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1 INFORMATIONAL TOPIC: STUDENT DATA INFORMATION FORM Instructions: Please PRINT legibly. Last Name First Name M.I. Student ID Permanent Street Address City State Zip Code Mailing Street Address City State Zip Code Home Telephone Number ( ) Car Make Cell Telephone Number ( ) Car Model Car Color Car Tag # Ramsmail Address Only (NO personal/business allowed) NOTE: Activate your Ramsmail account immediately this is our primary means of communication with you.

2 INFORMATIONAL TOPIC: UNIFORM AND SUPPLIES The uniform supplier for the University of Mobile is Uniforms by Bayou located at 4677 Airport Boulevard. The telephone number is Requirement: Students should purchase 2 uniforms and 1 lab coat. Students need to go to Uniforms By Bayou to be measured and to purchase their uniforms after receiving their acceptance letter into the nursing program. Students will be expected to have their uniforms, lab coat, shoes, and all required supplies by the first day of class (August 18, 2014). Uniforms: Female students Top: Women s white zipper top Pant: Women s burgundy pants Male students Top: Men s white zipper top Pant: Men s burgundy pants Lab Coat: A full length lab coat is required for all students. Uniform Shoes: Shoes may be purchased at a location of your choice. Uniforms By Bayou have some nursing shoes in stock. All shoes must be white leather. No clogs are allowed. If you have any questions regarding the shoes, please direct your questions to your clinical instructor. Required Supplies: 1. Stethoscope. May be purchased at Uniforms by Bayou, the University of Mobile bookstore, or a medical-supply company of your choice. 2. Watch with a second hand. The watch may be purchased from the store of your choice. Questions: Please contact Mrs. Mattie Easter by at

3 INFORMATIONAL TOPIC: NAME BADGES Each student is required to purchase 2 name badges. The name badge is to be affixed to the nursing uniform and lab coat on the left side. The name tag will include your first and last name. Dates and Time for Pick-up: Cost: Students will be given further instructions for obtaining name badges at Nursing Orientation on Tuesday, August 19, Name badges will be issued through the University of Mobile Admissions Department. The cost for two badges is $ Students must pay at the business office and submit their receipt in their packet attached to the designated form. The business office will accept cash, checks, or credit cards. Questions: Please contact Mrs. Mattie Easter by at

4 RECEIPT FROM BUSINESS OFFICE INDICATING PAYMENT FOR NAME BADGES (Attach Receipt) $20.00

5 INFORMATIONAL TOPIC: NURSING SKILLS EQUIPMENT KITS The Nursing Skills Equipment Kit includes all the necessary medical equipment to learn basic and advanced nursing skills. The supplies in the Nursing Skills Equipment Kit will be utilized during practice experiences in the School of Nursing Skills laboratory located in the Rosemary Adams School of Nursing building. The Nursing Skills Equipment Kit contains supplies that the student will use in their junior and senior years. Dates and Times for Pick-up: Monday, July 21, :00 AM 3:00 PM Location to receive Nursing Skills Equipment Kit: Mrs. Jenelle McElroy Rosemary Adams School of Nursing Building Office # 8 Students will sign a form acknowledging receipt of Nursing Skills Equipment Kit. Cost: The cost of the Nursing Skills Equipment Kit is $ Students must pay at the business office and submit their receipt to Mrs. Jenelle McElroy. The business office will accept cash, checks, or credit cards. Questions: Please contact Mrs. Jenelle McElroy by at

6 INFORMATIONAL TOPIC: SCHOOL OF NURSING STUDENT MANUAL The School of Nursing Student Manual is a formal document that addresses general information regarding the nursing program at the University of Mobile, as well as policies, student programs and services, rights and responsibilities, and specific information regarding the BSN nursing program. It is the responsibility of each student to read this document prior to beginning the BSN nursing program and then each semester while they are enrolled in the program. Students are expected to be compliant with all policies and procedures as outlined in the School of Nursing Student Manual. All students must sign a document acknowledging that they have read the Student Manual, will review it each semester and as needed, and will adhere to the tenets of the document. The Student Manual is located on the website for the School of Nursing under the Quick Link : School of Nursing Student Manual. Submission: Please refer to the CertifiedProfile page of this packet for instructions on how to submit the required Student Manual Acknowledgement Form.

