Mt. Vernon Area Vocational Center Basic Nursing Assistant Training Application

Transcription

1 Basic Nursing Assistant Training Application Application must be returned to the CTE Office (F101) by the end of school on Friday, March 11, 2016 Submission date: Student s Name: Last First MI ID#:

2 Basic Nursing Assistant Training HE400A/B AVC 14051A AVC The course is composed of a combination of subject matter and experiences designed to perform tasks of individuals receiving nursing services. The student learns those competencies needed to perform as a nurse assistant under the direction of the registered nurse. The units of instruction should include the role of the nurse assistant while covering general health care topics; medical terminology; patients/clients and their environment; special feeding techniques; psychological support and, in long term and terminal illness, death and dying (e.g., chronically ill, children, new mothers, and so on); and all other basic nursing skills. Topics covered typically include normal growth and development; feeding, transporting patients, hygiene, and disease prevention; first aid and CPR; observing and reporting; care of equipment and supplies; doctor, nurse, and patient relationships and roles; procedure policies; medical and professional ethics; and care of various kinds of patients including long-term care residents. Students will receive a certificate of completion in Basic Nurse Assistant Training upon successful completion of the course. Students may then apply to take the Nurse Assistant Training examination for certification. Passing this exam is necessary in order to be placed on the registry for the Illinois Department of Public Health as a Certified Nurse Assistant (C.N.A.). The cost of the C.N.A. examination is to be paid by the student. Supplies needed for this course are a watch with second hand, transfer belt, stethoscope, blood pressure cuff, uniform, and white shoes. Students are also required to submit to medical screening and criminal background check. Students will be introduced and encouraged to participate in HOSA leadership Activities. -- Taking the ASSET Test is not a requirement to take this course for high school credit or complete requirements to apply for the Nurse Assistant Training examination for certification. -- Length of course: 2 Semesters Credits per semester 1 Grade level: 11, 12 Prerequisite: Dual Credit: Health Core Skill recommended Rend Lake College: CNA 1201 Certified Nursing Assistant (7 credit hours) Junior/Senior only Note -- ASSET Test/Minimum Score is required to earn dual credit from Rend Lake College Application Process Steps 1. Complete the attached application. Fill in all blanks (write NA in any blank that does not apply to you). 2. You and your parent/guardian should carefully read the Student Agreement and sign. 3. Return the signed application packet to the CTE Office by the due date (Please note: LATE applications are a reflection of your work ethic and interest in the program.) Make every effort to turn in applications on or before the due date. 4. Call Mr. Knutson at if you have any questions concerning the application. Reminder: Step #3 does not guarantee placement into the program. References Teacher s Name Please list three teachers who will recommend you for this program. Please make sure you have their permission to use their name as a reference! Subject Taught Student Agreement If your application is approved and you are accepted into the Basic Nursing Assistant Program: Will you agree to attend school, class, and clinicals regularly? Yes No Will you agree to abide by the rules and regulations of the Basic Nursing Assistant Training Program? Yes No Student Signature: Parent/Guardian Signature: : : Make an appointment to see your Guidance Counselor to obtain the following information: Copy of current transcript Signature of Guidance Counselor: Take to the Attendance Office to answer these questions: Copy of attendance/disciplinary reports Signature of Attendance Office Official: Teacher recommendations, attendance, grades, and work ethic are extremely important and heavily considered when accepting students into this program!

3 Basic Nursing Assistant Training Application Please print neatly in blue or black ink or type Please complete ALL of this application. If part of it does not apply to you, write N/A. : Student s Name: Last First MI ID#: DOB: Age: Student s Cell Phone Number: Social Security #: - - Grade: Student s Address: Ethnicity (Circle) Asian American American Indian Black American Caucasian (White, Not Hispanic) Hispanic/Mexican American Other American Minority Parent/Guardian(s) (Primary Residence) / Title Dr. Miss. Mr. Mrs. Ms. Mr./Mrs. First Middle Last Address Home Address (Street, City, State, and Zip) Relationship Mother Father Step-Mother Step-Father Foster Mother Foster Father Grandmother Grandfather Sister/Brother 18+ Aunt Uncle Neighbor Adult Friend Co-worker Other Business Business 2 Home Phone ( ) Cell Number Emergency Contact / Title Dr. Miss. Mr. Mrs. Ms. Mr./Mrs. First Middle Last Address Home Address (Street, City, State, and Zip) Relationship Mother Father Step-Mother Step-Father Foster Mother Foster Father Grandmother Grandfather Sister/Brother 18+ Aunt Uncle Neighbor Adult Friend Co-worker Other Business Business 2 Home Phone ( ) Cell Number

