Oregon Online NA Program Application & Information

Transcription

1 Oregon Online NA Program Application & Information Successful completion provides eligibility to take the Oregon state certification exam to become a Certified Nursing Assistant (CNA-1) Southwestern Oregon Community College 1988 Newmark Avenue, Coos Bay, OR Contact: Ellen Riley [email protected] 1

2 ONLINE BASIC NURSING ASSISTANT (BNA) TRAINING PROGRAM Coordinated by Southwestern Oregon Community College DESCRIPTION The Online Basic Nursing Assistant Training is an Oregon State Board of Nursing (OSBN) program. The 9 credit program: 5 credits in online theory (51 hours): Includes instruction in bedside nursing skills, basic restorative skill, mental health and social service needs, personal care skills, and knowledge of client s rights. 4 credits in skills lab (24-30 hours) and clinical rotation (75 hours) minimum: Students will gain the knowledge and skills necessary to care for clients in long-term care and acute care facilities that are under direct care of a licensed nurse. Following successful completion of the course, a certificate of completion is awarded to the student and the student can receive certification with the OSBN by applying and successfully completing the Oregon Nursing Assistant CNA-1 Exam. COSTS FEES: Fee for Online Theory (51 hours, 5 credits) $565 Lab and Clinical at Community College (4 credits) $435 OTHER COSTS (ESTIMATED): Mosby s Textbook for Nursing Assistants 7 th ed $70-80 CPR course if not currently certified $45-60 Criminal History Check $52+ State Certification Exam $106 Scrubs $30 Nurse Quality Stethoscope $25 Gait Belt $25 Shoes (white leather uppers preferred) $40 Tuition and fees are subject to change. 2

3 COURSE REQUIREMENTS AND INFORMATION Attendance in hours of lab class and 75 hours clinical session is required. This is a requirement of OSBN, and neither the instructor nor the Program Director can waive the requirement. If you do not plan to attend every lab and clinical, you will need to make up the hours, as you will not pass or receive a refund of the course tuition and fees. English as a Second Language: The ability to read and understand English at a tenth grade level of competency is important for success in the course. All students are required to have a TB screening test (recorded in millimeters) within six months and proof of MMR immunization or titer. Some clinical facilities may require other immunizations, such as the Hepatitis B immunization (series of three) or tetanus. Official medical documentation, such as your immunization card, must be provided with the application. Prior to starting the clinical rotation, the student must obtain a current and valid CPR card from The American Heart Association (Basic Life Support for Healthcare Providers) or have an American Red Cross Professional Rescuer Card (minimum of CPR/AED). The following functional abilities are considered to be essential for success in this program: Fine motor skills, gross motor skills, physical endurance, physical strength, mobility, hearing, visual, tactile, smell, reading, mathematics, emotional stability, analytical thinking, critical thinking, interpersonal skills, and communication skills. All students are required to meet these essential functions. You are expected to maintain a professional appearance and conduct. For clinical, you will need scrubs (color of school s choice), white shoes (leather uppers, rubber soles), a watch that measures seconds, and a black ink pen. For student and client safety personal hygiene must be maintained. Students are to be free of the smell of fragrances and tobacco. Hair must be off the collar, pulled back from the face, and clean. Jewelry must be kept to a minimum; there is a limit of one ring per hand, one simple stud earring per ear; and no visible tattoos. Pagers and cell phones must be off during classroom and clinical hours. Financial Aid: The class is 9 credits, allowing students to apply for financial aid at 3/4 time. Once you are fully registered at SWOCC, FAX your Consortium Agreemen to Avena Singh at VA Representative, will work with students and requests that they call their home college representative. Criminal Clearance: Conviction of a felony and/or drug use or distribution may result in the OSBN withdrawing the privilege of administering the Certified Nursing Assistant examination. The Online Basic Nursing Assistant Program will deny admission to individuals who have committed crimes or have a history of arrests that will not allow them to be licensed or certified. Withdrawal: Students are responsible for withdrawing from courses they no longer wish to attend. Students need to withdraw from both the online theory and skills lab and clinical rotation. This must be done within the published withdrawal period or grades will be issued. Students are still responsible for payment of all charges. 3

4 HOW TO REGISTER FOR YOUR COURSE SOCC REGISTRATION INFORMATION Nursing 9091 (5 credits): 51 hours online theory Nursing 9091L (4 credits): 24 hours skills lab and 75 hours clinical The following requirements need to be sent to: Nursing Administrative Asst. Sumner Hall R-4, Southwestern Oregon Community College, 1988 Newmark Ave, Coos Bay, OR These records may be Faxed ( ) to or hand delivered to same address OREGON ONLINE BNA PROGRAM APPLICATION Complete and submit your Oregon Statewide BNA/CNA Application with required documentation that is attached to the back of the Application packet Scan and to: or Fax to: Postal mail to Ellen Riley, Sumner Hall 22, 1988 Newmark Avenue, Coos Bay, OR Immunizations records Criminal History Check initiated (make a copy of completed form and send the dated copy back) Current CPR card must be either of the following: American Heart Assn, BLS for Health Care Providers or American Red Cross, CPR.AED for Professional Rescuer To register for the BNA Online Didactic NUR 9190 and Skill Lab/Clinical NUR 9190 Apply for admission to SOCC: Complete the attached Student Record Form and mail signed form to above address or return during the Orientation you attend. (see back of packet) Additional Registration Info: Applicants are accepted on a first come, first served basis Applicants must be at least 16 years of age High school students may need written authorization from their high school and/or legal guardian Students must initiate online lessons no less than five school days before labs are scheduled to begin After you have completed your theory and passed your exam, you have two weeks to start your skills lab at your community college If you have any questions about your ability to meet the program requirements, please contact the Southwestern Oregon Community College Health and Human Development Assistant at or Ellen Riley at [email protected]. If you require special arrangement of accommodations during your program of study, please contact the appropriate Disability Services coordinator for your college. At Southwestern Oregon Community College, Disability Services can be reached at The Statewide Online BNA Program will be offered each quarter per demand. Check the Southwestern Oregon Community College and partner college schedule of classes for class dates. 4