7 INFORMATIONAL TOPIC: NURSING STUDENT STATEMENT OF CONTINUED HEALTH RESPONSIBLITY All students accepted to the School of Nursing are required to obtain and maintain the required examination and immunization information. This information must be uploaded to the vendor. The Statement of Continued Health Responsibility form must also be signed and uploaded. Submission: Please refer to the CertifiedProfile page of this packet for instructions on how to submit the required Nursing Student Statement of Continued Health Responsibility form.

8 INFORMATIONAL TOPIC: CPR CERTIFICATION AND TRAINING One of the requirements for admission into the nursing program at the University of Mobile is a current certification in Cardiopulmonary Resuscitation (CPR). Each hospital also requires this certification for your clinical experiences. Successful completion of the course is a two year certification by the American Heart Association. Students are required to take this course even if they hold a current CPR certification. The American Heart Association recently changed the sequencing of CPR and all students must be trained with the most current guidelines. Hospitals and other health care institutions that contractually provide clinical opportunities require that the School of Nursing show proof that students have CPR certification lasting until the day of graduation (August 2014 through May 2016). Dates and times of courses: The School of Nursing faculty will be offering CPR Certification on the following dates: Monday, August 4, :00 AM 1:00 PM Tuesday, August 5, :00 AM 1:00 PM Wednesday, August 6, :00 AM 1:00 PM Students must successfully pass written and practice examinations on the day of training to receive CPR certification. Students are expected to be on time and to stay for the duration of the course. Students who arrive late will be sent home and will have to reschedule for another day. Students who do not attend a CPR class at the University of Mobile on one of the scheduled dates will not be allowed to start the nursing program. Required Book: Students must purchase from the University of Mobile Bookstore and READ the following book prior to class: BLS for Healthcare Providers by the American Heart Association ISBN Number Schedule: To schedule the CPR Certification and Training course, contact the School of Nursing secretary, Mrs. Lynnelle Kahalley, at The School of Nursing secretary is available 9:00 AM 4:00 PM each day. Cost of CPR Course: The cost of the course is $ Students must pay at the business office and submit their receipt in their packet attached to the designated form. The business office will accept cash, checks, or credit cards. Questions: Please contact Mrs. Lynnelle Kahalley in the nursing office at or

9 RECEIPT FROM BUSINESS OFFICE INDICATING PAYMENT FOR CPR CERTIFICATION (Attach Receipt) $40.00

10 INFORMATIONAL TOPIC: IMMUNIZATION TRACKER Policy Statement: The curriculum at the University of Mobile requires that each student be immunized for measles, mumps, rubella, varicella, hepatitis B, tetanus/diphtheria and influenza. Additionally, students must submit a tuberculin skin test annually. Students who do not maintain current and required immunizations will not be allowed to begin clinical or continue to go to clinical agencies. Inability to complete required clinical days will result in course failure. Students who are pregnant or lactating should discuss immunizations and refer questions to their physician or obstetrician. Submission: Students will be required to follow the procedures established by the School of Nursing. Verification and tracking of required immunizations will be conducted by CertifiedBackground.com using established methods and procedures. Please refer to the CertifiedProfile page of this packet for instructions on how to submit the required immunization documentation. Cost of Immunization Tracker: The cost of immunization tracking is $ Students must pay at the business office and submit their receipt in the packet attached to the designated form. The business office will accept cash, checks, or credit cards. Questions: Please contact Mrs. Mattie Easter by at

