Montana Health Network
Nursing Student UAP Application
In 2005, the Montana Board of Nursing adopted rules that allow nursing students to be employed as Nursing
Student Unlicensed Assistive Personnel (UAPs). Generally speaking, a Nursing Student UAP may perform certain
nursing tasks through advanced delegation and the direct supervision of a Registered Nurse. Examples of nursing
tasks that a Nursing Student UAP may perform are:
 Calculation of medication dose
 Administration of medications by mouth, sublingually, subcutaneous injection, intramuscular injection,
tube, aerosol/inhalation, suppository and topical
 Insertion of peripheral IV catheters
 Hanging, without additives, IV fluids and adjusting IV flow rates
 Any other nursing task for which the student has received instruction within the nursing program
Eligibility to Apply
In order to meet the eligibility requirements of a Nursing Student UAP, the student must:
 Be currently enrolled in a state nursing board-approved nursing education program or a state nursing
commission-approved nursing education program
 In good academic standing
 Have satisfactory completed a course in the fundamentals of nursing
 Have satisfactory completed a pharmacology course (as a condition of receiving delegation of medication
administration)
How to Apply
1.
2.
3.
4.
Application packets are available at MHN or on-line at www.montanahealthnetwork.com.
Applications must be postmarked by April 1st for summer employment consideration.
Late or incomplete applications will not be considered.
Send completed application documents to:
Montana Health Network
Attn: Sherry Taylor
11 South 7th Street, Suite 241
Miles City, MT 59301
Phone: (406) 234-1420
Fax: (406) 234-1423
Recipient Selection
1. All completed Nursing Student UAP applications will be forwarded to the student’s preferred sites for
consideration.
2. Each participating facility will determine the most qualified applicant for their facility.
3. Positions are limited. Meeting eligibility requirements does not guarantee that an applicant will be employed.
4. Successful candidates will be notified with the expected term of employment defined. Term of employment will
generally be mid-May through late August.
5. Successful candidates will participate in each facility’s normal employment process i.e. employment paperwork
and orientation.
Nursing Student UAP Requirements
1. The names and photos of successful candidates may be used by Montana Health Network for marketing
purposes.
2. A signed skills check-list delineating nursing skills that the student has completed is required to be presented to
facility at time of employment.
Checklist of Application Documents
All applicants must include:
______Completed Nursing Student UAP Application Form
______Letter of Intent (One page or less) that answers the following:
1. Discuss why you chose to go into nursing.
2. Describe what interests you about rural nursing.
3. Identify the strengths that you will bring to a healthcare facility.
4. Describe your career goals for the next five years.
5. Discuss what motivates you.
6. Identify any additional skills or talents that should be considered such as
employment background.
______Completed Instructor Recommendation Form (included in packet)
Please note: Instructors may place completed recommendation form in a sealed envelope
and return to you for inclusion in application documents. However, instructors also have the
option to mail completed forms directly to Montana Health Network. Please confirm with
your instructor.
______Completed Dean/Director of Nursing Program Verification Form
MONTANA HEALTH NETWORK
NURSING STUDENT UAP APPLICATION FORM
Part I—PERSONAL INFORMATION
_______________________________________________________________________
Last
First
Middle
________________________________________________________________________
Street Address
Apt #
________________________________________________________________________
City
State
Zip Code
________________________________________________________________________
Telephone
Home
Cell
E-Mail Address__________________________________________
Part II—PROGRAM INFORMATION
College or University currently attending: ________________________________________________
Anticipated date of completion of nursing program: ________________________________________
Part III—SITE SELECTION
SITE PREFERENCE FOR NURSING STUDENT UAP POSITION
(Please number top three choices: 1, 2, & 3)
___BAKER
___CIRCLE
___SHERIDAN
___LEWISTOWN
___TERRY
___BILLINGS – ST. JOHN’S LUTHERAN MINISTRIES
___SCOBEY
___WOLF POINT/POPLAR
___EKALAKA
___NO PREFERENCE, WILL GO TO ANY SITE AVAILABLE
___LIST ANY OTHER FACILITY OF INTEREST NOT LISTED ABOVE
_________________________________________________________________________
Part IV—CERTIFICATION AND RELEASE
I certify that I am currently enrolled in a registered nurse educational program and that I am in good standing. To the best of my knowledge, by the end of
spring semester I will have successfully completed Fundamentals of Nursing and basic Pharmacology.
I certify that the information set forth in this application is true and complete to the best of my knowledge. I understand that if accepted into this
program, the falsification or willful omission of information on this application, shall be considered sufficient cause for my removal from the program. I
consent to and authorize MHN to request any information concerning my previous employment or academic record as indicated on this application. I
hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out
of furnishing such job or academically related information.
