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Pursuant to the Abraham S. Fischler College of Education (FCE) Student Grievance
Procedure, the Grievance Form is for use in filing a grievance when a satisfactory
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Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, "Authorization for the
use and/or Disclosure of Protected Health Information", and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
address it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine

Dear Applicant: Thank you for expressing an interest in the Associate Degree Nursing Program at Northwest College. There are two entry points to the Associate Degree Nursing program; 1) at the beginning of each fall with a new cohort or 2) at mid-pointjoining the ongoing sophomore cohort in Semester 3. Applicants potentially eligible for midpoint entry are advanced placement, transfer or re-entry students. Advanced Placement students must be Licensed Practical Nurses who meet advance placement application criteria. Candidates chosen for Advanced Placement status will enter the sophomore year of the Associate Degree Nursing Program. If you are a transfer student or student wishing to re-enter the nursing program, please see the Nursing Student Handbook pages 22-23 for entrance criteria on our website and contact the Director of Nursing, marnee.crawford@nwc.edu. Students beginning at the entry point of the program are admitted to the school of nursing each fall term through the application process outlined in this packet and consistent with the Nursing Student Handbook. Application packets are available online at www.nwc.edu/nursing or in the Nursing Program office. This packet contains Admission Criteria related to applying for admission to the Associate Degree Nursing Program (RN). Please read the packet in its entirety. You must apply to Northwest College and be accepted by the college before you can apply to and be accepted into the Nursing Program. You will receive a letter from the admissions department stating if you have been accepted by the college. This letter is not an indication that you have been accepted into the Nursing Program. You will receive a separate letter in this regard signed by the Director of Nursing regarding the status of your admission to the program. A satisfactorily completed application packet contains all the required items as stated below and on the Application Checklist. All materials must be received in the N ursing Department by the first Friday in March of each year. Applications are reviewed by the Director and faculty of the Associate Degree Nursing Program after the submission deadline. Applications that are incomplete or submitted past the application deadline will not be considered. Depending on the program and point of entry, students may be required to have a background check and meet technical and physical requirements as part of a two-tiered admission process. All students will be required to submit to entrance and random drug screening while in the program. STUDENT SELECTION PROCESS We select students based on the following criteria: 1) Students have met the math requirement 2) Students have met the lab/science requirement 3) Students have completed all the pre-requisite courses 4) Students have completed the TEAS test and meet the minimum programmatic mean 5) Students have met the GPA requirement 6) Students have a turned in a letter of intent 7) Students have submit ted official transcripts from all schools attended to Northwest College Registrar’s Office 8) Students have turned in a signed application checklist 9) All required materials as stated above have been turned in by the deadline for application Students who have satisfactorily completed all the numbered items above will be given first priority for consideration towards admission into the Associate Degree Nursing Program. Students who wish to apply but are currently enrolled in a pre-requisite course during the spring semester will be reviewed for placement on an alternate list for acceptance to the program. There is no guarantee that space will be available for alternates. A minimum cumulative GPA of 2.7 or higher (on a 4.0 scale) is required. Cumulative GPA is calculated using all courses completed in the program of study for the Associate Degree in Nursing at Northwest College. In addition, a ‘C’ or better 3 | P a g e is required on all courses required for the program of study for the Associate Degree in Nursing at Northwest College. For your reference the program of study is included on the website. It is the student’s responsibility to verify that all your application materials have arrived in the Nursing Department. Applications that are incomplete or submitted past the application deadline will not be considered.

