To Order

TO ORDER: COPY AGREEMENT FORM & MAIL IT IN

HOW TO ORDER A BKAT

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 and administer any BKAT.

1. FILL THIS OUT: Agreement: I work in critical care or I work in medical/surgical nursing and I want to order a copy of the Basic Knowledge Assessment Tool (BKAT)to use in my professional practice. 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. I agree to a–f above (yes/no) CIRCLE YES OR NO.

____________________________________________________________

Signature Date

2. FILL THIS OUT: Note: BKATs are not available to nurses taking a BKAT. Make check out to BKAT for $20 for each BKAT below [1-7].) 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 as a critical care RN? (yes/no) c. Do you work as a med/surg RN? (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 or Manager? (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 the: (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-BKAT5r Neonatal ICU _____

5. ED-BKAT3r Emergency Care _____

6. PEDS-ED BKAT Emergency Care _____