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1 CHISHOLM TRAIL TECHNOLOGY CENTER 283 STATE HIGHWAY 33 OMEGA, OKLAHOMA, Max Thomas, Superintendent Ronda Simpson, Principal Judy Schaffler, Business Manager Dear Prospective PN Applicant: Enclosed, please find the complete application packet for CTTC s Practical Nursing Program. Please read the ADMISSIONS PROCESS (pink sheet) carefully, and complete steps 1 thru 4. It is the applicant s responsibility to see that the entire application packet is completed and returned. An official copy of your high school transcript, with the school s seal present on the transcript; or a copy of your GED Certificate and scores, must be returned with the application. Any official college transcript or post-secondary education transcripts are required as well. Every applicant is required to take the Practical Nursing entrance exam. The testing is scheduled the first Tuesday of each month. To be considered for the next admission into the PN Program, a candidate must have submitted all of their required PN Application materials and taken the TEAS V testing. There is a $55.00 non-refundable fee required to take the entrance exams. The testing fee must be received at CTTC, at least one business day before the test date by 2pm. In order to be considered for admission, all of your required application materials must be completed and received at CTTC and applicant must have taken the TEAS V. Although no prerequisites are required, you are encouraged to be a certified nurse aide (CNA), and have successfully completed Medical Terminology and Anatomy & Physiology prior to admission. These courses may be obtained at CTTC. If you have any questions about the admissions process, please feel free to call. Sincerely, Deena Shepherd, RN, BSN Practical Nursing Director Enclosures: Admission POLICIES AND PROCEDURES (Lavender) ADMISSIONS PROCESS (Pink) Program TUITION, FEES, AND REFUND POLICY (Yellow) APPLICATION FOR ADMISSION (White) RELEASE OF INFORMATION (White) COMPLIANCE STATEMENT Four PN PERSONAL REFERENCE REPORTS (Green) Four Pre-printed Address Labels for Return Envelopes Phone Fax Website: or Board Members: Debbie Biehler, Dennis Baker, Loren Parham, Austin Lafferty, Jack Leitner

2 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSING PROGRAM POLICIES AND PROCEDURES A. ADMISSION POLICY 1. A student must be 18 years of age prior to completion from the Practical Nursing program. 2. A student is selected by an admission committee composed of the Practical Nursing Director, Practical Nursing Instructor(s), CTTC Superintendent or designee of the Superintendent, and the CTTC Counselor. 3. Selection of the nursing student will be based on the potential for success in completion of the nursing program and passing the NCLEX-PN. 4. To be considered by the Admissions Committee, the applicant must have on file: a. Minimum competency demonstrated on the required pre-entrance exam; b. An official copy of a high school diploma or GED certificate. c. Transcripts from any colleges or universities attended; d. Four references from persons other than family members. Education- and work-related references are preferred; e. Details of the applicant s work history; f. Copies of any health-related certifications held; g. Personal verification that the applicant is proficient in basic computer skills. 5. The Chisholm Trail Technology Center Practical Nurse career major is approved by the Oklahoma Board of Nursing. Graduates of this state-approved program are eligible to apply to write the National Council Licensure Examination (NCLEX) for (registered or practical) nurses. Applicants for Oklahoma licensure must meet all state and federal requirements to hold an Oklahoma license to practice nursing. In addition to completing a stateapproved nursing education program that meets educational requirements and successfully passing the licensure examination, requirements include submission of an application for licensure, a criminal history records search, and evidence of citizenship or qualified alien status. Applicants for practical nurse licensure must also hold a high school diploma or a graduate equivalency degree (G.E.D.) [59 O.S & 567.6]. To be granted a license, an applicant must have the legal right to be in the United States (United States Code Chapter 8, Section 1621). In addition, Oklahoma law only allows a license to be issued to U.S. citizens, U.S. nationals, and legal permanent resident aliens. Other qualified aliens may be issued a temporary license that is valid until the expiration of their visa status, or if there is no expiration date, for one year.

