Nurse Aide Training Program Application Checklist

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1 Nurse Aide Training Program Application Checklist The following checklist must be completed before enrolling in the Nurse Aide Training course: Complete, sign, and date the Application Form Have the physical form completed by your doctor/nurse practitioner and make certain the date of the exam is listed and signed by the physician. Please also obtain Hepatitis B immunization documentation or sign a waiver. Complete a two-step PPD Test (tuberculin skin test) After the first step is given, you will return in 48 to 72 hours to have it read. You will need to get the second test no sooner than 7 days from the date the first one was given but no more than 21 days from that date. You will then return in hours to have the second test read. You may have your physician s office do this testing or you may visit the Department of Tuberculosis Control ( ), 184 East McMillan Avenue for the test. The center is open Monday, Wednesday, Thursday and Friday from 8 a.m. 4 p.m. and Tuesday from 9 a.m. to 4 p.m. The charge is $10 for each of the two tests and, if needed, the chest x-ray is $40. No appointment is necessary. No testing on Thursdays. The tests must be documented with the date it was given and the date it was read along with the results and signature of who read it. HEALTH RECORDS MUST BE DATED SIGNED AND NOT MORE THAN ONE YEAR OLD FROM THE TIME THAT YOU WILL GO TO CLINICAL Return to the Health and Public Safety Division (Room 312 HPB) with: Completed forms Obtain the program coordinator s signature / instructor consent Register via the internet or in person for the course (MCH 4810) Classroom, lab and clinical attendance is mandatory for this course according to the Federal Regulations. YOU MUST BE ON TIME FOR ALL CLASSES, LABS AND CLINICALS. YOU WILL NOT BE ADMITTED TO CLASS IF YOU ARE LATE THE FIRST DAY. Clinical time is built into the class-scheduled days but may start a half hour earlier and will meet at the nursing facility as assigned (they are on a bus route). Once you have registered for the course, if you do not attend the class, you will be issued a NO SHOW (NS) grade for the course. This may affect your Financial Aid. If you have questions, please call the Nurse Aide Training Program office at (513)

2 Nurse Aide Training Program Expectations and Conditions As a potential student in the Nurse Aide Training program at Cincinnati State, it is important that you are successful in your efforts. Therefore, it is essential that you understand and comply with the conditions of the program. These conditions are taken from the program policies and procedures, which you will receive in their entirety on the first day of class. Admission Policy (minimum age: 16 years old) I. The applicant must submit: a. A completed application form including signature in appropriate section. If you are sponsored by an employer, the section marked For Sponsoring Agency Only must be completed by the employer. b. The results of a physical exam, completed within the past 12 months. Minimally, the physical exam must indicate that the nurse aide is capable of performing the required skills and is free of communicable disease, and include documentation of Hepatitis B immunization or waiver. c. The results of a two-step PPD Test (tuberculin skin test) performed within the past 12 months or an annual update test with proof of an original two-step. For those with a positive TB test you must have a chest x-ray with negative results. Attendance Policy I. Attendance is mandatory for all class, clinical, and skills lab activities. II. If absence occurs during any of the following sessions, the nurse aide will be unable to do clinical experience and, therefore, will be dropped from the program. a. The first 16 hours of class content cannot be made up and the student must withdraw. b. If the student misses any other session(s), these sessions must be made up in order to receive a certificate. This may require the student to return to the next class on a space available basis. If a clinical experience is missed, it needs to be made up in the next scheduled class if space is available. Termination Policy I. In addition to the conditions of the Attendance Policy, a student in the Nurse Aide Training program may be terminated for any of the following reasons: a. Unsafe nursing care during clinical performance. b. Non-compliance with Nurse Aide Training program policies. c. Exhibition of behavior that is inappropriate as outlined under the Code of Conduct. Refund Policy Cincinnati State students will follow College regulations as outlined in the catalog/handbook. All Workforce Development Center students will follow the guidelines set forth by Workforce Development Center policy.

