shared with another party if the applicant submits a written and signed release. However, the applicant must be present at all
discussions.
PLEASE NOTE:
1) Only complete files/applications will be reviewed.
2) Through the completion of the Nursing Program students may be exposed to blood borne pathogens.
3) All prerequisite/support courses must be completed, successfully, prior to starting the nursing program.
4) Acceptance is contingent on a clean/clear background report.
5) Satisfactory progress through the nursing program requires attendance in both theory and clinical sections. Clinical hours may include
evenings, nights and weekends and will include out of town travel.
6) Students must supply their own transportation to clinical sites.
7) Body Alterations (extreme hair color, tattoos, gauges, piercings-other than one conservative earring per ear, etc.) must be completely
coverable and/or removed for all clinical experiences.
I certify that I have read and understand the above statements and that all materials I have submitted for consideration by the
Department of Nursing Admissions and Advancement Committee are complete and accurate. I understand that if it is found that any of
the above information is falsified in any way, my application will not be considered and if I have been accepted to SUU’s Nursing
Program, falsified information is grounds for immediate removal. I understand that if I have not completed all course work
requirements prior to the start of Summer semester, my admission to the Department of Nursing will be canceled and it will be
necessary for me to reapply. I understand that failure to complete the application accurately, or failure to submit all required
documents, including a complete set of transcripts for all colleges attended, will result in denial of admission to the Department of
Nursing. I understand that my complete application must be received by the SUU Department of Nursing on or before 4:00 PM,
Friday, December 13, 2019, and that applications postmarked 12/13/2019, or received after this date will NOT be considered for
admission to the program.
It is understood that the application and all accompanying documents, including transcripts, become the property of the Department of
Nursing and will not be returned to the applicant. (It is strongly recommended that you make a copy for your records before
submitting your application.)
APPLICANT SIGNATURE ___________________________________________________________ DATE _________________
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
8
Pay in person to the SUU Cashier’s Office, with this completed form.
OR
Pay on-line using the U-Pay link.
PLEASE PRINT/COPY THREE (3) COPIES OF THE 3-Page LETTER OF RECOMMENDATION FORM BELOW.
SUU Department of Nursing
Deposit Disbursement
Application Processing Fee
Students: Pay On-Line, using the U-Pay information below OR
Complete this form and take it and your $20 Application Processing fee to SUU’s
Cashier’s Office (Sharwan Smith Center Rotunda). Cashier’s office cannot take your
payment without this form.
Date
date
Student Name
Your name goes here
Department
Nursing
Amount of Deposit
$20.00
Description
Nursing Admission Application Processing Fee
Deposit To
Account
Index
Fund
Org
Account
Prog
NURS2
5562
OR The U-Pay,on-line payment option is available on the SUU Nursing website; go to
http://suu.edu/cose/nursing/, select “Application On-line Payment Option” and follow
directions.
Include your receipt in your completed application.
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
9
TO THE APPLICANT: Please fill out section 1 ONLY for each recommender. (Please Print)
SECTION 1
Name of Applicant: _________________________________________________________________________________
T Number: _____________________________________________________________________
PLEASE NOTE: “The Family Educational Rights and Privacy Act of 1974 and its amendments guarantee student access to
educational records concerning them. Students are also permitted to waive their rights to access to recommendations.
The following signed statement indicates the applicant’s wish regarding this recommendation:
I waive, _______ or I do not waive _______ my right to see this form or any supplementary notes or letters pertaining to this
reference form.
Applicant Signature
________________________________________________ Date____________________
TO THE EVALUATOR: Please complete sections 2, 3 and 4.
SECTION 2
You have been chosen by the applicant as a reference in support of an application for nursing study at Southern Utah
University. We are particularly interested in your appraisal of the applicant’s abilities and potential for further
education.
Evaluator’s Name______________________________________________________________________________
Email ______________________________________________________ Phone _________________________
Occupation ___________________________________________________________________________________
Are you related to the Applicant: Yes No Relationship: ______________________________
Length of time you have known applicant____________________________________
Capacity in which you have known the
applicant_____________________________________________________________________________________
Signature___________________________________________________________ Date____________________
SECTION 3
OVERALL RECOMMENDATION:
I highly recommend this applicant for the Nursing Program.
