MMU Nurse Anesthesia
Critical Care Experience/RN Licensure Form
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 to
August 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.
Hospital
Type of Unit
# of Beds
Dates of
Hours
Total months/years
Employment
worked/week
of experience
Total months/years an RN
Total months/years in critical care as an RN:
Nursing Procedure/Skills
Frequency of Experience
Daily
Weekly
Monthly
Rarely/
Never /NA
Never
to my unit
Basic heart rhythm interpretation
Arterial pressure monitoring
Arterial blood gas interpretation
Mechanical ventilation / weaning
Titration of IV vasoactive drugs
CVP monitoring
12-lead EKG interpretation
Invasive cardiac output
PA pressure monitoring
Recovery of immediate postoperative hearts
Code blue team leader /
rapid response nurse
Continuous renal replacement therapy
Cardioversion / defibrillation
Intra- aortic balloon pump
Ventricular assist device (LVAD)
ICP monitoring
Preceptor Role
Shift charge nurse / leadership role
# of times spent shadowing/learning role of a nurse
anesthetist: 0
1
2 3 4 5 6
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:
Please include photocopies of all certifications held.
BLS Certification
r
Yes
r
No
Expiration Date:___________________
ACLS Certification
r
Yes
r
No
Expiration Date:___________________
PALS Certification
r
Yes
r
No
Expiration Date:___________________
CCRN Certification
r
Yes
r
No
Expiration Date:___________________
Other Certifications:_________________________________________________________________________
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)
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:
I attest that the information provided in this application is accurate.
Signature: ______________________________________________________ Date: ____________________