5 Southwestern Oregon Community College CRIMINAL BACKGROUND CLEARANCE RELEASE POLICY Students are required to meet all of the requirements of the Oregon State Board of Nursing and the clinical agency, including passing a criminal background check. The student is responsible to initiate the criminal background check as part of the application. Initiate the criminal background check in time for the college s authorized representative to review the results before the start of the clinical rotation. HOW TO OBTAIN A CRIMINAL BACKGROUND CLEARANCE REALEASE: Read the Department of Human Resources list of Potentially Disqualifying Crimes (ORS through ), below or view at: and the Nurse Practice Act, Division 63 viewed at: If you have questions about personal circumstances, call the Oregon State Board of Nursing office and speak to one of the practice advisors at Sign the Oregon Online BNA Program Application agreeing to the terms of SOCC s Criminal Background Clearance Release policy. Obtain fingerprints Complete the Oregon State Police Copy of Own Record Request form attached to this packet, mail the fingerprint card and appropriate fees to the address indicated on the form. Upon receiving the results of the Criminal Background Clearance from the Oregon State Police: o Submit the original letter to your home school contact as soon as possible in order to be cleared for clinical.. 5

6 Oregon State Board of Nursing Nurse Practice Act Divison 63 Stat. Auth: ORS , ORS , , Stats. Implemented: ORS , ORS , Causes for Denial, Reprimand, Suspension, Probation or Revocation of CNA Certificate Under the contested case procedure in ORS to the Board may deny, reprimand, suspend, place on probation or revoke the certificate to perform duties as a CNA for the following causes: (1) Conviction of the nursing assistant of a crime where such crime bears demonstrable relationship to the duties of a nursing assistant; ORS (2(a) (2) Any willful fraud or misrepresentation in applying for or procuring a certificate or renewal thereof; ORS (2)(b) (3) Use of any controlled substance or intoxicating liquor to an extent or in a manner injurious to the certificate holder or others or to an extent that such use impairs the ability to conduct safely the duties of a nursing assistant; ORS (2)(c) (4) Violation of any provision of ORS to or rules adopted thereunder; ORS (2)(d) (5) Physical or mental condition that makes the certificate holder unable to perform the duties of a nursing assistant; ORS (2)(e) (6) Conduct unbecoming a nursing assistant in the performance of duties. ORS (2)(f) Stat. Auth: ORS Stats. Implemented: ORS Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (1) Conduct related to the client s safety and integrity: (a) Leaving a nursing assistant assignment without properly notifying appropriate supervisory personnel; (b) Failing to report to proper authorities information regarding incompetent, unethical or illegal practice of any health care provider; (c) Failing to respect client rights and dignity regardless of social or economic status, personal attributes or nature of health problems or disability; (d) Failing to report actual or suspected incidents of client abuse; or (e) Engaging in sexual misconduct related to the client or to the workplace. (2) Conduct related to other federal or state statutes/rule violations: (a) Knowingly aiding, abetting or assisting an individual to violate or circumvent any law, rule or regulation intended to guide the conduct of health care providers; (b) Violating the rights of privacy, confidentiality of information or knowledge concerning the client, unless required by law to disclose such information; (c) Discriminating against a client on the basis of age, race, religion, sex, sexual preference, national origin or disability; (d) Abusing a client. The definition of abuse includes but is not limited to intentionally causing physical harm or discomfort, striking a client, intimidating, threatening or harassing a client; (e) Neglecting a client. The definition of neglect includes but is not limited to unreasonably allowing a client to be in physical discomfort or be injured; (f) Engaging in other unacceptable behavior or verbal abuse towards or in the presence of a client such as using derogatory names or gestures or profane language; (g) Using the client relationship to exploit the client by gaining property or other items of value from the client either for personal gain or sale, beyond the compensation for services; Oregon State Board of Nursing Nurse Practice Act (h) Possessing, obtaining, attempting to obtain, furnishing or administering prescription, or controlled drugs to any person, including self, except as directed by a person authorized by (i)removing or attempting to remove drugs, supplies, property or money from the workplace without authorization. (3) Conduct related to communication (a) Inaccurate recordkeeping in client or agency records; 6

7 (b) Incomplete recordkeeping regarding client care; including but not limited to document care given or other information important to the client s care or documentation which is inconsistent with the care given; (c) Falsifying a client or agency record; including but not limited to filling in someone else s omissions, signing someone else s name, recording care not given, fabricating data/values; (d) Altering a client or agency record; including but not limited to changing words/letters numbers from the original document to mislead the reader of the record, adding to the record after the original time/date without indicating a late entry; (e) Destroying a client or agency record; (f) Failing to maintain client records in a timely manner which accurately reflects management of client records, including failure to make a late entry within a reasonable time period; or (g) Failing to communicate information regarding the client s status to the supervising nurse or other appropriate person in a timely manner. (4) Conduct related to the client s family (a) Failing to respect the rights of the client s family regardless of social or economic status, race, religion, or national origin; (b) Using the CNA client relationship to exploit the family for the CNA s personal gain or for any other reason; (c) Stealing money, property, services, or supplies from the family; or (d) Soliciting or borrowing money, materials, or property from the family; (5) Conduct related to co-workers: violent, abusive threatening, harassing, or intimidating behavior towards a coworker which either occurs in the presence of clients or otherwise relates to the delivery of safe care to clients. (6) Conduct related to achieving and maintaining clinical competency: (a) Failing to competently perform the duties of a nursing assistant; (b) Performing acts beyond the authorized duties for which the individual is certified; or (c) Assuming duties and responsibilities of a nursing assistant without nursing assistant training or when competency has not been established or maintained. (7) Conduct related to impaired function: (a) Use of drugs, alcohol or mind-altering substances to an extent or in a manner dangerous or injurious to the nursing assistant or others or to an extent that such use impairs the ability to conduct safely the duties of a nursing assistant; or (b) Having a physical or mental condition that makes the nursing assistant unable to perform safely the duties of a nursing assistant. (8) Conduct related to certificate violations: (a) Providing, selling, applying for or attempting to procure a certificate by willful fraud or misrepresentation; (b) Functioning a a medication assistant without current certification as a medication assistant. (c) Altering a certificate of completion of training and/or nursing assistant certification issued by the Board; (d) Disclosing contents of the competency examination or soliciting, accepting or compiling information regarding the contents or the examination before,during or after its administration; (e) Allowing another person to use one s nursing assistant certificate for any purpose; (f) Using another s nursing assistant certificate for any purpose; or (g) Representing oneself as a CNA without current, valid CNA certification. (9) Conduct related to the certificate holder s relationship with the board: (a) Failing to cooperate with the Board during the course of an investigation. The duty to cooperate does not include waiver of confidentiality privileges, except if a client is harmed. This waiver of confidentiality privileges does not apply to client-attorney privilege. (b) Failing to answer truthfully and completely any question asked by the board on an application for initial certification, renewal of certification or recertification; (c) Failing to provide the Board with any documents requests by the Board; or (d) Violating the terms and conditions of a Board order. Stat. Auth: ORS Stats. Implemented: ORS Conduct Unbecoming 7

