EXEMPTION SUBMISSION Supplemental Application Name: _ Graduation Date (or anticipated Graduation Date): _ School Name (State, if not CO): Current UCHealth Employee? Yes No If yes; in what role, facility, and department? Reason for Exemption application submission: If applying with 1-6 months of RN experience, please also provide: o Exact dates (month/year – month/year) of employment as an RN: _ o Location of RN experience: _ o Facility name: During the one year Nurse Residency Program you will be required to attend monthly residency seminars, clinical specialty classes and work a staff nurse schedule, which may include 12-hour rotating day/night/weekend and holiday shifts You will also be required to sign a financial contract stating your commitment to work for one full year following the oneyear Nurse Residency Program in your unit of hire Do you agree to these requirements? Yes If yes, please respond to the following questions No EXEMPTION SUBMISSION Supplemental Application List the top three clinical units/areas in which you would like to apply and WHY you feel this would be a good professional fit (Please refer to the website for unit descriptors.) #1 #2 #3 As a UCH employee, you will be held to the UCHealth standards of excellence, these include a commitment to service, quality, teamwork, personal responsibility and communication Discuss a professional experience in which you exemplified one of these standards of excellence (Word count limit: 250) Share with us an accomplishment you are most proud of professionally (Word count limit: 250) Describe any leadership or volunteer activities you have participated in that have contributed to your professional growth (Word count limit: 250) **If you have applied for an Adult ICU, Neonatal ICU or ED position, you must have participated in either a “paid” or “unpaid” clinical experience in an area of critical care Please use the template below to outline your experience(s) to meet this eligibility requirement If you not have any prior healthcare experience, feel free to delete this table** Type of Experience (example) Senior Practicum (example) Advanced Care Partner Approximate Dates Total hours November 2019 225 hours January – December 2019 12 hours/week Name of Hospital and/or Institution Medical Center of the Rockies University of Colorado Hospital Name of Department or Department Description Surgical ICU ED