Nursing Assistant I Admission Requirements

Transcription

1 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Nursing Assistant I Admissin Requirements 1. High Schl Diplma, GED r Cllege Transcripts 2. Driver s License r State ID 3. Scial Security Card 4. Physical Examinatin 5. Criminal Backgrund Check (included with curse) Panel Drug Test ($40.00, dne n the premises 1 week prir t Clinical rtatin) 7. CPR Certificatin ($35.00, dne n premises during class) 8. TB Test ($20.00, dne n premises prir t clinicals) 9. Verificatin f the Immunizatin: (must have immunizatin verificatin frm cmpleted and attached t applicatin) Tetanus r Diptheria (within 10 years) Varicella (Chicken Px) (psitive histry r titer dcumented) Rubella r psitive titer (German Measles) Rubela (Measles) 1 dse and (2 dses after 1 st birthday fr any persn brn after 1957) r psitive titer Mumps (1 st dse fr any persn brn n r after January 1, 1957) r psitive titer PPD Skin Test (TB) (have ne dne each year) Chest X-Ray and INH if PPD is psitive Chest X-Ray if knwn t be PPD psitive in the past 1 f 19

2 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Fax: Applicatin Name: Address: City: State: Zip: DOB: Scial Security #: Hme Phne #: Cell: Alternate Cntact #: Emergency #: Address: Are yu ver 18 years ld? Have yu been cnvicted by any gvernment Yes N agency f child, patient resident, r elderly abuse? Yes If yes, explain: Are yu being spnsred by a Medicaid certified facility? Yes N If yes, yu are nt respnsible fr any cst assciated with training including the cst f textbk and r supplies. Name f Facility: Address: Phne Number: Cntact Persn: Educatin: SCHOOL NAME AND ADDRESS START MO/YR END DATE MO/YR DID YOU GRADUATE? DEGREE Cllege/University: SCHOOL START MO/YR END DATE MO/YR DID YOU GRADUATE? DEGREE Other Educatin: 2 f 19

3 Other Certificatins: Emplyment Histry: (mst recent emplyment first) Emplyer Name and Address START MO/YR END DATE MO/YR POSITION CPR Certified? YES NO Wh referred yu t us? I certify that the infrmatin prvided in this applicatin is true and cmplete t the best f my knwledge. I agree that if I misrepresent r mit any relevant infrmatin r prvide false answers, American Academy f Healthcare will disqualify r discharge me frm the Prgram withut refund. Signature Nursing Assistant I Nursing Assistant II Medicatin Aide Phlebtmy Pharmacy Tech Health Unit Crdinatr Wund Care Prgram DON/Administratr Prgram Maintaining a Hme Care Agency Return the fllwing items: *Cmpleted Applicatin *Backgrund Cnsent Frm *Student Interview Frm *Immunizatin Recrd *Physical Examinatin *Driver s License (Clr Cpy) *$125 Nn-refundable Registratin Fee *Scial Security Card (Clr Cpy) MAIL TO: American Academy f Healthcare, LLC 5000 Natins Crssing Rad Charltte, NC Accepted Frms f Payment Cash Mney Order $ Depsit Secures Seat in NA I Class 3 f 19

4 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Enrllment Agreement Student Name: Address: City: Phne #: State: Zip: S.S. #: Address: Prgram Infrmatin: Nursing Assistant I Nursing Assistant II Medicatin Aide Phlebtmy Pharmacy Tech Start : Health Unit Crdinatr Maintaining a Hme Care Agency Wund Care Prgram DON/Administratr Prgram End : A class schedule fr which yu enrlled (meets n day f week): A Certificate f Cmpletin will be awarded at the end f the prgram and successful students will be recmmended fr listing as a CNA I by the NC Nurse Aide Registry. Fees and Charges: Yu are respnsible fr paying the fllwing Fees and Charges: Registratin Fee Tuitin Text Bk Criminal Check Ttal $ $ $ Incl. $ Incl. $ Ttal charges fr Registratin and the Nursing Assistant I Curse is due and payable n r befre the first day f class, if yu chse t make a payment plan, yu are still respnsible t cmplete the payment even if yu did nt cmplete the prgram. 4 f 19