8 The Oregon Administrative Rules contains OARs filed through October 31, 2010 DEPARTMENT OF HUMAN SERVICES, ADMINISTRATIVE SERVICES DIVISION AND DIRECTOR S OFFICE Division 7: Criminal History Checks: DHS Employees, Volunteers, and Contractors (portions relevant to the Basic Nursing Assistant Course) EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 2 of Disqualifying Convictions Under ORS (1) The crimes listed in section (3) of this rule are disqualifying crimes for those employees and individuals subject to ORS , and as specified in the relevant program administrative rules. For the purpose of this rule, a subject individual does not include a peer support specialist who: (a) Is providing peer support services as defined by OAR ; (b) Is under the supervision of a qualified clinical supervisor; (c) Has completed training required by the Department; and (d) Is currently receiving or has formerly received mental health services, or is in recovery from a substance use disorder and meets the abstinence requirements for staff providing services in alcohol or other drug treatment programs. (2) Individuals who are employees and hired prior to July 28, 2009 are exempt from section (3) of this rule provided that the employee remains in the same position working for the same employer after July 28, This exemption is not applicable to licensees. (4) Public funds may not be used to support, in whole or in part, the employment of an individual in any capacity identified in section (1) of this rule who has been convicted: (a) In the last 10 years of a crime involving the delivery or manufacture of a controlled or (b) Of any of the following crimes: (A) ORS , Aggravated murder (B) ORS , Murder (C) ORS , Manslaughter I (D) ORS , Manslaughter II (E) ORS , Criminally negligent homicide (F) ORS , Aggravated vehicular homicide (G) ORS , Assault III (H) ORS , Assault II (I) ORS , Assault I (J) ORS , Strangulation (K) ORS , Criminal mistreatment II (L) ORS , Criminal mistreatment I (M) ORS , Kidnapping II (N) ORS , Kidnapping I (O) ORS , Subjecting another person to involuntary servitude II (P) ORS , Subjecting another person to involuntary servitude I (Q) ORS , Trafficking in persons (R) ORS , Coercion (S) ORS , Rape III (T) ORS , Rape II (U) ORS , Rape I (V) ORS , Sodomy III substance; 8

9 (W) ORS , Sodomy II (X) ORS , Sodomy I (Y) ORS , Unlawful sexual penetration II (Z) ORS , Unlawful sexual penetration I (AA) ORS , Sexual abuse III (BB) ORS , Sexual abuse II (CC) ORS , Sexual abuse I (DD) ORS , Online sexual corruption of a child II, if the offender reasonably believed the child to be more than five years younger than the offender (EE) ORS , Online sexual corruption of a child I, if the offender reasonably believed the child to be more than five years younger than the offender (FF) ORS , Contributing to the sexual delinquency of a minor (GG) ORS , Sexual misconduct, if the offender is at least 18 years of age (HH) ORS , Public indecency (II) ORS , Private indecency (JJ) ORS , Incest with a child victim (KK) ORS , Abandonment of a child (LL) ORS , Buying or selling a person under 18 years of age (MM) ORS , Using a child in display of sexually explicit conduct (NN) ORS , Paying for viewing a child s sexually explicit conduct (OO) ORS , Encouraging child sexual abuse I (PP) ORS , Encouraging child sexual abuse II (QQ) ORS , Encouraging child sexual abuse III (RR) ORS , Possession of materials depicting sexually explicit conduct of a child I (SS) ORS , Possession of materials depicting sexually explicit conduct of a child II (TT) ORS , Invasion of personal privacy (UU) ORS , Theft I EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 1 of 52 (VV) ORS , Aggravated theft I (WW) ORS , Organized retail theft (XX) ORS , Theft of services, if charged as a felony (YY) ORS , Burglary II (ZZ) ORS , Burglary I (AAA) ORS , Arson I (BBB) ORS , Computer crime, if charged with a felony (CCC) ORS , Robbery II (DDD) ORS , Robbery I (EEE) ORS , Criminal possession of a forged instrument I (FFF) ORS , Criminal possession of a forgery device (GGG) ORS , Identity theft (HHH) ORS , Aggravated identity theft (III) ORS , Promoting prostitution (JJJ) ORS , Compelling prostitution (KKK) ORS , Furnishing sexually explicit material to a child (LLL) ORS , Luring a minor (MMM) ORS , Sex crimes, including transporting child pornography into the state 9

