PRACTICAL NURSING CERTIFICATE OF PROFICIENCY PROGRAM APPLICATION

Transcription

1 PRACTICAL NURSING CERTIFICATE OF PROFICIENCY PROGRAM APPLICATION Cohort FOR QUESTIONS ABOUT THE APPLICATION OR ASSOCIATED DOCUMENTATION: Tracy Owens, BBA

2 APPLICATION REQUIREMENTS The following is a list of requirements for the Practical Nurse Certificate (PNC) program. Applicant must be at least 17 years of age when applying and 18 years of age prior to start of clinical rotation experience. Graduation from a regional accrediting association as defined by the United States Office of Education High School or other appropriate state educational agency; or a Certificate of Equivalency (GED). Appropriate score on MCC Compass test or successfully passing PCS 021 (Reading); and TRE 089 (Transitional English); and MAT 101 (Math Literacy for College Students) which is preferred and recommended or TRM 091 (Beginning Algebra). HES 113 Medical Terminology with a minimum grade of 2.0 (C). HES 129 Allied Health Anatomy & Physiology; or, Bio 201-Anatomy & Physiology I and BIO 202 Anatomy & Physiology II with a minimum grade of 2.0 (C). NAP 115 Nurse Assistant Program. Other Allied Health experience must be reviewed and approved by program Director. Minimum grade of 2.0 (C) must be achieved. Student Check Background Check (this is a nationwide check and different from the AZDPS fingerprint check/card). AZDPS fingerprint check/card. (Cards and application forms are available in the Nursing office.) Verification of Residency. Student copy of transcripts from other educational institutions needed to verify education requirements. The application review process will not discriminate based on race, color, national origin, gender, religious background, sexual orientation, age or disability. Any official transcripts should be acquired through the issuing facilities and directly mailed to: MCC Practical Nursing Department PNC Program 1801 Detroit Ave. Kingman, AZ Application for the PN Program is in addition to the application for general admission to Mohave Community College. Class positions are limited; therefore, students are encouraged to make early application submissions. Application does not guarantee admission to the program. INCOMPLETE applications will not be considered. ***Application deadline April 1, 2016, at 5pm***

3 Admission to the program will be considered on the basis of: Receipt of a completed PNC Program application. Three (3) professional references from persons who have known the applicant in a supervisory or educational setting and who are familiar with applicant s academic and/or work ethics. Official college transcripts, (Student copy of transcripts other than MCC, may be attached to the application). Complete educational and prerequisite requirements as outlined above. Applicants will be notified of their status in 10 to 15 days after application deadline. A completed application packet must be received by: Mohave Community College Practical Nursing Department PNC Program 1801 Detroit Avenue Kingman, Arizona NO LATER THAN 5:00 P.M. ON APRIL 1, Applicants conditionally accepted to the PNC program must notify the Practical Nursing Department NO LATER THAN MAY 31, 2016 that they desire to attend the program. Applicants not accepted to the Practical Nursing Program may be given an opportunity to be considered for the next admitting semester.

4 AFTER ADMISSION TO THE PN PROGRAM After conditional acceptance of initial application, the following must be completed per PNC Program requirements: CPR certification (American Heart Association-Healthcare Provider or the American Red Cross Professional Rescuer level) and certification must be maintained during the entire program. (Adult, child, or community CPR is not acceptable.) Online recertification IS NOT accepted. Physical examination and health clearance indicating ability to perform all aspects of nursing, as outlined in the Essential Skills and Functional Abilities of a Nurse, attached. Proof of healthcare insurance. Proof of immunizations and/or immunity to: Hepatitis B MMR Varicella Negative TB test or X-ray within six (6) months of clinical experience start in October. Negative drug screening within twelve (12) months of start of class. Completely filled out Degree Declaration; Students must notify the Practical Nursing Department of any change in address or plans to attend classes. After successful completion of the requirements for the PN certificate of proficiency, the student will be eligible to apply to write the licensure examination offered by the National Council Licensure Examination for PN (NCLEX-PN). Licensure requirements are the exclusive responsibility of the Arizona State Board of Nursing and students must satisfy those requirements independently of requirements for graduation from the college. FINANCIAL ASSISTANCE Financial assistance is available in the form of scholarships, and federal financial aid. The necessary forms can be secured at the Financial Aid Office or at Students are encouraged to contact the Financial Aid Director in the year preceding admission to the nursing program. It is strongly recommended to apply for financial assistance and scholarships along with the application process to the PN Program. PN PROGRAM CLINICAL EXPERIENCE Clinical experience takes place in health care facilities in Mohave County including the cities of Lake Havasu City, Bullhead City and Kingman. Travel between clinical facilities will be required at the student s expense.

