GateWay Community College NURSING ASSISTANT PROGRAM

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1 GateWay Cmmunity Cllege NURSING ASSISTANT PROGRAM Infrmatin/Applicatin Packet Nursing Assistant/Patient Care Technician Crdinatr: Kathy Prireschi, MSN, BSN, RN (602) Directr, Nursing Divisin: Margi Schultz, PhD, RN, (602) fax: (602) GateWay Cmmunity Cllege 108 N. 40 th Street Phenix, AZ

2 Curse Infrmatin Upn satisfactry cmpletin f the Nursing Assistant Curse (NUR158), the student is eligible t receive a Certificate f Cmpletin frm the cllege. Each student must apply fr the Certificate f Cmpletin by the specific date f graduatin checkut, apprximately 6-8 weeks befre the end f the prgram (Refer t the Curse Schedule). Prerequisites Cllege Placement Exam indicating eligibility fr CRE101, r HESI-A2 English Cmpsite scre f 75% r higher. Cmpleted Health and Safety Dcumentatin Checklist (prf f immunity, immunizatin r current testing fr identified diseases) and cmpleted Health Care Prvider signature frm. Fr infrmatin n the supplemental backgrund check requirement, please see infrmatin lcated at: Occupatinal Infrmatin Nursing Assistants perfrm rutine tasks in the general care f hspital, clinic, and nursing hme patients. They wrk directly under the supervisin f registered and practical nurses. Their rle in perfrming basic patient care assists the licensed staff in prviding quality nursing t the patient. The Nursing Assistant ccupatin is ne f a series f pssible steps n a career ladder in the health care field. Nursing Assistants are an imprtant member f a health care team. Typical patient-care duties include bathing and dressing patients, helping with persnal hygiene, taking vital signs, answering call lights, transprting patients, servicing and cllecting fd trays, and feeding patients. Certificatin Infrmatin The Maricpa Cmmunity Clleges ffer a cmprehensive Nursing Assistant Curse that is apprved by the Arizna State Bard f Nursing. Upn satisfactry cmpletin f this curse, the student is eligible t take the Arizna State Bard f Nursing certifying exam, becme a Certified Nursing Assistant, and chse t g directly t wrk r cntinue t pursue educatin pprtunities in ther health care careers. Infrmatin n the Arizna State Bard f Nursing applicatin prcess is available at The certifying exam is administered by state certified evaluatrs and students may take the exam scheduled at nearby testing centers. The fee fr this exam is $85 (subject t change) and is payable t the state evaluatrs. An additinal and separate LEVEL ONE Fingerprint Clearance Card is required fr certificatin. The Department f Public Safety card required fr enrllment in nursing classes at the clleges will nt meet the requirements fr state certificatin. Allw a minimum f six (6) weeks fr fingerprint clearance when applying fr nursing assistant certificatin. The Arizna State Bard f Nursing ffice is lcated at 4707 Nrth 7 th Street, Suite 200, Phenix, Arizna, Phne , FAX https://www.azbn.gv Cst Estimate fr the Nursing Assistant Prgram * Registratin Fee/Curse Fee NUR158 Nursing Assistant Curses (6 credits x $84.00; Maricpa Cunty Resident) Fingerprinting fee Cst will Vary Textbks Apprx Backgrund Check/Urine Drug Screen Unifrm and Clinical Supplies Cst will Vary Physical Exam and Immunizatins Cst will Vary Ttal Estimated Cst f Nursing Assistant Prgram $1, *Fees are subject t change by the Gverning Bard f the Maricpa Cunty Cmmunity Cllege District. All csts quted are subject t change. Nursing Assistant Infrmatin Revised 6/14 ar 2

