Ogden-Weber Applied Technology College PRACTICAL NURSING PROGRAM APPLICATION CHECKLIST

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1 Ogden-Weber Applied Technology College PRACTICAL NURSING PROGRAM APPLICATION CHECKLIST Application Guidelines: Complete the following checklist. It is your responsibility as the applicant to ensure that all items are completed. The completed application packet can be mailed to: 200 N Washington Blvd, ATTN: Cashier, Ogden, Utah or be submitted in person to the cashier s window Monday through Friday, 9:00 a.m. - 4:00 p.m. THE REQUESTED DOCUMENTS MUST BE POSTMARKED ON OR BEFORE MARCH 1 FOR FALL ADMISSION. Turn in the application packet only when all of the information, forms, transcripts, and reference letters are in the packet. Please note that any missing information/forms not included in the packet will render your file incomplete, and you will not be considered as a possible candidate for this program. Please initial or place N/A in each of the following boxes and sign and date on page 2. Include this checklist as part of your application. I have fully completed, signed, dated, and returned the OWATC Application Form. I have fully read, signed, dated, and returned the OWATC PNP Disclaimer. I have submitted a copy of my High School Diploma or High School Transcript or GED Certificate. This is required to verify high school completion for state testing requirements by DOPL. Verification of all prerequisite classes must be documented via: Official College or University transcript, AP testing Score Sheet or High School Transcript, or Accuplacer Score Sheet. I have submitted all current official transcripts, received either by mail or in person in a sealed official envelope, by the application deadline. OFFICIAL TRANSCRIPTS FROM THE ORIGINAL SCHOOL ARE REQUIRED EVEN IF THE CREDITS HAVE BEEN TRANSFERRED AND SHOW UP ON ANOTHER COLLEGE TRANSCRIPT. Attach proof of official transcript request to any unofficial transcript submitted. Web page printouts will not be accepted. I understand that in order to receive application points for prerequisite courses, these courses must be completed with a grade of C or better. I am submitting transcripts from another state, and I have provided a course description for each course so it can be determined if transfer credit can be given. I understand that I only need to submit course descriptions for the prerequisite courses I want to transfer. Please complete the information below for prerequisite courses only. Example: Intermediate Algebra 105 course taken at University of Calif. should transfer for Math 1010 course taken at should transfer for Updated 11/19/14

2 I understand that IF OWATC will not accept my out-of-state prerequisite courses for transfer credit, that I will need to retake those courses. (Please contact an OWATC counselor prior to application deadline if you have questions on course transfers). I have a cumulative Grade Point Average of 2.7 or higher. I have submitted an Accuplacer Score Sheet if placed in Math 1030, 1040, or I have submitted Current Nursing Assistant Certification from the State of Utah or Current Notice of Nursing Assistant Certification Renewal from the State of Utah OR must submit proof of current enrollment in CNA course. Certification must be received prior to beginning the PN Program. Contact the CNA Utah Registry (801) for any questions. I have submitted verification of work or volunteer experience for all direct patient healthcare. Please provide a letter from a Human Resources representative or supervisor with your job title, job description, and dates of employment on company letterhead. A company printout of positions and dates, or website requests for this information, will not be accepted. I have included three completed OWATC reference forms. Each reference form must be completed IN FULL by either a current or past supervisor or instructor, not co-workers. Please select evaluators that can respond to all criteria on the reference form. Otherwise, you will only receive points for the categories scored. ALL REFERENCE FORMS MUST BE SUBMITTED WITH THE APPLICATION PACKET. References must include your name on the front of the envelope and must be signed across the envelope seal from the person completing the reference. (Use OWATC reference forms only, references on any other school s form will be disqualified). I have paid or enclosed the $25.00 application fee payable to OWATC. Payments can also be paid at the cashier s window in person (Monday through Friday, 9:00 a.m. - 4:00 p.m.). The receipt must be included in the application packet. I understand the application fee is non-refundable and used to process my application. Applications without a receipt of payment will be disqualified. I understand that if I am accepted into the program, or a top ten alternate, I will be required to have a satisfactory National Criminal Background Check and Sex Offender Check. I have completed, initialed, or placed N/A on every line of the application checklist and submitted all forms requested. I understand that failure to provide the above information by the application deadline will render my file incomplete and disqualified. If you have any questions regarding the application packet, please call Signature of Applicant Date Updated 11/19/14