5 TEST OF ESSENTIAL ACADEMIC SKILLS (TEAS) MOHAVE COMMUNITY COLLEGE WHAT IS THE TEAS TEST? The Test of Essential Academic Skills evaluates PN Program applicants in four (4) foundational areas, which are essential to your academic success in the PN Program. The Nursing Program requires you to take the TEAS Test as an entrance examination. Basically, the test has four parts that ask you to answer multiple-choice questions covering the following: Reading: paragraph comprehension, passage comprehension, and inferences/conclusions. (40 items, 50 minutes) Math: Whole numbers, metric conversion, fractions, decimals, algebraic equations, percentages, and ratio/proportion. (45 items, 56 minutes) Science: science reasoning, science knowledge, biology, chemistry, anatomy, physiology, basic physical principles, and general science. (30 items, 38 minutes) English and Language Usage: punctuation, grammar, sentence structure, contextual words and spelling. (55 items, 65 minutes) Total of 170 multiple choice questions. WHO ADMINISTERS THE TEAS TEST? The Testing centers at Mohave Community College administer the TEAS Test. The test is purchased from the Assessment Technologies Institute (ATI). Your TEAS scores are stored by ATI and are available to you and to your school via the Internet. You can also have TEAS results sent to other nursing schools at minimum cost through ATI. HOW MUCH DOES THE TEAS TEST COST? The cost of taking either test is $40.00 for students and $50.00 for non-students. HOW CAN I BEST PREPARE FOR TAKING THE TEAS TEST? A review of basic concepts and theories in mathematics, reading, science, English and language usage is recommended. ATI has two products, the TEAS Study Manual and a TEAS Online Practice Assessment, available to guide your review and provide feedback on your study progress. These products can be purchased online at the ATI website which is CAN I USE A CALCULATOR ON THE TEAS TEST? Calculators are NOT allowed during the TEAS TEST. WHAT DO I BRING TO THE TESTING CENTER? Photo bearing identification such as a; passport, driver s license, student identification card. WHAT CANNOT BE BROUGHT TO THE TESTING CENTER? Cell phones, textbooks, backpacks, calculators. Scratch paper and pencils will be provided.

