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.   FILL OUT THE FOLLOWING:

1.   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).  

____________________________________________________________
Signature Date

 2.   Note:  BKATs are not available to nurses taking a BKAT. Make check out to BKAT   for $15 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-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                                                                                        JT 10/15/17