FULL-TIME ADULT STUDENT APPLICATION ACCEPTANCE PACKET For completion by Certified Nurse Assistant (C.N.A.) Students Only

Transcription

1 FULL-TIME ADULT STUDENT APPLICATION ACCEPTANCE PACKET For completion by Certified Nurse Assistant (C.N.A.) Students Only CONNECTICUT STATE DEPARTMENT OF EDUCATION Connecticut Technical High School System Middletown Revised July 2013

2 Certified Nurse Assistant Application Checklist 1. Complete and sign the enclosed Application for Admission. 2. Include a copy of your High School diploma, transcript or GED Certificate. 3. Complete and sign the Full-time Adult Student Information Form. 4. Bring/mail the Application for Admission, Full-time Adult Student Information Form and the copy of your diploma/ged certificate to the Adult C.N.A. Program to which you are applying. 5. Pay the tuition on or before the first class session begins. OR 6. If student meets one of the three qualifications outlined on the Tuition Waiver Request Form for Short Term, Extension or Apprentice Program, complete a tuition waiver form at least 4 weeks prior to the start of class. Bring/mail this form with your supporting documentation and your application to the school. 7. If you receive an acceptance letter to the program, bring the $50 registration fee (cash, certified check, or money order made out to Treasurer State of CT ) to the Business Office with a copy of your acceptance letter. Note: This Registration/application fee is NOT covered by tuition waivers. Everyone must pay this fee. 8. If accepted, complete the Adult Physical Examination Form and bring on the 1 st day of class or make an afternoon appointment for your physical and bring the date of the appointment. Note: Physical appointments can take several weeks to schedule plan ahead.

3 Page 1 Application for Student Admission for Full-Time Adult Programs In order to be considered for admission to a Technical High School, applicants must: provide the Connecticut Technical High School with a high school transcript or evidence of successfully completing the General Educational Development (GED) test; submit signed and dated copy of the Full-time Student Information Sheet included at the end of this application Licensed Practical Nurse Program applicants must have taken ATI s TEAS test. Applicants must also include: -Resume -Documentation of having passed the following college level courses ºIntermediate Algebra or equivalent with a C or better ºEnglish Composition or equivalent with a C or better Incomplete applications will not be processed Instructions Complete this application and return the completed application with the required documentation specified above to the appropriate Technical High School addressed to the applicable trade Department Head. Applicants may have to participate in an interview as part of the application process depending on the trade program.. Student Name: Technical High School applying to: Adult program applying for: ( ) Aviation Maintenance Technician ( ) Certified Nurse Assistant ( ) Dental Assistant ( ) Medical Assistant ( ) Surgical Technician ( ) Licensed Practical Nurse For Bristol Technical Education Center, specify program:. NOTE: Interested candidates, who want to be considered for admission at more than one technical school, must submit a complete application packet to each Technical High School. It is the policy of the Connecticut Technical High School System that no person shall be excluded from participation in, denied the benefits of, or otherwise discriminated against under any program, including employment, because of race, color, religious creed, sex, age, national origin, ancestry, marital status, sexual orientation, gender identity or expression, disability (including, but not limited to, intellectual disability, past or present history of mental disorder, physical disability or learning disability), genetic information, or any other basis prohibited by Connecticut state and/or federal nondiscrimination laws. The Connecticut Technical High School System does not unlawfully discriminate in employment and licensing against qualified persons with a prior criminal conviction. Inquiries regarding the Connecticut High School System s nondiscrimination policies and practices should be directed to the Superintendent of Schools, Connecticut Technical High School System, 25 Industrial Park Road, Middletown, CT 06457, and/or, regarding race, color, national origin, age, sex and/or disability to the Office for Civil Rights, U.S. Department of Education, Boston, MA , telephone , fax , TTY/TDD The Connecticut Technical High School System is an equal opportunity/affirmative action employer. For Technical High School Use Only Application fee submitted High School Transcript or GED submitted LPN program entrance test scores submitted Intermediate Algebra grade submitted English Composition grade submitted Resume submitted Date: Signature: Title: Applicant s State Assigned Student ID Applicant Student Identification number:

4 Page 2 This application requests information about your national origin, gender, racial or ethnic group, and primary language spoken in the home. Providing this information is voluntary. The information you do provide will be used for record-keeping purposes only; it will not be used as a factor in any action concerning education, activities or employment. Personal Information Full Name: ( ) (Last) (Maiden) (First) (Middle) Address: (Box, Apartment, Street Name and Number) (City or Town) (State) (Zip Code) Mailing Address: (If different) (Box, Apartment, Street Name and Number) (City or Town) (State) (Zip Code) Birth Date: Place of Birth: (Month/Day/Year) (City) (State) (Country) Home Phone: ( ) Other Phone: ( ) address: Gender: Male Female General Information Racial or Ethnic Group: American Indian or Alaskan Native (1) Asian American or Pacific Islander (2) Black (3) White (4) Hispanic (5) Primary Language: High School graduate? Yes No If yes, name of High School: If no, do you have a GED certificate? Yes No NOTE: A copy of a High School transcript or GED certificate must be included with this application. Are you a U. S. Veteran? Yes No Dates of Service to Type of discharge: Are you interested in applying for financial aid (Pell Grant)? Yes No (Note: The Certified Nurse Assistant program does not meet the minimum number of required hours to qualify for a Pell Grant. The applicant can apply for a tuition waiver if receiving aid from a means-tested program as specified on the tuition waiver form or is a senior citizen or has a veteran status.) Have you attended/applied to another Connecticut Technical High School? Yes No If you answered yes, name of school: Have you ever been convicted of any crime? Yes No Are there any criminal charges pending against you? Yes No If you have answered yes to either of these questions, attach a sheet providing specific information. If conviction of a crime or pending criminal charges is a basis for rejection, you will be notified in writing and you will be provided an opportunity to request reconsideration (see CGS 46a-79 and 80). Failure to disclose a conviction or pending criminal charges will be a basis for rejection, or dismissal if enrolled.. Please tell us how you heard about the adult education programs in the CTHSS. ( ) word of mouth ( ) newspaper ads ( ) newspaper articles ( ) cable TV ( ) TV ads ( ) radio ads ( ) career fairs ( ) internet ( ) other I hereby certify that the information provided by me in this application is true, complete and accurate. I understand that applications will not be returned. Signature of Applicant Date:

5 Revised 7/2013 Connecticut Technical High School System (CTHSS) Full-Time Adult Student Information/Financial Obligation Tuition and Fees The tuition and fee schedule for academic year as approved by the Connecticut State Board of Education are as follows: Program Resident/ Non-Resident Tuition Registration Fees (nonrefundable) Payment Due Dates Returning Licensed Practical Nurse In-State Resident returning in good standing during the school year Total of $10,200 payable over three semesters ($3,400 per semester) per program Based on selected payment plan Returning Licensed Practical Nurse Non-State Resident returning in good standing during the school year Total of $21,000 payable over three semesters ($7,000 per semester) per program Based on selected payment plan NEW January 2014 Class Licensed Practical Nurse In-State Resident newly enrolled Total of $11,550 payable over three semesters per program Based on selected payment plan ($3,850 per semester) NEW January 2014 Class Licensed Practical Nurse Non-State Resident newly enrolled Total of $23,772 payable over three semesters per program Based on selected payment plan ($7,924 per semester) Returning Aviation Resident returning in good standing during the school year Total of $6,200 payable over two years ($2, per installment) per program August 2013 January/February 2014 New Aviation (starting with December 2013 Class) Resident newly enrolled Total of $6,576 payable over two years ($2,192 per installment) per program December 2013 May/June rd Installment in Certified Nurse Assistant Not applicable $1,400 per ten week cohort Dental Assistant Not applicable $3,500 payable over two semesters ($1,750 per semester) per academic year per academic year Date of first scheduled class Date of first scheduled class Medical Assistant and Surgical Technology Not applicable $3,500 payable over two semesters ($1,750 per semester) per academic year Date of first scheduled class

