2015 LPN Advanced Placement Application. For Fall 2016 Entry, Second Year, Nursing Program

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1 Umpqua Community College 2015 LPN Advanced Placement Application For Fall 2016 Entry, Second Year, Nursing Program Please to reserve a seat for the required Elsevier s HESI LPN-ADN Entrance Exam test by October 15, Please mail all application materials in a sealed envelope (include a complete return address including applicant s name on the outside of the envelope), postmarked by 5pm, October 30, To: Umpqua Community College Enrollment Services Attention: LaVera Noland LPN Advanced Placement Application 110 Umpqua College Road Roseburg, OR

2 Umpqua Community College 2015 LPN Advanced Placement Application For Fall 2016 Entry, Second Year, Nursing Program Student Information Please type or print neatly in blue or black ink and complete all requested information Last Name First Name Middle Initial Maiden Name Last digits of Social Security Number **UCC Student ID Number** Date of birth (mm/dd/yy) Current age Current mailing address City County State Zip Residential address if different from mailing address City County State Zip Daytime phone Evening phone Message/Cell phone Secure address (Important Note: official notifications will occur by it is the applicant s responsibility to provide a secure address and ensure the college and Nursing Program secretary are notified of any change in address.) Citizenship (country): _ Type of Visa (if applicable): _Resident Alien No. (if applicable): Ethnic Background and Gender (optional information that will help us provide the Oregon State Board of Nursing and/or Oregon Health Sciences University School of Nursing and/or Oregon Center for Nursing with important recruitment and admissions statistics; please clearly mark responses): Gender: _Male Female Primary Ethnicity: Nonresident Alien For non-hispanics only: Race and Ethnicity unknown Hispanics of any race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Two or more races Language background (please select one): English as Primary *English as secondary *List primary language if English is your secondary language: **Last digits of SS number for verification purposes; Application is considered incomplete if no UCC ID number appears on this line 2

3 Education Information Name/Student ID: List your Practical Nursing Program and also ALL regionally accredited colleges or universities where you have completed nursing prerequisites, preparatory or other required courses and/or a degree, and by October 30, 2015, submit official transcripts for courses completed in ALL previously attended colleges or universities to Enrollment Services. (Note: Degrees completed outside of the United States will be taken into consideration based on equivalency as determined by the credential evaluation agency.) Name of College: Include Practical Nursing Program institution. For general education courses, college must be regionally accredited & courses accepted by UCC Enrollment Services Indicate (A) if official copy of transcript attached or (PS) if previously submitted to Enrollment Services State Years attended (e.g ) Number of Credits Earned Certificate or Degree (If Awarded) and Year (NA if not applicable) I have read and I understand the LPN Advanced Placement program information and admission criteria (including requirement for negative urine drug screen and criminal history background check in order to be admitted) for the nursing program at Umpqua Community College. Program information including LPN Advanced Placement selection points may accessed from the website. I understand that it is my responsibility to meet all program and application criteria. I understand that if accepted to the second year of the program I will be required to pass a criminal history background check and urine drug screen from the program selected vendors and must self-disclose any pertinent history prior to admission and must disclose any warrant, arrest, citation, charge or conviction if such occurs after admission. I understand that certain crimes might result in my being deemed not approved for the program. I verify that all statements on this application are complete and true and I understand that falsification of any information may lead to disqualification or dismissal from the program. I give my permission for release of pertinent application and academic information to the OCNE partner schools, including OHSU as needed to facilitate my program of study or financial aid or for statistical or evaluative purposes. In addition, I am authorizing release of my information to the Oregon Center for Nursing and the Oregon State Board of Nursing for statistical and research purposes only. Signature Date Please mail all application materials in a sealed envelope (include a complete return address including applicant s name on the outside of the envelope) by 5 pm October 30, 2015 to: Umpqua Community College Enrollment Services, Attention LaVera Noland LPN Advanced Placement Application 110 Umpqua College Road Roseburg, OR