Dear Nursing Program Applicant: Thank you for your interest in the undergraduate nursing program at Winona State University. Please review the following information carefully. The application for admission to the WSU nursing program is attached. This application is for the Fall 2016 Semester Admission only. All application materials must be received no later than February 1, 2016 by 4:00 p.m. Be sure to fill out your information accurately – especially your WSU e-mail address. An e-mail will be sent to your WSU e-mail to verify that your application has been received. If you do not receive an email by January 29, 2016, you will need to contact our office by 4:00 p.m. on February 1, 2016 to verify that your application has been received. No applications will be accepted after the deadline. Breakdown for Admission Criteria: 60% prerequisite GPA (calculated on the 3 most recent natural sciences, not including nutrition, 3 most recent social sciences, English and statist ics), 20% TEAS score, 15% starting coursework at WSU or Rochester Community & Technical College (RCTC), and 5% not repeating or withdrawing from any prerequisites. ** All students admitted to the Nursing: Generic Option for Fall 2016, must complete all prerequisites, including the requirement for certification as a nursing assistant, listed as “active” on a Nursing Assistant Registry within the United States before courses begin for Fall 2016. For more information, please see attached letter in the application packet. Reminders for applicants: 1. Review admission policies and procedures to be sure your file is complete and you are ready to apply. Complete the Application Readiness Checklist at http://www.winona.edu/nursingandhs/nurseadmissions.asp The checklist is designed to be completed on the computer. Print out the completed checklist, sign, attach and submit with your application for admission. You need not print the checklist in color. 2. Applicants for admission must be declared as nursing candidates (PNUG or PNGE) as of the application due date. 3. Students who signed the Preferred Admission Contract as first-year WSU students and meet the contract requirements will have first priority for admission to the nursing program. 4. Students with credits earned at other colleges or universities, including college credits earned while in high school and credits for CNA courses completed at community and technical colleges, must verify that all transcripts have been received by WSU and that all completed courses are reflected on the student Degree Audit Report (DAR) as of the application due date. The Department of Nursing Undergraduate Progression Committee will meet in March to review applicant files and determine who will be admitted to the nursing program. By mid-April, each person applying to the nursing program will receive a letter regarding his or her admission status at his or her permanent address in official university records. Nursing is an exciting and personally satisfying profession. The faculty looks forward to working with you as you prepare to become a professional nurse. Please do not hesitate to contact the Department of Nursing if you have any questions. The Winona Campus Nursing Department telephone number is (507) 457-5120 and the Rochester Campus Nursing Department telephone number is (507) 285-7349. Sincerely, The Department of Nursing Undergraduate Progression Committee 11/1/15 WINONA STATE UNIVERSITY College of Nursing and Health Sciences Department of Nursing APPLICATION FOR ADMISSION TO THE NURSING MAJOR FOR FALL 2016 – GENERIC OPTION – WINONA & ROCHESTER CAMPUS Due Date: February 1, 2016 by 4:00 p.m. Full Legal Name ___________________________________________________________________________________________ Last First Middle Previous Warrior ID # __________________________ WSU E-mail: ______________________________________ Please note: Your Letter of Acce ptance will go to your permanent address in official university records. Phone # - Cell __________________________ Permanent Home Phone ________________________ First semester of attendance at WSU: _________________ Date of high school graduation: _______________ (Requirement) (Month/Year) (Month/Year) Cumulative GPA (including all WSU and transfer credits): ___________ Are you currently attending WSU? ____ Yes ____ No Names of All Institutions Attended* Including WSU (If more space is needed, list on a separate sheet) Are these college credits earned while in high school? (Y/N) Dates of Attendance GPA Degrees /Certificates (i.e. CNA, AA/AS) * All college level credits taken while in high school will be counted as transfer credits. COMPLETION OF PREREQUISITE COURSE WORK WITH GRADE OF "C" OR BETTER (At least 4 of 5 Natural Sciences with Chem 210 or 4 of 6 with Chem 212 & 213, 3 of 4 Social Sciences, English 111, and Statistics must be completed with a grade of C or better or AP credit in order to apply. Show grade as “AP” for AP courses.) Course or its Equivalent per Official Evaluation of Credit (Degree Audit Report (DAR)) Completed Grade Received Will complete by May 6 List Other Plans for Completion Biology 206 Normal Nutrition ~ OR ~ HERS 205 Nutrition for Lifetime Fitness 209 Microbiology 211 Anatomy & Physiology I 212 Anatomy & Physiology II Chemistry 210 General, Organic & Biochemistry ~ OR ~ 212 Principles of Chemistry I ~ AND ~ 213 Principles of Chemistry II Psychology 210 Introduction to Psychological Science 250 Developmental Psychology Sociology 150 Introduction to Sociology 212 Sociology of Families English 111 College Reading and Writing Statistics 110, 301 or 305 or Psychology 231 I certify that the information I have provided on this application is correct to the best of my knowledge and that the Department of Nursing may request additional information upon admission to the major. I understand that if information submitted on my application is found to be inaccurate or incomplete, my admission to the nursing program will be forfeit.