Junior Level Distant Site Experiences
Instructions for Completing Application
1.
Fill out the attached application.
2. Ask two faculty members to complete the evaluation for you. One of the faculty must be your
Nurs221 clinical faculty. Please advise faculty of the application deadline to ensure completion
in a timely manner. The completed evaluations should be returned to you in sealed envelopes.
Include the sealed envelopes in your completed application pack.
3. Submit a letter of support from one of your parents stating their permission for you to
participate (if you are over 21, this is not necessary).
4. Develop an essay of 250 words or less, in APA format,
entitled “Why I Want to Participate in a Junior Level Distant Site Experience”.
5. Present all of the items above in a large, sealed envelope with your name and “Junior Level
Distant Site Experience” printed on the outside of the envelope to the nursing kiosk in the
nursing department by the deadline listed on the Distant Site webpage.
Application Process Timeline:

Application packets are to be completed and returned to the student worker at the front desk in
the nursing department by the due date listed on the Richmond and Roanoke webpage.
o Application
o Parental letter of support (if under age 21). Please indicate if you are 21 or over
o Two clinical evaluations in sealed envelopes from faculty – these must accompany the
application.
o Essay
LIBERTY UNIVERSITY DEPARTMENT OF NURSING APPLICATION
Junior Level Distant Site Experiences
Please indicate which experience you are applying for (number by preference if you
are willing to consider different locations):
___Richmond(Peds/Med-surg) ____Roanoke (Peds/Med-surg) ____Salem (OB/Med-surg)
Name (first, middle, last)
LU ID #
Birth date
Mailing Address
social security number
Signature for permission to release info to clinical sites
LU email address
cell phone number
Emergency contact: Name___________________Relationship________________ Phone #___________
Please indicate if you are 21 or older. Applicants 21 or older do not need to include a parental
letter of support.
Housing Preference (Please check one):
I plan to stay with relatives during the five power weekends or find another housing
option (or drive to each clinical, if applicable).
Name of host_____________________ Relationship________________
Address________________________________________________________________
I am willing to have another student stay with me and my family.
I plan to stay with relatives of another Liberty University Nursing Student.
Name of student_________________________________________________________
I would like to be housed by a church host family.
I HEREBY FORMALLY REQUEST TO BE CONSIDERED FOR Fall or Spring (circle one) 2014-2015:
Signature: __________________________________________
Date: __________________
JUINIOR LEVEL DISTANT SITE CLINICAL EVALUATION FORM
STUDENT NAME: (PRINT) _________________________________________
STUDENT SIGNATURE: ___________________________________________
FACULTY MEMBER: (PRINT) _______________________________________
COURSE WORK EVALUATED: ______________________________________
The above student is applying for the Richmond Experience. As lab or clinical faculty for this
student in NURS 210 or NURS 221, your evaluation is necessary for the student to be
considered. Please place the completed form in an initialed envelope and return to the
student by date ____________________________
1. This student was late to class
a. Consistently late
b. 4 or more times
c. 2-3 times
d. Once
e. Never
2. In comparison to other students in the clinical group, this student was
a. The least prepared of any of the students
b. In the bottom 25% of the group in preparedness
c. An average student in the level of preparedness
d. Above average in the level of preparedness
e. Consistently the most prepared student in the group
3. Please rate this student in her/his demonstrated professional conduct
a. Low level of professional conduct
b. Moderate
c. Above average
d. Excellent
e. Exceptional
4. What is this student’s current average in your course? If the student is in a clinical section,
indicate how the student is performing clinically.
5. In the clinical/lab learning sessions, this student is,
a. Very social and/or tends to be a distraction to others
b. Listens, but gives verbal or nonverbal indication that the class is not a priority
c. Listens but does not impress the faculty as being eager to learn
d. Provides verbal/nonverbal indicators that the content is important to them
e. Asks good questions, listens intently, tends to get the skills on the first try
6. This student’s skill sets, as I think back across the semester, are:
a. Inadequate on the first try, consistently
b. Minimally acceptable, often requiring correction or remediation
c. Average
d. Above average
e. Stellar, often clarifying issues for fellow students
7. Has this student evidenced the qualities associated with teamwork? Please specify.
8. If applicable, has this student required remediation?
9. Please cite any incidences that you have witnessed that would cause you to doubt that this
student is submissive to authority.
10. How do you see this student representing Liberty University, the Nursing Department and its
mission statement?
Due_________________________ (Applicant- please fill in this date as listed on the website)