4 2015 LPN Advanced Placement Application For Fall 2016 Entry, Second Year, Verification Checklist Please complete this verification checklist as part of your nursing application. Be sure to attach all supporting documentation (i.e. sealed official transcripts from PN program and colleges other than UCC if not previously submitted to Enrollment Services, Prerequisite and First and Second Year General Education Completion Chart, copy of verification of unencumbered Oregon LPN license, any other required documents related to selection points) as well as this checklist and the application fee (check or money order only) to your application. Applications will be accepted until the deadline at 5pm (if mailed, application must be postmarked by 5pm). It is the responsibility of the applicant to ensure that all required documents listed below are received by the UCC Enrollment Services office by the deadline. Please initial each statement below indicating that you have read and understand what is required of you in order to successfully apply to the UCC Nursing Program. Students who do not complete general admission to Umpqua Community College and obtain student ID number, submit application fee (check or money order ONLY), all pages of application, and official transcripts from ALL previously attended colleges or universities that have not already been submitted to Enrollment Services will be disqualified and the application will not be processed, nor will it be returned to the applicant. 1. I have completed the Umpqua Community College Nursing Program LPN Advanced Placement Application as well as forms required for general admission to Umpqua Community College. (If not already admitted to UCC, the UCC general college admission application is available on the college website.) I understand that by making application to the Umpqua Community College Nursing Program LPN Advanced Placement, I am also applying for co-admission to OHSU and authorizing the release of my application and academic information to OHSU as required to facilitate my program of study or financial aid or for statistical or evaluative purposes. 2. I have previously submitted (and verified arrival of transcripts at UCC) or have attached sealed official transcripts showing completion of a Practical Nursing Program as well as college transcripts from any regionally accredited university or college previously attended and for all prerequisite and program general education courses that have been completed prior to the deadline and that I may be deemed ineligible if I do not submit such transcripts. (Umpqua Community College transcripts do not need to be attached.) 3. I have or completed all nursing program prerequisites (minimum of 5 credits) with a minimum grade of C or better and a minimum cumulative GPA of 3.0 by the completion of Fall I will be allowed one course in progress from the above pre-requisites to be completed by Fall My required my anatomy and physiology courses will not be older than 7 years by the deadline.. I understand that I am responsible to submit official transcripts with pending course by December 18, I have attached documentation regarding at least 500 hours work as an LPN. 6. I have completed and attached the Prerequisite and First and Second Year General Education Completion Chart indicating when and where all prerequisites have been completed or In-Progress (IP) and understand that any documents submitted but not requested by this application form will be discarded/shredded. 7. I understand that completion of this application enters me in Phase L1 of the LPN Advanced Placement selection process, and following the point assignment process of Phase L1 the highest ranked applicants will be allowed to enroll in available spaces in the pharmacology and pathophysiology courses (NRS230 and NRS232 in winter [Phase L2 of the process]. 8. I understand that selection for enrollment in the pathophysiology and pharmacology courses does not guarantee admission to the nursing program (course size is limited and program applicants may complete NRS230 and NRS232 [and NRS231 and NRS233] at other Consortium partner schools, e.g. MHCC, but still be the highest ranked applicant for available spaces in the UCC Nursing Program second year), that points will be scored for the grades earned in NRS230 and NRS232 (Phase L2 of the LPN Advanced Placement selection process), and after Phase L1 and L2 points are combined, the highest ranked applicants to UCC will be allowed to enroll in the bridge course, NRS115 LPN Transition to OCNE, to be offered at Umpqua Community College during the Spring or Summer of 2015.

5 9. I understand that if I am allowed to enroll in the bridge course NRS115, some of the course will be delivered through distributed learning (online), but I will also be required to be present for scheduled intensive seminar sessions of clinical (high fidelity simulation and/or other activities) and class face to face meetings (day of week yet to be determined) during the spring of 2016 and I will be responsible for arranging my work schedule so as not to conflict with class or clinical requirements and for any travel expenses. 10. I have attached the $25 non-refundable nursing application-processing and testing fee (check or money order made out to Umpqua Community College). 11. For international students only: See Enrollment Services for admissions and registration information. 12. I have attached a copy from the OSBN website of verification of my unencumbered Oregon LPN license along with the LPN Work Experience form(s) signed by the appropriate individual(s) sealed in their agency envelope, and two completed copies of the OCNE LPN to RN Advanced Placement Reference forms sealed by the reference sources in their agency envelopes. I understand my LPN license must remain current and unencumbered throughout the advanced placement process. 13. By October 15, 2015, I must and reserve a seat on for the proctored national standardized exam ( HESI LPN-ADN Entrance Exam from Elsevier). 1. All students accepted into the Bridge program will be required to submit all required documentation: e.g., vaccinations, drug screen and background checks. 15. I understand that if I have a financial hold at UCC, my application WILL NOT be processed unless the financial hold is removed before 5pm, October 30, I understand that reading and following directions is critical to success in any nursing program. Incomplete applications (e.g. not completing admission to college, lack of application/testing fee, lack of submission of official transcripts to Enrollment Services or attached to application, lack of signature, etc.) will result in disqualification and that disqualified applicants will only receive notice of such after the application deadline has passed. 17. I understand to earn selection points for being a military veteran I must attach proof of honorable discharge. For points for clinical and/or work experience in a hospital as a LPN employee or a medic or corpsman I must attach a completed Hospital Experience form. (Several copies may be submitted if needed to show a total of 500 hours.) (Signature required below) Name (Printed) Signature Date In compliance with state and federal laws, Umpqua Community College does not discriminate on the basis of race, religion, color, national origin, age, gender or disability in employment, or in any of its educational programs, or in the provision of benefits to students. For information about Umpqua s policy of non-discrimination, contact HR at In addition, the nursing program adheres to the Oregon State Board of Nursing rules, which prohibit discrimination in selection and progression of students based on sexual preference or marital status. 5