10 (c) Of an attempt, conspiracy, or solicitation to commit a crime described in section(b) of this rule; or (d) Of a crime in another jurisdiction that is substantially equivalent to a crime described in section (2)(b) of this rule. The Department may conduct a weighing test under ORS on employees and individuals convicted of any crime in section (3) of this rule. However, the preclusive effect of ORS shall outweigh all other factors described in OAR EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 2 of 52 Stat. Auth.: ORS & Stats. Implemented: ORS & ORS Potentially Disqualifying Convictions A conviction of any of the following crimes is potentially disqualifying. Offenses or convictions that are classified as less than a misdemeanor, such as violations or infractions, are not potentially disqualifying (see ORS to ). The crimes listed in this section are permanent review crimes which require that a fitness determination be completed regardless of date of conviction. ORS , Escape II (b) ORS , Escape I (c) ORS , Tampering with a witness (d) ORS , Hindering prosecution (e) ORS , Criminal homicide (f) ORS , Aggravated murder (g) ORS , Murder (h) ORS , Manslaughter I (i) ORS , Manslaughter II (j) ORS , Criminally negligent homicide (k) ORS , Aggravated vehicular homicide (l) ORS , Assault IV (m) ORS , Assault III (n) ORS , Assault II (o) ORS , Assault I (p) ORS , Strangulation (q) ORS , Menacing (r) ORS , Criminal mistreatment II EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 3 of 52 (s) ORS , Criminal mistreatment I (t) ORS , Female genital mutilation (u) ORS , Assault of public safety officer (v) ORS , Unlawful use of an electrical stun gun, tear gas, or mace I (w) ORS , Kidnapping II (x) ORS , Kidnapping I (y) ORS , Custodial interference II (z) ORS , Custodial interference I (aa) ORS , Subjecting another person to involuntary servitude in the second degree (bb) ORS , Subjecting another person to involuntary servitude in the first degree (cc) ORS , Trafficking in persons 10

11 (dd) ORS , Coercion (ee) ORS , Rape III (ff) ORS , Rape II (gg) ORS , Rape I (hh) ORS , Sodomy III (ii) ORS , Sodomy II (jj) ORS , Sodomy I (kk) ORS , Unlawful sexual penetration II (LL) ORS , Unlawful sexual penetration I (mm) ORS , Sexual abuse III (nn) ORS , Sexual abuse II (oo) ORS , Sexual abuse I EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 4 of 52 (pp) ORS , Online sexual corruption of a child in the second degree (qq) ORS , Online sexual corruption of a child in the first degree (rr) ORS , Contributing to the sexual delinquency of a minor (ss) ORS , Sexual misconduct (tt) ORS , Custodial sexual misconduct I (uu) ORS , Custodial sexual misconduct II (vv) ORS , Public indecency (ww) ORS , Private indecency (xx) ORS , Unlawfully being in a location where children regularly congregate (yy) ORS , Unlawful contact with a child (zz) ORS , Bigamy (aaa) ORS , Incest (bbb) ORS , Abandonment of a child (ccc) ORS , Buying or selling a person under 18 years of age (ddd) ORS , Child neglect II (eee) ORS , Child neglect I (fff) ORS , Criminal nonsupport (ggg) ORS , Endangering the welfare of a minor (hhh) ORS , Using child in display of sexually explicit conduct 40(iii) ORS , Paying for viewing a child s sexually explicit conduct (jjj) ORS , Encouraging child sexual abuse I (kkk) ORS , Encouraging child sexual abuse II (LLL) ORS , Encouraging child sexual abuse III EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 5 of 52 (mmm) ORS , Possession of materials depicting sexually explicit conduct of a child I (nnn) ORS , Possession of materials depicting sexually explicit conduct of a child II (ooo) ORS , Failure to report child pornography (ppp) ORS , Invasion of personal privacy (qqq) ORS , Stalking (rrr) ORS , Violating court's stalking protective order (sss) ORS , Theft I (ttt) ORS , Aggravated theft I (uuu) ORS , Theft by extortion (vvv) ORS , Theft by deception 11

12 (www) ORS , Organized retail theft (xxx) ORS , Theft of services (yyy) ORS , Unauthorized use of a vehicle (zzz) ORS , Laundering a monetary instrument (aaaa) ORS , Burglary II (bbbb) ORS , Burglary I (cccc) ORS , Arson II (dddd) ORS , Arson I (eeee) ORS , Criminal mischief I (ffff) ORS , Computer crime (gggg) ORS , Robbery III (hhhh) ORS , Robbery II (iiii) ORS , Robbery I EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 6 of 52 (jjjj) ORS , Forgery I (kkkk) ORS , Criminal possession of a forged instrument I (LLLL) ORS , Criminal possession of a forgery device (mmmm) ORS , Fraudulent use of a credit card (nnnn) ORS , Negotiating a bad check (oooo) ORS , Cellular counterfeiting I (pppp) ORS , Identity theft (qqqq) ORS , Aggravated identity theft (rrrr) ORS , Unlawful possession of a personal identification device (ssss) ORS , Treason (tttt) ORS Aggravated harassment (uuuu) ORS , Abuse of corpse II (vvvv) ORS , Abuse of corpse I (wwww) ORS , Intimidation II (xxxx) ORS , Intimidation I (yyyy) ORS , Unlawful use of weapon (zzzz) ORS , Possession of weapons by certain felons (aaaaa) ORS , Unlawful possession of machine guns, certain short36 barreled firearms silencers (bbbbb) ORS , Possession of weapons by inmates of institutions (ccccc) ORS , Possession of firearm or dangerous weapon in public building or court exceptions; discharging firearm at school (ddddd) ORS , Possession of destructive device prohibited (eeeee) ORS , Unlawful manufacture of destructive device (fffff) ORS , Firearms used in felony and firearm facility; EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 7 of 52 (ggggg) ORS Obliteration or change of identification number on firearms (hhhhh) ORS , Racketeering activity unlawful (iiiii) ORS , Promoting prostitution (jjjjj) ORS , Compelling prostitution (kkkkk) ORS , Furnishing sexually explicit material to a child 12