4 What is your career interest area? Please state in words or less why you wish to participate in this program.

5 Basic Nursing Assistant Training Program Guidelines The Basic Nursing Assistant Training class requires classroom and clinical experiences. experiences to be beneficial, all parties must undertake certain responsibilities. For these Responsibilities of the Student: (Refer to Student Agreement Form) Responsibilities of the Parent/Guardian: 1. The parent or guardian will encourage the student to carry out all classroom/clinical duties and responsibilities to the best of the student s ability. 2. The parent or guardian will share the responsibility for the conduct of the student while training in the program. Responsibilities of the School: 1. The school will employ and retain a qualified coordinator. 2. The school will allow the instructor sufficient time to carry out the necessary coordinating activities. Responsibilities of the Training Sponsor(s): 1. Training sponsor(s) will consult the coordinator about difficulties arising at the training station. 2. Training sponsor(s) will provide experiences and training that contribute to the attainment of the student s skills. The student should be learning new skills and assuming new responsibilities as appropriate. 3. It shall be agreed that parties participating in this program will not discriminate in employment opportunities on the basis of race, color, sex, national origin, or handicap. I approve of my son/daughter taking this program. My signature indicates knowledge of and agreement with the above conditions. Responsibilities of the Instructor: 1. The instructor will supervise all classroom and clinical portions of the program. 2. The instructor agree(s) to instruct the student in safety procedures and safe work practices in on-the-job training. 3. The instructor will visit each training station as appropriate. 4. The instructor will address any issue with all parties concerned and shall have the authority to transfer or remove a student from a training station if needed. 5. The instructor, after consulting with professional medical training sponsor(s), will evaluate the student and assign clinical and classroom grades. 6. The instructor will submit all required forms to Nurse Aide Testing. Student s Signature Parent/Guardian(s) Signature

6 Basic Nursing Assistant Training Program Student Agreement Form The Basic Nursing Assistant Training Program is planned to develop a student academically, economically, & socially. To meet these goals the student must be willing to strive & work toward fulfilling certain relevant responsibilities. As a condition of admittance to the Mt. Vernon Area Vocational Center s Basic Nursing Assistant Training program, I agree: 1. to realize that I am under the jurisdiction of the school throughout the school day. 2. to perform all of my duties in a commendable manner and to complete study assignments thoroughly and on time. 3. that the instructor has the same authority over me at clinical as in the classroom at school. 4. that the instructor is the recognized authority for making adjustments or changes to my training at clinical. 5. to be well-dressed and groomed both in school and at clinical site in a manner acceptable to employer and school authorities. 6. to carry out my training in such a manner that I will reflect positive credit upon myself, Mt. Vernon Area Vocational Center and the Basic Nursing Assistant Training program. 7. to participate in class and to complete the required classroom-related work. 8. to be in regular attendance at school and at clinical. 9. to be on time at school and clinical. 10. to notify the school, the instructor, as soon as I know I will be absent for good cause. 11. to conduct myself in a satisfactory manner, both at clinical and in the classroom. 12. to serve and attend in full any discipline hours or suspensions that I am assigned. 13. the student may not leave or change clinical assignment(s). 14. to join, participate, and complete related activities in the Health s Students of America (HOSA) club at Mt. Vernon Township High School. 15. to follow the HOSA Creed in both the classroom as well as during clinical times. 16. that if I am required to leave school because of any disciplinary reasons, I cannot report to the clinical site. 17. to attend an orientation meeting with a parent and/or guardian(s) over the summer. I Believe in the Health Care Profession. HOSA Creed I Believe in the profession for which I am being trained; and the opportunities which my training offers. I Believe in education. To fulfill the following requirements: by the last Monday in August ring binder 1 - regular notebook 1 plain edge notebook paper 1 composition notebook by mid September Completed background check form and $35 money order submitted to instructor. by the 2 nd Monday in October TB test completed and documentation submitted to instructor. 1 - Gait belt ($12) by the first Monday in November 1 - One uniform ($30) 1 pair of white shoes/tennis shoes 1 watch with a second hand by the last Friday in March Complete CNA testing application and submit it along with $65 to instructor. by the first Monday in January 1 Blood Pressure Cuff 1 Stethoscope I fully understand the above statements and I agree to cooperate in carrying them out to the fullest of my ability. I understand that repeated disregard of the following requirements may be considered as grounds for removal from the program and loss of credit. I Believe that through education I will be able to make the greatest use of my skills, knowledge, and experience in order to become a contributing member of the health care team and of my community. I Believe in myself. I Believe that using the knowledge and skills of my profession, I will become more aware of myself. Through fulfilling these goals I will become a more responsible citizen. Student s Signature I Believe that each individual is important in his or her own right; therefore I will treat each person with respect and love. To this end, I dedicate my training, my skills, and myself to serve others through Health s Students of America. Parent/Guardian(s) Signature