Attached is your application packet to the LVN/Paramedic to A.D.N. Mobility Program.

Transcription

1 Dear Applicant, Attached is your application packet to the LVN/Paramedic to A.D.N. Mobility Program. Please complete and return the following documents in a folder: Incomplete applications will not be accepted or considered Prospective Applicant Checklist Mandatory Information Session Attendance Program Admissions Application Official copy of ALL your transcript(s) and evaluation to the Enrollment Services Department and the A.D.N. Mobility program department Immunization Requirement Form (include a copy of all required immunization records and titers with results) Copy of your CPR card (front and back) or ACLS (Paramedics) Copy of your LVN license or Paramedic certificate (internet printout is acceptable) Degree Evaluation (instructions attached) After receipt of your completed application, applicants are eligible to register for the HESI admission exam; prospective applicant will send an to adn.mobility@sjcd.edu with HESI Date in the subject line. All students are required to take the HESI admission exam and meet the required scores prior to final acceptance to the program. You must score a score of 75% or higher on each of the required sections of the HESI Exam. All students must have a minimum G.P.A. of 2.5 or above in required pre-requisites in order to be eligible for admission. Applications should be returned to Shaterica Washington, in the Vocational Building 13, RM. S for the following periods: Spring Admission Fall Admission September 1-November 1 (deadline) April 15-June 1 (deadline) If you have any questions, please call us at x3315 or via at adn.mobility@sjcd.edu.

2 San Jacinto College South Application for Admission Date: Please Print Social Security - - Last Name First MI Mailing Address Apartment # City State Zip Address Home Phone ( ) Cell Phone ( ) *Date of Birth / / *Gender Male Female *Ethnicity: Caucasian Hispanic Black American Asian Native American Foreign Unknown *Marital Status: Single Married Separated Divorced Widowed *Number of Children (If applicable) Give Ages: Current Employer Address Employer Phone Supervisor Position Type of Unit (i.e. Med-Surg, Maternity, etc) *Optional

3 EDUCATIONAL DATA Name of High School: Graduation Date: Type of Diploma: Standard (regular) Certificate of Attendance Collegiate Honors GED No HS Diploma List all colleges attended. You must complete this section if you have ever attended college before, including San Jacinto College. List additional colleges on back if necessary. 1. Colleges Attended (list last college first) Location (City, State, Zip) Dates To/From Hours Earned Degree Earned List your LVN license number (REQUIRED): Expiration Date: OR List your Paramedic Certification: Exp Date: Date & Location of Skills Proficiency Exam Person to Notify in Case of Emergency: Name: Telephone: Address Street, City, State, Zip Code Relationship of this person to you:

4 How did you first hear about San Jacinto College South LVN to ADN Mobility Program for which you are applying? 1. Newspaper/TV 2. Through Work 3. Friend 4. Your Own Research 5. Other (Specify) Upon completion of the Associate Degree Nursing program, you will be required to answer the following questions as part of the Application for Licensure as a Registered Nurse in Texas: Have you ever been denied licensure by any licensing/certifying authority in any country, state or province? Have you ever had disciplinary action taken against you by a licensing/certifying authority in any country, state or province? Have you ever been convicted of a crime other than minor traffic violations? Have you been diagnosed with or treated or hospitalized in the past five (5) years for schizophrenia or other psychotic disorders, major depression, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder. (You may answer "no" if you have completed and/or in compliance with TPAPN for mental illness). Have you been addicted or treated for the use of alcohol or any other drug within the past five (5) years? (You may answer "no" if you have completed or/are in compliance with TPAPN for substance abuse.) If you answered "Yes" to any of the above questions, you may be ineligible take the licensure exam. To determine your eligibility, you may contact the Board of Nurse Examiners for the State of Texas regarding your particular circumstances by phone or mail: Box 430, Austin, Texas I hereby certify that the information in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification is cause for denial or admission or expulsion from the College. I understand that the information contained in this application will be read by the faculty and staff of San Jacinto College South Associate Degree Nursing Program. Signature of Applicant Date

5 San Jacinto College South LVN/Paramedic to ADN Mobility Program Immunizations Applicant s Name Date: Return this form and a copy of your immunization records with your application. In order to continue clinical, you must provide this office with a copy of the indicated items BEFORE the date they will expire. Please use the following guidelines for immunizations. Tdap MMR Series All students must show proof of at least one dose of tetanus/diphtheria since All students must provide proof of positive titer results. TB Skin Test Hepatitis B Series Varicella Influenza Results must show date administered and date read. TB Skin test must have been administered within the past 12 months. Chest X-ray must be administered within the past 24 months. All students must show proof of 3 doses of Hepatitis B vaccine (No older than 3 years) OR serologic confirmation of immunity. Include copy of Hep B titer report. All students must provide proof of a positive titer results. All students must show proof of seasonal influenza vaccine and must show proof of renewal PRIOR to yearly expiration. Pandemic Vaccine (H1N1) may be requested and required depending on hospital clinical assignment. TDAP: MMR: Flu: TB/CXR result H1N1: Varicella Hep B Hep B Titer