3 Application for Admission Practical Nursing Program 1. Full Name Last First Middle Initial Maiden Name 2. Mailing Address Number and Street City State Zip Code 3. Home Address _ Number and Street City State Zip Code 4. Telephone # ( ) ( ) ( )_ Home Phone Cell Phone Work Phone 5. Social Security # _ 6. Person to be notified in case of emergency: Relationship Telephone # ( ) Address Number and Street City State 7. Please provide information concerning high schools, technical schools and colleges you have attended. Include any you are currently attending, and begin with most recent. Name of School City and State Dates Attended (mo/yr) Major or Emphasis Diploma or Certification

4 8. Please provide information about your health-related employment. Include any paid positions you have held in the health care field. Attach letters of proof of employment. (A letter from Human Resources with your job title and dates of employment on letterhead is sufficient). (Print out from HR database will not be accepted.) Name of Employer City and State Dates of employment (mo/yr) Position Held Supervisor and Phone Number 9. List all other employment. Include any paid positions you have held that were not listed above. Name of Employer City and State Dates of employment (mo/yr) Position Held Supervisor and Phone Number 10. Please list your volunteer experience. Include any practicums or on-the-job training. Name of Employer City and State Dates of employment (mo/yr) Position Held Supervisor and Phone Number 11. Please list your extracurricular activities, awards, honors, scholarships, etc. Include any other activities you have been involved in the past 5 years.

5 12. Satisfactory progress through the Practical Nursing Program requires regular attendance in class and clinical, as well as study time outside of class. Clinical hours may include evenings and weekends. Are you willing to commit to the prescribed hours and course study? 13. Optional Data (for statistical purposes only) Ethnic Background Black non-hispanic Asian or Pacific Island Hispanic White non-hispanic Native American Other Gender: Male Female 14. Note: To be licensed as a Practical Nurse in the state of Utah, the application must be in conformity with the Utah Nurse Practice Act. Applicants who have been convicted of a felony, treated for mental illness or substance abuse should discuss their eligibility with the Utah State Board of Nursing ( ). Acceptance and completion of the OWATC Practical Nursing Program does not assure eligibility to sit for the practical nursing licensure exam. The Utah State Board of Nursing makes the final decisions on issue of license to practice nursing in the state of Utah. I do hereby certify the statements in this application are true and complete to the best of my knowledge. I understand that falsifying information on this application may be grounds for dismissal. Signed Date Diversity encompasses acceptance and respect which means understanding that each individual is unique, and recognizing and appreciating our individual differences. In compliance with the American with Disabilities Act, persons needing auxiliary communicate aids and services should call the Office of Diversity at (801) (TDD number (801) ), allowing at least 48 hour advance notice.