6 CAN YOU ACCOMMODATE STUDENTS WITH DISABILITIES? Students with documented disabilities requiring accommodations should contact the Disability Services Office at the local campus to make arrangements to take their test. Students requiring extra time will not be able to take the computer based test because the program is self-timing and cannot be adjusted. These students will be given a paper and pencil test instead. This test cannot be scored locally, but must be sent back to ATI for scoring, requiring at least a one (1) to two (2) week turnaround. Please take this into consideration when scheduling and allow sufficient time prior to nursing program application due dates. HOW LONG WILL IT TAKE TO GET MY TEAS TEST SCORES? If you have taken the computer administered TEAS Test, your scores are available immediately after the examination. If you have taken the pencil/paper version of the test, your examination will be scored within 24 hours of receipt by ATI. Note that the 24-hour window is NOT 24 hours from the time you tested, but within 24 hours of ATI s receipt of testing materials from Mohave Community College. HOW DO I KNOW IF I PASSED THE TEAS TEST? The applicant s adjusted individual total score is considered for admission as follows: 57.3% or above 1 st priority for admission 50% to 57.2%--2 nd priority for admission 40% to 49.9% 3 rd priority for admission, if positions are available CAN I RETEST TO GET A HIGHER SCORE? Tests may be retaken after a minimum of 30 days and up to 3 times a year period. HOW TO REGISTER YOURSELF AS A TEST CANDIDATE FOR THE TEAS. If you are not a current user on you need to set up a new account. This will allow you access to the testing and to complete a purchase on ATI s online store. Please follow the steps below to setup a new account: 1. Go to Just under the Username and Password fill-in boxes, there is a small link that states, New to ATI? Create an account. Click on that link to register yourself with ATI. 2. Next, a web form will appear. Fill in all of the blue fields. Blue fields are required information necessary to create a new account. 3. You will receive an from ATI confirming your user login and password. 4. You will need to bring your user name and password with you when you go to the testing center to take the TEAS. TO SCHEDULE THE TEAS TEST, CONTACT THE TESTING COORDINATOR AT YOUR LOCAL CAMPUS PROVIDED BELOW: Heather DeJesus: hdejesus@mohave.edu, Bullhead City Campus, Cheri Stromle: cstromle@mohave.edu, Neal Campus Kingman Campus, Kevin Smith: ksmith@mohave.edu, Lake Havasu City Campus, Kim Naylor: knaylor@mohave.edu, North Mohave Campus, MCC Toll Free:

7 Mohave Community College Practical Nursing Certificate Program Technical Standards (Functional Abilities Essential for Practical Nursing Practice) The purpose of the Practical Nursing Certificate Program is to educate students to meet the program outcomes and to ensure that no graduate will pose a danger to the patient. Certain functional abilities are essential for the delivery of safe, effective nursing care. These abilities are essential in the sense that they constitute core components of nursing practice, and there is a high probability that negative consequences will result for patient/clients under the care of nurses who fail to demonstrate these abilities. Reference material used in the development of these standards include local health facilities job descriptions and requirements, the Arizona Nurse Practice Act, The Functional Abilities Essential for the Delivery of Safe, Effective Nursing Care (a descriptive research study conducted by the National Council of State Boards of Nursing). The Technical Standards are reflected in the Nursing Program s performance-based outcomes, which are the basis for teaching and evaluating all nursing students. Practical Nursing Certificate students will receive both classroom and clinical instruction in multiple nursing specialty areas (Medical/Surgical, Maternal/Child, Pediatric, Mental Health, etc.) and will be required to demonstrate competency in each area. In order to provide safe and effective patient care in the Practical Nursing Certificate Program, the student must be able to demonstrate, with or without reasonable accommodation, physical, cognitive, and behavioral abilities required for satisfactory completion of all aspects of the program curriculum and clinical agency requirements. Any applicant who has met the necessary academic prerequisites and can, with or without reasonable accommodation, meet and/or perform the Practical Nursing Certificate Program Technical Standards will be accepted for admission. Students admitted to the Practical Nursing Certificate Program gain experience in many settings that are physically demanding, e.g., hospitals, long term care facilities, community agencies, school settings and clinics. During each clinical experience, the practical nursing certificate student is assigned clinical care which includes medication administration and direct patient care. Students will be expected to adhere to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 which safeguards patient confidentiality. Transportation to and from health care facilities is the responsibility of the student. Please carefully read the Practical Nursing Program Technical Standards. The practice of nursing requires the following functional abilities with or without reasonable accommodations. Functional Ability Gross Motor Skills Fine Motor Skills Physical Endurance Standards and Examples of Required Activities Gross motor skills sufficient to provide the full range of safe and effective patient care activities Move within confined spaces such as treatment room or operating suite Assist with turning and lifting patients Administer CPR Fine motor skills sufficient to perform manual psychomotor skills Manipulate small equipment and containers, such as insulin syringes, vials, ampules, and pills and medication packages, to administer medications Perform tracheotomy suctioning, insert urinary catheter Safely dispose of needles in sharps containers Accurately place and maintain position of stethoscope for detecting sounds of bodily functions Physical stamina sufficient to remain continuously on task for up to a 12- hour clinical shift while standing, sitting, moving, lifting, and bending to perform patient care activities Walk/stand for extended periods of time; turn, position, and transfer patients. Manually resuscitate patients in emergency situations.