I recommend this applicant for the Nursing Program.
I do not recommend this applicant for the Nursing Program.
Page 1 of 3
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
10
SECTION 4
Evaluators should: (1) rate each statement independently, and (2) avoid a tendency to rate on general impressions. One
characteristic might influence the rating of all characteristics.
The following questions or statements identify a variety of traits, skills, attitudes, etc. Please indicate the degree to which each
quality is characteristic of the applicant you are rating by: (1) reading the statement carefully, (2) reading the points on the
scale, and (3) encircle the number of your choice on the scale.
Specific comments in each category are encouraged. If you do not feel that you have enough information to rate the
candidate on a particular item, please circle “UNABLE TO ASSESS”.
1. Problem Solving: Ability to identify and solve problems:
1 2 3 4 5
UNABLE TO ASSESS
Poor Average Excellent
2. Sense of Responsibility: Ability to complete tasks, duties & honors commitments:
1 2 3 4 5
UNABLE TO ASSESS
Doesn’t complete; Average Always completes;
Avoids responsibility Accepts responsibility
3. Maturity: Ability to conduct self in a mature, adult manner:
1 2 3 4 5
UNABLE TO ASSESS
Immature, childish Average Mature, adult behavior
4. Attitude: Based upon your experience, what type of attitude does the applicant project toward life, school, job, etc.
1 2 3 4 5
UNABLE TO ASSESS
Very negative Average Very positive
5. Caring Attitude: Does the applicant display a degree of caring for others?
1 2 3 4 5
UNABLE TO ASSESS
Very little Average Exceptional
6. Stress/Anxiety Response: Ability to deal with stressful, anxiety-producing situations:
1 2 3 4 5
UNABLE TO ASSESS
Poorly, ineffective Average Excellent
7. Motivation: Extent to which individual applies self:
1 2 3 4 5
UNABLE TO ASSESS
Uninspired Average Self-starter;
Systematically a hard worker
8. Appearance: Extent to which standards of appearance are met:
1 2 3 4 5
UNABLE TO ASSESS
Untidy Average Well groomed
Page 2 of 3
SOUTHERN UTAH UNIVERSITY
APPLICATION TO THE DEPARTMENT OF NURSING
LPN/PARAMEDIC TO BACHELOR OF SCIENCE IN NURSING DEGREE – 2020 Admission
SUU Department of Nursing – Admissions, 351 W. University Boulevard, SCA 108, Cedar City, UT 84720
435/586-1906 or 435/586-7915, RobertsonV@suu.edu
11
9. Acceptance of Personal Feedback: Extent to which applicant accepts constructive critique and considers others points of view:
1 2 3 4 5
UNABLE TO ASSESS
Resents, rejects, Average Seeks, utilizes,
doesn’t respond responds effectively
10. Communication Skills: Ability to communicate with peers, co-workers, teachers, etc.:
1 2 3 4 5
UNABLE TO ASSESS
Expresses self Average Excellent expression;
poorly Fluent
11. Integrity: Extent to which applicant displays an ethical code:
1 2 3 4 5
UNABLE TO ASSESS
Cheats, untruthful, Average Always honest, admits error,
blames others for mistakes truthful, trustworthy
12. Interpersonal Relationships: Ability to cooperate and get along with peers, co-workers, teachers, employers, etc.:
1 2 3 4 5
UNABLE TO ASSESS
Inappropriate behavior; Maintains satisfactory Outstanding ability to work
generally antagonizes relationship well with others
13. How would you characterize the following regarding this applicant? (Additional comments may be placed on a separate page if desired)
A. Greatest Strengths:
B. Weakest points:
C. Other comments:
Thank you for your help in evaluating the applicant. A separate letter is not required but can be included.
Please seal this form in the envelope provided, sign your name across the seal and return it to the applicant or
mail directly to:
SUU Department of Nursing
Attn: Vikki Robertson
351 W. University Blvd
Cedar City, UT 84720
(Please indicate students name on outside of envelope)
All Letters of Recommendations must be received at above location on or before Friday, December 13, 2019.
Page 3 of 3
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SUU LPNPARAMEDIC TO BSN DEGREE application

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Completed 25 December 2019

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