3 INFORMATION FOR STUDENTS ZERO TOLERANCE POLICY: The Maricpa Cmmunity Clleges Nursing Assistant Prgram supprts a Zer Tlerance Plicy fr the fllwing behavirs: Intentinally r recklessly causing physical harm t any persn n the campus r at a clinical site, r intentinally r recklessly causing reasnable apprehensin f such harm. Unauthrized use r pssessin f any weapn r explsive device n the campus r at a clinical site. Unauthrized use, distributin, r pssessin fr purpses f distributin f any cntrlled substance r illegal drug n the campus r at a clinical site. Nursing Prgram student engaging in this miscnduct is subject t immediate dismissal frm nursing classes and disciplinary actin as described in the Student Handbk f the cllege. HEALTH DECLARATION: It is essential that nursing students be able t perfrm a number f physical activities in the clinical prtin f the prgram. At a minimum, students will be required t lift patients, stand fr several hurs at a time and perfrm bending activities. Students wh have a chrnic illness r cnditin must be maintained n current treatment and be able t implement direct patient care. The clinical nursing experience als places students under cnsiderable mental and emtinal stress as they undertake respnsibilities and duties impacting patients lives. Students must be able t demnstrate ratinal and apprpriate behavir under stressful cnditins. Individuals shuld give careful cnsideratin t the mental and physical demands f the prgram prir t making applicatin. All students placed in the nursing prgram must prvide dcumentatin f cmpliance f all health and safety requirements required t prtect patient safety. Only students prviding dcumentatin f cmpliance are permitted t enrll in nursing curses. Students will meet these requirements by prviding the Health/Safety Requirements Dcumentatin Checklist and the signed Health Declaratin Frm, with all dcumentatin attached, as directed. FINGERPRINTING REQUIREMENT: Fingerprint clearance is required fr enrllment in nursing curses. Fingerprint clearance is required t wrk and care fr children, the elderly, and any vulnerable adult. If there is a psitive criminal histry, a fingerprint clearance may be denied. The Level One Fingerprint Clearance Card cannt expire during the Nursing Assistant prgram. The Level One Fingerprint Clearance Card required fr the Nursing Assistant prgram will nt meet the requirements fr certificatin thrugh the Arizna State Bard f Nursing. DRUG SCREENING: All students are required t submit t a urine drug screening labratry test. Students must cmplete the urine drug screening under the prgram accunt number, within the specified timeframe, and accrding t directins given at the time f ntificatin t meet this requirement. Only students meeting the drug screening requirement and receiving negative drug screens, as reprted by the Medical Review Officer (MRO), will be permitted t maintain enrllment in nursing curses. WAIVER OF LICENSURE/CERTIFICATION GUARANTEE: Admissin r graduatin frm the Nursing Prgram des nt guarantee btaining a license r certificate t practice nursing. Licensure and certificatin requirements and the subsequent prcedures are the exclusive right and respnsibility f the Arizna State Bard f Nursing. Students must satisfy the requirements f the Nurse Practice Act: Statutes, Rules and Regulatins, independently f any cllege r schl requirements fr graduatin. Accrding t A.R.S (B), an applicant fr nursing assistant certificatin is nt eligible fr certificatin if the applicant has had any felny cnvictins and has nt received an abslute discharge frm the sentences fr all felny cnvictins. The abslute discharge frm the sentence fr all felny cnvictins must be received five (5) r mre years befre submitting this applicatin. If yu cannt prve that the abslute discharge date is five r mre years, the Bard will ntify yu that yu d nt meet the requirements fr certificatin. All nursing assistant applicants fr certificatin will be fingerprinted t permit the Department f Public Safety t btain state and federal criminal histry infrmatin. All applicants with a psitive histry are investigated. If there is any questin abut eligibility fr licensure r certificatin, cntact the nursing educatin cnsultant at the Arizna State Bard f Nursing ( ). Nursing Assistant Infrmatin Revised 6/14 ar 3

4 REQUIRED INFORMATION (PRINT) Name Student ID Number Phne: Day Evening Cell Mailing Address City State Zip (PRINT) Address will be used t cntact yu abut registratin fr classes. DIRECTIONS: Applicants must apply fr admissin t GateWay Cmmunity Cllege by creating a Student Accunt at: r in persn at the Admissins and Recrds Office. Review applicatin frm with a GWCC nursing advisr, call t schedule appintment The advisr will direct cmpleted applicatins t the prgram crdinatr, Kathy Prireschi, RN. the Health and Safety Dcumentatin Checklist and Health Care Prvider Signature Frm with all dcumentatin attached, a cpy f the frnt and back f the Level One Fingerprint Clearance Card, a cpy f the frnt and back f the Health Care Prvider CPR card. It is the respnsibility f the student t verify that all Health and Safety Requirements remain current thrugh the last day f the Nursing Assistant curse, and t prvide updated dcumentatin t the curse instructr. Upn cmpletin f this frm (including cpies f Health and Safety dcumentatin requirements) schedule appintment with the nursing advisr fr applicatin review. Only students with cmplete dcumentatin f health and safety requirements will be registered by the prgram crdinatr in the nursing assistant curse. Nursing Assistant Infrmatin Revised 6/14 ar 4

