American Association of Critical-Care Nurses
Greater Cincinnati Chapter (GCC)
Scholarship Application Form A
Name:
Date of submission:
Email address:
Fiscal Year of scholarship request:
(Fiscal year July 1-June 30)
Enter # of points allotted under the month completed
Professional
Activity
Indicator
Comments
July Aug Sept Oct
Nov
Dec
Jan
Feb
Mar
Apr
May June
2014 2014 2014 2014 2014 2014 2015 2015 2015 2015 2015 2015
KEY:
Category 1
Indicator
1
2
3
4
5
6
7
8
9
10
Category 2
Indicator
11
12
13
114
*15
Points
1/hr.
4/hr.
5
10
15
25
25
25
50
75
Points
10
15
35
75
25-50
Professional Activity
Attendance at AACN-GCC Sponsored Workshop/Lecture/Meeting
Per hour service for AACN-GCC meeting attendance, committees, or work related to the chapter
Guest attended AACN-GCC Sponsored Event (list name under comments section)
Recruited new member (List name under comments section)
AACN-GCC committee member with >75% attendance at committee meetings.
Attended a national AACN sponsored conference (NTI/Progressive Pathways…etc) (Attach copy of CEU form)
AACN-GCC board member or chairperson of a committee with >75% attendance at meetings
Poster presentation at AACN or AACN-GCC local, regional or national workshop / meeting
Speaker at AACN or AACN-GCC local, regional or national workshop / meeting
Hold national AACN Office
Professional Activity
Active ACLS or PALS (Attach copy of card with application form)
Active CPR / ACLS / PALS Instructor
Active CCRN/PCCN/CCNS/ACNPC/CMC/CSC Certification (Attach copy of card with application form)
Editor or author of Professional Nursing Book (Attached copy of book cover)
Author of article for professional nursing journal (copy of cover page with listed authors or copy of letter acknowledging
manuscript acceptance)
*16
25-50
Principle or co-investigator of research
*Scholarship committee will assign points
Approved AACN-GCC 01/2015/TMessinger