8 Physical Strength Mobility Hearing Visual Tactile Smell Emotional/ Behavioral Professional Attitudes Interpersonal Skills Physical strength sufficient to perform full range of required patient care activities Push and pull up to 300 pounds (with assistance) as well as emergency carts; stretchers and wheel chairs with and without patients; medication carts; wheel chairs; and other equipment Lift/move heavy objects up to 50 pounds without assistance Physical ability sufficient to move from room to room and maneuver in small spaces; full range of motion to twist/bend, stoop/squat, reach above shoulders and below waist and move quickly; manual and finger dexterity; and hand-eye coordination to perform nursing activities Move around in work area and treatment areas. Position oneself in the environment to render care without obstructing the position of other team members or equipment. Auditory ability sufficient for physical monitoring and assessment of patient healthcare needs Hear normal speaking level sounds Detect sounds related to bodily functions using a stethoscope Hear auditory alarms (monitors, fire alarms, call bells) Hear cries for help Hear in noisy environments Normal or corrected visual ability sufficient for accurate observation and performance of nursing care. See objects up to 20 feet away Visual acuity to read calibrations on 1 ml syringe Assess skin color (cyanosis, pallor) Tactile ability sufficient for physical monitoring and assessment of health care needs Feel vibrations (pulses); Detect temperature changes; Palpate veins for cannulation; Able to work with hands in water and wash hands frequently, Olfactory ability sufficient to detect significant environmental and patient odors. Detect abnormal odors from patient (foul smelling drainage, alcohol breath); Detect smoke. Emotional stability and appropriate behavior sufficient to assume responsibility/accountability for actions. Present professional appearance and demeanor; demonstrate ability to communicate with patients, supervisors, coworkers to achieve a positive and safe work environment. Follow instructions and safety protocols; Honesty and integrity beyond reproach; Establish rapport with patients, instructors and colleagues; Respect and care for persons whose appearance, condition, beliefs and values may be in conflict with their own; Deliver nursing care regardless of patient s race, ethnicity, age, gender, religion, sexual orientation or diagnosis; Conduct themselves in a composed, respectful manner in all situations and with all persons; Work with teams, workgroups, and other disciplines; Establish and maintain therapeutic boundaries; Demonstrate emotional skills to remain calm and maintain professional decorum in an emergency/stressful situation; Demonstrate prompt and safe completion of all patient care responsibilities; Adapt rapidly to changing environment/stress; Exhibit ethical behaviors and exercise good judgment; Function effectively under stress, to work as a part of a team and to respond appropriately to supervision; to adapt to changing situations, to respond appropriately to patients and families under stress, and to follow through on assigned patient care responsibilities. Abilities sufficient to demonstrate competencies such as: Ability to arrive to a clinical on a timely basis; Meet the demands for performance of duties; Meet organizational requirements to perform these duties in a professional and competent manner.