11 RECEIPT FROM BUSINESS OFFICE INDICATING PAYMENT FOR IMMUNIZATION TRACKER (Attach Receipt) $30.00

12 INFORMATIONAL TOPIC: HEALTH HISTORY FORM Policy Statement: Each student must complete the Health History Form. A component of the health history is the University of Mobile School of Nursing Core Performance Standards Policy as it describes health and wellness requirements in order to be effective in the clinical settings. Students admitted to the School of Nursing must be able to meet the Core Performance Standards for Admission and Progression when entered in clinical nursing course. The School of Nursing will collaborate with students on making reasonable accommodation(s) for known physical and/or mental impairments. The cost of special equipment will be the responsibility of the student. However, it must be acknowledged that nursing is a physically and mentally demanding profession. The following Core Performance Standards will be used by students, along with faculty, to determine whether or not accommodation(s) can be made reasonably. 1. Interpersonal (Behavioral/Social). Nursing students must exhibit patterns of behavior that demonstrate emotional maturity that allow for intellectual development, sound judgment and personal accountability. Nursing students will need to demonstrate the ability to develop therapeutic and effective nurse-patient/client relationships. Nursing students need to demonstrate interpersonal abilities sufficient to interact with individuals, families and community groups from a variety of cultural, emotional, intellectual, and social backgrounds. Nursing students must be able to function effectively under stress. 2. Critical Thinking (Cognition). Nursing students must have the ability to calculate, reason, and analyze information. Synthesis and application of complex information is also required. Nursing students must be totally alert and attentive at all times in clinical settings in order to develop competent and professional nursing care. 3. Motor/Mobility. Nursing students must have physical abilities sufficient to gather information from patients/clients. This includes the movements required for palpation, percussion, auscultation, and other diagnostic procedures. Nursing students must be able to have sufficient mobility to provide general and emergency care to patients/clients. This care requires the nursing student to have moderate muscle strength, coordination of both fine and gross motor skills, equilibrium, and functional use of all extremities and all senses, especially hearing and vision. *Core Performance Standards for Admission and Progression (for non-licensed students) for Clinical Coursework in the School of Nursing (Adapted from the Southern Council on Collegiate Education for Nursing). Submission: Please refer to the CertifiedProfile page of this packet for instructions on how to submit the required Health History Form. Questions: Please contact Mrs. Mattie Easter by at

13 INFORMATIONAL TOPIC: BACKGROUND CHECK POLICY AND PROCEDURE Policy Statement: The curriculum at the University of Mobile requires that each student have a background check completed prior to starting the nursing curriculum. The School of Nursing must certify to clinical agencies where students practice that each student has had an acceptable background screen. When a student is accepted for admission to the program, he/she will be informed that his/her acceptance will be pending a negative background check as defined in section carried out by the appropriate agency. Admission will be withdrawn for students failing to authorize a background check. After review by the program and consultation with the applicant, admission may be withdrawn based on the findings of the background check. Procedure for Background Check: Students will be required to follow the procedures established by the School of Nursing. The background check will be conducted by CertifiedBackground.com using established methods and procedures. Please refer to the CertifiedProfile page of this packet for instructions on how to submit the required personal and background information. The company performing background checks will notify the Dean when the results of the check become available. The original reports will be kept confidential with the Dean of the School of Nursing. Submission of Background Waiver Agreement: Students must submit a thoroughly completed Background Waiver Agreement in their packet. Cost of Background Check: The cost of the background check is $ Students must pay at the business office and submit their receipt in their packet attached to the designated form. The business office will accept cash, checks, or credit cards. Additional Costs: Any additional costs incurred by the agency conducting the background check must be paid for by the student. The average background check is done at a fee of $50.00; however, if a student has lived in numerous states, the cost may be greater. Notary: The Background Waiver Agreement must be notarized. Most banks provide this service at no cost. Additionally, Mrs. Barbara Green, in the President s office, or Ms. Tammy Hadley, in the Center for Adult Programs, can notarize the document. The form should be signed in the presence of the Notary Public. Questions: Please contact Mrs. Mattie Easter by at

14 UNIVERSITY OF MOBILE SCHOOL OF NURSING BACKGROUND WAIVER AGREEMENT I understand that as a requirement for admission to the University of Mobile School of Nursing, I must submit to a background check of which the results will be provided to the Dean of the School of Nursing. I understand that I may be denied admission to the School of Nursing if the background check is unfavorable. I further understand that I will be subject to background checks while enrolled in the School of Nursing. Any adverse findings may result in dismissal from the School of Nursing. BY SIGNING THIS DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I WILL COMPLY WITH THE SCHOOL OF NURSING BACKGROUND CHECK POLICY. THIS NOTARIZED DOCUMENT CONSTITUES MY CONSENT FOR BACKGROUND CHECKING BY A SCHOOL OF NURSING DESIGNATED VENDOR. IT ALSO CONSTITUTES CONSENT FOR THE VENDOR TO RELEASE THE RESULTS OF MY BACKGROUND CHECK TO THE DEAN OF THE SCHOOL OF NURSING AND FOR THE DEAN TO RELEASE MY BACKGROUND INFORMATION AS REQUIRED TO ANY CLINICAL AGENCY WHERE I AM ASSIGNED. In Witness Whereof, this instrument is executed this the day of, 20. WITNESS: Signature Applicant s Signature Applicants Printed Name STATE OF COUNTY OF On this day of, 20, before me appeared To be known to be the person described in and who executed the foregoing instrument. Given under my hand and seal on the day and year above written. SEAL NOTARY PUBLIC My commission Expires:

