MSHA Human Resources | Nurse Intern II Statement of Interest Form

Full Name: *

Email Address: *

Street Address: *

City: *

State: *

Zip: *

Phone: *

School of Nursing: *

Expected Graduation Date: *

Are you a current MSHA Team Member?

Yes
No

Are you a MSHA scholarship recipient?

Yes
No

Please upload 500 word essay on "Why you would like to participate in the Nurse Intern Program" *

How did you hear about the Nurse Intern II PROGRAM?

What are your expectations of the Nurse Intern II Program?

Which MSHA facility are you most interested in completing your Nurse Intern Program Preceptorship? (Please indicate your first and second choices below)

First Choice (choose one)

Dickenson Community Hospital
Franklin Woods Community Hospital
Indian Path Medical Center
James H. & Cecile C. Quillen Rehabilitation Hospital
Johnson City Medical Center
Johnson County Community Hospital
Johnston Memorial Hospital
Niswonger Children's Hospital
Norton Community Hospital
Russell County Medical Center
Smyth County Community Hospital
Sycamore Shoals Hospital
Woodridge Hospital

Second Choice (choose one)

Dickenson Community Hospital
Franklin Woods Community Hospital
Indian Path Medical Center
James H. & Cecile C. Quillen Rehabilitation Hospital
Johnson City Medical Center
Johnson County Community Hospital
Johnston Memorial Hospital
Niswonger Children's Hospital
Norton Community Hospital
Russell County Medical Center
Smyth County Community Hospital
Sycamore Shoals Hospital
Woodridge Hospital

Which clinical areas are you most interested in completing the Nurse Intern II Program Preceptorship?

First Choice

Behavioral Health
Critical Care
Emergency Services
Float / Resource
Labor and Delivery
Medical / Surgical Unit
Neonatal ICU
Oncology
Pediatrics
Progressive Care Unit
Rehabilitation
Skilled Nursing

Second Choice

Behavioral Health
Critical Care
Emergency Services
Float / Resource
Labor and Delivery
Medical / Surgical Unit
Neonatal ICU
Oncology
Pediatrics
Progressive Care Unit
Rehabilitation
Skilled Nursing