2022 Application - RISHI Power of Nursing FDW Training

2022 Application RISHI Power of Nursing Faculty Development Training

1. Name and Education History *This question is required.

First Name
Last Name
Degree
Nursing School
Year of Graduation
License #
State of Issue

2. Nursing School/Health Care Institution where you will implement The Power of Nursing *This question is required.

Name
Address
City
State, Zip
Country

4. Professional Specialty *This question is required.

5. Professional Nursing Position *This question is required.

University or Organization
Title
Professional Role
Years in Position

Professional Position (if more than one held concurrently)

University or Organization
Title
Professional Role
Years in Position

6. Work Contact Information *This question is required.

Name
Address
City, State, Zip
Country
Work Phone
Work Fax
Work Email

7. Home Contact Information

Address
City, State, Zip
Country
Home Phone
Cell Phone
Home Email

8. Which is your preferred email? *This question is required.

Work
Home

9. How did you hear about The Power of Nursing? *This question is required.

Please enter an 'other' value for this selection.

10. What courses do you teach at your Nursing school? *This question is required.

11. When do you plan to implement The Power of Nursing at your nursing school? *This question is required.

Pilot Start Date
Full Course Start Date

12. What institutional support including financing (if any) do you have for this plan? *This question is required.

13. What obstacles do you anticipate in implementing this course? *This question is required.

14. Approximately how many nursing students would participate in the course at your school?

15. What are the unmet needs of your nursing students that you hope to address with The Power of Nursing or with other work you are planning to do? *This question is required.

16. What draws you personally to teaching this course? What would you like to gain from it? Please describe briefly. *This question is required.

17. Do you have any experience leading small groups or workshops? Please describe. *This question is required.

18. Please tell us one way that being a nurse has enriched your life. *This question is required.

19. Do you have any health care needs that our staff should know about? Please describe. *This question is required.

20. Is there anything else you would like us to know?

CONTINUING EDUCATION CREDIT FOR NURSES: Provider approved by the California Board of Registered Nursing, Provider # 10064, credit for this workshop training is forthcoming. BRN continuing education credits are accepted by most state nursing boards; please verify with your state agency if you are outside of California.

CANCELLATION & REFUND POLICY: A deposit of $300 is due at time that your application is accepted. The balance is due by June 15, 2022. A full refund of deposit (less processing fee of $25) will be issued for cancellations on or BEFORE July 1. Cancellations after July 1 will forfeit deposit.