Estimated course cost: $2,647 (Fees: $550 lab, $63 network, $387 consolidated) Fingerprinting $15 (completed and paid in class) $15 Textbook $100

Transcription

1 Certified Nurse Aide (C.N.A.) Training Application UAS / Juneau - Health Sciences Department Fall 2015 August 31 to December 10, 2015 Health Sciences (HS) Section J01 (CRN 78514) 9 credit course Wildflower Court: Lecture/Lab: Tuesdays and Thursdays from (10:30a to 4:30p) CPR/First Aid: Friday, October 23, 2015 from (5:00p to 9:30p) and Saturday, October 24, 2015 from (8:30a to 5:30p) Technical Education Center Clinical: Thursday, Friday, Saturday from (6:00a to 2:30p) WFC and JPH Clinical Dates: October 29, 30, 31, and November 5, 6, 7 Mandatory Orientation: Friday, August 28, hours TBA via doodle poll of selected applicants Interested students are encouraged to submit their application as soon as possible as maximum enrollment is eight (8) students. Application review and acceptance into the class is based on receipt of a completed application that includes: (1) criminal background check, (2) health screening form, (3) personal data sheet, and (4) Accuplacer English placement exam (or completion of college level English course verified by college transcript official or unofficial). Applications will be reviewed starting April 20, 2015, and applicants will be notified via or phone call regarding acceptance into the course. When approved, applicants will have two weeks to register. If applicants do not register during notified time period, their training seat may be given to another application on the waitlist without notification. (Please note that the course can be canceled due to low enrollment.) Tuition and fees will be billed at the time of registration, and all account balances are due to UAS by Tuesday, August 25, Students without financial aid or payment arrangements by the above deadline may be dropped from the course without notification. (Please note this course is only eligible for federal financial aid if a student has applied and been admitted to a UAS degree program.) Please contact UAS Student Accountants at to discuss payment options or visit Please return completed applications to: Health Sciences Department / University of Alaska Southeast Glacier Highway / Office: Hendrickson 205 / Mailstop: HB2 / Juneau, AK (907) fax / eawilliams2@uas.alaska.edu Estimated course cost: In-State Tuition & Fees $1,647 in-state tuition + $1,000 fees $2,647 (Fees: $550 lab, $63 network, $387 consolidated) Fingerprinting $15 (completed and paid in class) $15 Textbook $100 $100 ( State Exam Fee $260 $260 (paid to Board of Nursing with application to test) Total $3,022 Out-of-State Tuition & Fees (resident less than 2 years) $5,841 out-of-state tuition (total $6,841)

2 Application Information & Requirements State of Alaska Board of Nursing Nurse Aide Registry: 1. Criminal Background Check (CBC): Copy is accepted if dated December 10, 2014 to present date. Copies can be obtained for $20.00 at: Juneau Trooper Station (above DMV in Valley) (907) Hours: 8am-12noon & 1:00-3:30pm 2 pieces of ID needed Cash or personal check (no debit/credit cards) If applicants have any violations on their criminal background check (as minor or adult), applicants should contact the Nurse Aide Licensing Examiner before submitting their training application to UAS. Please see attached letter regarding Certified Nurse Aide eligibility. Lisa Maroney, Records and Licensing Supervisor Telephone: (907) lisa.maroney@alaska.gov Address: 550 W. 7 th Avenue, Suite 1500, Anchorage, AK Website: 2. Health Screening Form: Health screenings need to be current (dated December 10, 2014 to present date) to verify physical and emotional fitness for direct patient care work. A Nurse Practitioner, Physician Assistant, or Doctor must sign-off the attached physical form. TB (PPD) tests must also be dated December 10, 2014 to present date. (If you have ever tested positive for TB, please tell the practitioner before being retested.) Students taking at least one Juneau campus credit are eligible to use the UAS Health Center, located in the Student Resource Center, to complete their physical with the PA-C. To make an appointment, please call the SRC at , and clarify that you would like to make an appointment for a C.N.A. physical and Tb (PPD) test. 3. UAS English Placement Exam: If you have not completed a college level English course at UAS or another college/university, applicants are required to submit English placement assessment results. (English course taken at another college or University must be confirmed via an official or unofficial transcript.) The Accuplacer English Placement Assessment can be taken at the UAS Testing & Learning Center (bottom floor of the Egan Library on the Auke Bay campus). There is no fee for the first attempt, and the test takes approximately 2.5 hours (no time limit) to complete. The assessment can be taken anytime the Learning Center is open - no appointment needed. Hours: Monday-Thursday 9am-8pm / Friday 9am-4pm / Saturday Closed /Sunday 3pm-7pm Acceptance into course requires minimum reading score of 55. Applicants with a reading assessment score at or above 65 preferred. Applicants with English placement scores at Engl 110 or higher preferred. Please retain page 1-2 and letter re: certified nurse aide eligibility and professional conduct for your records. 2 revised jneaw- FA15

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7 Certified Nurse Aide Training Course Application University of Alaska Southeast / School of Career Education Health Sciences Department / Juneau Personal Data First: M.I. Last: Mailing Address: City: State: Zip: UAS ID#: Birthdate: / / Phones: (home) (cell) 1. Are you a UAS degree seeking student? If so, degree program? 2. Any known allergies: 3. Highest level of education: 4. Do you have any health care work experience? (Not required): 5. Are you in good standing academically and financially with the University?: Yes No 6. How do you plan to pay for the course? (check all that apply) Financial aid/scholarships Agency Sponsorship: Out-of-Pocket Other: I have read and understand the course requirements provided in the coversheet as well as the Board of Nursing Certified Nurse Aide Eligibility letter. I agree to all conditions of application. Printed Name Signature Date For Office Use Required Items for Consideration Received Initials Date Received Application Check-Off 1. Personal Data and Signature (page 1) Notification SFASRPO 2. Criminal Back Ground Check Without Violations With Violations 3. Health Screening by Health Professional w/ TB results (page 2) 4. Accuplacer English Assessment or College (Official or Unofficial) Transcript Phone

8 Health Screening Form (This must be completed & signed by an MD, NP, or PA.) Tuberculosis Test (PPD) (MANDATORY) Date Given Result Signature/Date TB test must have been done between December 10, 2014 to present. If the TB test was positive, please give details: PHYSICAL FITNESS This individual has adequate physical ability and endurance necessary to: Yes No Stand, walk, climb stairs, stoop, kneel, crouch, flex, and bend. Apply correct body mechanics for lifting, rolling, and sliding persons or objects weighing at least 50-pounds. Accurately perceive sound (ex: normal speech, work place noises, alarms, and bells). Accurately perceive odors (ex: food, body fluids, and medications). Accurately see and read small print and wrist watch (ex: charting documents, BP gauges). Accurately identify colors. EMOTIONAL FITNESS This individual has the emotional capability to: Yes No Appropriately cope with illness, death, and dying. Appropriately communicate (oral/written) with co-workers, supervisors, and instructors. Knows and employs positive coping mechanisms and support systems. If the answer is NO to any of the above physical and/or emotional fitness evaluations, please provide details. I have examined (applicants name here), and I (health care professional) verify that the applicant is fit and able to carry out the duties required of a direct care health care worker. Printed Name: Title: Date: / / Medical Provider s Signature: Release of Information: I hereby authorize the release of medical information relevant to my fitness and ability to provide direct patient care during my clinical program training at the University of Alaska Southeast. Applicant s Signature Date 2 revised jneaw- FA15