Nurse Aide Certification Program and Patient Care Technician, Part Three Registration Packet

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1 Nurse Aide Certification Program Brookhaven College Workforce Continuing Education Division COVER SHEET Prepare for the nurse aide certification examination with this course addressing both written clinical skills required for those that are or plan to be long- term- care nursing assistants. Successful completion of this course is a prerequisite to taking the state exam for certification to work as a nurse aide. The course content encompasses 100 hours of instruction, 60 hours of lecture lab 40 hours of clinical practice. Students do not need previous nursing home experience or to be currently employed to take this course. Note: For students enrolled in the Patient Care Technician program, the Nurse Aide Certification course is considered Part Three, Patient Care Technician. Your registration packet includes the following: 1. Nurse Aide Certification Program Cover Sheet 2. Nurse Aide Certification Program Requirements Sheet 3. Drug Screens Criminal Background Check Sheet 4. Nurse Aide Certification Program Student Checklist 5. Nurse Aide Registry (NAR) Form 6. Brookhaven College Continuing Education- Immunization Record Form 7. Dallas County Community College District, Workforce Continuing Education Registration Form Helpful Information Step 1 Please take your immunization records to our Health Center located inside the Student Services Center, Building S, Room S072. The Brookhaven College nurse MUST complete the Immunization Record form before you can register for this program. If you are missing any immunizations, ask the nurse for a list of shots for which she can assist you. TITER tests can be taken to confirm that you have the required immunizations. The Brookhaven College Health Center offers two different Hepatitis series. The most common one requiring up to six months to complete or the TWINRIX series that can be completed within 21 days. Step 2 Once the Immunization Record has been completed signed, take all required documentation (see student checklist) to the Health Careers office located in Building W, Room W109. The office hours are 9 a.m.- 6 p.m., Monday- Thursday 9 a.m.- 4 p.m. on Friday. No appointment is necessary. A representative will review approve your documentation. You will receive a completed Registration Permission Slip. Step 3 Take the Registration Permission Slip DCCCD, Continuing/Workforce Education Registration Form to the Admissions Office located in Building S, to register for your classes. Step 4 Take your receipt to the Cashier s window to pay for your courses. Payment is due at the time of registration. Note: Liability Insurance MUST be paid at the time of registration. Drug Screenings Criminal Background Check required to be completed no more than 30 days before the start of the clinical experience. Driver s license, Passport or State/Military issued ID card is required. (You will be required to present one of these forms of ID at the time you take the State of Texas Nurse Aide Certification Exam.) Social Security Card Will also be required at the time you take the State of Texas Nurse Aide Certification Exam. The clinical component for all Nurse Aide Certification classes meets at Christian Care Center, 1000 Wiggins Pkwy. in Mesquite the last week of class. For additional information about the Nurse Aide Certification Program or please call Susana Ruelas at

2 Nurse Aide Certification Program REQUIREMENTS Nurse Aide Certification (NURA- 1001) 100 hours Total 100 hours Course prerequisites MUST be completed prior to registration. Upon successful completion of this program, the student is eligible to take the State of Texas Nurse Aide Certification exam. Course Prerequisites Registration must be done in person. Ability to lift 50 lbs Nurse Aide Registry (NAR) Form, completed signed. All applicants must be checked for listing on the Nurse Aide Registry prior to admission. Brookhaven College Continuing Education- Immunization Record Form Brookhaven College will require a copy of proof of immunization. Immunizations must be current. The Immunization Record must be completed signed ONLY by Brookhaven College s Health Center nurse. The student must provide proof of immunization complete a Brookhaven College Continuing Education- Immunization Record Form. The following immunizations are required: Measles, Mumps, Rubella (MMR), Varicella, TD or TDAP, all 3 doses of the Hepatitis B series, Flu Shot, a current TB test (within the last year). If students have had a previous positive PPD test, documentation or history of treatment is required. A copy of current completion card of Basic Cardiac Life Support, BCLS, for Health Care Providers A copy of valid U.S. or Texas State Government Issued Photo I.D. (e.g. driver s license) Pass a criminal background check drug screens* (Students accepted into the Brookhaven College Workforce Continuing Education Health Programs are required by the Dallas- Fort Worth Hospital Council Member Facilities to undergo a criminal background check drug screening prior to beginning their clinical experience. These checks must be completed no more than 30 days before the start of the clinical experience.) Students who do not pass these two requirements will not be allowed to continue on to clinicals. Dallas County Community College District, Continuing /Workforce Education Registration Form Social Security Card- Will also be required at the time you take the State of Texas Nurse Aide Certification Exam The clinical component for all Nurse Aide Certification classes meets at Christian Care Center, 1000 Wiggins Pkwy. in Mesquite the last week of class The following are not included in the cost of the Nurse Aide Certification Program are the responsibility of the student. Textbooks State of Texas Nurse Aide Certification exam Liability insurance (MUST be paid at the time of registration) Drug Screens Criminal Background check Uniform (scrubs, royal blue) Watch with second h