6 Ogden-Weber Applied Technology College Practical Nursing Program Disclaimer Admission to the Ogden-Weber Applied Technology College (OWATC) Practical Nursing Program is contingent upon submission of a satisfactory FBI Background Check, Sex Offender Check, and negative drug screen. If you have a record of criminal actions, it may affect your eligibility. Applicants/students who have committed felonies and have not met the stated criteria in the Utah Nurse Practice Act Subsections (1)(c) and (1)(c) will not be allowed to enter/progress into the OWATC Practical Nursing Program. Admitted applicants/students are required to inform the Practical Nursing Program Manager of any criminal charges they may have pending against them. Accepted applicants/students who have falsified or withheld information regarding pending criminal charges will be not be allowed to enter/progress into the OWATC Practical Nursing Program. Admitted applicants/students who have been treated for mental illness or substance abuse should discuss their eligibility status with the Utah State Board of Nursing. Acceptance to the nursing program does not assure eligibility to write the PN or RN licensing examination. The Utah Board of Nursing makes final decisions on issue of licensure. The OWATC Practical Nursing Program is a rigorous two-semester program. Please carefully evaluate your situation and do all you can to allow your studies to be a major priority. Full-time employment while in the program is not recommended. Pre-requisite courses must be completed with a C or better prior to beginning the Practical Nursing Program. Admitted applicants/students who are suspended or withdrawn from the OWATC Practical Nursing Program may not be entitled to reimbursement of tuition or other fees. Students accepted into the OWATC Practical Nursing Program may be exposed to blood-borne pathogens during their time in the program. Diversity encompasses acceptance and respect which means understanding that each individual is unique, and recognizing and appreciating our individual differences. The College will not tolerate any form of harassment and acknowledges that such conduct will be grounds for immediate and appropriate disciplinary action. The College will comply with all federal, state, and local laws on these issues. The College is committed to providing an environment free from harassment and discrimination. Such an environment is a necessary part of a healthy learning and working atmosphere. Harassment and discrimination undermine the sense of human dignity and sense of belonging of all people in an environment. I have read and understand the OWATC Practical Nursing Program Disclaimer information. Student Signature: Date: _ In compliance with the American with Disabilities Act, persons needing auxiliary communicate aids and services should call the Office Of Diversity at (801) (TDD number (801) ), allowing at least 48 hour advance notice. Updated 7/30/2014

7 OGDEN-WEBER APPLIED TECHNOLOGY COLLEGE PRACTICAL NURSING PROGRAM REFERENCE FORM Section A: This information is to be filled out by the applicant requesting the reference.* *Name of Applicant Requesting Reference: (Print Applicant Name) (Applicant Signature) Name/Title of Evaluator: _ (Please print or type information) Address: Phone #: To the Evaluator: You have been selected to supply a reference for the student named above for the Practical Nursing Program. Please review the reference form carefully and make sure that you are either a supervisor or instructor and are able to evaluate the applicant on ALL categories, otherwise the applicant will only receive points for the categories scored. This will become part of the student s file and thus will be available to him/her should the request be made as guaranteed by the Family Educational Rights and Privacy Act of 1974 and its amendments. Capacity in which you have known this applicant: Supervisor Instructor (Circle the appropriate choice.) Please complete your evaluation on the numerical rating scale of each of the following as it is related to the applicant s potential for pursuing nursing as a career. Comments in each area are helpful Skill 1. Communication: Verbal and Nonverbal Poor Average Outstanding 2. Interpersonal Relationships: Poor Satisfactory Outstanding 3. Appearance/Grooming: Untidy Usually Tidy Always well-groomed 4. Motivation: Poor Fair Excellent 5. Integrity: Dishonest Usually honest Always honest, truthful Updated 6/16/14

8 Skill Punctuality/Absenteeism: Often late or absent Immature; 7. Dependability/Responsibility/Maturity: undependable; irresponsible Usually present; punctual Usually mature; dependable; responsible Excellent attendance; Always punctual Always dependable; assumes responsibility very well; very mature 8. Problem Solving/Decision Making/Critical Thinking: Poor Satisfactory Excellent 9. Anxiety Level: Very stressed & anxious Stress level average somewhat anxious Calm, in control in stressful, anxiety-provoking situations 10. Caring Attitude: Rarely considers other s needs Usu ally p o sitiv e, carin g attitu d e Exceptional attitude of caring for & about others Additional comments: Choose one of the following: I highly recommend this applicant to the Practical Nursing Program. I recommend this applicant to the Practical Nursing Program. I do not recommend this applicant to the Practical Nursing Program. Please answer the following questions regarding the applicant: Yes No Has this applicant worked as a CNA, Respiratory Therapist, EMT, Surgical Tech, Paramedic, Medical Assistant, Home Health Aide, Pharmacy Tech, or Radiography Technician at your facility for more than six (6) months (Please circle the applicant s job title.) Evaluator s signature: Evaluator s Place of Employment: Length of time you have known this applicant: _ Thank you for your assistance in this important matter. Use OWATC reference forms only; references on any other forms will be disqualified. Please place the evaluation in an envelope, write the applicant s name on front of envelope, sign your name over the seal of the envelope, and return to applicant.

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