6 San Jacinto College South LVN/Paramedic to ADN Mobility Program C.P.R. REQUIREMENTS All individuals are required to have a course in Cardiopulmonary Resuscitation. If the course is offered by: 1. American Heart Association-a course completion card called Health Care Provider is needed and is valid for two (2) years. To find a class near you, visit their website at 2. American Red Cross-a course called CPR for the Professional Rescuer is needed and is valid for one (1) year. To find a class near you, visit their website at You will not be allowed in the clinical area without this card! You will need to show proof of the course completion by submitting a copy of the card (front & back) along with the completed Physical Examination form. Your CPR card must remain current throughout your San Jac nursing program training. All students are responsible for submitting an updated copy of your CPR card to the A.D.N. Mobility Main office, Room I have read the above and am aware of my responsibility during my enrollment in the LVN/Paramedic to A.D.N. Mobility Program. G: Name (Please Print) Student ID # Signature Date

7 Medical Record &Physical Examination This form should be completed by a physician/nurse practitioner/physician s assistant Name of Applicant: (Miss. Mrs. or Mr.) Last First Middle Date of Birth: / / Weight: Height: Allergies: include medications, latex, and environmental: Medical History of applicant Does patient have any of the following: Please answer yes or no and provide additional information when applicable. No Yes 1. Shortness of breath or moderate exertion 2. Hoarseness, excessive coughing 3. Tuberculosis 4. Seizure disorder 5. Mental disorders/ emotional instability 6. Frequent headaches 7. Diabetes 8. Heart disease 9. Hay fever/sinus infections 10. Asthma 11. Musculo-skeletal problems Please discuss any significant issues listed above on the following page. 12. Childhood diseases, list if significant 13. Medical conditions, list if significant 14. Surgeries, list if significant

8 15. Injuries, list if significant Physical Examination 1. Vision Hearing 2. Heart rate BP Please note any abnormalities of the following systems. 3. Circulatory 4. Respiratory/ lungs 5. Muscluo-skeletal 6. Neuro 7. GI/GU 8. Reproductive Recommendations 1. In your professional judgment, is the applicant mentally and physically able to undertake the program? (Please check one) Yes No 2. Is the applicant fit with no restrictions? (Please check one) Yes No Remarks M.D. Signature Facility Address Please Print Name City State Zip Date Telephone

9 INSTRUCTIONS FOR OBTAINING YOUR BACKGROUND CHECK and DRUG SCREENING FOR A CLINICAL EDUCATION PROGRAM SJC South ADN Mobility BackgroundCheck & DrugScreen (San Jacinto College South - ADN Mobility BackgroundCheck & DrugScreen) Background checks and drug screening are required on incoming students to ensure the safety of the patients treated by students in the clinical education program. You will be required to order your background check and complete the drug screening in sufficient time for it to be reviewed by the program coordinator or associated hospital prior to starting your clinical rotation. A background check typically takes 3-5 normal business days to complete, and turnaround time of the drug screening results is determined by a variety of factors. The background checks are conducted by PreCheck, Inc., a firm specializing in background checks for healthcare workers. The drug screening service is conducted by E-Screen/Pembrooke. All your orders must be placed online through StudentCheck. Go to and select your School and Program from the drop down menus for School and Program. It is important that you select your school worded as SJC South ADN Mobility BackgroundCheck & DrugScreen. Complete all required fields as prompted and hit Continue to enter your payment information. The payment can be made securely online with a credit or debit card. You can also pay by money order, but that will delay processing your background check until the money order is received by mail at the PreCheck office. Texas residents will pay $91.47 and New Mexico residents will pay $ Residents in all other states will pay $ For your records, you will be provided a receipt and confirmation page of background check and drug screening through PreCheck, Inc. Drug Screening: You must pre-register for drug screen collections before heading to a collection lab. If you pay by credit card, the link to the instructions for pre-registration will be provided at the confirmation page after you complete your order. If you are paying by money order, you will be ed instructions to obtain your drug screen once payment has been received. Note on Drug Screen Collection Pre-Registration and Appointments: This process only pre-registers you for a drug screen and does not set up an appointment time with the collection site. Collection sites have different policies on setting up appointments for drug screening. For your convenience, we recommend calling your chosen collection site ahead of time to set up an appointment. It is also your responsibility to pre-register and complete the drug screen at the time frame required by the school. For most students, the Electronic Chain of Custody (ECOC) process will register them to a collection site instantly; however the location of some students may require us to mail a paper Chain of Custody Form to get you to a collection site close to your location. We encourage you to pre-register with enough time to allow mailing time, if needed. PreCheck will not use your information for any other purposes other than the services ordered. Your credit will not be investigated, and your name will not be given out to any businesses. FREQUENTLY ASKED QUESTIONS: Does PreCheck need every street address where I have lived over the past 7 years? No. Just the city and state. I selected the wrong school, program, or need to correct some other information entered, what do I do? Please StudentCheck@PreCheck.com, with the details. How long does the background check take to complete? Most reports are completed within 3-5 business weekdays. How long does the drug screening take to complete? Screening can be impacted by a variety of factors. Do I get a copy of the background report? Yes. Log into and click on Check Status, and enter your SSN and DOB. If your report is complete, you may click on the application number to download and print a copy. This feature is good for 90 days after submittal. After 90 days, you will be charged $14.95 for a copy of your report, and will need to contact PreCheck directly to request this. Do I get a copy of the drug screening? Your school or clinical site may have a designated administrator who receives results via fax or through e-results, however if they direct you to contact PreCheck please

10 your name, request, and the last 4 digits of your SSN to studentcheck@precheck.com. We will advise you of whether we house the results. I have been advised that I am being denied entry into the program because of information on my report and that I should contact PreCheck. Where should I call? Call PreCheck s Adverse Action hotline at Adverse Action is the procedure established by the Fair Credit Reporting Act that allows you to see the report and to dispute anything reported. If you need further assistance, please contact PreCheck at StudentCheck@PreCheck.com