3 Nurse Aide Certification Program DRUG SCREENS AND CRIMINAL BACKGROUND CHECK Drug Screens The Brookhaven College WCE /or a clinical agency reserve the right to remove a student from the classroom or clinical facility for suspicion of drug or alcohol use to submit to a drug alcohol screen at the student s expense. Additionally, the college /or clinical agency reserve the right to request that a student submit to a drug alcohol screen at rom at the student s expense. Students with a positive drug screen without an authorized provider prescription or a positive alcohol screen will be removed from Brookhaven College WCE Health Program. Failure to comply with a drug screen request from Brookhaven or one of its clinical agencies will result in the student s immediate expulsion from the Brookhaven College. Furthermore, regardless of testing or testing results, clinical agencies reserve the right to expel students from their facilities. The drug screen follows National Institute on Drug Abuse guidelines screens for 10 substances, as designated in the Substance Abuse Panel 10, SAP 10. These substances are: amphetamines, barbiturates, benzodiazepines, cocaine metabolites, alcohol, marijuana metabolites, methadone, opiates, phencyclidine propoxyphene. SAP 10 test results that fall outside of any of the acceptable ranges are considered positive test results are automatically sent for a separate confirmatory test by a gas chromatography mass spectrometry method. If these results are positive, the test results are sent to a medical review officer who will review the results at an additional cost to the student. The medical review officer will then contact the student to determine if there is a valid prescription for the drug in question. If a valid prescription exists is verified, the test result will be deemed negative acceptable. An individual with a positive drug screen will not be allowed to enroll in any health- related continuing education courses for a minimum of 12 months according to the Community Stard. Prior to enrolling or returning to the clinical agency/rotation, a student must provide proof of a negative drug screen as verified by the college/school. Failure to comply with this policy will result in disciplinary action dismissal from the Brookhaven College. Criminal Background Check The criminal background check reviews a person s criminal history at least seven years prior to the date of program application. The check will include all cities counties of the person s residency during that time period. The following histories will disqualify an individual from consideration for a clinical rotation: felony convictions; misdemeanor convictions or felony deferred adjudications involving crimes against persons, e.g. physical or sexual abuse; misdemeanor convictions related to moral turpitude, e.g. prostitution, public lewdness/exposure, etc.; felony deferred adjudications for the sale, possession, distribution or transfer of narcotics or controlled substances; or status as a registered sex offender.

4 Nurse Aide Certification Program STUDENT CHECKLIST All forms in this packet must be completed approved prior to registration. Last Name First Name Course Section Number Semester Please bring the following documentation to the Brookhaven College Workforce Continuing Education Health Careers office. The Health Careers office is located in Building W, Room W109. Business hours are Monday Thursday, 9 a.m. - 6 p.m. Friday, 9 a.m. 4 p.m. No appointment is necessary. 0 Brookhaven College Continuing Education- Immunization Record Form 0 A copy of current Basic Cardiac Life Support, BCLS, for Health Care Providers completion card 0 A copy of valid U.S. or Texas State Government Issued Photo I.D. (e.g. driver s license) 0 Dallas County Community College District, Continuing /Workforce Education Registration Form 0 Nurse Aide Registry Form, completed signed For WCE Health Careers Office Use Only: Registration Permission Slip approved by: Date: Time: (Signature)

5 Nurse Aide Certification Program NURSE AIDE REGISTRY FORM All applicants must be checked for listing on the Nurse Aide Registry, NAR, prior to admission. Pursuant to 42 code of Federal Regulation (CFR) (1) (ii), nurse aides with a finding of abuse, neglect, or misappropriation of resident s property are prohibited from employment in nursing skilled nursing facilities. In addition 42 CFR (c)(4)(d) mates that all findings of abuse, neglect, or misappropriation of resident s property remain on the registry permanently. In order to determine if an individual is listed on the Nurse Aide Registry as UNEMPLOYABLE due to abuse, neglect or misappropriation of resident s property, please call the departments toll- free voice information system at To Be Filled Out By Applicant: Full Name Social Security Number - - Have you ever been certified as a Nurse Aide in Texas? If yes, when? What name was on the certificate? I certify that the information provided in the above application is true correct. I underst that false information on this application may result in immediate suspension or removal from the course with no refund. Signature of Applicant Date ************************************* To Be Filled Out By Brookhaven College Representative Nurse Aide Registry checked? Yes No Results: Signature of Brookhaven College Representative / Date