6 Revised 7/2013 Connecticut Technical High School System (CTHSS) Full-Time Adult Student Information/Financial Obligation Tuition and Fees The tuition and fee schedule for academic year as approved by the Connecticut State Board of Education are as follows: Program Resident/ Non-Resident Tuition Registration Fees (nonrefundable not covered by tuition waiver) Payment Due Dates Certified Nurse Assistant Not applicable $1,400 per ten week cohort Acceptable methods of payment per academic year On or before first class session Bank check or money order made payable to Treasurer, State of Connecticut for the exact amount due; Cash will be accepted in the school business office only during regular business hours (8:30 a.m. 4:30 p.m.); Unacceptable methods of payment Personal checks; Debit and Credit cards; Cash (except during normal business hours); Other financing options (It is the responsibility of the student to initiate and follow up on the methods listed below): The Connecticut Technical High School System offers other financing options including: Tuition Waivers - The Certified Nurse Assistant program does not meet the minimum number of required hours to qualify for a Pell Grant; however, Tuition Waiver is available only for qualified C.N.A. applicants that meet the requirements listed below. Tuition Waiver Request form must be submitted NO LATER THAN four weeks prior to the first class session. A tuition waiver does not cover the Registration Fee. **Any student failing to pay or be approved for an alternative financing option by the payment due date will be immediately dismissed from their program of study. As regular attendance is a critical aspect of the educational process, students with attendance problems may be dismissed from the program. Applying for a tuition waiver Eligible students wishing to apply for a tuition waiver must complete a Tuition Waiver Request form (no later than four weeks prior to the first class session. Download Tuition Waiver Request form. Veterans requesting a tuition waiver must attach a copy of their Certificate of Release or Discharge (DD Form 214) (90 days of honorable active duty service in addition to that spent in active duty training and in attendance at military service academies for any war period after August 2, 1990 or engaged in combat or in combat support role in specific conflicts prior to August 2, 1990); Senior Citizens Students age 62 and over requesting a waiver must attach a copy of their proof of age; Financial Hardship (ONLY for students enrolled in the Certified Nurse Assistant program) students requesting a tuition waiver MUST provide proof of the student s or student s spouse or dependent student s parent current approval to participate in one or more of the following means-tested benefit programs: o o o o o Supplemental Security Income (SSI) from Social Security Adm. Or State of Connecticut Assistance - not Social Security Income; Connecticut Documentation for Food Stamps; Free or Reduced Price Lunch; Temporary Assistance for Needy Families (TANF); Women in Crisis (WIC); Unemployment compensation is NOT a means-tested benefit program and therefore is not considered when determining financial hardship; Students whose tuition is being paid by another state agency must submit written documentation (i.e. voucher) identifying the agency responsible for payment. Students receiving educational assistance benefits under the G.I Bill from the Veterans Administration must submit enrollment verification or training agreement. The student should provide the school Certification Officer, VA Form for submission to the Veterans Administration to receive the education benefits payment form VA. If a student is denied tuition waiver, all tuition and fees are due by the next class session.