5 Terms and Understanding: As a Student f American Academy f Healthcare, I understand that: 1. The schl des nt guarantee emplyment fllwing graduatin. 2. The schl deserves the right t terminate a student s training fr failure t abide by the Attendance Plicy, failure t maintain satisfactry academic prgress, failure t abide by the schl rules and regulatins and fr ther reasns as detailed by the schl catalg. 3. All fees such as tuitin, unifrms, stethscpes, bks, CPR and ther miscellaneus items are t be paid prir t clinical rtatin in a facility, r the schl deserves the right t terminate a student s training Initials fr failure t abide by the Payment Plicy. Initials 4. The textbk is prvided by the schl and I am paying fr it under the heading textbk, all ther materials that I will use in the lab and in the prcess f learning des nt belng t me and shuld nt be remved frm the classrm. 5. The schl des nt guarantee the transfer f credit t any ther institutin. 6. Any ntificatin f withdrawal r cancellatin must be in writing. 7. This agreement is legally binding instrument when signing by yu and accepted by the schl. Yur signature n this agreement acknwledges that yu have been given reasnable time t read and understand it and that yu have been given the schl catalg including a descriptin f this prgram, including all material facts cncerning the schl and the prgram f instructin which are likely t affect yur decisin t enrll. Students Right t Cancel: Yu may cancel this enrllment agreement fr the schl at any time up t the first day f class. If yu cancel this agreement, any payment yu have made will be refunded t yu within 30 days. T cancel the enrllment agreement fr the schl yu must mail r deliver a signed and dated cpy f the cancellatin ntice r any written ntice t the schl at its fficial address. Fr all ther refunds, please see the refund plicy. Acknwledgement: D nt sign this cntract befre yu read it r if it cntains blank spaces. Yu are entitled t an exact cpy f the cntract that yu sign. Keep it t prtect yur legal rights. My signature certifies that I have read, understd and agreed t my rights and respnsibilities, that the institutin s cancellatin and refund plicies have been clearly explained t me and that I have a cpy f this agreement. Student Signature I hereby accept this agreement n behalf f the schl. Schl Official Signature Title 5 f 19

6 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: STUDENT ACKNOWLEDGEMENT Name: : I hereby acknwledge that I have received the American Academy f Healthcare Orientatin Plicy Manual and I have reviewed the plicies in this bklet with the Instructr assigned. Attendance Plicy Unifrm Plicy Privacy Acknwledgement and Nn-Disclsure Abuse and Neglect Plicy Cmpetency Evaluatin Skills Testing Prcedures Initials I have been given the pprtunity t ask any questins needed t clarify the infrmatin cntained within. I als understand that I may request additinal infrmatin r explanatin at any time while I am a student with American Academy f Healthcare. Initials I als understand that all students fees have t be paid in full prir t clinical rtatin. If my clinical file is incmplete prir t clinical rtatin, I will nt be attending the rtatin at the assigned facility and will nt be able cntinue in the prgram. TB Results Immunizatin Recrd Physical Examinatin Drug Screen Request, Authrizatin, Cnsent and Release fr Backgrund Check Criminal Backgrund Check Initials I als understand that if any part f my student file is incmplete at the time f cmpletin f the curse, I will nt receive Transcripts and/r a Certificate f Cmpletin. Educatin Criteria Driver s License Scial Security Card CPR Certificatin Quizzes/Final Exam/Mck Skills Exam Initials Student Signature I hereby accept this agreement n behalf f the schl. Schl Official Signature 6 f 19

7 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Attendance Plicy All students are expected t attend required class, labratry and related experiences, shw evidence f preparatin fr learning and activity and be punctual. Students must cmplete hurs which includes 75.0 hurs (seventy five hurs f classrm) instructin/skill practicum and 40.0 hurs (frty hurs f clinical) experience in the apprved lng-term care facility as apprved by the prgram. Absences shuld ccur nly in situatins f persnal illness, immediate family illness, military leave r death. It is the respnsibility f the student t arrange fr a make up which is at the discretin f the Prgram Directr. Excessive absences mre than sixteen hurs will result in failure t meet prgram requirement and the student may be asked t withdraw r jin the next class. A Physician s verificatin fr illness may be required at the prgram directr s discretin. Print Name Signature Schl Official Signature 7 f 19

8 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: UNIFORM POLICY American Academy f Healthcare, LLC believes that prper dressing is essential fr the student t present themselves in a prfessinal manner t prmte a psitive envirnment. Therefre, students are expected t dress in an apprpriate and acceptable manner fr class, fr clinical and any activity related t training. Students are required t wear ID badges at all times while at the academy fr clinical rtatin. CLINICAL: Students will wear white scrub unifrms with natural r white hse fr wmen and white scks fr men. White crew neck tee shirt r white mck turtle necks may be wrn under the scrub tps fr warmth. White lab cats r jackets may als be wrn. White shes/tennis shes and name badge. N visible bdy piercing is allwed ther than earrings. Limited jewelry, earrings are t be nly small tack r small hp. Artificial nails r nails that are lng may nt be wrn by any student wh prvides direct resident care. Printed Name Schl Official Signature 8 f 19