6 Brookhaven College Continuing Education - Immunization Record Last Name First Name Middle Initial Date of Birth Sex: M F Student ID # Program *Please have the BHC Center Nurse/ Physician / Nurse Practitioner initial form. MEASLES (Rubeola) Select option 1 or 2 provide requested documentation. 1. Dates of immunization: Two (2) are required. A. First immunization with live attenuated virus. (Given after 1957 given on or after student s first birthday). B. Second dose separated by 28 days or more. Date of immunization: / / ( )* / / ( )*OR AND Quantitative result #: HEPATITIS B / Twinrix (Hep A/B) 1. Date of immunization: / / ( )* 2. Date of immunization: / / ( )* 3. Date of immunization: / / ( )* 4. Date of blood titer: / / ( )* AND Quantitative result # *** TITER REQUIRED FOR PARAMEDIC*** MUMPS Select option 1 or 2 provide requested documentation. 1. Dates of immunization: Two (2) are required. a. First immunization with live attenuated virus. (Given after 1957 given on or after student s first birthday). Date of immunization: / / ( )* / / ( )*OR Quantitative result #: RUBELLA (German Measles) Select option 1 or 2 provide requested documentation. 1. First immunization with live attenuated virus. (Given after 1957 given on or after student s first birthday). Date of immunization: / / ( )* / / ( )*OR Quantitative result #: MMR 1. Date of immunization: / / ( )* 2. Date of immunization: / / ( )* FLU VACCINATION 1. Seasonal Flu Shot: / / ( )* VARICELLA 1. 2 Doses (30 days apart or more) / / ( )* / / ( )* AND Quantitative result #: *TITER OR VACCINATION REQUIRED FOR NURSING/ RADIOLOGY/ EMS PPD Date: / / ( )* Result : Negative Positive mm. ( )* OR TB Chest X Ray Date: / / ( )* Result : Negative Positive ( )* ***WITHIN THE LAST YEAR AND YEARLY THEREAFTER*** Tdap/ tetanus, diphtheria acellular pertussis (Within 10 years for ALL students). 1. Date of immunization: / / ( )* BHC Center Nurse/ Physician / Nurse Practitioner Signature SIGNATURE: DATE: UPDATED 12/03/2014

7 Continuing/Workforce Education Registration Educational opportunities are offered by the Dallas County Community College District without regard to race, color, age, national origin, religion, sex, disability or sexual orientation. Please check the college you plan to attend. Brookhaven College Cedar Valley College Eastfield College El Centro College (ECC) 3939 Valley View Lane 3030 North Dallas Avenue 3737 Motley Drive Main & Lamar Streets Farmers Branch, TX Lancaster, TX Mesquite, TX Dallas, TX fax fax fax Mountain View College North Lake College Richl College ECC-Bill J. Priest Campus 4849 West Illinois Avenue 5001 N. MacArthur Blvd Abrams Road 1402 Corinth Street Dallas, TX Irving, TX Dallas, TX Dallas, TX fax fax fax fax Dallas TeleCollege 9596 Walnut Street Dallas, TX fax Student Information Please print. * Please check appropriate box; your responses to these questions are voluntary - information is used to meet Texas State reporting requirements only. New Student * Male *Social Security Number: - - Existing Student * Female DCCCD Student I.D. Number: Ethnicity information is used to meet Texas State reporting requirements providing this information is voluntary on your part. White, Non-Hispanic Hispanic American Indian/Alaskan Native Other Black, Non-Hispanic Asian/Pacific Isler International/Non-Immigrant No Response Last Name First Name MI Address City State Zip County Country Home Phone Work Phone Cell Phone Fax Address Date of Birth I verify that the above information is accurate. Signature Date Course Information (Certain Continuing Education courses have entrance requirements that student must meet prior to registration. Consult college for details.) REG # TERM COURSE # SECTION # COURSE TITLE DAYS DATES TIME LOCATION FEE Payment Information You are able to pay by credit card on the web if you have previously registered provided your address. If paying by check, include Driver s License Number State on the top of the check, not on this form. Refund Policy: A refund of 100 percent will be made if requested prior to the first scheduled meeting day. Your request for a refund must be made during business hours prior to the first day of class to qualify for a 100 percent refund. A refund of 80 percent is allowed before the close of business on the day of the second class meeting. No refund is allowed after the second class meeting. Should the college cancel the class a 100 percent refund will be issued. Refunds may take up to four weeks to process. The Colleges of the Dallas County Community College District reserve the right to make changes that may include, but are not limited to, the days times courses are offered, classroom location, instructors who teach the course, cancellation of courses. Third Attempt to Enroll in a Course: Effective for Fall Semester 2005, the Dallas County Community Colleges will charge a higher tuition rate to students registering the third or subsequent time for a course. All third subsequent attempts of the majority of credit Continuing Education/Workforce Training courses will result in higher tuition to be charged. Developmental Studies some other courses will not be charged a higher tuition rate. Third attempts include courses taken at any of the Dallas County Community Colleges since the Fall 2002 semester. FORM NO /06

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