5 Nursing Department Check f Registratin Requirements Name: Date Nursing Staff Initials Requirement Cmplete Incmplete Ntes RDG091 grade r ACCU Test Results Health Care Prvider Signature Frm Level One Fingerprint Clearance Card CPR card (Healthcare Prvider Level) Tetanus/Diphtheria/Pertussis (Tdap) MMR x 2/ Titer MMR Rube Mumps Rub Varicella x 2/ Titer (IgG) Hepatitis B x3/ titer (hbsab) Tw-Step TB Skin Test r Chest X-ray & Symptm frm Backgrund Check Disclsure Frm Headmaster Infrmatin Sheet Recmmendatin fr Registratin Nursing Assistant Infrmatin Revised 6/14 ar 5

6 Applicant: Student ID Date: Hme Phne: Cell Phne: A. MMR (Measles/Rubela, Mumps and Rubella): Requires dcumented prf f a psitive IgG MMR titer OR dcumented prf f MMR series. Date & results f titer: Measles/Rubela Mumps Rubella If unable t prvide prf f psitive titer, list immunizatins and dates received: MMR Series/Dates: #1 #2 B. Varicella (Chickenpx): Requires dcumented prf f psitive IgG titer OR dcumented prf f Varicella series. Date & results f IgG titer: If unable t prvide prf f psitive titer, list immunizatins and dates received: Varicella series/dates: #1 #2 C. Tetanus/Diphtheria/Pertussis (Tdap): One-time dse f Tdap, fllwed by a Td bster every 10 years. Tdap Date: Td (update): D. Tuberculsis: Dcumentatin f a Tw-Step TB Skin Test: This cnsists f an initial TB skin test and a bsted TB Skin test 1-3 weeks apart. After cmpletin f the tw-step, an annual update f TB skin test is sufficient. If yu have a psitive skin test, prvide dcumentatin f a negative chest X-ray within the last 2 years, and annual dcumentatin f a TB disease-free status. Mst recent skin testing r bld test must have been cmpleted within the previus six (6) mnths. Tw-Step: Initial Test (#1) Date: Date f Reading: Results: Negative OR Psitive AND Bsted Test (#2) Date: Date f Reading: Results: Negative OR Psitive Annual Update: Date: Date f Reading: Results: Negative OR Psitive (skin testing r bld drawn titer is acceptable) OR Chest x-ray Date: Results: Date f Symptm Sheet E. Hepatitis B: Dcumented evidence f cmpleted series r psitive antibdy titer. If yu have nt received any injectins, d nt get a titer. If yu are beginning the series, first injectin must be prir t admissin, the secnd in ne mnth and third 5 mnths after #2. Obtain Hep B titer 1-2 mnths after dse #3 t cnfirm immunity. Date Titer received: Results: Date f 1st injectin: Date f 2nd injectin: Date f 3rd injectin: OR HBV Vaccinatin Declinatin Frm Date: F. CPR Card (Healthcare Prvider level): Date card issued: Expiratin Date: (An fficial card is required; internet (cmputer) certificates are nt acceptable) G. Level One Fingerprint Clearance Card: Date card issued: Expiratin Date: H. Health Care Prvider Signature Frm: Reviewed and signed by a licensed physician (M.D., D.O.), a nurse practitiner, r physician s assistant within the past twelve (12) mnths. I. Criminal Backgrund Check Disclsure Frm: Requires a signed cpy f the Acknwledgement f Criminal Backgrund Check Requirements Frm (attached). J. Headmaster Infrmatin Sheet: Requires a signed cpy f the Headmaster Infrmatin Sheet (attached). Nursing Assistant Infrmatin Revised 6/14 ar 6