3 Applicants who are qualified aliens must present to the Board office, in person, valid documentary evidence of: a. A valid, unexpired immigrant or nonimmigrant visa status for admission into the United States; b. A pending or approved application for asylum in the United States; c. Admission into the United States in refugee status; d. A pending or approved application for temporary protected status in the United States; e. Approved deferred action status; or f. A pending application for adjustment of status to legal permanent resident status or conditional resident status. g. The Board has the right to deny a license to an individual with a history of criminal background, disciplinary action on any professional or occupational license or certification, or judicial declaration of mental incompetence [59 O.S ]. These cases are considered on an individual basis at the time application for licensure is made, with the exception of felony convictions. An individual with a felony conviction cannot apply for licensure for at least five years after completion of all sentencing terms, including probation and suspended sentences, unless a presidential or gubernatorial pardon is received [59 O.S & 567.6]. 6. The Admission Committee will complete the Applicant Rating Sheet. Using a rating system, the Admissions Committee will determine the tentative acceptance or non-acceptance of applicants. 7. The Practical Nursing Director will notify the applicant of tentative acceptance. 8. The applicant tentatively accepted for admission must submit: a. Current physical status; b. Physical history; c. Evidence of current immunization to tetanus, recommended every ten years. d. Evidence of current immunization to MMR (measles, mumps, and rubella): two vaccinations spaced at least 1 month apart or positive titer; e. Evidence of a negative tuberculin skin test or evidence of a negative chest x-ray in the event of a positive tuberculin skin test, within past 12 months to be repeated annually; f. Evidence of the first injection of the Hepatitis B vaccine, with timely completion of the series to follow; g. Evidence of positive varicella titer, varicella history, or childhood immunization. h. Criminal History (Background check) 9. Final acceptance into the nursing program depends on the results of the physical exam. No accepted applicant will be allowed to start the program

4 without the previously referenced requirements concerning the physical examination and required immunizations. 10. Applications to the PN program will be valid for a period of 2 years from the date on the application; or if not dated, 2 years from the date the PN application is received at CTTC. Applicants on the waiting list no longer wishing to be admitted in the program should contact CTTC to remove their names from the list. 11. If an applicant declines acceptance in the Practical Nursing program when a position becomes available, the applicant will be required to reapply to the program to be considered. Extenuating circumstances will be individually evaluated by the Admissions Committee. 12. A student will be admitted on a probationary status pending the results of a felony/background check that includes sex offender check and a urine drug screen completed within the first 250 clock hours of attendance. A clear felony background check and urine drug screen will result in the probationary status being removed and the student considered for regular admission status. A felony conviction on the background check not meeting the satisfaction of the Oklahoma Board of Nursing will result in dismissal from the program. A student who is convicted of a felony while enrolled in the program will be dismissed. A student with a criminal record will not be able to attend clinical, therefore not able to complete the program objectives. Any student who tests positive for drugs or alcohol or refuses or fails to participate in or cooperate with any part of the testing process will be immediately dismissed from the practical nursing program. 13. Applicants accepted to practical nursing will be required to have an ipad for use in the program. It is the applicants responsibility to purchase and maintain the ipad according to school policy. The ipad fee is an optional part of the tuition and fees. Therefore, if an applicant already has an ipad, no ipad fee will be charged. For applicants needing an ipad, the applicant will purchase the ipad (latest version). It is the applicant s responsibility to bring in the original receipt for reimbursement. Reimbursement will occur once financial aid monies are available and have been designated. Keyboard, protective case and $25 itunes card may also be purchased. 14. The Practical Nursing program is an approximate 18 month Instructor Facilitated Independent Study Program. It may be completed in less than 18 months depending upon the pace set by the student. There are minimum pace requirements that must be met each month. Students should plan to be in class/clinical Monday-Thursday with additional study time at home to be successful in the program.

5 15. Advanced Standing: If Advanced Standing Credit is given to a student, the length of program will be calculated according to course hours advanced. All Nursing curriculums must be completed within twenty-four (24) months. This includes Nursing and Pre-Nursing curriculum. Developed: 4/90 Revised: 8/90; 1/92; 6/92; 4/93; 4/95; 1/96; 2/98; 1/99; 2/00; 10/02; 6/04; 6/05; 6/06; 11/06; 1/07; 8/08; 05/11; 5/12; 2/13; 5/14; 6/15 B. Readmission of Former Student Policy Readmission will be considered on an individual basis. Readmission of a former student will be considered depending upon the reasons for withdrawal, academic grades and clinical status. The following procedures will be followed: The returning student must complete the admission packet. The returning student may not re-admitted for six (6) months after withdrawal. The returning student may enter the Practical Nursing Program according to space availability in the program. After an absence on more than one year, the returning student may be required to take and pass challenge exams. The student may enter at the appropriate point in the curriculum according to the advanced standing credit awarded. Completion of the third level is required for completion of the program. The returning student shall not exceed 24 months in the completion of the program. The total time of enrollment from both admissions will be counted in the 24 months. The returning student will be subject to any procedure utilized for new admissions. A student may not be admitted more than twice. Developed: 6/06 C. ADMISSION POLICY IF CONVICTED OF A FELONY OR ARRESTS/CONVICTIONS/PRIOR DISCIPLINARY ACTION/JUDICIALLY DECLARED INCOMPETENT This policy has been developed based on the Oklahoma Nurse Practice Act. See the following excerpt for any clarifications: An applicant for a license to practice as a licensed practice nurse shall submit to the Oklahoma Board of Nursing certified evidence that the applicant: 3. has never been convicted in this state, the United States or another state of any felony, unless five (5) years have elapsed since the date of the criminal conviction or the termination of any probation or other requirements imposed on the applicant by the sentencing court, whichever shall last occur, or a presidential or gubernatorial pardon for the criminal offense has been received, provided that the provisions of this paragraph shall not be effective until November 3, 2003;