9 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: PRIVACY ACKNOWLEDGEMENT AND NON-DISCLOSURE AGREEMENT The facility is cmmitted t prtecting the privacy f all Residents and prtecting the cnfidentiality f their health care infrmatin. The fllwing specific principles are applicable t all f the facility emplyees, independent health care prfessinals invlved in the care f Residents at the facility, vlunteers, students, faculty, vendrs and cntractrs regardless f their jb classificatin r psitin. While wrking with Residents at/r the facility, I realize that I may have access t/r becme aware f cnfidential Resident medical infrmatin, whether r nt I am directly invlved in prviding care t that Resident. I understand that I must keep this infrmatin n the strictest f cnfidence. As a cnditin f my emplyment r wrk at the facility, I agree that I: Will nt verbally r in any written frm disclse cnfidential Resident infrmatin t any unauthrized persn. Will nt permit any unauthrized persn t examine r make cpies f any Resident s recrds, reprts, ther dcuments, r data files prepared, cntrlled, r accessible by me at any time during r after my emplyment r wrk at the facility. Will nt examine, use, r disclse cnfidential Resident medical infrmatin except as needed t perfrm the duties f my jb. Will nt knwingly include r cause t be included in any recrd r reprt, a false, inaccurate, r misleading entry. Will nt remve r cpy any recrd r reprt frm the ffice where it is kept except in the perfrmance f my duties. Will reprt any vilatin f this plicy. If I have access t cmputerized infrmatin r prgrams at the Nursing Hme, I understand that the infrmatin accessed thrugh all facility infrmatin systems cntains sensitive and cnfidential Resident care, business, financial and Nursing Hme emplyee infrmatin that shuld nly be disclsed t thse authrized t receive it. I cmmit t: Respect the wnership f prprietary sftware, by nt making any unauthrized cpies f sftware even when the sftware is nt physically prtected Respect the finite capability f the systems and limit my wn use s as nt t interfere unreasnably with the activity f ther users. Respect the prcedures established t manage the use f the system. Prevent unauthrized use f any infrmatin in files maintained, stred r prcessed by the facility. 9 f 19

10 Nt perate any nn-licensed sftware n any cmputer prvided by the facility. Nt utilize anyne else s authenticatin cde r device in rder t access any f the facility system. Respect cnfidentiality f any reprts printed frm any infrmatin system cntaining Resident/member infrmatin and handle, stre and dispse f these reprts apprpriately. Nt release my authenticatin cde. Understand that all access t the system will be mnitred. Understand that my cmputer system privileges hereunder are subject t peridic review, revisin and if apprpriate renewal. I understand that a vilatin f this agreement may result in crrective actin up t and including discharge r terminatin f my student enrllment at American Academy f Healthcare, LLC and that my bligatins under this agreement will cntinue after terminatin f my student enrllment. By signing this, I agree that have read, understand and will cmply with the facility s plicies cncerning cnfidentiality f infrmatin and use f cmputerized infrmatin systems and the statements made in this Agreement. Student Signature Schl Official Signature 10 f 19

11 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: ABUSE AND NEGLECT POLICY It is the plicy f American Academy f Healthcare t ensure that service will be free f physical, verbal, psychlgical, sexual abuse and neglect. Patients, Residents and/r Clients serviced by American Academy f Healthcare Students, during clinical rtatin, will be treated with respect and dignity. Any frm f abuse r neglect is strictly prhibited. Definitins: Physical Abuse: Includes, but is nt limited t shving, striking r kicking a persn serviced, unauthrized restrictins f freedm f mvement (i.e., restraint, seclusin). Verbal Abuse: Includes, but is nt limited t teasing, ridiculing, and sclding, speaking harshly r rudely, laughing at r using prfane r abusive language tward the persn being cared fr. Sexual Abuse: Includes any sexual activity between staff and persns being cared fr, r nncnsenting sexual activity between persns t include staff persuading, enticing and /r encuraging sexual activity between ne r mre unwilling persns. Psychlgical Abuse: The use f nn-verbal expressins r actins in such a manner that subjects a persn t ridicule, humiliatin, scrn r cntempt. Neglect/Mistreatment: Includes, but is nt limited t the failure t prvide the persn with fd, clthing, and medical care, assistance with persnal hygiene, supervisin and clean and safe envirnment. Explitatin: The unfair use f an individual t ne's wn advantage. Cmment All students/staff/cnsultants share the respnsibility f assuring that all persns being cared fr are free frm abuse r neglect. All Persns being cared fr shuld be treated with respect and shuld nt be demeaned, belittled r degraded. American Academy f Healthcare will nt teach individuals with a cnvictin r prir emplyment histry f child, elderly, r any abuse, neglect r mistreatment. Reference f past criminal activity will be checked by American Academy f Healthcare. LLC, as per federal, state, and lcal rules and regulatins. American Academy f Healthcare and the facility, will actively and aggressively investigate all allegatins f abuse and/r neglect. At the time f the reprt, investigatin prcedures are t be fllwed. 11 f 19

