Eddie Bernice Johnson Health Equity Policy Scholars Institute

Eddie Bernice Johnson Health Equity Policy Scholars Institute

Official Application Form | 12-Month Leadership Program
Thank you for your interest in the Eddie Bernice Johnson Health Equity Policy Scholars Institute, a 12-month leadership program designed to prepare nurses and nursing students to advance health equity through policy, advocacy, and community engagement.

Participants must commit to engaging fully in all program activities:
- Eight 90 minute Virtual Sessions
- One 90 minute session during the NBNA Institute & Conference
- One 90 minute session during National Black Nurses Day on Capitol Hill
- Three Community Lab sessions
Please submit your application by April 20, 2026.
Section 1 - Applicant Information
Applicant's Name*

First NameLast Name
Preferred Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resume or CV*

Cancelof
Section 2 - Demographics
FemaleMaleNon BinaryPrefer to Self DescribeOther
Black or African AmericanHispanic Latina/LatinoNative American or Alaska NativeNative Hawaiian or Pacific IslanderAsianMultiracialWhiteOther
Age*
Section 3 - NBNA Membership
YesNo
ActiveInactive
NBNA Chapter Name: (type Direct Member if you have no chapter affiliation)*
Chapter City and State (type City and State you live in if you have no chapter affiliation)*
Section 4 - Nursing Credentials
Registered Nurse (RN)Licensed Practical or Vocational Nurse (LPN/LVN)Advanced Practice Registered Nurse (APRN)Student Nurse (enrolled in baccalaureate or higher nursing program)
Applicant's Current Position / Role
Employer or School
Section 5 - Eligibility Verification
YesNo
YesNo
YesNo
Section 6 - Program Commitment

Are you prepared to participate fully in all scheduled activities and meetings, including virtual sessions, the NBNA Institute and Conference, and National Black Nurses Day on Capitol Hill?
Yes, I am fully committedNo
Section 7 - Professional and Advocacy Experience
Question 1 - Overview of healthcare or community advocacy experience working with underserved populations*

0/250
Question 2 - List and briefly describe any public service initiatives you have led or participated in*

0/250
Section 8 - Community Policy Lab Experience
Describe your experience collaborating within multisector coalitions or community initiatives*

0/250
How have you identified and addressed health equity gaps within your community?*

0/250
Provide examples of working with community stakeholders to design solutions to health or policy challenges*

0/250
Section 9 - Policy Methods and Implementation
YesNo
YesNo
Section 10 - Legislative Shadowing and Field Experience
Describe any experience or interest in legislative shadowing, health policy advocacy, or government relations*

0/250
Section 11 - Simulation and Case-Based Learning

Participants will engage in simulation-based policy learning, case studies, and mentored writing sessions.
YesNo
Section 12 - Personal Statement

In 300 words, describe: your motivation for applying, your professional and advocacy goals, and how this program will help you advance health equity.
Personal Statement*

0/300
Section 13 - References

Please provide three references who can speak to your qualifications and character.
Reference 1 - Full Name of NBNA Chapter President or NBNA Leader if you are not affiliated with a chapter*
Reference 1 Title*
Reference 1 Name of NBNA Chapter*
Reference 1 Email*
example@example.com
Reference 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Recommendation Letter Upload*

Cancelof
Reference 2 Full Name of Community or Advocacy Leader*
Reference 2 Title*
Reference 2 Email*
example@example.com
Reference 2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Recommendation Letter Upload*

Cancelof
Reference 3 Full Name of Professional Reference (known 5+ years)*
Reference 3 Title*
Reference 3 Email*
example@example.com
Reference 3 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3 Recommendation Letter Upload*

Cancelof
Section 14 - Attestation & Submission

"I certify that the information provided in this application is accurate and complete. I understand that incomplete applications may not be considered."
Applicant Signature (Full Legal Name)*
This serves as the typed signature
Date*

MonthDayYear
Date
Should be Empty:

Eddie Bernice Johnson Health Equity Policy Scholars Institute

Section 1 - Applicant Information

Section 2 - Demographics

Section 3 - NBNA Membership

Section 4 - Nursing Credentials

Section 5 - Eligibility Verification

Section 6 - Program Commitment

Section 7 - Professional and Advocacy Experience

Section 8 - Community Policy Lab Experience

Section 9 - Policy Methods and Implementation

Section 10 - Legislative Shadowing and Field Experience

Section 11 - Simulation and Case-Based Learning

Section 12 - Personal Statement

Section 13 - References

Section 14 - Attestation & Submission