6 4. has submitted a criminal history records search conducted by the Oklahoma State Bureau of Investigation that is not more than ninety (90) days old (Oklahoma Nursing Practice Act. 59 O.S ) The Board shall impose a disciplinary action pursuant to the provisions of subsection A of this section ( 567.8) upon proof that the person: 6. Has been adjudicated as mentally incompetent, mentally ill, chemically dependent or dangerous to the public, or has been committed by a court of competent jurisdiction, within or without this state; 10. Has had disciplinary actions taken against the individual s registered or practical nursing license, advanced unlicensed assistive certification, or any health-related license, in this or any state, territory or country. (Oklahoma Nursing Practice Act. 59 O.S ) It will be the policy of the practical nursing program that admission not be granted to any applicant who has any of the following actions taken against the applicant: 1. Conviction of a felony, unless five (5) years have elapsed since the date of the criminal conviction or the termination of any probation or other requirements imposed on the applicant by the sentencing court, whichever shall last occur, or a presidential or gubernatorial pardon for the criminal offense has been received; 2. Has been adjudicated as mentally incompetent, mentally ill, chemically dependent or dangerous to the public, or has been committed by a court of competent jurisdiction, within or without this state; or 3. Has had disciplinary actions taken against the individual s registered or practical nursing license, advanced unlicensed assistive certification, or any health-related license, in this or any state, territory or country. Due to clinical facility requirement and request, and Oklahoma Board of Nursing regulations/rules, the program will complete a felony/background check within the first 250 clock hours the student is in attendance. If a student is charged with a felony while attending the Practical Nursing program, the student must report this immediately to the Practical Nursing Director, and submit a copy of the final disposition of the case. Revised 10/02; 6/04; 6/05; 5/12 D. ADVANCED STANDING POLICY AND PROCEDURES It shall be the policy of the Chisholm Trail Technology Center to admit students to the Practical Nursing program on an advanced standing basis. Advanced standing shall be based on an evaluation of an individual s previous educational experience and the application of such education to the requirements of specific courses within the program of study.

7 Advanced Standing Student Admissions Procedure Any applicant who desires to be admitted on an advanced standing basis shall meet the following requirements: 1. All applicants will be considered on an individual basis by the Practical Nursing faculty. 2. The applicant must meet standard admission requirements: Submit an application, high school transcript or GED scores and certificate, reference sheets, and immunization record. The applicant must take the required Chisholm Trail Practice Nursing entrance exam and submit scores. In addition to these standard admission requirements, it is the responsibility of the applicant to submit an official nursing school transcript a letter of good standing from a past school official (Practical Nursing Director), a copy of the curriculum plan and course syllabi with course objectives from the previous school, and any supplemental information upon request. 3. The applicant who has taken the Advanced Acute Care Nursing Assistant (Pre Nursing) career pathway at Chisholm Trail Technology Center with a minimum of 77% average course grade may directly articulate into the practical nursing program if: a. Successfully achieved 77% on curriculum b. Meets the admission requirements c. Completes the admission process 4. The applicant who has been a certified nursing assistant (CNA) or (LTCNA) in good standing for one (1) consecutive year will be given credit for mastered skills in the Long Term Care Nurse Aide. 5. The applicant who has been a certified medication aide (CMA) in good standing for one (1) consecutive year will be given credit for skills mastered in the CMA course in the Pharmacology course. 6. Make an appointment with the PN Director for a review of records. 7. When it can be determined by evaluation of submitted materials that an applicant has previously completed comparable objectives in both the theory and clinical courses, the applicant will be admitted as an advanced standing student. 8. When it cannot be determined by evaluation of submitted materials that an applicant has previously completed comparable objectives in both the theory and clinical areas, and/or has sufficient recent clinical experience, the applicant will be required to take challenge exams. The applicant may appeal the decision to require the applicant to take the challenge exam by following the Appeals Policy, Section T In this handbook. 9. Achieve 80% accuracy on challenge exams. This will consist of the final exams for each course as well as a skills performance test if necessary. Fees will be $75.00 per level. If the applicant passes and is accepted, $50.00 applies toward the tuition. 10. Successful completion of a four-week probationary period is required by evidence of passing grades in theory as well as clinical, negative drug screen and clear felony background check. Developed 1999 Revised 2/03; 6/05; 6/06;1/07; 8/08; 5/12; 4/14; 6/15