7 Health Care Prvider Signature Frm Instructins fr Cmpletin f Health Care Prvider Signature Frm A health care prvider must sign Health Care Prvider Signature Frm within 12 mnths f applicatin and indicate whether the applicant will be able t functin as a nursing student. Health care prviders wh qualify t sign this declaratin include a licensed physician (M.D., D.O.), a nurse practitiner, r physician s assistant. (Please Print) Applicant Name Student ID Number It is essential that nursing students be able t perfrm a number f physical activities in the clinical prtin f the prgram. At a minimum, students will be required t lift patients, stand fr several hurs at a time and perfrm bending activities. Students wh have a chrnic illness r cnditin must be maintained n current treatment and be able t implement direct patient care. The clinical nursing experience als places students under cnsiderable mental and emtinal stress as they undertake respnsibilities and duties impacting patients lives. Students must be able t demnstrate ratinal and apprpriate behavir under stressful cnditins. Individuals shuld give careful cnsideratin t the mental and physical demands f the prgram prir t making applicatin. I believe the applicant WILL OR WILL NOT be able t functin as a nursing student as described abve. If nt, explain: Licensed Healthcare Examiner (M.D., D.O., N.P., P.A.) Print Name: Title: Signature: Date: Address: City: State: Zip: Phne: Nursing Assistant Infrmatin Revised 6/14 ar 7

8 INSTRUCTIONS FOR COMPLETING HEALTH AND SAFETY FORMS IMPORTANT: All students placed in the CNA Prgram must prvide dcumentatin f cmpliance fr the vaccinatins and TB testing required t prtect patient safety. Only students prviding dcumentatin f health and safety requirements are enrlled in nursing curses. The Nursing Department will accept nly phtcpies f all dcumentatin f health related materials. Students are respnsible fr maintaining their recrds and must submit dcumentatin when due. All immunizatin recrds must include yur name and signature f the healthcare prvider. A health care prvider s signature n the Health Declaratin frm, withut prf f immunizatin status, is NOT acceptable. A. MMR (Measles/Rubela, Mumps, and Rubella) Optins t meet this requirement: HEALTH AND SAFETY REQUIREMENTS a. Attach a cpy f prf f psitive IgG antibdy titer fr Measles/Rubela, Mumps and Rubella r cmpletin f ne series f MMR immunizatins. One series f immunizatins includes immunizatin fr each disease n separate dates at least 28 days apart. b. If yu had all three illnesses OR yu have received the vaccinatins but have n dcumented prf, yu can have an IgG MMR titer drawn. If the titer results are POSITIVE, attach a cpy f the lab results t the health declaratin frm. If any f the titer results are NEGATIVE r EQUIVOCAL, yu must get yur first MMR vaccinatin and attach dcumentatin t this health and safety dcumentatin checklist. The secnd MMR must be cmpleted after 28 days and prf submitted t the nursing department. B. Varicella (chickenpx) Optins t meet this requirement: a. Attach a cpy f prf f a psitive IgG titer fr varicella. b. If the titer is NEGATIVE r EQUIVOCAL, attach a cpy f prf t this health and safety dcumentatin checklist that yu received the first vaccinatin. Cmplete the secnd vaccinatin 30 days later and submit prf t the nursing department. C. Tetanus/Diphtheria/Pertussis (Tdap): REQUIRED: Tdap = Tetanus / Diphtheria / Pertussis Td = Tetanus / Diphtheria Yu must prvide prf f Tdap vaccinatin, fllwed by a Td bster every 10 years. Attach prf f a Tdap vaccinatin and Td if indicated. D. Tuberculsis (TB) REQUIRED: Attach a cpy f an initial tw-step TB and all subsequent annual updates if applicable. Date given, date read, result f reading and signature f healthcare prvider cmpleting prcess must be included. T be in cmpliance, fllw these steps: 1. Have the first test placed and read (step 1) weeks later, have a secnd test placed and read (step 2) If yu had the initial 2-step-test cmpleted in the past, all subsequent annual updates must be included in the dcumentatin. The mst current annual update testing must have been cmpleted within the last 6 mnths. If yu have a psitive skin test, prvide dcumentatin f a negative chest X-ray cmpleted within the last tw Nursing Assistant Infrmatin Revised 6/14 ar 8