3 Nurse Aide Training Program Application for Admission I plan to enroll in the class for (month and year) Date _ Check one of the following: Cincinnati State Student Private Pay Student PLEASE PRINT ALL INFORMATION CLEARLY Facility-Sponsored Student Industry-Training Student Full Name last first middle Mailing Address _ street city state zip Home Telephone Number ( ) Social Security # Address In Case of Emergency Notify _ Phone Number ( ) EDUCATION HISTORY: List high school, college, or other schools attended including other Nurse Aide Training programs. School City & State Date Started Date Left Reason for Leaving EMPLOYMENT HISTORY: List your two most recent positions. Employer City & State Date Started Date Left Reason for Leaving Is your general state of health: Excellent Good Fair I declare the above statements to be correct and that I have read (or have had read to me) and agree to the expectations and conditions on the back of this form. Signed _ Date _ FOR PRIVATE PAY PARTICIPANTS: If you are paying for your own training, you must read the statement below. I am not working in a long-term care facility and have not been offered a job in a job in a long-term facility. Signed _ Date _ FOR SPONSORING AGENCY ONLY: Name of Facility _ Contact Person _ Phone Number ( )_ Hire Date _ Physical Exam Date

4 Nurse Aide Training Program Health Certificate Student Last Name First Name Middle Address City State Zip Employer (if applicable) Employer s Phone Number DATES OF TWO-STEP PPD First Step date given _ Signature Date read Results Signature Second Step date given _ Signature Date read Results Signature Date of last PPD screening: _ If positive PPD result, chest x-ray date and results: _ Signature_ Hepatitis B vaccination? No_ Yes_ Must sign a waiver form if you choose not to have Hepatitis B vaccination. Dates: First_Second_Third_ ESSENTIALS OF PHYSICAL EXAM Date of exam: Temperature Respiration Pulse Blood Pressure Weight Height Any pertinent findings: Is this person free of communicable disease? _ Have you noted any emotional or physical condition(s) which might prevent this person from fulfilling his/her duties as a Nurse Aide? _ Signature of Physician: Date: Name of Physician: _ Address: _ Phone:

5 Hepatitis B Vaccine Recombinant Hepatitis, the disease is a vital infection caused by hepatitis B virus (BV) which causes death in 1-2% of affected patients. Most people with hepatitis B recover completely; but approximately 5-10% become chronic carriers for the virus. Most of these people have no symptoms but can continue to transmit the disease to other. Some may develop chronic active hepatitis and cirrhosis. HVB also appears to be a causative factor in the development of liver cancer. Thus immunization against hepatitis B can prevent acute hepatitis and also reduce sickness and death from chronic active hepatitis, cirrhosis and liver cancer. The vaccine is produced from highly purified yeast cells. Recombinant HBV is not recommended in the presence of hypersensitivity to yeast or any component of the vaccine. This vaccine has been extensively tested for safety in chimpanzees and for safety and efficacy in large scale clinical trials with human subjects. A high percentage of healthy people who receive the recommended three doses of vaccine achieve high levels of surface antibody and protection against other agents such as hepatitis A virus, non-b or other virus known to infect the liver. Full immunization requires three doses of vaccine over a six-month period, although some people may not develop immunity even after three doses. There is no evidence that the vaccine has ever caused hepatitis B; however, because of the long incubation period, HBV people who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis is spite of immunization Duration of immunity is unknown at this time. The vaccine is free of association with human blood or blood products and is not recommended for pregnant individuals except in severe need, although risk is unknown at this time. Incidence of possible vaccine side effects is very low. No serious side effects have been reported with the vaccine. A few people do experience tenderness and redness around the site of the injection. Low grade fever may occur, along with rash, nausea, mild fatigue, and back, neck, and shoulder pain. Diarrhea, abdominal cramps and dizziness also have been reported. In some patients, a delayed reaction of up to several weeks after injection may occur resulting in fever, joint pain, rash and nervous and blood system reactions. The possibility exists that more serious side effects may be identified with more extensive use. After reading the above information, please direct questions you may have to your physician and or nurse. Acknowledgement of Information /Hepatitis B Recombinant Vaccine I have read the Patient Information Statement regarding hepatitis B recombinant vaccine. My questions have been answered to my satisfaction and I have been given the option to discuss my concerns with the my physician. I understand that the college recommends that I receive the hepatitis B series of three injections required to produce immunity for my protection, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effect of the vaccine. I have completed the Hepatitis B vaccine series dates: 123 I am in the process of taking the vaccine series Signature: Waiver: I understand that the educational experiences in my program may expose me to blood or other potentially infections materials and that I may be at risk to acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with HBV. However, I decline HBV at this time I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B. a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine. I do not consent to be vaccinated at this time: signature_

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