8 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSING PROGRAM ADMISSIONS PROCESS Step 1: Application Complete the Application for Admission and check that all required information is complete. Return to the following address as quickly as possible: Chisholm Trail Technology Center Attn: Denise Oppel, PN Adm. Asst. 283 State Highway 33 Omega, OK All required PN application materials and references must be received at CTTC by the required deadline. Step 2: References It is your responsibility to deliver the four (4) Personal Reference Reports (green forms) to the individuals you select, and have the individuals return the forms to CTTC. These are required prior to consideration for admission. References must be confidentially returned. It is suggested that you distribute pre-addressed (to the address above), stamped envelopes with the reference sheets. Step 3: Transcripts/Certifications Provide an official copy (contains the school s seal) of your high school transcript showing date of graduation, OR a copy of your General Education Development Certificate AND scores. Provide an official transcript from each college attended. Provide a copy of all health-related certifications held. Step 4: Entrance Exam The TEAS V test is the required entrance exam. It is typically offered once per month. All required registration and a $55 payment for the test, must be received at CTTC by 2pm the day before testing to be allowed to sit for the exam. TEAS V results taken at another institution will be accepted if within the last 3 years. Testing begins promptly at 8:30 a.m. on the day of testing. It is recommended that you arrive by 8:15 a.m. with a photo id. The testing lasts from 2.5 hours to 4 hours. Calculators nor cell phones are not allowed. To ensure that a testing slot is available, a non-refundable $55.00 fee for testing services should be received at CTTC two (2) business days prior to testing. On the day of testing, applicants must bring an official picture identification. (Ex.: driver s license). The TEAS V may be repeated up to 3x/year in an effort to improve scores. Applicants must wait 30 days between retakes. Testing will be administered on the computer. It is necessary that an applicant possess these basic computer skills to take the exams and for completion of the program: Use the computer mouse; Execute basic commands; and, 1

9 Create a Word document, using spell check for accuracy. An applicant not meeting this requirement must learn these basic computer skills prior to admittance into the program. These may be learned through a variety of ways: Self-taught or taught by an acquaintance. Enrollment in a program at this or other technology center. Adult education evening programs are available and are usually short-term in duration. Microsoft Word for Beginners is suggested. Contact Chisholm Trail Technology Center to check on availability of training for these programs. (405) (800) Enroll in college or other postsecondary course(s). Purchase a book that teaches, and requires practice of these skills. Ask the local librarian to assist you with these basic skills on a library computer. Step 5: Applicant Rating Process Applicants will be accepted upon the recommendation of the Admissions Committee. Acceptance is based on a point record and is based upon the following entrance requirements: 1. Age of 18 years prior to graduation from the PN program; 2. Receipt of all required documentation; 3. Verification by applicant of basic computer skills; 4. Must submit official copy of high school transcript or GED Certificate and scores; 5. Health-related certifications; 6. Health-related work history; 7. Education- and work-related references; 8. Entrance exam scores (ATI Teas V) 9. Interest paragraph (composed at time of entrance exams). 10. Applicants successfully earning the required minimum points on the Preference Point Record and who are currently students in good standing with a minimum of 77% average course grade or completers of CTTC s Pre- Nursing (Advanced Acute Care Nursing Assistant) Career Major may be awarded additional points. Step 6: Acceptance Following notification of acceptance, finalize enrollment by: 1. Attendance at the Orientation to the program. Tentatively Admitted applicants will be notified when the session is scheduled. 2. Complete CTTC regular program application and enrollment forms. 3. Handle financial obligations with the Business/Financial Aid offices. 4. Submit completed physical examination form, required immunizations, and online background check prior to the first day of class. Please feel free to call with any questions regarding the admissions process: (405) ; 1(800) /12, 02/13, 6/14, 2/15, 6/15 2