9 years. MARICOPA COMMUNITY COLLEGE DISTRICT NURSING PROGRAM E. Hepatitis B If yu have nt received the injectins in the past, d nt get a titer. Yu must btain the first injectin and attach a cpy as requested. Yu must receive the 2nd injectin in ne mnth and the 3rd five mnths after the secnd (6 mnths ttal). a. Submit a cpy f prf f a psitive HbsAg titer. OR b. Attach a cpy f yur immunizatin recrd, shwing cmpletin f the three Hepatitis B injectins. c. If the series is in prgress, attach a cpy f the immunizatins received t date. Yu must remain n schedule fr the remaining immunizatins and prvide the additinal dcumentatin. One t tw mnths after yur last immunizatin, yu may have an HbsAg titer drawn. F. CPR Card Yu must have a Healthcare Prvider Level CPR card. CPR certificatin must include infant, child, and adult, 1 and 2-man rescuer, and evidence f a hands-n skills cmpnent. Attach a cpy f bth sides f the CPR card t this frm. CPR certificatin must remain current thrugh the semester f enrllment. A fully nline CPR curse r an internet r cmputerized certificate will nt be accepted. G. Level One Fingerprint Clearance Card Prvide a cpy f bth sides f the Level One Fingerprint Clearance Card (FCC). The FCC must remain current thrughut the semester f enrllment. If at any time the card becmes sanctined r is revked, the student must immediately ntify the Prgram Crdinatr. The actual FCC will need t be presented t and validated by the nursing advisr at the time f applicatin. H. Health Care Prvider Signature Frm Reviewed and signed by a licensed physician (M.D., D.O.), nurse practitiner, r physician s assistant within the past twelve (12) mnths. I. Criminal Backgrund Check Disclsure Frm Requires a signed cpy f the Acknwledgement f Criminal Backgrund Check Requirements Frm (attached). J. Headmaster Infrmatin Sheet Requires a signed cpy f the Headmaster Infrmatin Sheet (attached). Nursing Assistant Infrmatin Revised 6/14 ar 9

10 (Student Cpy) Allied Health and Nursing Prgrams Maricpa Cunty Cmmunity Cllege District Summary f Criminal Backgrund Check Requirements effective September 1, 2011 Overview f the Requirements In rder fr students t be admitted t r maintain enrllment in gd standing in Maricpa Cunty Cmmunity Cllege District s ( MCCCD ) Allied Health and Nursing prgrams ( Prgrams ) beginning n September 1, 2011, students must prvide with their applicatin t a Prgram all f the fllwing: A cpy f an Arizna Department f Public Safety Level-One Fingerprint Clearance Card ( Card ). Students are required t pay the cst f applying fr the Card. Cards that are NOT Level-One status will nt be accepted. An riginal versin f the Criminal Backgrund Check Disclsure Acknwledgement frm attached t this Summary signed by the student. At all times during enrllment in a Prgram, students must btain and maintain BOTH a valid Level-One Fingerprint Clearance Card and passing dispsitin n supplemental backgrund check perfrmed by MCCCD authrized vendr. Admissin requirements related t backgrund checks are subject t change as mandated by clinical experience partners Implementatin f the Requirements 1. Students that are denied issuance f a Card may be eligible fr a gd cause exceptin thrugh the Arizna Department f Public Safety. It is the student s respnsibility t seek that exceptin directly with the department. Until the student btains a Card and meets the ther requirements fr admissin, he r she will nt be admitted t a Prgram. 2. Students admitted t a Prgram whse Card is revked r suspended must ntify the Prgram Directr immediately and the student will be remved frm the Prgram in which they have been admitted r are enrlled. Any refund f funds wuld be made per MCCCD plicy. 3. The Criminal Backgrund Check Disclsure Acknwledgement directs students t disclse n the data cllectin frm f the MCCCD authrized backgrund check vendr all f the requested infrmatin as well as any infrmatin that the backgrund check may discver. Hnesty is imprtant as it demnstrates character. Lack f hnesty will be the basis fr denial f admissin r remval frm a Prgram if the infrmatin that shuld have been disclsed but was nt wuld have resulted in denial f admissin. Failure t disclse ther types f infrmatin cnstitutes a vilatin f the Student Cde f Cnduct and may be subject t sanctins under that Cde. Students have a duty t update the infrmatin requested n the [backgrund check vendr] data cllectin frm prmptly during enrllment in a Prgram. The [backgrund check vendr] data cllectin frm may ask fr the fllwing infrmatin but the frm may change frm time t time: Legal Name Maiden Name Other names used Scial Security Number Date f Birth Arrests, charges r cnvictins f any criminal ffenses, even if dismissed r expunged, including dates and details. Pending criminal charges that have been filed against yu including dates and details. Participatin in a first ffender, deferred adjudicatin r pretrial diversin r ther prbatin prgram r arrangement where judgment r cnvictin has been withheld. The authrized MCCCD backgrund check vendr will be asked t pass r fail each student based n the standards f MCCCD s clinical experience partners that have established the mst stringent requirements. The sle recurse f any student wh fails the backgrund check and believes that failure may have been in errr is with the backgrund check vendr and nt MCCCD. Nursing Assistant Infrmatin Revised 6/14 ar 10