15 RECEIPT FROM BUSINESS OFFICE INDICATING PAYMENT FOR BACKGROUND CHECK (Attach Receipt) $50.00

16 INFORMATIONAL TOPIC: DRUG POLICY AND PROCEDURE STATEMENT Policy Statement: The University of Mobile School of Nursing requires that a student submit to a drug test prior to attending clinical experiences at local healthcare facilities and to submit, as required, to additional tests once enrolled in the School of Nursing. Students will be responsible for the cost of each drug testing. Each student will participate in a drug check as a requirement of the clinical agencies and healthcare facilities. Admission or progression in the curriculum will be withdrawn for any student who tests positive. Any student who is found to have a positive drug test will be sanctioned consistent with the University of Mobile School of Nursing Drug, Alcohol and Controlled Substances Testing Policy. Procedure for Drug Testing: Drug tests will be conducted by a qualified laboratory using established methods and procedures. Confidentiality of the student as well as integrity of the urine sample will be protected. The procedure for collection, as determined by the laboratory, will involve a witness to the voiding of the urine sample, securable urine containers, and a chain of custody procedures. The urine sample will be screened for all drugs. Presumed positives will be confirmed by a second test from the original urine sample. If the test is positive, the available evidence, including health history, will be used to determine the presence or absence of drug misuse or abuse. The testing laboratory will notify the Dean of the School of Nursing with test results. The School of Nursing will ensure confidentiality of results by making the information available only to the student and appropriate university administrators and faculty. Drug Testing after Admission to the School of Nursing: Drug testing for any student in the professional component can be requested by the School of Nursing. Refusal by a student to submit to testing will be considered a positive test. Cost of Drug Testing: The cost of the drug test is $ Students must pay at the business office and submit their receipt in their packet attached to the designated form. The business office will accept cash, checks, or credit cards. This fee covers two random drug tests. Notary: The Drug Testing Waiver Agreement must be notarized. Most banks provide this service at no cost. Additionally, Mrs. Barbara Greene, in the President s office, or Ms. Tammy Hadley, in the Center for Adult Programs, can notarize the document. The form must be signed in the presence of the Notary Public. Questions: Please contact Mrs. Mattie Easter by at

17 UNIVERSITY OF MOBILE SCHOOL OF NURSING DRUG, ALCOHOL AND CONTROLLED SUBSTANCES TESTING POLICY ACKNOWLEDGEMENT AND CONSENT FORM I understand that as a requirement for admission to the University of Mobile School of Nursing, I must submit to a drug test of which the results will be provided to the Dean of the School of Nursing. I understand that I may be denied admission to the School of Nursing if the drug test is positive. I further understand that I will be subject to drug tests while enrolled in the School of Nursing. A positive drug test or refusal to submit to testing will result in sanctions consistent with those stipulated in the University of Mobile School of Nursing Drug, Alcohol and Controlled Substances Testing Policy. BY SIGNING THIS DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I WILL COMPLY WITH THE SCHOOL OF NURSING DRUG, ALCOHOL AND CONTROLLED SUBSTANCES TESTING POLICY. I UNDERSTAND THAT A NEGATIVE DRUG TEST IS REQUIRED FOR ADMISSION AND FOR PROGRESSION IN THE SCHOOL OF NURSING. THIS NOTARIZED DOCUMENT CONSTITUES MY CONSENT FOR DRUG TESTING BY A SCHOOL OF NURSING DESIGNATED LABORATORY AND SERVES AS NOTIFICATION OF TESTING. IT ALSO CONSTITUTES CONSENT FOR THE LABORATORY TO RELEASE THE RESULTS OF MY DRUG TEST TO THE DEAN OF THE SCHOOL OF NURSING AND FOR THE DEAN TO RELEASE ANY POSITIVE FINDINGS TO THE APPROPRIATE LICENSING BOARD IF INDICATED. In Witness Whereof, this instrument is executed this the day of, 20. WITNESS: Signature STATE OF Applicant s Signature Applicants Printed Name COUNTY OF On this day of, 20, before me appeared To be known to be the person described in and who executed the foregoing instrument. Given under my hand and seal on the day and year above written. SEAL NOTARY PUBLIC My commission Expires:

18 RECEIPT FROM BUSINESS OFFICE INDICATING PAYMENT FOR DRUG TESTING (Attach Receipt) $90.00

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