TO ORDER:  COPY AGREEMENT FORM & MAIL IT IN

HOW TO ORDER A BKAT:  Make a Copy of this Form

AGREEMENT FORM

          DIRECTIONS. The Med-Surg or the CRITICAL CARE RN giving and scoring the BKAT must sign the following Agreement Form and return it with your check.  Do not send by Certified Mail or Express Mail. If the form is not filled out completely, it will be returned to you.  Every ICU RN or Med/Surg RN must submit an Agreement Form if you want to obtain & administer any BKAT.   ​​FILL OUT THE FOLLOWIN​G:

1.  Agreement:   I work in critical care (yes/no).   I work in medical/surgical nursing (yes/no).   I want to order a copy of the Basic Knowledge Assessment Tool (BKAT) to use in my professional practice.  (yes/no).   I understand & agree to all of the following (a-f); that,  a. any copies made of the BKAT will only be used by me,  b. that I may make copies,  c. that the BKAT is copyrighted and may NOT be changed in any way,  d. that I will NOT use the BKAT(s) in screening, hiring, or firing including travelers,  e. that I will not place any BKAT on any computer, including any intranet, for any purpose,  and f. that the BKAT is only one measure of basic knowledge in critical care or medical/surgical nursing.  

____________________________________________________________
Signature Date

2.  Note:  BKATs are not available to nurses taking a BKAT. Make check out to BKAT for $15 for each BKAT ordered.)   ONLY four (4) BKATs may be ordered.   MAIL TO:  BKAT, PO Box 6295, WASHINGTON, DC 20015    ALL BKATS WILL BE MAILED TO YOUR JOB ADDRESS ONLY.   Wait time is 2-3 weeks after we receive your request.

Name (Print your name)______________________________________________________________

Highest Degree Obtained_________________________

a. Are you a RN?(yes/no)    b. Do you work in critical care (yes/no)   c.  Do you work in med/surg nursing? (yes/no) d.  Are you responsible for the education of RNs working in the units of the BKAT(s) you wish to order? (yes/no)   e. Are you a critical care educator or manager? (yes/no)   f.  Are you a Med-Surg Educator? (yes/no),   g. Are you giving and reviewing the BKAT(s) with the RN (yes/no).



Position/title______________________________________________________________

Name of hospital/urgent center employer___________________________________________________

         Street address of employer:__________________________________________________________

         City, State, Zip code__________________________________________Country______________

Your E-mail address at work:  _____________________________________________________________

​                                          I want to order​ (LIMIT is 4 [four] BKAT’s)  
                                              Only Critical Care RNs may order 1-6

                     1. BKAT-9r Adult ICU                       _____

                     2. BKAT-9S Progressive Care            _____  

                     3. PICU-BKAT6r Pediatric ICU       _____

                     4. NICU-BKAT5 Neonatal ICU         _____  

                     5. ED-BKAT2 Emergency Care        _____

                     6. PEDS-ED BKAT Emergency Care _____
                                                __________________

                     7. MED-SURG BKAT2 Med-Surg Units _____ [non-critical care BKAT] 

                           RNS WITH MED-SURG EXPERIENCE AND CRITICAL CARE NURSES MAY ORDER # 7

    May be reproduced                                                                                                            JT06/12/17