12 Immediately upn bservatin r discvery f abuse r neglect, a reprt t the Executive Directr f the facility r Directr f Nursing f the facility must be made. Failure t reprt will result in disciplinary actin up t, and including, terminatin f enrllment. Students/staff/independent cntractrs will ensure that medical/nursing attentin is prvided immediately as needed fr treatment f pssible trauma. Guardian/advcates and /r advcates care crdinatrs, case managers, and apprpriate state agencies must be ntified as per federal, state, and lcal rules and regulatins. A preliminary decisin regarding the allegatin shall be made within five (5) calendar days f the allegatins unless ding s wuld vilate prtective service prcedures. A final written reprt must be cmpleted within 7 days frm the incident. All students/staff/independent cntractrs will receive instructin/training in preventing and reprting abuse, mistreatment r neglect f persns n at least an annual basis as well as instructins in the apprpriate appraches t managing persns with Alzheimer's and Parkinsn's disease. Any persn wh is subjected t retaliatry actin upn making a reprt f individual abuse, neglect r explitatin, r whse reprt is ignred withut cause, shall immediately cntact the Executive Directr. Any emplyee fund guilty f retaliatry actin may be subject t disciplinary actin. In accrdance with State guidelines. I have read and understand the abve plicy n abuse and neglect. I agree t abide by this plicy n abuse and neglect. Print Name Student Signature Schl Official Signature Psitin at the Facility Nte: This plicy must be signed and n file, prir t acceptance f enrllment. 12 f 19

13 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Student Interview Frm : Student: 1. What d yu think it takes t be a gd Nurse Aide? 2. What are (3) three wrds yur friends wuld use t describe yu? 3. Give me an example f a time when yu had t learn smething new i.e. task r prcedure. Hw did yu learn the new task r prcedure? 4. Describe yur best learning experience. What made the experience a gd ne? 5. Where d yu see yurself in 3-5 years? Results f Interview: Eligible fr Enrllment Nt eligible fr Enrllment Other Representative Signature 13 f 19

14 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Schl Orientatin Checklist Tur f the Schl Lcatin f: Break & Lunch Areas Smking Areas Parking Wrk Areas Restrms Review f Schl Hurs Use f: Telephne Cell Phnes Fire and Disaster Prcedure Lcatin Use f Fire Equipment Fire Exits Review f HIPAA infrmatin Review f Resident/Family Cncerns Review f Emergency Prcedures Substance Abuse Plicy Sexual Harassment Dress Cde Attendance Plicy Campus Safety ID Cards Usual Class Size Weather Absences Refund Plicy Hnr Cde Privacy Act Internship Academic Prgress Grading Plicy Make-up Exams Terminatin Plicy I have received, reviewed, understand and will adhere t all f the infrmatin, plicies and prcedures given during the facility rientatin. Student Signature Instructr Signature 14 f 19

15 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: EMERGENCY NOTIFICATION INFORMATION Name: Address: Apt N: City: State: Zip: Phne Number: [ ] - HOSPITAL PREFERENCE: ALLERGIES: NEW ADDRESS INFORMATION Address: Apt N: City: State: Zip: Phne Number: [ ] - Mbile Number: [ ] - Pager Number: [ ] - Fax Number: [ ] - Other Cntact Number: [ ] - Address: Cntact Name: Phne Number: [ ] - 15 f 19

16 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Immunizatin Recrd Name: DOB: Scial Security #: Prf f Immunizatin is required fr admissin int any Health Educatin Prgram that includes a Clinical Experience. Hepatitis B (series must have been cmpleted) (s) f Immunizatin: Measles, Mumps, Rubella (individuals brn befre 1957 are nt required t have prf f MMR Immunizatin) (s) f Immunizatin: Tetanus (within the last 10 (ten) years f last Bster: Tuberculin Skin Test (PPD) within the last 3 mnths: given: read: Results: Alternative: Chest X-Ray within the last 5 years given: read: Results: Varicella (Chicken Px) (s) f Varicella Immunizatin: Alternative: Histry f disease r Psitive Titer Results Histry f Disease: : f Titer: Results: Signature f Examining Medical Prfessinal Print Name f Examining Medical Prfessinal (MD, PA r NP) Telephne Number Address City State Zip 16 f 19

