Apply - UNMC | Primary Care Fellowship Program

Program Application

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Heads up! Please complete the fields below. All required fields are marked with an asterisk (*). After completing each section please click continue to submit the application. If you would like to start over, click cancel. Once your resgitration is complete you will receive email notification with further instructions.

Personal Information

First Name *

Last Name *

Phone *

Email Address *

Credentials* (Multiple values separate with comma)

Specialty* (Multiple values separate with comma)

Age Group*

Gender *

Male
Female

Ethnicity *

Hispanic/Latino
Non-Hispanic Latino

Race *
(Select all that apply)

White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Address *

State *

City *

Zipcode *

Employer Information

Employer Name *

Address *

State *

City *

Zipcode *

Job Information

Current Position/Title *

Are you currently employed as a Primary Care Nurse? *

Yes No

How many years have you worked in Primary Care? *

Job Details*

Education Information

Please list your most recent degree first.

Add Education

Institution Name *

Graduation Year*

Degree Recieved*

Beyond basic nursing education, please describe what additional preparation for primary care nursing. For example, on the job training, continuing education, formal certificate (100 words)*

Other Information

Please read the HRSA criteria for Disadvantaged Background Status.

Do you meet the HRSA criteria for Disadvantaged Background Status? *

Yes No Do Not Wish to Provide

Please write a short (250 word) statement explaining why you are interested in the Primary Care Fellowship. *

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PERSONS IN FAMILY/HOUSEHOLD	ECONOMICALLY DISADVANTAGED GUIDELINE
1	$24,980
2	$33,820
3	$42,660
4	$51,500
5	$60,340
6	$69,180
7	$78,020
8	$86,860

Accreditation Statement and Contact Hours

The University of Nebraska Medical Center College of Nursing Continuing Nursing Education is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is provided for 45.0 contact hours under ANCC criteria.

The University of Nebraska Medical Center College of Nursing Continuing Nursing Education (UNMC CON CNE) has been awarded Accreditation with Distinction, the highest recognition awarded by the American Nurses Credentialing Center's Accreditation Program. This distinction is valid through 2020.

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For Questions

University of Nebraska Medical Center
College of Nursing
Transformational Practice and Partnerships
985330 Nebraska Medical Center
Omaha, NE 68198-5330
Phone: 402.559.4117
Fax: 402-559-4303
Email: pricare@unmc.edu