9 Communicatio n Cognitive/ Quantitative Abilities Conceptual/Sp atial Abilities Clinical Reasoning Flexibility Oral communication skills sufficient to communicate in English with accuracy, clarity and efficiency with patients, their families and other members of the healthcare team including non-verbal communication, such as interpretation of facial expressions, affect and body language. Give verbal directions to or follows verbal directions from other members of the health care team, and participate in health care team discussions of patient care; Elicit and record information about health history, current health state and responses to treatment from patients or family members; Convey information to patients and others as necessary to teach, direct and counsel individuals in an accurate, effective and timely manner; Recognize and report critical patient information to other Caregivers; Communicate clearly in telephone conversations; Ability to speak, comprehend, read, and write English at a level that meets the need for accurate, clear, and effective communication. Reading comprehension skills and mathematical ability sufficient understand written documents in English and solve problems involving measurement, calculation, reasoning, analysis and synthesis. Calculate appropriate medication dosage given specific patient parameters; Analyze and synthesize data and develop an appropriate plan of care; Collect data, prioritize needs and anticipate reactions; Transfer knowledge from one situation to another; Accurately process information on medication container, physicians orders, monitor and equipment calibrations, printed documents, flow sheets, graphic sheets, medication, administration records, other medical records, and policy and procedure manuals. Ability to collect, analyze, and integrate information and knowledge to make clinical judgments and manage decisions that promote positive patient outcomes Conceptual/spatial ability sufficient to comprehend three-dimensional and spatial relationships Comprehend spatial relationships in order to properly administer injections, start intravenous lines, assess wounds of varying depths etc. Ability to reason across time about a patient s changing condition and/or changes in the clinician s understanding. Evaluate patient or instrument responses, synthesize data, and draw sound conclusions. Adapt to Nursing Department course scheduling policy Available to work the hours of an assigned schedule which could include any shift and day of the week. Once the program is in receipt of application and student receives letter of contingent acceptance to the Practical Nursing Certificate Program, the student is responsible for notifying the Director of the Practical Nursing Certificate Program of conditions that impact the student s ability to meet the Practical Nursing Certificate program Technical Standards. Any change in the student s ability to meet and/or perform the Practical Nursing Certificate Program Technical Standards would require the student to provide the Director with documentation that they once again meet Technical Standards for functional abilities essential to practical nursing practice. If an accommodation is necessary to participate in the Practical Nursing Certificate Program, participation is dependent on the identification of a reasonable accommodation. Students should seek accommodation advising as soon as possible so that a plan for accommodation can be in place at the beginning of the program. Applicants seeking admission to the Nursing Program who may have questions about the Technical Standards and appropriate reasonable accommodations are invited to discuss their questions with the Office of Disability Services. Reasonable accommodation will be directed toward providing an equal educational opportunity for students with disabilities while adhering to the standards of practical nursing practice for all students. Registration with Disability Services is required before any accommodation requests can be granted. Under no circumstances will any course requirements or technical standards be waived for any student, with or without a disability. Reasonableness is determined by the office of student disabilities and Student Services and the Practical Nursing Certificate Program on a case-by-case basis utilizing the Practical Nursing Certificate Program Technical Standards. Mohave Community College provides reasonable accommodations to those students who qualify under the Americans with Disability Act, as amended (ADA). Appropriate documentation will be required to determine eligibility to receive accommodations. It is the student s responsibility to contact the office of student disabilities and request accommodations in a timely manner.

10 INSTRUCTIONS FOR OBTAINING YOUR BACKGROUND CHECK FOR A CLINICAL EDUCATION PROGRAM Mohave Community College-Practical Nurse Program Background checks are required on incoming students to insure the safety of the patients treated by students in the clinical education program. You will be required to order your background check 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. The background checks are conducted by PreCheck, Inc., a firm specializing in background checks for healthcare workers. Your order 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 Mohave Community College-Practical Nurse. 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 $53.58 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 the background check performed through PreCheck, Inc. 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. 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. 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.