17 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Physical Examinatin : Must be within 12 mnths f the start f Clinical Experience Student Name: Print Clearly T the Medical Prfessinal: In rder t ensure the safety f students and patients, a recent physical Examinatin is required fr all students entering a healthcare prgram. Students wrk in all envirnments where the sick and injured may be cared fr. They are required t sit, stand and walk fr extended perids f time as well as lift, turn and care fr patients in a clinical setting. Students are physically challenged thrugh ut this curse. Yur signature certifies that the fllwing statements are true: This individual has been examined and fund t be fit t participate withut restrictin in the strenuus activities demanded f a Healthcare Prfessinal. This individual has been fund t be free f any cntagius disease, which may cause a threat t patient safety. This individual is physically and mentally cmpetent t perfrm the duties required in a rigrus, perfrmance based educatinal experience. Signature f Examining Medical Prfessinal Print Name f Examining Medical Prfessinal (MD, PA r NP) Address City State Zip Telephne Number 17 f 19

18 Please Type r Print Request, Authrizatin, Cnsent and Release fr Backgrund Check I, Last Name First Name Middle Name (Include Jr., Sr., II, III Etc.) Understand that in cnjunctin with my applicatin fr emplyment, American Academy f Healthcare, LLC, will use the services f an utside agency t research and verify the infrmatin I have prvided n my applicatin fr patient cntact including my persnal backgrund and character. This agency will prvide a reprt t American Academy f Healthcare, LLC. American Academy f Healthcare, LLC uses a screening agency, as an agent t perfrm backgrund verificatins. These agencies will utilize varius surces f infrmatin it deems apprpriate including but nt limited t: credit reprting agencies, Wrkers Cmpensatin recrds, Department f Mtr Vehicle recrds, criminal cnvictin recrds, current and frmer emplyers, military recrds, educatin recrds, prfessinal and persnal references. I request, authrize and cnsent t the release and disclsure f any and all infrmatin including but nt limited t the abve t American Academy f Healthcare, LLC. I request, authrize and cnsent t the prcurement f an Investigative Cnsumer Reprt and understand that it may cntain infrmatin abut my backgrund, mde f living, character, persnal characteristics and general reputatin. This authrizatin in riginal r cpy frm shall be valid fr ne year frm the date indicated next t my signature. Accrding t the Fair Credit Reprting Act, I will be ntified by American Academy f Healthcare, LLC if enrllment is denied because f infrmatin btained frm a Cnsumer Reprting Agency. Additinally, I understand that if requested within 60 days, I will be given a full and accurate disclsure as t the nature and substance f all infrmatin prvided t American Academy f Healthcare I further understand that when requesting a cpy f the reprt, prper identificatin will be required and I shuld direct my request t: Secure Select, Inc. LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES. I HEREBY RELEASE AMERICAN ACADEMY OF HEALTHCARE AND ITS AGENTS, BACKGROUNDS ONLINE AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR REPORTS ABOUT ME FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE ABOVE MENTIONED INFORMATION OR REPORTS. Signed Printed Name Nurse Aide I Student Psitin Applied Fr Scial Security Number f Birth Driver s License Number State Other names yu have used r are als knwn as: Residential Addresses fr last 7 Years: Current Address: Street Apt. # City State Zip Cde Hw lng here? Frmer Address: Frmer Address: Street Apt. # City State Zip Cde Hw lng here? Street Apt. # City State Zip Cde Hw lng here? 18 f 19

19 American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 5000 Natins Crssing Rad Charltte, NC Phne: Cmpetency Evaluatin Skills Testing Prcedures T successfully pass the clinical and skills cmpetency evaluatin, the student must demnstrate unassisted, 100% mastery f all skills based n identified critical elements as utlined in the Nrth Carlina Nurse Aide I curriculum. The skills evaluatin will be cmpleted in the clinical setting as well as the classrm, but the student must cmplete a simulatin practice test and shw cmpetency befre clinical demnstratin in a skilled facility. The student has tw ther pprtunities t prve 100% mastery f skills t be allwed t cntinue with the prgram, which is nt mre than three ttal attempts. If the student fails n the third attempt, they will be asked t withdraw frm the prgram. NO REFUND WILL BE MADE. It is the RN instructrs respnsibility t ensure that the skills the cmpetency skills the student s demnstrate are signed ff n an apprpriate dcumentatin as necessary are made. The RN instructr is respnsible fr the students training and evaluatin thrugh ut the prgram. Print Student Name Last 4-digits f S.S. # Student Signature Instructr s Name 19 f 19