13 (LLLLL) ORS , Luring a minor (mmmmm) ORS , Sadomasochistic abuse or sexual conduct in live show (nnnnn) ORS , Exhibiting an obscene performance to a minor (ooooo) ORS , Displaying obscene materials to minors (ppppp) ORS , Tampering with drug records (qqqqq) ORS , Adult using minor in commission of controlled substance offense (rrrrr) ORS , Animal abuse II (sssss) ORS , Animal abuse I (ttttt) ORS , Aggravated animal abuse I (uuuuu) ORS , Sexual assault of animal (vvvvv) ORS , Assaulting law enforcement animal (wwwww) ORS , Sex crimes including transporting child pornography into the state (xxxxx) ORS , Failure to report as sex offender (yyyyy) ORS , Spreading disease (willfully) prohibited (zzzzz) ORS , Sale of drug paraphernalia prohibited (aaaaaa) ORS , Providing hypodermic device to minor prohibited (bbbbbb) ORS , Prohibited acts generally (regarding drug crimes formerly ORS ) EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 8 of (cccccc) ORS , Unlawful manufacture of heroin (dddddd) ORS , Unlawful manufacture of heroin within 1,000 feet of school (eeeeee) ORS , Unlawful delivery of heroin (ffffff) ORS , Unlawful delivery of heroin within 1,000 feet of school (gggggg) ORS , Unlawful possession of heroin (hhhhhh) ORS , Unlawful manufacture of marijuana (iiiiii) ORS , Unlawful manufacture of marijuana within 1,000 feet of school (jjjjjj) ORS , Unlawful delivery of marijuana (kkkkkk) ORS , Unlawful delivery of marijuana within 1,000 feet of school (LLLLLL) ORS , Unlawful possession of marijuana (mmmmmm) ORS , Unlawful manufacture of 3,4-methylenedioxymethamphetamine (nnnnnn) ORS , Unlawful manufacture of 3,4-methylenedioxymethamphetamine within 1,000 feet of school (oooooo) ORS , Unlawful delivery of 3,4-methylenedioxymethamphetamine (pppppp) ORS , Unlawful delivery of 3,4-methylenedioxymethamphetamine within 1,000 feet of school (qqqqqq) ORS , Unlawful possession of 3,4-methylenedioxymethamphetamine (rrrrrr) ORS , Unlawful manufacture of cocaine (ssssss) ORS , Unlawful manufacture of cocaine within 1,000 feet of school (tttttt) ORS , Unlawful delivery of cocaine (uuuuuu) ORS , Unlawful delivery of cocaine within 1,000 feet of school (vvvvvv) ORS , Unlawful possession of cocaine EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 2 9 of 52 (wwwwww) ORS , Unlawful manufacture of methamphetamine (xxxxxx) ORS , Unlawful manufacture of methamphetamine within 1,005 feet of school (yyyyyy) ORS , Unlawful delivery of methamphetamine (zzzzzz) ORS , Unlawful delivery of methamphetamine within 1,000 fee 10 of school (aaaaaaa) ORS , Unlawful possession of methamphetamine 13

14 (bbbbbbb) ORS , Unlawful delivery of controlled substance within 1, feet of school (ccccccc) ORS , Penalties for distribution to minors (ddddddd) ORS , Causing another person to ingest a controlled substance (eeeeeee) ORS , Application of controlled substance to the body of another person (fffffff) ORS , Prohibited acts for registrants (with the Oregon State Board of Pharmacy) (ggggggg) ORS , Possession of precursor substance with intent to manufacture controlled substance (hhhhhhh) ORS , Commercial drug offense (iiiiiii) ORS Prohibited acts generally (regarding drug crimes; renumbered to ORS in 2005) (jjjjjjj) ORS , Prohibited acts (regarding the practice of medicine) (kkkkkkk) ORS , Penalties (pertaining to naturopathic medicine) (LLLLLLL) ORS Prohibited practices; rules (pertaining to pharmacy technicians and practitioners) (mmmmmmm) Any federal crime (nnnnnnn) Any U.S. military crime (ooooooo) Any unclassified felony defined in Oregon Revised Statutes not listed in this rule EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 0 of 52 (ppppppp) Any other felony in Oregon Revised Statutes not listed in this rule that is serious and indicates behavior that poses a threat or jeopardizes the safety of vulnerable persons, as determined by the AD (qqqqqqq) Any felony in a jurisdiction outside Oregon that is not the substantial equivalent of any of the Oregon crimes listed in this section but that is serious and indicates behavior that poses a threat or jeopardizes the safety of vulnerable persons, as determined by the AD (rrrrrrr) Any crime of attempt, solicitation, or conspiracy to commit a crime listed in this section pursuant to ORS , , or , including any crime based on criminal liability for conduct of another pursuant to ORS (sssssss) Any crime in any other jurisdiction that is the substantial equivalent of any of the Oregon crimes listed in section (1) of this rule, as determined by the AD (ttttttt) Any crime that is no longer codified in Oregon or other jurisdiction but that is the substantial equivalent of any of the crimes listed in section (1)of this rule, as determined by the AD (2) The crimes listed in this section are ten-year review crimes which require that a fitness determination be completed if the date of conviction is within ten years of the date the Background Check Request form was signed or the date the Department conducted a criminal records check due to imminent risk. (a) ORS , Contempt of court b) ORS , Prohibited fees-adoption (c) ORS , Failure to appear on criminal citation (d) ORS (3), Violation of restraining order (e) ORS , Punishment by contempt of court (violation of release agreement) (f) ORS , Bribe giving (g) ORS , Bribe receiving (h) ORS , Perjury (i) ORS , False swearing (j) ORS , Public investment fraud EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 1 of 52 (k) ORS , Escape III (L) ORS , Unauthorized departure 14