11 In applying fr admissin t a Nursing r Allied Health prgram ( Prgram ) at the Maricpa Cunty Cmmunity Cllege District, yu are required t disclse n the Arizna Department f Public Safety (DPS) frm all required infrmatin and n the MCCCD authrized backgrund check vendr data cllectin frm any arrests, cnvictins, r charges (even if the arrest, cnvictin r charge has been dismissed r expunged), r participatin in first ffender, deferred adjudicatin, pretrial diversin r ther prbatin prgram n this frm. Additinally, yu must disclse anything that is likely t be discvered in the MCCCD supplemental backgrund check that will be cnducted n yu. Please cmplete the DPS frm, the MCCCD authrized backgrund check vendr frm and any clinical agency backgrund check frm hnestly and cmpletely. This means that yur answers must be truthful, accurate, and cmplete. If yu knw f certain infrmatin yet are unsure f whether t disclse it, yu must disclse the infrmatin, including any arrest r criminal charge. Additinally, By signing this acknwledgement, yu acknwledge the fllwing: (Student: Sign and Attach t Applicatin) ACKNOWLEDGEMENT OF CRIMINAL BACKGROUND CHECK REQUIREMENTS APPLICABLE TO STUDENTS SEEKING ADMISSION TO ALLIED HEALTH OR NURSING PROGRAMS ON OR AFTER SEPTEMBER 1, 2011 Maricpa Cunty Cmmunity Cllege District I understand that I must submit t and pay any csts required t btain a Level-One Fingerprint Clearance Card and an MCCCD supplemental criminal backgrund check. I understand that failure t btain a Level-One Fingerprint Clearance Card will result in a denial f admissin t a Prgram r remval frm it if I have been cnditinally admitted. I understand that I must submit t and pay any csts required t btain an MCCCD supplemental backgrund check prir t the start f the class. I understand that failure t btain a pass as a result f the MCCCD supplemental criminal backgrund check will result in a denial f admissin t a Prgram r remval frm it if I have been cnditinally admitted. I understand that, if my Level-One Fingerprint Clearance Card is revked r suspended at any time during the admissin prcess r my enrllment in a Prgram, I am respnsible t ntify the Prgram Directr immediately and that I will be remved frm the Prgram. I understand that a clinical agency may require an additinal criminal backgrund check t screen fr barrier ffenses ther than thse required by MCCCD, as well as a drug screening. I understand that I am required t pay fr any and all criminal backgrund checks and drug screens required by a clinical agency t which I am assigned. I understand that the bth the MCCCD supplemental r the clinical agency backgrund check may include but are nt limited t the fllwing: Natinwide Federal Healthcare Fraud and Abuse Databases Scial Security Verificatin Residency Histry Arizna Statewide Criminal Recrds Natinwide Criminal Database Natinwide Sexual Offender Registry Hmeland Security Search By virtue f the MCCCD supplemental backgrund check, I understand that I will be disqualified fr admissin r cntinued enrllment in a Prgram based n my criminal ffenses, the inability t verify my Scial Security number, r my being listed in an exclusinary database f a Federal Agency. The criminal ffenses fr disqualificatin may include but are nt limited t any r all f the fllwing: Scial Security Search-Scial Security number des nt belng t applicant Any inclusin n any registered sex ffender database Any inclusin n any f the Federal exclusin lists r Hmeland Security watch list Any cnvictin f Felny n matter what the age f the cnvictin Any warrant any state Any misdemeanr cnvictin fr the fllwing-n matter age f crime Nursing Assistant Infrmatin Revised 6/14 ar 11

