MISSOURI STATE UNIVERSITY
DEPARTMENT OF NURSING
MASTER OF SCIENCE IN NURSING- NURSE EDUCATOR APPLICATION
Deadlines for Completed Application (at 5PM CST on the following dates):
August 1 for fall admission - December 1 for spring admission - May 1 for summer admission
DATE: ___________________________
NAME:
Ms.
Mrs.
Mr.
_________________________________________________________________________________________
(Last)
(First)
(Middle)
(Maiden)
ADDRESS: _______________________________________________________________________________
(Street and Number)
(City)
(State)
(Zip Code)
TELEPHONE: ______________________ E-MAIL ADDRESS: _____________________________________
SOCIAL SECURITY NUMBER: __________________________
DATE OF BIRTH: ________________
MSU BEARPASS NUMBER: ____________________________
CLOSEST RELATIVE: _____________________________ RELATIONSHIP: ________________________
ADDRESS: _______________________________________ TELEPHONE: ___________________________
EMPLOYER NAME: ____________________________ DEPARTMENT: ____________________________
EMPLOYER ADDRESS: ____________________________________________________________________
EMPLOYER PHONE NUMBER: ____________________________
PREVIOUS EDUCATIONAL PREPARATION (Nursing Schools & Colleges in chronological order):
Name of School
Updated 5/4/2015
Address
Length of Time
Date of
Graduation
Degree or
Certification
MASTER OF SCIENCE IN NURSING- NURSE EDUCATOR
APPLICATION, CONTINUED
LIST ALL WORK EXPERIENCE SINCE GRADUATING FROM YOUR BASIC NURSING PROGRAM:
Position
Organization
Anticipated Enrollment:
City/State
How long Employed
Full-time____ (9 or more credits/semester)
Part-time____
Note: Many, if not most, clinical experiences will occur during daytime hours (e.g. 9-5) and weekdays. Classes
also may be scheduled during day time hours, due to resource availability.
Is there anything about you not included on your application that you feel we should consider in the admission
process?
___________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
WHERE DID YOU HEAR ABOUT OUR PROGRAM? ______________________________________________
I verify that everything on this application is correct.
_____________________________________________
Signature of applicant - (hard copy or e-signature)
Updated 5/4/2015
_________________________
Date
MASTER OF SCIENCE IN NURSING- NURSE EDUCATOR
NURSE EDUCATOR – MSN ADMISSION CHECKLIST
M#_____________________
Prerequisites for MSN Program:
______ Undergraduate Statistics
______ Undergraduate Health Assessment
______ Undergraduate Nursing Research
______ Health Care Informatics course
______ Graduate Statistics
______ Cumulative GPA of 3.0 + (for last 60 hrs)
Application Materials:
______ Admission to Graduate College of Missouri State University (http://graduate.missouristate.edu)
Submit the following IN A SINGLE PACKET directly to the Nursing Department for consideration to
admission in specialization, for each item initial that they are included (if applicable):
______ Completed MSN Application
___ NE
___ Post Master’s Certificate
______ Application Fee of $50.00 (For students admitted Fall 2014 and following)
Pay online at: https://commerce.cashnet.com/NursingDept
______ GRE Score (if cumulative GPA is less than 3.0)
______ RN license without disqualification in state of practice
Exp. date__________
______ Varicella (chicken pox) titer or vaccination
_____ Evidence of vaccination for or immunity titer, to Measles, Mumps, and Rubella (MMR)
______ Evidence of vaccination (must complete series of 3 vaccinations) for or immunity titer to, Hepatitis B
______ Evidence of Tetanus vaccine (within 10 years, renewed when expired)
Exp. date__________
______ Proof of negative TB status or medical follow-up (within 1 year, renewed yearly)
Exp. date__________
______ Evidence of current American Heart Association BLS for Healthcare Providers certification (CPR)
Exp. date__________
______ Evidence of Professional Liability Insurance (minimum limits of $1,000,000 each occurrence and $6,000,000 aggregate)
Exp. date__________
______ Evidence of current Personal Health Insurance
______ Evidence of Family Care Safety Registry online: http://health.mo.gov/safety/fcsr
______ Arrange for Criminal Background Check (registration instructions will be provided through the Nursing Department)
______ Arrange for Urine Drug Screening (registration instructions will be provided through the Nursing Department)
Additional documentation needed after admittance to program:
______ Mandatory orientation attendance on campus - First Monday before classes start each semester (August, January,
June)
______ Academic Plan and Application to Degree Program completed with advisor
______ Blood Borne Pathogens training online yearly (renewed every August)
Exp. date__________
______ HIPAA Missouri State University training online
______ Signed Student Disclosure Form (renewed every August)
Exp. date__________
______ Influenza Vaccination documentation for clinicals (within 1 year)
Exp. date__________
______ Purchase Polo Shirt for clinicals
______ Purchase Name Badge for clinicals
______ Pay fee for tracking software (Typhon) $50.00
Updated 5/4/2015