15 (m) ORS , Supplying contraband (n) ORS , Failure to appear II (o) ORS , Failure to appear I (p) ORS , Interfering with a peace officer (q) ORS , Interfering with a firefighter or emergency medical technician (r) ORS , Bribing a witness (s) ORS , Bribe receiving by a witness (t) ORS , Tampering with physical evidence (u) ORS , Tampering with public records (v) ORS , Resisting arrest (w) ORS , Compounding (x) ORS , Simulating legal process (y) ORS , Criminal impersonation (z) ORS , Criminal impersonation of peace officer (aa) ORS , Possession of false law enforcement identification card (bb) ORS , Initiating a false report (cc) ORS , Giving false information to police officer for a citation (dd) ORS , Official misconduct II (ee) ORS , Official misconduct I (ff) ORS , Misuse of confidential information (gg) ORS , Recklessly endangering another person (hh) ORS , Aggravated driving while suspended or revoked EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 2 of 52 (ii) ORS , Unlawful use of an electrical stun gun, tear gas, or maceii (jj) ORS , Theft III (kk) ORS , Theft II (LL) ORS , Theft by receiving (mm) ORS , Criminal possession of a rented or leased motor vehicle (nn) ORS , Criminal possession of rented or leased personal property (oo) ORS , Mail theft or receipt of stolen mail (pp) ORS , Possession of a burglary tool or theft device (qq) ORS , Criminal trespass I (rr) ORS , Criminal trespass while in possession of firearm (ss) ORS , Unlawful entry into motor vehicle (tt) ORS , Criminal mischief II (uu) ORS , Forgery II (vv) ORS , Criminal possession of a forged instrument II (ww) ORS , Criminal simulation (xx) ORS , Fraudulently obtaining a signature (yy) ORS , Possessing fraudulent communications device (zz) ORS , Unlawful factoring of credit card transaction (aaa) ORS , Falsifying business records (bbb) ORS , Sports bribery (ccc) ORS , Sports bribe receiving (ddd) ORS , Misapplication of entrusted property (eee) ORS , Issuing a false financial statement 15

16 EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 3 of 52 (fff) ORS , Obtaining execution of documents by deception(ggg) ORS , Obtaining contents of communication (hhh) ORS , Interception of communications (iii) ORS , Improper use of emergency reporting system (jjj) ORS , Interference with making a report (kkk) ORS , Cellular counterfeiting III (LLL) ORS , Cellular counterfeiting II (mmm) ORS , Making false claim for health care payment (nnn) ORS , Riot (ooo) ORS , Disorderly conduct I (ppp) ORS , Disorderly conduct II (qqq) ORS , Harassment (rrr) ORS , Abuse of a memorial to the dead (sss) ORS , Telephonic harassment (ttt) ORS , Interfering with public transportation (uuu) ORS , Negligently wounding another (vvv) ORS , Pointing firearm at another (www) ORS , Carrying of concealed weapon (xxx) ORS , Unlawful possession of firearms (yyy) ORS , Limitations and conditions for sales of firearms (zzz) ORS , Sale or gift of explosives to children (aaaa) ORS , Throwing an object off an overpass II (bbbb) ORS , Throwing an object off an overpass I (cccc) ORS , Unlawful paramilitary activity EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 4 of 52 (dddd) ORS , Prostitution (eeee) ORS , Publicly displaying nudity or sex for advertising purposes (ffff) ORS , Unlawful gambling in the second degree (gggg) ORS , Unlawful gambling in the first degree (hhhh) ORS , Cheating (iiii) ORS , Frequenting a place where controlled substances are used (jjjj) ORS , Animal neglect II (kkkk) ORS , Animal neglect I (LLLL) ORS , Interfering with law enforcement animal (mmmm) ORS , Animal abandonment (nnnn) ORS , Interfering with assistance, search and rescue or therapy animal (oooo) ORS , Involvement in animal fighting (pppp) ORS , Dogfighting (qqqq) ORS , Participation in dogfighting (rrrr) ORS , Cockfighting (ssss) ORS , Participation in cockfighting (tttt) ORS , Concealing the birth of an infant (uuuu) ORS , Criminal penalty (pertaining to Address Confidentiality Program) (vvvv) ORS , Evading requirements of law prohibited (tax evasion) (wwww) ORS , Unlawfully obtaining public assistance (xxxx) ORS , Unlawfully receiving public assistance 16

17 (yyyy) ORS , Submitting wrongful claim or payment (e.g., public assistance) (zzzz) ORS , Unlawfully obtaining or disposing of food stamp benefits EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 5 of 52 (aaaaa) ORS , Unauthorized use and custody of records of temporary assistance for needy families program (bbbbb) ORS , Sharing assistance prohibited (ccccc) ORS , Penalty for placement of children in violation of compact (ddddd) ORS , Providing liquor to persons under 21 or to intoxicated persons; allowing consumption by minor on property (eeeee) ORS , Unlawful delivery of imitation controlled substance (fffff) ORS , Prohibited acts involving records and fraud (ggggg) ORS , Falsifying drug test results (hhhhh) ORS , Failure to report precursor substances transaction (iiiii) ORS , Failure to report missing precursor substances (jjjjj) ORS , Illegally selling drug equipment 2(kkkkk) ORS , Providing false information on precursor substances report (LLLLL) ORS , Forging, altering or unlawfully producing or using title or registration (mmmmm) ORS , Giving false information to police officer (nnnnn) ORS , Vehicular assault of bicyclist or pedestrian (ooooo) ORS , Reckless driving (ppppp) ORS , Fleeing or attempting to elude police officer (qqqqq) ORS , Failure to perform duties of driver when property is damaged (rrrrr) ORS , Failure to perform duties of driver to injured persons (sssss) ORS , Possession of a stolen vehicle (ttttt) ORS , Failure to perform the duties of an operator (boat) (uuuuu) Any unclassified misdemeanor defined in Oregon Revised Statutes not listed elsewhere in this rule EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 6 of 52 (vvvvv) Any other misdemeanor in Oregon Revised Statutes not listed in this rule that is serious and indicates behavior that poses a threat or jeopardizes the safety of vulnerable persons, as determined by the AD (wwwww) Any misdemeanor in a jurisdiction outside Oregon that is not the substantial equivalent of any of the Oregon crimes listed in section (2) of this rule but that is serious and indicates behavior that poses a threat or jeopardizes the safety of vulnerable persons, as determined by the AD. If a misdemeanor in a jurisdiction outside Oregon is similar to a violation in Oregon, then it may not be considered potentially disqualifying under this section. (xxxxx) Any crime of attempt, solicitation or conspiracy to commit a crime listed in this section pursuant to ORS or , including any conviction based on criminal liability for conduct of another pursuant to ORS (yyyyy) Any crime in any other jurisdiction which is the substantial equivalent of any of the Oregon crimes listed in section (2) of this rule, as determined by the AD (zzzzz) Any crime which is no longer codified in Oregon, but which is the substantial equivalent of any of the crimes listed in section (2) of this rule, as determined by the AD The crimes listed in this section are five-year review crimes which require that a fitness 17