12 - vilent crimes - sex crime f any kind including nn cnsensual sexual crimes and sexual assault - murder, attempted murder - abductin - assault - rbbery - arsn - extrtin - burglary - pandering - any crime against minrs, children, vulnerable adults including abuse, neglect, explitatin - any abuse r neglect - any fraud - illegal drugs - aggravated DUI Any misdemeanr cntrlled substance cnvictin last 7 years Any ther misdemeanr cnvictins within last 3 years Exceptins: Any misdemeanr traffic (DUI is nt cnsidered Traffic) I understand that I must disclse n all backgrund check data cllectin frms (DPS, MCCCD backgrund check vendr and a clinical agency backgrund check vendr) all required infrmatin including any arrests, cnvictins, r charges (even if the arrest, cnvictin r charge has been dismissed r expunged), r participatin in first ffender, deferred adjudicatin, pretrial diversin r ther prbatin prgram. That includes any misdemeanrs r felnies in Arizna, any ther State, r ther jurisdictin. I als understand that I must disclse any ther relevant infrmatin n the frms. I further understand that nn-disclsure f relevant infrmatin n the frms that wuld have resulted in failing the backgrund check will result in denial f admissin t r remval frm a Prgram. Finally, I understand that my failure t disclse ther types f infrmatin f the frms will result in a vilatin f the Student Cde f Cnduct and may be subject t sanctins under that Cde. I understand that, if a clinical agency t which I have been assigned des nt accept me based n my criminal backgrund check it may result in my inability t cmplete the Prgram. I als understand that MCCCD may, within its discretin, disclse t a clinical agency that I have been rejected by anther clinical agency. I further understand that MCCCD has n bligatin t place me when the reasn fr lack f placement is my criminal backgrund check. Since clinical agency assignments are critical requirements fr cmpletin f the Prgram, I acknwledge that my inability t cmplete required clinical experience due t my criminal backgrund check will result in remval frm the Prgram. I understand the Prgrams reserve the authrity t determine my eligibility t be admitted t the Prgram r t cntinue in the Prgram and admissin requirements r backgrund check requirements can change withut ntice. I understand that I have a duty t immediately reprt t the Prgram Directr any arrests, cnvictins, placement n exclusin databases, suspensin, remval f my DPS Fingerprint Clearance Card r remval r discipline impsed n any prfessinal license r certificate at any time during my enrllment in a Prgram. Signature Printed Name and Student ID Date Nursing Assisting Prgram Desired Health Care Prgram Nursing Assistant Infrmatin Revised 6/14 ar 12

13 Student Acknwledgement: As f January 1, 2012 the Arizna State Bard f Nursing requires all Certificates f Cmpletin assciated with Nursing Assistant Prgrams be issued by Headmaster LLP/D & S Diversified Technlgies LLP (Referred t as Headmaster). The student is required t prvide the fllwing infrmatin t the Nursing Assistant Prgram instructr f recrd in rder t receive a Certificate f Cmpletin fr NUR158. This infrmatin will be cnveyed electrnically t Headmaster. Upn receipt f this infrmatin, the student will be registered with Headmaster. PLEASE PRINT LEGIBLY: Name: (as it appears n Arizna issued picture ID) *Picture IDs need t be cpied and handed t Kathy Prireschi at time f rientatin Scial Security Number: Date f Birth: Mailing Address: City: State: Zip Cde: Address: Cell Phne (with area cde): I (print legibly), have read and understand the cntents f the Headmaster Student Acknwledgement Frm and give Gateway Cmmunity Cllege permissin t share this infrmatin with Headmaster LLP/D & S Diversified Technlgies LLP. Signature: Date: Nursing Assistant Infrmatin Revised 6/14 ar 13

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