11 MCC MOHAVE COMMUNITY COLLEGE PRACTICAL NURSING PROGRAM Student Application Form All qualified applicants are considered for admission, and students are treated without regard to race, color, religion, sex, national origin, age, or marital status. Information related to these areas will be used for statistical analysis and not as criteria for admission to the nursing program. All information will be kept confidential. APPLICANT INFORMATION Social Security #: MCC ID #: Full Name: Mailing Address: (Last) (First) (Middle) Street (Apt #) HOME PHONE: City ST Zip (Area Code) Phone Number Address: Cell Phone: (Area Code) Phone Number ACADEMIC HISTORY List all colleges, universities and institutions attended, including high school. High School: Location: Degree: Date(s): College: Location: Degree: Date(s): College: Location: Degree: Date(s): Other: Location: Degree: Date(s): Practical Nursing Program PREREQUISITES: Please state if Completed or In Progress COMPASS READING: Score 74 or above; or PCS 021 Completed In Progress COMPASS WRITING: Score 70 or above; or TRE 089 Completed In Progress COMPASS NUMERICAL MATH: TRM 091 Completed In Progress or MAT 099 Completed In Progress TEAS Completed Retaking to improve score HES 113 Medical Terminology Location: Completed In Progress HES 129 Allied Anatomy & Physiology Location Completed In Progress or BIO 201 Anatomy & Physiology I Location: Completed In Progress And BIO 202 Anatomy & Physiology II Location: Completed In Progress Last five (5) years, beginning with most recent: 1 WORK HISTORY Occupation/Job Title Employer City/State Start Date End Date

12 Personal Demographic Information Responses to Gender, Birth Date, Marital Status, and Ethnicity/Race are voluntary and will be kept confidential. Failure to furnish this information will not adversely affect the status of this application; it is for statistical purposes only. Date of Birth: Gender: Male Female Marital Status: Single Married Divorced Widowed MM/DD/YYYY Maiden Name: Other Name(s) Used: Number of Children: Ethnicity/Race American Indian or Alaskan Native Asian or Pacific Islander Hispanic Black/Non-Hispanic White/Non-Hispanic Other/Unknown ANSWER THE FOLLOWING QUESTIONS 1. Have you ever been addicted to habit-forming drugs: Yes No If YES, please explain: 2. Do you have any physical or mental limitations: Yes No If YES, please explain 3. Have you ever been convicted of a felony: Yes No If YES, please explain Licensure is the sole responsibility of the Arizona State Board of Nursing (AZBON). If you have been convicted of a felony, contact the Arizona State Board of Nursing to verify eligibility to be licensed prior to submitting this application. DISCLAIMER AND SIGNATURE I have read all associated documentation contained within this admission packet and fully understand the functional skills and requirements as outlined in the Technical Standards document included. I understand that if accepted into the Practical Nursing Program, I will be required to travel for clinical experience and that I will be responsible for my own transportation and meals. I understand that if accepted, I will be required to meet the health requirements of the Practical Nursing Program. I hereby certify that the facts set forth in this Student Application are true and complete to the best of my knowledge. I understand that if accepted into the Practical Nursing Program, any falsified statements on this application or within any of the associated documentation shall be considered cause for suspension or dismissal. Signature: MAIL COMPLETED APPLICATION TO: Practical Nursing Program Mohave Community College 1801 Detroit Ave. Kingman, AZ 86401

13 TRANSCRIPT REQUEST This form is for Transcripts from other institutions, not for MCC- the PN Program is able to view your MCC Transcripts there is no need to order one. Institution Name Mailing Address City State Zip Please send one (1) OFFICIAL COPY of my transcript to: Practical Nursing Program Mohave Community College 1801 Detroit Avenue Kingman, AZ I do not know the Transcript fee, please bill me. I am enclosing the transcript fee of $ for (number) transcripts. PLEASE PRINT Student Name Social Security Number Mailing Address City State Zip Maiden or Previous Name(s) Address While attending your institution If there is a charge against my account, I hereby agree to clear all indebtedness before this record will be released. Student Signature STUDENT is responsible for mailing this

14 PRACTICAL NURSING PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nursing Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Practical Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: PLEASE RETURN TO Practical Nursing Program Mohave Community College 1801 Detroit Avenue Kingman, AZ 86401

15 PRACTICAL NURSING PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nursing Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Practical Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: PLEASE RETURN TO Practical Nursing Program Mohave Community College 1801 Detroit Avenue Kingman, AZ 86401

16 PRACTICAL NURSING PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nursing Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Practical Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: PLEASE RETURN TO Practical Nursing Program Mohave Community College 1801 Detroit Avenue Kingman, AZ 86401

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