10 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSING PROGRAM TUITION, FEES, AND REFUND POLICY A. The CTTC district consists of the following school districts: Kingfisher, Watonga, Lomega, Dover and Hitchcock. Books, instructional supplies, and other fees/costs are not included in the following tuition costs: Current tuition costs (subject to board-approved increase): In-district: $2, Out-of-district: $5, Costs below are an estimate only. CTTC does not have a book buyback program. Fees/Instructional Supplies (In-district & Out-of-district) $ Books/ Online Curriculum (In-district & Out-of-district) $1, ipad Fee *Optional (In-district & Out-of-district) $ * Students accepted to practical nursing will be required to have an ipad for use in the program. It is the applicants responsibility to purchase and maintain the ipad according to school policy. The ipad fee is an optional part of the tuition and fees. Therefore, if an applicant already has an ipad, no ipad fee will be charged. For applicants needing an ipad, the applicant will purchase the ipad (latest version). It is the applicants responsibility to bring in the original receipt for reimbursement. Reimbursement will occur once financial aid monies are available and have been designated. Keyboard, protective case and $25 itunes card may also be purchased. B. Payment Due Date. Costs tuition, books, and instructional supplies are charged by the number of hours in the Career Major and are due or payment plan established by end of 2 nd week of class. Other expenses shop/lab supplies, uniforms, insurance, etc. are also due by the end of the second week of class. Student cannot receive uniforms, etc., until these fees have been paid. Failure to make payment by the due date may result in termination from the Career Major and/or withholding of completion certificate at time of graduation. Students can setup payment arrangements by coming to the financial aid office to setup a payment plan. All payment plans must be paid in full prior to completion of the Career Major. C. Upon written notification of a student s intent to withdraw, Chisholm Trail Technology Center will refund the unused portion of any tuition in excess of the $5.00 enrollment fee, instructional supplies, and other fees/costs according to the following policy: Institutional charges (tuition, books, instructional supplies, and other fees/ costs) associated with the career major which the student is enrolled will be reduced or refunded to the student or the agency providing the assistance in the event the student withdraws, is dismissed, fails to return from an approved leave of absence, or otherwise stops attending class.

11 There are no refunds or reductions in institutional charges after 25% of the scheduled clock hours in the semester/level have passed. Refunds or reductions in institutional charges are based on the percent of clock hours scheduled to be completed in the semester/level as of the withdrawal date. Institutional charges are always the charges that were initially assessed the student for the semester/level, minus any testing fee and the enrollment fee. These charges are not refundable and are not included in the refund/reduction calculation D. The official withdrawal date is defined as the student s last date of attendance as submitted by the program instructor(s) on the CTTC attendance records. The student s withdrawal slip must be signed by the Practical Nursing Director and the CTTC Administration for withdrawal to be complete. E. Students will be required to purchase supplies in addition to those covered by tuition and must pay all school-related fees by the designated times. F. Students are responsible for their own transportation and living expenses. G. The Licensed Practical Nursing Program is 1463 clock hours. It should take approximately 18 months to complete the program from admittance into Pre- Nursing or regular admittance directly into the PN Career Major. The above listed charges are for an 18 month completion time. IF YOU DO NOT COMPLETE WITHIN 18 MONTHS, YOU WILL BE CHARGED $ (IN- DISTRICT) AND $ (OUT-OF-DISTRICT) PER MONTH UNTIL YOU COMPLETE. Program must be completed within 24 months. ***PRICING SUBJECT TO CHANGE WITHOUT NOTICE** Revised: 6/92; 1/96/ 2/01/ 11/05/ 11/06; 1/07; 8/08; 8/09, 6/13, 6/14

12 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSE PROGRAM (405) (800) Return completed application to: Chisholm Trail Technology Center c/o Denise Oppel, PN Administrative Assistant 283 State Highway 33 Omega, OK Date of Application: APPLICATION FOR ADMISSION 1. Name: Last First Middle SS#: Present Address: Street or Box # City State Zip Code 3. Contact Information: Home # Cell # Other # 4. Will the applicant be 18 years of age prior to graduation from the Practical Nursing Program?: (check one) Yes No 5. In case of an emergency, notify: Name: Telephone: Address: Relationship: 6. School District in which you currently reside: 7. Highest grade completed in high school: (ENCLOSE COPY OF ANY HIGH SCHOOL TRANSCRIPTS.) 8. Name of last high school attended: 1 of 4