Signature of Applicant
Date
Instructor Recommendation Form
_____________________________________ (Student’s name) has applied with Montana Health Network for
employment in the Nursing Student UAP program. In our effort to consider this individual, we would appreciate
you furnishing the information requested below. Your prompt response to this inquiry will be most helpful and will
be held in strict confidence.
Please rate this student in the following areas using this rating grid:
5 = Outstanding
4 = Highly Competent/Strongly Present
3 = Competent/Moderately Present
2 = Needs Improvement
1 = Unacceptable
NA = Unable to assess
Attendance
 No more than 2 absences per semester
1 2 3 4 5 NA
 No more than 2 times arrived late for school
1 2 3 4 5 NA
Positive Work Habits
 Demonstrates mature and professional attitude
 Flexible—modifies course of action as needs or priorities
change
 Completes assigned work on time without asking for
extensions or exceptions
 Demonstrates responsibility and accountability
 Demonstrates pride in work setting
 Complies with policies
 Demonstrates dependability
Interpersonal Relationships
 Works well in teams
 Willing to consider a variety of viewpoints
 Demonstrates tact and sensitivity when dealing with
others
 Shares credit for team accomplishments
Communication Skills
 Articulates views in a concise and understandable
manner
 Is a receptive listener; shows interest and
understanding
 Asks questions which clearly define the
information being sought
 Communicates clearly in writing
1 2 3 4 5 NA
1 2 3 4 5 NA
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
NA
NA
NA
NA
NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA


Demonstrates congruent verbal and
nonverbal communication
Expresses abstract ideas in concise and
understandable terms
Critical Thinking
 Demonstrates an ability to use problemsolving techniques
 Uses available resources to aid in solving
problems; seeks other opinions
 Generates more than one alternative to
solving a problem
 Gathers data and asks questions to avoid
making assumptions about situations
 Follows up on outcomes of chosen solutions
to provide feedback for future decisions
Clinical Competence
 Demonstrates clinical competence consistent
with educational standards for this level
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
1 2 3 4 5 NA
Additional Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Based on my observations of ____________________________________ in a clinical setting, the following
statement is true:
(student’s name)
(check one)
______I recommend that this student be considered for employment as a Nursing Student UAP.
______I do not recommend that this student be considered for employment as a Nursing Student UAP.
Instructor: ________________________________________________________________________
(printed name)
(signature)
Nursing Program: ___________________________________________________________________________
Date: __________________________
THANK YOU FOR YOUR COOPERATION
PLEASE RETURN TO STUDENT IN SEALED ENVELOPE OR MAIL DIRECTLY TO:
MONTANA HEALTH NETWORK
Attn: Sherry Taylor
11 SOUTH 7TH STREET, SUITE 241
MILES CITY, MONTANA 59301
(406) 234-1420
FAX: (406) 234-1423
Dean/Director of Nursing Program Verification Form
_____________________________________ (Student’s name) has applied with Montana Health Network for
employment in the Nursing Student UAP program. In our effort to consider this individual, we would appreciate
you furnishing the information requested below. Your prompt response to this inquiry will be most helpful and will
be held in strict confidence.
In 2005, the Montana Board of Nursing adopted rules that allow nursing students to be employed as Nursing
Student Unlicensed Assistive Personnel (UAPs). Generally speaking, a Nursing Student UAP may perform certain
nursing tasks through advanced delegation and the direct supervision of a Registered Nurse. Examples of nursing
tasks that a Nursing Student UAP may perform are:
 Calculation of medication dose
 Administration of medications by mouth, sublingually, subcutaneous injection, intramuscular injection,
tube, aerosol/inhalation, suppository and topical
 Insertion of peripheral IV catheters
 Hanging, without additives, IV fluids and adjusting IV flow rates
 Any other nursing task for which the student has received instruction within the nursing program
In order to meet the eligibility requirements of a Nursing Student UAP, the student must:
 Be currently enrolled in a state nursing board-approved nursing education program or a state nursing
commission-approved nursing education program
 In good academic standing
 Have satisfactory completed a course in the fundamentals of nursing
 Have satisfactory completed a pharmacology course (as a condition of receiving delegation of medication
administration)
I hereby verify that ______________________________________________________________
(student’s name)
(Please check all that apply)
___________ Is currently enrolled in our Registered Nursing Program and is in good standing.
___________ Has completed or is currently enrolled in a Fundamentals of Nursing Course
___________ Has completed or is currently enrolled in a Introductory Pharmacology Course
___________ Is projected to enter their final year of nursing education this coming fall semester
Your name ___________________________________
(
printed name)
___________________________________________
(signature and title)
College/University _______________________________________________________
Date _____________________________
THANK YOU FOR YOUR COOPERATION
PLEASE RETURN TO STUDENT