6 Umpqua Community College LPN Advanced Placement Prerequisite and Other General Education Completion Chart Student Name: UCC ID #: Date: Please complete the following chart indicating where you have completed the required nursing prerequisites and other general education courses. Please note that all nursing program prerequisites (minimum of 5-8 credits) must have been completed with a minimum grade of C or better and a minimum cumulative GPA of 3.0 with the exception of one course to be completed by the end of Fall Only the most recent grade will be used for repeated courses. Required Prerequisites MTH95 Intermediate Algebra or higher level math BI231 Anatomy and Physiology I (within 7 years) BI232 Anatomy and Physiology II (within 7 years) BI233 Anatomy and Physiology III (within 7 years) Course Name & Number Term & Year Completed College Grade # of Quarter (Q)/Semester (S) Credits WR121 English Composition I 3- WR122 English Composition II or WR 227 PSY237 Lifespan Human Development or HDFS 201 NFM 225 Nutrition BI23 Microbiology w/lab Psychology (100 or 200 level course) Social Science or Arts & Letter Electives List two (2) Courses** Course 1 3- Course 2 3- Genetics 3 Quarter Credits Required Total Credits: **Please see the UCC College Catalog for a list of Social Science, Humanities (Arts and Letters), acceptable for the AAS degree (to count as elective course must not already be named as required for the Nursing Program. Electives may include foreign language (100 level or higher) or speech and may include the extra credits when a or 5 credit course is taken to meet a listed 3-credit requirement.

7 OCNE LPN TO RN ADVANCED PLACEMENT REFERENCE Applicant s Name: _ I am applying for advanced placement in the Umpqua Community College Nursing Program and give permission for (colleague/supervisor name) to complete this form, place it in a sealed agency envelope and return it to me to attach to my application before October 30, I waive my right to review this reference at any time: Applicant Signature Date Instructions to Applicants: References from two individuals with direct knowledge of your work as an LPN are required for your application for advanced placement into a Nursing program implementing the OCNE curriculum, using one of the copies in this application. One reference must come from a colleague or instructor who has worked with you in a healthcare setting and one reference must be from a healthcare facility supervisor who has been involved in supervising and/or evaluating your performance within the past year. Fill in your name and your colleague s or instructor s name or healthcare facility supervisor s name on the lines provided above and sign and date the form in the space provided. The colleague, instructor or supervisor is asked to circle the appropriate number on each line, sign (including title and agency name and phone number) and date the form, place it in an agency envelope with their name signed across the seal and return it to you to attach to your application. Instructions to Healthcare Colleague and Healthcare Facility Supervisor: The LPN whose name appears on the line above is applying for advanced placement to the Umpqua Community College Nursing Program. Their application will not be complete without the required references. Please take a few moments to answer the following questions based on your experience with this applicant. Please circle the number that best matches your knowledge of the applicant. Do Not write in partial points. (The score, in a case where a partial point is written, will be rounded down to the lower whole number.) 1 = Doesn t Meet Expectations; 2 = Meets at Least Minimum Expectations; 3 = Serves as a Role Model for Others. 1. How well would you say this individual interacts with individuals from varied backgrounds, cultures, ethnicity and lifestyles? How closely does this individual demonstrate the ethical behavior, honesty and integrity you would expect of a Nurse? How articulate is this individual when communicating orally and in writing? How suitable is this individual for transitioning from the Licensed Practical Nurse role to the role of the Registered Nurse? How likely is this individual to remain calm and stable when performing under pressure? How would you rate this individual s leadership and problem solving abilities? _ Colleague or Supervisor signature and title / Date Agency Name /Phone Number Comments:

8 OCNE LPN TO RN ADVANCED PLACEMENT REFERENCE Applicant s Name: _ I am applying for advanced placement in the Umpqua Community College Nursing Program and give permission for _ (colleague/supervisor name) to complete this form, place it in a sealed agency envelope and return it to me to attach to my application before October 30, I waive my right to review this reference at any time: _ Applicant Signature Date Instructions to Applicants: References from two individuals with direct knowledge of your work as an LPN are required for your application for advanced placement into a Nursing program implementing the OCNE curriculum, using one of the copies in this application. One reference must come from a colleague or instructor who has worked with you in a healthcare setting and one reference must be from a healthcare facility supervisor who has been involved in supervising and/or evaluating your performance within the past year. Fill in your name and your colleague s or instructor s name or healthcare facility supervisor s name on the lines provided above and sign and date the form in the space provided. The colleague, instructor or supervisor is asked to circle the appropriate number on each line, sign (including title and agency name and phone number) and date the form, place it in an agency envelope with their name signed across the seal and return it to you to attach to your application. Instructions to Healthcare Colleague and Healthcare Facility Supervisor: The LPN whose name appears on the line above is applying for advanced placement to the Umpqua Community College Nursing Program. Their application will not be complete without the required references. Please take a few moments to answer the following questions based on your experience with this applicant. Please circle the number that best matches your knowledge of the applicant. Do Not write in partial points. (The score, in a case where a partial point is written, will be rounded down to the lower whole number.) 1 = Doesn t Meet Expectations; 2 = Meets at Least Minimum Expectations; 3 = Serves as a Role Model for Others. 1. How well would you say this individual interacts with individuals from varied backgrounds, cultures, ethnicity and lifestyles? How closely does this individual demonstrate the ethical behavior, honesty and integrity you would expect of a Nurse? How articulate is this individual when communicating orally and in writing? How suitable is this individual for transitioning from the Licensed Practical Nurse role to the role of the Registered Nurse? How likely is this individual to remain calm and stable when performing under pressure? How would you rate this individual s leadership and problem solving abilities? _ Colleague or Supervisor signature and title / Date Agency Name /Phone Number Comments:

9 LPN WORK EXPERIENCE Umpqua Community College School of Nursing LPN Advanced Placement Application for Fall 2016 Second Year Entry Student Name: Date: Dear Employer/Supervisor/Human Resources Manager: The above individual is planning to apply to the Umpqua Community College School of Nursing for available LPN advanced placement positions in the second year of the Nursing Program, fall 2016 entry and must prove accumulation of a minimum of 500 hours work experience as a Licensed Practical Nurse (in any setting in a position that requires the LPN license and for work that would qualify for license renewal in Oregon) before the application deadline to be eligible to apply. To assist this applicant with the process, please fill in the requested information, seal it in an envelope (preferably a company letterhead envelope) and sign your name across the seal. The applicant may submit documents from more than one employer in order to provide proof of required hours of work experience. The applicant must attach the sealed envelope to the application and submit it no later than 5:00 p.m. on October 30, 2015 to be eligible to apply. Can you verify that this applicant has worked as an LPN for >500 hours at your facility in a position for which an LPN License is required and in which regular supervision by a registered nurse occurs? Yes No Total Number of Hours Worked here as LPN = If less than 500 hours, how many hours of LPN work experience (in a position for which the LPN license is required) Has this individual obtained at your facility? (Applicants may submit this form from more than one employer.) Hours: Does this position require LPN licensure? Yes No Does a registered nurse regularly supervise this individual? Yes No Signature of Supervisor or HR Manager Printed Name and Title Facility Phone Number

10 LPN WORK EXPERIENCE Umpqua Community College Nursing Program LPN Advanced Placement Application for Fall 2016 Second Year Entry Student Name: Date: Dear Employer/Supervisor/Human Resources Manager: The above individual is planning to apply to the UCC Nursing program for available LPN advanced placement positions in the second year of the Nursing Program, fall 2015 entry and must prove accumulation of a minimum of 500 hours work experience as a Licensed Practical Nurse (in any setting in a position that requires the LPN license and for work that would qualify for license renewal in Oregon) before the application deadline to be eligible to apply. To assist this applicant with the process, please fill in the requested information, seal it in an envelope (preferably a company letterhead envelope) and sign your name across the seal. The applicant may submit documents from more than one employer in order to provide proof of required hours of work experience. The applicant must attach the sealed envelope to the application and submit it no later than 5:00 p.m. on October 30, 2015 to be eligible to apply. Can you verify that this applicant has worked as an LPN for >500 hours at your facility in a position for which an LPNlicense is required and in which regular supervision by a registered nurse occurs? Yes Total Number of Hours Worked here as LPN = If less than 500 hours, how many hours of LPN work experience (in a position for which the LPN license is required) has this individual obtained at your facility? (Applicants may submit this form from more than one employer.) Hours: Does this position require LPN licensure? Yes No Does a registered nurse regularly supervise this individual? Yes No Signature of Supervisor or HR Manager Printed Name and Title Facility Phone Number

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