18 determination be completed if the date of conviction is within five years of the date the Background Check Request form was signed or the date the Department conducted a criminal records check due to imminent risk. (a) ORS , Unsworn falsification (b) ORS , Obstructing governmental or judicial administration (c) ORS , Criminal trespass II (d) ORS , Reckless burning (e) ORS , Criminal mischief III (f) ORS , Unlawful telephone solicitation of contributions for charitable purposes (g) ORS , Unlawful possession of fictitious identification (h) ORS , Abuse of venerated objects EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 7 of 52 (i) ORS , Misconduct with emergency telephone calls (j) ORS , Criminal driving while suspended or revoked (k) ORS , Driving under the influence of intoxicants (DUII) (L) ORS , Reckless operation of a boat (m) ORS , Operating boat while under influence of intoxicating liquor or controlled substance (n) ORS , False information to peace officer or Oregon State Marine Board (o) Any conviction for attempt, solicitation or conspiracy to commit a crime listed in this section pursuant to ORS or , including any conviction based on criminal liability for conduct of another pursuant to ORS (p) Any crime in any other jurisdiction which is the substantial equivalent of any of the Oregon crimes listed in section (3) of this rule, as determined by the AD (q) Any crime which is no longer codified in Oregon, but which is the substantial equivalent of any of the crimes listed in section (3) of this rule, as determined by the AD (4) Evaluations of crimes may be based on Oregon laws and laws in other jurisdictions in effect at the time of the fitness determination, regardless of the jurisdiction in which the conviction occurred (5) An SI may not be denied under these rules due to the existence or contents of a juvenile 33 record that has been expunged pursuant to ORS 419A.260 to 419A (6) An SI may not be denied under these rules due to the existence or contents of an adult 36 record that has been set aside pursuant to ORS Stat. Auth.: ORS & Stats. Implemented: ORS , & Other Potentially Disqualifying Conditions The following are potentially disqualifying conditions: (1) The SI makes a false statement to the QE, AD, or Department, including the provision of 47 materially false information, false information regarding criminal records, or failure to EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 8 of 52 1 disclose information regarding criminal records. Nondisclosure of violation or infraction 18

19 2 charges may not be considered a false statement. 3 4 (2) The SI is a registered sex offender in any jurisdiction. There is a rebuttable presumption 5 that an SI is likely to engage in conduct that would pose a significant risk to vulnerable 6 individuals if the SI has been designated a predatory sex offender in any jurisdiction 7 under ORS or found to be a sexually violent dangerous offender under ORS (or similar statutes in other jurisdictions) (3) The SI has an outstanding warrant for any crime in any jurisdiction (4) The SI has a deferred sentence, conditional discharge, or is participating in a diversion 13 program in any jurisdiction for any potentially disqualifying crime. (5) The SI is currently on probation, parole, or post-prison supervision for any crime in any jurisdiction, regardless of the original conviction date (or date of guilty or no contest plea if there is no conviction date). (6) The SI has been found in violation of post-prison supervision, parole, or probation for any crime in any jurisdiction, regardless of the original conviction date (or date of guilty or no contest plea if there is no conviction date), within five years from the date the Background Check Request form was signed or the date the Department conducted a criminal records check due to imminent danger. (7) The SI has an unresolved arrest, charge, or a pending indictment for any crime in any jurisdiction. (8) The SI has been arrested in any jurisdiction as a fugitive from another state or a fugitive from justice, regardless of the date of arrest. (9) The SI has an adjudication in a juvenile court in any jurisdiction, finding that the SI was responsible for a potentially disqualifying crime that would result in a conviction if committed by an adult. Subsequent adverse rulings from a juvenile court, such as probation violations, shall also be considered potentially disqualifying if within five years from Department conducted a criminal the date the Background Check Request form was signed or the date the records check due to imminent danger. (10) The SI has a finding of guilty except for insanity, guilty except by reason of insanity, not guilty by reason of insanity, responsible except for insanity, not responsible by reason of mental disease or defect, or similarly worded disposition in any jurisdiction regarding a potentially disqualifying crime, unless the local statutes indicate that such an outcome is considered an acquittal. (11) Child protective services reports that have a outcome of founded, substantiated, or valid in which the SI is determined to have been responsible for the abuse. This potentially disqualifying condition only applies when: EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 3 9 of 52 (a) The Department administrative rules specifically require a protective services background check as part of the application process including but not limited to child homes, adoptive families, licensed private child caring agencies, or child care providers; and 6(b) The BCU has the authority to conduct an abuse check. foster Stat. Auth.: ORS & Stats. Implemented: ORS , &

