Dear Potential Transfer Student,

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1 Dear Potential Transfer Student, Thank you for your interest in Faulkner State Community College s Nursing Program. The forms and checklist to be completed in order to be considered for transfer are enclosed. A team will review your transfer packet for consideration only after a complete packet is received. Incomplete packets will not be reviewed. Transfer requests are accepted based on review of packet information and space availability. Place the checklist on top and send your completed packet to: Jean Graham, Director of Nursing and Allied Health Faulkner State Community College 1900 Hwy 31 South Bay Minette, AL The completed packet must be received in the nursing department no later than 3 weeks before the end of the semester prior to transfer. Please feel free to contact the nursing department at (251) or Allison Spillman at for questions or assistance. Sincerely, Jean D. Graham, MSN, ANP, CNOR Director of Nursing and Allied Health

2 FAULKNER STATE NURSING PROGRAM TRANSFER CHECKLIST Date Applicant Name Check the following to confirm items are completed and included in the packet: 1. Nursing Application marked transfer request and reason for request 2. Unofficial transcript(s) from previous nursing program 3. College application and official transcripts from all previous colleges attended received by FSCC Admissions. 4. Copy of syllabi for all nursing courses taken outside the two year college statewide system including outline of specific content covered in each course 5. Letter from the Dean of Nursing or Director of Nursing indicating good standing and eligibility to continue in the program you are transferring from 6. Copy of results of TEAS nursing entrance exam from no longer than 3 years ago. 7. Completed, current Immunization Form (Form included) 8. Completed, current History & Physical Form (Form included) 9. Copy of current Healthcare Provider CPR 10. Proof of current health insurance coverage 11. Video of a Head to Toe Assessment done by you and placed on a thumb drive (memory stick) for our review. A copy of a head to toe outline is included for your reference.

3 FAULKNER NURSING PROGRAM APPLICATION Program Applying For: RN Program PN Program Either RN or PN Program Mobility (LPN to RN) Reinstatement Transfer Request Application Deadlines: Fall Semester is April 1 - June 1 Spring Semester is July 1 September 20 Mobility Program is September 1 November 20 I. PERSONAL DATA Date: Last Name: First: MI: Maiden: Social Security Number: FSCC Student Number: Mailing Address: City: State: Zip Code: Telephone: ( ) address: Emergency Contact: Telephone: ( ) II. EDUCATION High School Graduation Year: High School Name: GED (if applicable): Date Completed: Are you currently taking college courses? Yes No If yes, what college: List all colleges attended and the year(s) attended. (Add separate page as necessary) Name of College (DO NOT ABBREVIATE) Year(s) attended Degree (if completed) HAVE YOU PREVIOUSLY BEEN ADMITTED TO A NURSING PROGRAM? YES NO If YES, a letter from that program Dean/Director must be sent to the FSCC Nursing Department indicating you have not been dismissed for disciplinary or unsafe practice. List the college(s), dates attended, and reason for withdrawal. A COPY OF YOUR TEAS V EXAM RESULTS MUST BE ATTACHED. NOTE: Score must be achieved within 3 years of application deadline to satisfy eligibility requirement. Your name, as listed when tested:

4 III. EMPLOYMENT Are You Currently Employed? Yes No Place of Employment: Employer s Address: Employer s Phone Number: ( ) Name of Supervisor: Are You Employed Full-Time? Part-Time? Initial Date of Employment: I understand that completion of this application is a component of the student profile and does not in itself grant admission to the Nursing Program. I understand a new application must be submitted if I am not selected and wish to reapply. I certify that the information given in this application is true and correct. I understand that providing false information may be deemed sufficient reason to dismiss the student and/or to refuse admission. All application materials become the property of Faulkner State Community College. It is the sole responsibility of the applicant to ensure that the Nursing Department has received all of the requested documentation. MINIMUM ADMISSION STANDARDS INCLUDE: 1. Unconditional admission to the college (Application must be updated if student did not attend FSCC last semester). Original transcripts from all colleges attended must be in the Admissions Office by the deadline (transcript must be sent by the institution s registrar directly to FSCC Registrar). High school transcript required if no prior accredited colleges attended. 2. Completed nursing application turned into the Nursing Department by appropriate deadline Minimum of 2.5 GPA on a 4.0 scale based on the last 24 credit hours for students with previous college coursework. Minimum of 2.5 cumulative high school GPA for students without prior college work (GED acceptable). Eligibility for ENG 101 and MTH 100 for the ADN program (if not previously taken); ENG 101 and Mathematical Applications for the PN program. Eligibility for BIO 201, if not previously taken, during the first term of Nursing Programs (Must have completed BIO 103, General Biology with a C or higher). Good standing with college Meeting the essential functions or technical standards required for nursing 9. Attached copy of Nursing Entrance Exam score, TEAS V edition 10. Mobility (LPN to ADN) applicants only, must also provide a copy of a valid, unencumbered Alabama LPN license. All information must be submitted by the appropriate deadline or the application will be considered incomplete. It is recommended that applicants check with the Admissions Office, at (251) , to confirm that their College application and transcripts are on file and up to date. Applicant s Signature Date

5 Health Assessment Physical Examination Check List Identification of Client Hand Hygiene Provide for Privacy Assessment of: Head & Neck Mouth Ears Eyes Skin Turgor Skin Integrity Capillary Refill Lungs & Chest Bilateral breath sounds (anterior and posterior) Symmetry History of Problems with respiratory System Heart and Peripheral Vascular System Heart Sounds PMI Pulses Edema Neuro LOC Movement (Active or Passive) Any cranial nerves if appropriate Abdomen Symmetry Bowel Sounds Palpation of the abdomen Bladder/Bowels Vital Signs: Temperature: Pulse: Respirations: Blood Pressure:

6 I certify that has had the following: MMR vaccine: date Or titers: Varicella vaccine: date Or titer: Tetanus vaccine: date TB skin test: date results Or Chest X-ray: date results Hepatitis B vaccine date 1 st dose date 2 nd dose date 3 rd dose Name of practitioner (MD, NP, or PA) Signature of practitioner

7 PART I COMPLETED BY STUDENT FAULKNER STATE COMMUNITY COLLEGE STUDENT HEALTH EXAMINATION FORM Name Soc Sec # DOB Sex Address City State Zip Phone Person to notify in case of emergency Address Phone PART II COMPLETED BY PHYSICIAN, NP, or PA History. (If any of the following are answered affirmatively, please give details). Does this person have or has this person ever had any of the following? Yes No Yes No Operations Cancer Serious Accidents Diabetes Mellitus Seizures disorder Hearing Difficulty Cardiovascular Disease Visual Impairment Tuberculosis GI Disease Muscular-skeletal problems GU Disease Any other pertinent health issues Allergies: Physical Exam Fill in All Blanks Ht Wt B/P P Vision: Rt eye Corrected Nose, Mouth Throat Lt eye Corrected Chest/Lungs Hearing: Rt Lt Heart Abdomen GU Extremities Reflexes ROM Is this person able to perform essential functions such as reading fine print, lifting lbs, pulling and pushing lbs, walking or standing for 12 hrs at a time, bending freely, hearing soft sounds, and performing fine motor skills? Yes No (circle correct answer) If no, explain Physician s name DATE Physician s signature Address:

8 FAULKNER STATE COMMUNITY COLLEGE STUDENT HEALTH EXAMINATION FORM PLEASE LIST ALL MEDICATIONS TAKEN BY STUDENT:

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