7 Revised 7/2013 Connecticut Technical High School System (CTHSS) Full-Time Adult Student Information/Financial Obligation Procedures for Withdrawal In order to officially withdraw from an adult education program in the CTHSS and be considered for a tuition refund, candidates must complete and submit to the school s Guidance Office, the following two documents available from the district s Adult Education webpage ( 1. Student Withdrawal Form 2. Request for Tuition Refund Form (Appendix IX) Upon approval of the Student Withdrawal Form by a school administrator (principal or assistant principal), students may be eligible for a tuition refund. Eligibility for Tuition Refunds Except for withdrawal due to military action or serious illness, if the Student Withdrawal Form is received from the student prior to the first scheduled class session, the student is eligible for a 100% tuition refund. Except for withdrawal due to military action or serious illness, If the Student Withdrawal Form is received from the student after the first scheduled class session, but prior to the fourteenth (14 th ) calendar day from the first scheduled class session, the student is eligible for a 60% tuition refund. Except for withdrawal due to military action or serious illness, if a Student Withdrawal Form is received after the fourteenth (14 th ) calendar day from the first scheduled class session; the student is not eligible for a tuition refund. All requests for tuition refunds due to military action and supported by written documentation from the military are eligible for 100% tuition reimbursement; All requests for tuition refunds due to serious illness and supported by written documentation from a medical professional are also eligible for 100% tuition reimbursement; Except for military action or serious illness, no refunds will be provided to students who are dismissed from their program of study due to issues with attendance, unsatisfactory educational performance or violation of the district s discipline policy as detailed in the Full- Time Adult Student Handbook. Processing of Tuition Refunds If the student meets the eligibility requirements for a tuition refund, the Request for Tuition Refund Form (Appendix IX) completed by the student will be forwarded from the school administrator to the school s business office and then to the State Department of Education s (DOE) Payments Unit. The SDE Payments Unit will then issue a state invoice utilizing the State of Connecticut s official accounting system (CORE-CT) and transmits the invoice to the State Comptroller for issuance of a refund check payable to the student within the state s payment timelines (currently net 45 days). I have read and understand the above: Student Signature Printed Name Date

8 Connecticut Technical High School System Student s Name Student ID # Date of Birth Address City State Zip Student s Home Phone Cell Alt/ Emergency Contact Name Phone (1) (2) ( ) Aviation Maintenance Technician ( ) Certified Nurse Assistant ( ) Dental Assistant ( ) Licensed Practical Nurse ( ) Medical Assistant ( ) Surgical Technician TO THE EXAMINING PHYSICIAN/HEALTHCARE PROVIDER: On the basis of my health assessment and physical exam: Date of Exam: Student denies Latex Allergy Student is clear to participate in clinical nursing courses with no restrictions (please check) Yes No IF NO, please explain the nature of the restrictions/limitations related to the delivery of patient care: IMMUNIZATION ASSESSMENT Please refer to the CDC Healthcare Personnel Vaccination Recommendations at TITERS MUST BE POSITIVE PER LABORATORY STANDARD; REPORT MUST ACCOMPANY THIS FORM. If titers show student is not immune, please state plan of how non-immunity will be addressed. RUBEOLA (MEASLES) TITER Immune? Yes No May be Qualitative or Quantitative Titer Laboratory report must be attached RUBELLA (GERMAN MEASLES) TITER Immune? Yes No May be Qualitative or Quantitative Titer Laboratory report must be attached If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines May be Qualitative or May be May MUMPS TITER Immune? Yes No May be Qualitative or Quantitative Titer Laboratory report must be attached If No, include plan for or evidence of receipt of 2 doses of MMR Vaccine; refer to CDC guidelines VARICELLA (CHICKEN POX) Provide Evidence of Immunity by: Physician diagnosis or Titer or Lab confirmation of disease or 2 doses of varicella vaccine > 28 days apart May be Qualitative or Quantitative Titer Laboratory or physician report of diagnosis must be attached TETANUS/DIPHTHERIA/PERTUSSIS (Tdap/Td) Date of Tdap/Tetanus/Td Booster (date given must be within last 10yrs) All healthcare personnel (HCP), regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since last Td dose; then they should receive Td boosters every 10 years thereafter. For further information see:

9 ANNUAL ASSESSMENTS/REQUIREMENTS: Hep. B SERIES: Per protocol 1 st dose 2 nd dose 3rd dose Student has been determined to be a non-responder and is aware of CDC recommendations for exposure to Hepatitis B surface antigen positive blood, refer to CDC guidelines Hep. B Surface Antibody Titer Immune? Yes No (if no, revaccinate with add l 3 dose series) >10mlU/ml is positive/immune (1-2 months following Dose #3) Laboratory report must be attached TST (Tuberculosis Skin Test required yearly) (TST must be performed in accordance with requirements of clinical facilities) Date Given Date Read Results If previously positive TST (Year 2 and forward) complete Annual TB screening form: Student shows no evidence of TB symptoms If new positive TST provide: chest x-ray report showing no evidence of active TB disease Attach Official report(s)/record(s) Influenza Vaccination is required yearly; please provide evidence of vaccination per CDC protocol Official report/record must be attached Date Given Healthcare Provider Print Name Healthcare Provider Signature DEA Number DATE Address: Telephone ( ) - 6/2013

