MINORITY NURSE LEADERSHIP INSTITUTE (MNLI)
School of Nursing Educational Opportunity Fund Program Telephone: 973- 353-1091
Minority Nurse Leadership Institute (MNLI) FAX: 973-353-1495
180 University Avenue Email: vstephen@rutgers.edu
Ackerson Hall, Room 109-C
Newark, New Jersey 07102
Instructions: MNLI Application must be mailed, Emailed, or faxed to the above address
PERSONAL INFORMATION
Name:
Street Address:
City, State, Zip:
Email:
County:
Telephone:
Mobile:
HIGHEST LEVEL OF EDUCATION COMPLETED
Degree Major(s) Institution Year
1.
2.
3.
4.
CURRENT ENROLLMENT IN AN EDUCATIONAL PROGRAM
Degree Major(s) Institution Number of Credits
Are you currently licensed as a registered professional nurse in New Jersey? Yes No
Please indicate your race/ethnicity:
African American/Black
Hispanic
Asian
Pacific Islander
Native American
Other (Specify)
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EMPLOYMENT
Current employment as a registered professional nurse in New Jersey?
Full Time Part Time
Place of Employment:
Employer’s Address:
Work Telephone:
Title:
Work FAX:
Why are you applying to be a Minority Nurse Leadership Institute (MNLI) Fellow? Please state your MNLI leadership development goal(s).
Briefly describe your present job responsibilities and the nature of your work. Include any leadership experience related to your current nursing position.
Briefly describe your most significant contribution(s) or achievement(s) in your current nursing position.
Briefly describe any previous leadership experience you may have.
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Which of the following best describes your present place of employment?
Hospice Hospital Private Practice Ambulatory Care
Education
Occupational
Health
Home Care Government
Extended Care/Rehabilitation
Community
Other (Specify)
CIVIC AND PROFESSIONAL INVOLVEMENT
Please list recent (5 years) civic, religious and/or community activities in which you are involved, the dates of participation and any leadership experience that may apply.
Please list all professional organizations in which you are currently or have previously been involved, the dates of participation and any leadership experience that may apply.
Please list all offices you currently hold or have held in the past.
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PERSONAL GOALS AND PARTICIPATION IN LEADERSHIP ACTIVITIES
In addition to developing/enhancing MNLI Fellows’ leadership skills, it is expected that
MNLI workshops will increase Fellows’ understanding of and involvement in minority healthcare issues. All MNLI Fellows are expected to provide leadership for and complete a team project designed to improve evidence-based nursing practice that addresses a selected minority community health challenge.
Please identify a topic related to minority health and briefly describe strategies you intend to develop as part of a team project that would improve minority health. Provide a brief project plan, including: the project’s intended impact on the community, nursing practice environment, and the nursing profession. (If needed, additional pages may be attached.)
Developing a mentor-protégé relationship is an integral part of the MNLI experience.
Please describe what you are seeking in a mentor and what you are willing to do to facilitate the mentor-protégé relationship. (If needed, additional pages may be attached.)
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PERSONAL BACKGROUND
Completing this section is completely voluntary, however, the information will be helpful in better ensuring the diversity of each MNLI cohort.
50 + Age < 25 25 to 30 31to 40
Gender Female Male
41 to 50
Do you need handicapped or special accommodations? No Yes Specify:
COMMITMENT
The MNLI experience takes place September 2016 through June 2017 and consists of: 10 full-day seminars that take place one Saturday each month (please see the MNLI schedule provided on page 6 of this application packet). Participating in the seminars is mandatory.
MNLI Fellows are expected to attend all Saturday seminars and to complete all requirements of the Institute. Fellows may not miss more than one Saturday seminar. In order to fulfill the requirements of the Institute, each MNLI Fellow must: (1) complete an individual team leadership project designed to improve evidence-based nursing practice that addresses a selected minority community health challenge, and (2) submit an executive summary and present a formal professional poster presentation based on their team project.
The tuition for the MNLI is $1,995.00 payable to Rutgers University School of Nursing
(RUSN) Minority Nurse Leadership Institute (MNLI). Employer sponsorships are strongly encouraged.
I UNDERSTAND THE PURPOSE AND REQUIREMENTS OF THE MINORITY NURSE
LEADERSHIP INSTITUTE (MNLI) AND WILL ABIDE BY THEM. I WILL DEVOTE
SUFFICIENT TIME TO COMPLETE THE MNLI EXPERIENCE AND PARTICIPATE
IN ALL MNLI ACTIVITIES.
__________________________________________________
Candidate’s Signature
__________________
SUBMIT NO LATER THAN JANNUARY 15, 2016
Date
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Month
September 2015
October 2015
January 15, 2016
March 1, 2016
Activity
Calendar of Events for MNLI Fellows
Outcomes
Advertise for MNLI Fellows and Leadership Mentors.
MNLI application packets go out.
MNLI application packets due in.
MNLI Fellows and Leadership
Mentors selected.
Competitive pool of MNLI applications received.
First cohort of 10 Fellows and Mentors are selected and notified for MNLI 2016-2017.
Leadership Mentors are trained for participation in the MNLI.
April 9, 2016 MNLI Leadership Mentor training in accordance with the
ONE-NJ Mentoring Toolkit.
September 10, 2016 Saturday Seminar #1
October 8, 2016
Meeting with Mentor
Saturday Seminar #2
Meeting with Mentor
November 12, 2016 Saturday Seminar #3
Meeting with Mentor
December 10, 2016 Saturday Seminar #4
Meeting with Mentor
January 14, 2017 Saturday Seminar #5
Meeting with Mentor
February 11, 2017 Saturday Seminar #6
Meeting with Mentor
March 11, 2017
April 8, 2017
Saturday Seminar #7
Meeting with Mentor
Saturday Seminar #8
May 13, 2017
June 10, 2017
Meeting with Mentor
Saturday Seminar #9
Meeting with Mentor
Saturday Seminar #10
Meeting with Mentor
Institute on Leadership in
Minority Health (1 day)
Each Fellow will present a poster related to their
Leadership of a Team Project addressing a
Minority Health issue reflecting their work over the past year. Certificates are awarded.
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