20 Weighing Test When making a fitness determination, the AD shall consider any of the following factors if an SI has potentially disqualifying convictions or conditions as disclosed by the SI or which is otherwise known: (1) Circumstances regarding the nature of potentially disqualifying convictions and conditions including but not limited to: (a) The details of incidents leading to the charges of potentially disqualifying convictions or resulting in potentially disqualifying conditions. (b) Age of the SI at time of the potentially disqualifying convictions or conditions. (c) Facts that support the convictions or potentially disqualifying conditions. (d) Passage of time since commission of the potentially disqualifying convictions or conditions. (e) Consideration of state or federal laws, regulations, or rules covering the position, facility, employer, or QE regarding the potentially disqualifying convictions or conditions. (2) Other factors when available including but not limited to: (a) Other information related to criminal activity including charges, arrests, pending indictments, and convictions. Other behavior involving contact with law enforcement may also be reviewed if information is relevant to other criminal records or shows a pattern relevant to criminal history. (b) Periods of incarceration. (c) Status of and compliance with parole, post-prison supervision, or probation. (d) Evidence of alcohol or drug issues directly related to criminal activity or potentially disqualifying conditions. EFFECTIVE 10/31/2010 (based on date subject individual signs the Background Check Request form) Page 4 0 of 52 (e) Evidence of other treatment or rehabilitation related to criminal activity or potentially disqualifying conditions. (f) Likelihood of repetition of criminal behavior or behaviors leading to potentially disqualifying conditions, including but not limited to patterns of criminal activity or behavior. (g) Information from the Department s protective services, abuse or other investigations in which the investigator documented behavior or conduct by the subject individual that would pose a risk to or jeopardize the safety of vulnerable individuals. (h) Changes in circumstances subsequent to the criminal activity or disqualifying conditions including but not limited to: (A) History of high school, college, or other education related accomplishments. (B) Work history (employee or volunteer). (C) History regarding licensure, certification, or training for licensure or certification. (D) Written recommendations from current or past employers, including Department client employers. (i) Indication of the SI s cooperation, honesty, or the making of a false statement during the criminal records check process, including acknowledgment and acceptance responsibility of criminal activity and potentially disqualifying conditions. (3) The AD shall consider the relevancy of the SI s criminal activity or potentially disqualifying conditions to the paid or volunteer position, or to the environment in which the SI will reside, work, or visit. 36 Stat. Auth.: ORS & Stats. Implemented: ORS , &

21 DISCLOSURE AND AUTHORIZATION REGARDING PROCUREMENT OF BACKGROUND REPORTS In connection with my nursing assistant training, I understand that investigative background inquiries are to be made on me which may include criminal convictions, and other reports. Further, I understand that you will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my, criminal, civil and other experiences. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from any liability and responsibility for doing so. This authorization and consent shall be valid in original, fax or copy form. Applicant Signature: Date: Please PRINT clearly: Name: Maiden / AKA: First Middle Last Current Address: County: City: State: Zip: How long: Phone Number: Cell Phone #: Fitness Determination Oregon History Results No potentially disqualifying history Potentially disqualifying history disclosed Probationary status granted Yes No Signature: Date: Return signed copy with completed BNA - Application 21

22 COPY OF OWN RECORD REQUEST This form is to be used ONLY when requesting a copy of YOUR OWN Oregon Criminal History information or clearance letter. This form may be copied. NAME: Last, First, Middle OTHER NAMES USED: DATE OF BIRTH: / / month day year SOCIAL SECURITY NUMBER: (optional) - - YOUR MAILING ADDRESS: Street or P.O. Box City, State, Zip Code Country TELEPHONE ( ) MY CHECK OR MONEY ORDER, PAYABLE TO OREGON STATE POLICE, IS INCLUDED FOR THIS SERVICE AS FOLLOWS: COPY OF OWN RECORD ($33.00) $ PLEASE NOTARIZE RESPONSE ($5.00) $ TOTAL INCLUDED $ **Your fingerprint card will be returned with your response. Mail this document with your fingerprints (and money) to the following address: Oregon State Police Identification Services Section Unit 11 P.O. Box 4395 Portland, OR The results, along with the fingerprint cards submitted will be returned to you. Please allow 5-10 business days to receive your response. DUE TO THE CONFIDENTIALITY OF CRIMINAL HISTORY RECORD INFORMATION, RESULTS WILL BE MAILED ONLY TO THE REQUESTOR. For questions or further information, please contact us at: (503) Make a copy and return with BNA - Application Date submitted 22

23 OREGON ONLINE BNA PROGRAM Southwestern Oregon Community College 1988 Newmark Ave, Coos Bay, OR (541) Full Legal Name Home Community College Address: Street City State Zip Social Security # Phone Number(s) Home Cell Race Birth date City & State where you were born Attach copies of documentation verifying the following Do not submit original documents Immunizations, titers or diagnosis by a medical doctor of childhood illness Program Staff Only MMR (Measles, Mumps, Rubella) Dose 1 MMR (Measles, Mumps, Rubella) Dose 2 Tdap (Tetanus and Diptheria) (within the last 10 years) Varicella (Chicken pox) Tuberculin skin test (PPD) or chest x ray (within the last 6 months) Hepatitis B CPR Card Date Criminal Background Check Initiated : Oregon State Police Other: NAME Are there any conditions requiring you to need accommodations while in the course? Yes No (If yes, please explain) I verify that I have received and reviewed the BNA Information Packet. I recognize that I am responsible for understanding and complying with the written material in the Information Packet. Applicant Signature Date I verify that I have reviewed the Department of Human Resources list of Potentially Disqualifying Crimes (ORS through ), viewed at: and the Nurse Practice Act, Division 63 viewed at: I have read and agree with the terms of SOCC s Criminal Background Clearance Release policy. Applicant Signature Date I understand that I must obtain CPR certification before clinical begin. Only American Heart Association BLS (Basic Life Support) for Healthcare Providers or American Red Cross CPR/AED for the Professional Rescuer cards will be accepted. Applicant Signature Date Make a copy of this application and supporting documentation for your records Application received and documentation verified: Community College is an equal opportunity educator and employer Southwestern Oregon 23