10 Connecticut Technical High School System Student Statement of Responsibility I understand that I must submit a completed Health Assessment form prior to participation in any clinical experiences. I am aware that if my health status should change in a way that would impact my ability to perform in the nursing program, I must notify the Director/Administrator of the program immediately. The need for additional clearance will be determined at that time. Student Name (Please Print) Student Signature Date

11 Connecticut Technical High School System Annual Tuberculin Screening Form Student Name: Date: History of Positive Tuberculin Skin Test: YES NO History of BCG Vaccine: YES NO Date of last chest x-ray: Results: Current Symptom Assessment: Signs and symptoms of active TB: YES NO If yes, indicate medical treatment plan: Student is cleared to attend clinical assignments with no restrictions: YES NO Primary Care Provider (Print Name) Date Primary Care Provider Signature Telephone Number Street Address City State Zip Code

12 Information for Students and Healthcare Providers about Immunity Assessment/Titers for Nursing Students MMR: the MMR titers once determined do not have to be rechecked, regardless of when drawn. It is possible that they may be lowered during pregnancy, but otherwise should remain consistent. In this case a qualitative titer is acceptable. In a situation whereby a student was vaccinated in year one of the program, titers should be validated in year 2 of the program. Varicella: Quantitative titers should be drawn once; if immunity is determined to be present then student does not need titer drawn for second year. In any case if student is immunized year 1 then titer should be drawn year 2, the key is QUANTITATIVE titer vs. qualitative (i.e. EIA index is not a quantitative titer). Hepatitis B: Very Tricky. Some people NEVER develop immunity; some can lose immunity over time, thereby requiring a booster. So with this in mind: Those students that go through their series of injections during or in preparation for year one of the program, should then go on to have a QUANTITATIVE test for year 2. This value must exceed 10 milliunits / ml to establish immunity. If immunity is not established, the student should have a booster and have immunity rechecked. If a student produces a recent titer (less than 5 years old) that establishes immunity this will suffice for both years. In the event that a student produces a titer 5 years or older a quantitative titer is required for year 1. The student that comes to us stating they have had the series in the past, regardless of proof of the shots, still need to have a quantitative titer done to establish immunity. For all intents and purposes for any student (even those who are readmitted or transferred) this should suffice as long as we were within a 5 year window of time from the initial establishment of immunity. If a student refuses to receive Hepatitis B immunization a waiver must be signed and kept on file. PPD: Must be updated on a yearly basis in order to maintain status in the program, exceptions: Students who have received BCG immunization should not get a PPD Students who have had a positive PPD Students who are immunosuppressed, have cancer, or are on steroids should not get a PPD If PPD cannot be obtained because of the above, student should have a SINGLE chest x-ray to document freedom from disease. Thereafter, on a yearly basis, a note must be received from the Healthcare provider stating that the student shows no evidence of symptoms of TB. Source: Quest Diagnostic Laboratory, July 2004

13 REFUSAL FOR USE OF HEPATITIS B VIRUS VACCINE I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. However, I decline hepatitis B vaccination at this time. I understand that by declining this hepatitis B vaccination at this time, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can then receive the vaccination series. NAME: DATE: WITNESS: DATE:

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18 Revised 9/2011 CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM ADULT EDUCATION TUITION WAIVER REQUEST SHORT-TERM, APPRENTICE* OR EXTENSION* PROGRAMS Qualified Certified Nurse Assistant (C.N.A.) students complete this form to request a tuition waiver *Apprentice and Extension students can apply for a waiver only if they meet the Veteran or Senior Citizen requirements. Requests due at the School: -The student encloses the waiver request and supporting documentation with the program application and bring/mail to the Program of his/her choice for review and approval at least two weeks prior to the first class session; -The assigned school staff will forward the request to Central Office by the due dates specified under the school completion section. If the request is denied, tuition is due on or before the first class session, or if the student is already enrolled, tuition is due on the day of their next class session following the date of the denial letter. STUDENT INFORMATION Date Submitted Student Type Apprentice, Extension, C.N.A. Short Term Student Name Student Identification Number Street Address City, State, Check reason type and attach copy of appropriate documentation: Type of Waiver Request Veteran Financial Hardship (Apprentice or Extension Students do not qualify) Acceptable Documentation 1) DD-214 with proof of honorable discharge from Active Duty Service (Active Duty Training [ADT] does not qualify for tuition waiver); OR 2) Proof of current active duty service. Proof that student (and/or spouse or dependent student s parent) is a current recipient of benefits from one of the following means-tested benefit programs: Supplemental Security Income (SSI); Connecticut Documentation for Food Stamps, Free or Reduced Price Lunch, TANF, WIC. (Unacceptable Documentation: copy of benefit member card, copy of Husky medical program participant documentation.) NOTE: Unemployment Compensation is NOT a means-tested benefit program. Senior Citizen Valid photo ID with DOB showing student is age 62 or older based upon seat availability. TO BE COMPLETED BY SCHOOL School Name Waiver Number Course Number/Name Course Start Date Course Number/Name Course Start Date Supervisor Signature Date Requests due at Central Office (forwarded by the school staff with appropriate documentation/signatures). SEND ATTENTION OF: Ada Kercadó, CTHSS, 25 Industrial Park Road, Middletown, Connecticut TO BE COMPLETED BY CENTRAL OFFICE Approved Denied Superintendent or Designee Date 1

19 Revised 9/2011 PLEASE NOTE: A COPY OF THE APPLICATION/REGISTRATION FORM MUST BE ATTACHED CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM - ADULT EDUCATION TUITION WAIVER REQUEST SHORT-TERM, APPRENTICE OR EXTENSION PROGRAMS Important information regarding documentation that should be attached to Veteran s tuition waiver requests: OR Copy of DD-214 with proof of honorable discharge Proof of current active duty service Important information regarding documentation that should be attached to support financial hardship tuition waiver requests: Please note changes in the acceptable documentation to support a student s waiver request. Student (and/or spouse or parent(s) if the student is a dependent student) must provide documentation that they are currently receiving benefits from one of the following means-tested benefit programs in order to be eligible for tuition waiver: *Supplemental Security Income (SSI) [SSI from Social Security Adm. or State of Connecticut Assistance] Food Stamps (State of Connecticut) Free or Reduced Price Lunch (State of Connecticut) TANF (State of Connecticut) WIC (State of Connecticut) Students should provide a copy of their benefit approval letter from the agency providing the assistance which lists the period of eligibility. Copies of only the member s benefit card(s) are not acceptable documentation. Those not receiving benefits from one of the above sources, but enrolled in the Husky medical program are not eligible for waiver. *Only Supplemental Security Income (SSI) benefit is considered for hardship. Regular monthly Social Security Benefits is not a means-tested benefit program. Therefore, the documentation from the Social Security Administration will need to state: Supplemental Security Income benefits not monthly Social Security Benefits; unless the applicant can provide proof that he/she is a current recipient of benefits from one of the State of Connecticut means-tested programs, cash assistance, food stamps, free or reduced price lunch, TANF, or WIC. Please do not collect or submit copies of income tax returns, W-2 forms, or any other documentation that is not proof of receipt of assistance from any of the programs listed above. Unemployment compensation is not a means-tested benefit program and is not considered when determining financial hardship. Important information regarding documentation that should be attached to support senior citizen tuition waiver requests: Copy of current valid photo ID with DOB showing student is age 62 or older. 2