13 9. GED: (Check one) Yes No GED Score: ACT: (Check one) Yes No ACT Score: 10. Education following high school: (Attach additional information on a separate sheet if needed.) (ENCLOSE COPY OF ANY COLLEGE/POST-SECONDARY TRANSCRIPTS.) Dates of Attendance School Location Hours Earned Area of Study/Course(s) 11. Will you need accommodations in order to successfully participate in the assessment process or to successfully perform the essential functions of the Practical Nursing program? (Check one.) Yes No If yes, please describe needed accommodations: 12. I verify that I am skilled in these basic computer operations: Using the computer mouse. Executing basic commands. Developing a Word document and using spell check for accuracy. (Check one.) Yes No 13. Health-related certifications held: (ENCLOSE COPY OF CERTIFICATIONS) Name of Certification Place Certification Earned Date 2 of 4

14 WORK HISTORY/EMPLOYMENT 14. Tell us about your work history and employment experience. List most recent first. Dates of Employment (Start & Ending Month & Year) Place & Location of Employment Job Title/Duties Contact Person, Title & Phone # 15. Verification of Citizenship or Qualified Alien Status: (Enclose copy of Official Photo Identification verifying citizenship or qualified alien status.) Have you enclosed copy of above ID? (Check one) Yes No 16. Have you ever been convicted of a felony? (Check one) Yes No 17. Have you ever been in a Nursing Program? (Check one) Yes No If so, name of school(s)? 3 of 4

15 I certify that all information is true and correct to the best of my knowledge. I realize that falsification of the application may result in my not being admitted to this program or being dismissed if I am admitted. I authorize the Chisholm Trail Technology Center Practical Nursing program to investigate all liability result from such. I do hereby apply for admission to the Chisholm Trail Technology Center and agree by its rules and regulations. I understand this is an application for admission only and not for the purpose of enrollment in the program. Signature of Applicant: Date: Chisholm Trail Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, qualified disability, or veteran status in any of its practices, policies, or procedures. Revised 5/2012; 7/2013; 6/ of 4

16 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSING PROGRAM 283 State Highway 33 Omega, OK (405) (800) RELEASE OF INFORMATION Name (Please print): Last First Middle Maiden Social Security Number: - - Dates Attended/Employed: Type of Information Needed: I do hereby give my permission to release information to Chisholm Trail Technology Center concerning my qualifications for entrance into the Practical Nursing program. Student Signature Date Return this sheet with your application. Chisholm Trail Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, qualified disability, or veteran status in any of its practices, policies, or procedures.

17 CHISHOLM TRAIL TECHNOLOGY CENTER PRACTICAL NURSING PROGRAM COMPLIANCE STATEMENT Chisholm Trail Technology Center Chisholm Trail Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, qualified disability, or veteran status in any of its practices, policies, or procedures. Oklahoma Department of Career and Technology Education 1500 W 7 th Street Stillwater, OK Telephone: (800) Fax: (405) Website: Full approval status: 2014 Oklahoma Board of Nursing 2915 North Classen Boulevard, Suite 524 Oklahoma City, OK Telephone: (405) Fax: (405) Website: Full approval status: /2013; 6/2014

18 RETURN DIRECTLY TO: CONFIDENTIAL CHISHOLM TRAIL TECHNOLOGY CENTER PN PERSONAL REFERENCE REPORT Chisholm Trail Technology Center c/o Denise Oppel, PN Administrative Assistant 283 State Hwy 33 Omega, OK My acquaintance with has been as: (Name of Person Applying to PN Program and Requesting this Reference) Employer Friend Advisor Teacher Physician Supervisor Fellow Worker Other: 2. How long have you known the applicant? 3. Rating of applicant? (Check one column for each descriptive term.) Common Sense & Judgment Concern for Others Cooperation with Others Dependability Initiative Intellectual Endowment Sense of Responsibility Outstanding Above Average Average Below Average Poor 4. What qualities or characteristics does the applicant have that you believe would contribute to the applicant s success as a practical nurse? 5. What qualities or characteristics does the applicant have that you believe would interfere with the applicant s success as a practical nurse? 6. Briefly describe this person in your own words. Your Name: Job/Occupation Title: Contact #: Address: Signature: Date: Chisholm Trail Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, qualified disability, or veteran status in any of its practices, policies, or procedures.