NURSE AIDE PROGRAM APPLICATION FORM

Transcription

1 Semester/Year Summer Fall Spring Pueblo Durango Campus Fremont Mancos Health Academy Student NURSE AIDE PROGRAM APPLICATION FORM Name: Application Instructions: 1. Applications will be accepted beginning on for classes beginning 2. Deadline for submission is. 3. Place your initials in the space provided to indicate that you have read and understand the following statement. 4. Qualifications for program admission include: A.) Completion of criminal background check B.) Completion of a drug screen C.) A complete immunization record and submission of a current Health Provider CPR card (If applicant is not a CPR card holder, a course is offered on campus) D.) Meet or surpass course prerequisites or Accuplacer scores or CCPT exemptions 5. Qualified applicants will be admitted on a first come, first served basis, contingent upon seat availability. 6. Attendance on the first day of class is mandatory. Students absent the first day of class will be dropped from the program and all associated classes. 7. IT IS THE APPLICANT S RESPONSIBILITY TO ASSURE THAT THEIR PHONE NUMBER IS CURRENT. 8. If unable to contact by phone and/or student does not respond to phone contacts, the next applicant will be contacted. 9. IN ADDITION TO ACADEMIC REQUIREMENTS, ALL STUDENT S ACCEPTANCE IS CONDITIONAL PENDING RESULTS OF MANDATORY BACKGROUND CHECKS AND DRUG SCREEN. 10. I understand that this program requires time outside of class to complete clinical requirements for certificate. Return Application Form to HS 202 Suite or mail to: Health Sciences Building 900 W. Orman Avenue Pueblo, CO (719) Date Received: Received by:

2 NURSE AIDE CERTIFICATE PROGRAM APPLICATION FOR ADMISSIONS Name: Last First Middle Date: S#: Maiden/Former Name (s): Address: Mailing Address: City State Zip Phone: Best Alt. Emergency Are you a high school student? Yes No Applicant Check List Please all items 1 2 before submitting application _1. Admission Application to Pueblo Community College submitted 2. College Transcript and/or assessment scores (Attach copies) Score (Reading) Score (English) Score (Math) Accuplacer (RC 40 or greater) (SS 50 or greater) (EA30-84 or AR>40) SAT (430 or greater) (440 or greater) (460 or greater) ACT CCPT ( 17or greater) (18 or greater) (19 or greater) Successful completion of CCR 092 and MAT 050 or qualifying exemptions Developmental (preparatory) course work is required prior to program entry, if Accuplacer or CCPT scores are low. Successful completion of CCR 092 and MAT 050 or higher will exempt you from taking the Accuplacer or CCPT tests. To the best of my knowledge and belief, the information I have given on this form is correct and can be verified. I have not withheld information that would affect my acceptance into the nurse aide program. I have read and understand the instructions and process for admissions into the nurse aide program. I understand that only complete applications with copies of College Transcripts and/or assessment scores attached will be considered. APPLICANT S SIGNATURE: Completion of this form does not constitute admission to the program. Students will be notified if they are accepted or denied acceptance into the program. Date:

3 FUNCTIONAL ABILITIES ESSENTIAL FOR NURSE AIDE PRACTICE Gross Motor Skills Move within confined spaces Sit and maintain balance Stand and maintain balance Reach above shoulders Reach below waist (e.g., plug electrical appliance into wall outlets) Fine Motor Skills Pick up objects with hands Grasp small objects with hands Write with pen or pencil Key/type (e.g., use a computer) Pinch/pick or otherwise work with fingers Twist (e.g., turn objects/knobs using hands) Squeeze with finger Physical Endurance Stand Sustain repetitive movements (e.g., CPR) Maintain physical tolerance (e.g., work entire shift) Physical Strength Push and pull 25 pounds (e.g., position clients) Support 25 pounds of weight (e.g., ambulate client) Lift 25 pounds (e.g., pick up a child, transfer client) Move light objects weighing up to 10 pounds Move heavy objects weighing from 11 to 50 pounds Defend self against combative client Carry equipment/supplies Use upper body strength (e.g., performs CPR, physically restrain a client) Squeeze with hands (e.g., operate fire extinguisher) Mobility Twist Bend Stoop/squat Move quickly (e.g., response to an emergency) Climb (e.g., ladders/stools/stairs) Walk Hearing Hear normal speaking level sounds (e.g., person-to-person report) Hear faint voices Hear faint body sounds (e.g., blood pressure sounds) Hear in situations when not able to see lips (e.g., when masks are used) Hear auditory alarms (e.g., fire alarms, call bells) Visual See objects up to 20 inches away (e.g., information on a computer screen, skin conditions) See objects up to 20 feet away (e.g., client in a room) See objects more than 20 feet away (e.g., client at end of hall) Use depth perception Use peripheral vision Distinguish color (e.g., color codes on supplies, charts, bed) Distinguish color intensity (e.g., flushed skin, skin paleness) Tactile Feel vibrations (e.g., palpate pulses) Detect temperature (e.g., skin, solutions) Feel differences in surface characteristics (e.g., rashes) Feel differences in sizes, shapes Detect environmental temperature (e.g., check for drafts)

4 FUNCTIONAL ABILITIES ESSENTIAL FOR NURSE AIDE PRACTICE CONTINUED Smell Detect odors from client (e.g., foul smelling drainage, alcohol breath, etc.) Detect smoke Detect gases or noxious smells Reading Read and understand written documents (e.g., policies, protocols) Arithmetic Competence Read digital displays Read graphs (e.g., vital sign sheets) Tell time Count rates (e.g., pulse) Use measuring tools (e.g. thermometer) Read measurement marks (e.g., scales) Add, subtract, multiply, and/or divide whole numbers Use a calculator Write numbers in records Emotional Stability Establish therapeutic boundaries Provide client with emotional support Adapt to changing environment/stress Deal with the unexpected (e.g., client going bad, crisis) Focus attention on task Monitor own emotions Perform multiple responsibilities concurrently Handle strong emotions (e.g., grief) Analytical Thinking Transfer knowledge from one situation to another Process information Problem solve Prioritize tasks Use long term memory Use short term memory Critical Thinking Synthesize knowledge and skills Interpersonal Skills Negotiate interpersonal conflict Respect differences in clients Establish rapport with clients Establish rapport with co-workers Communication Skills Explain procedures Give oral reports (e.g., report on client s condition to others) Interact with others (e.g., health care workers) Speak on the telephone Influence people Convey information through writing (e.g., charting)

5 PUEBLO COMMUNITY COLLEGE HEALTH PROFESSIONS DIVISION I have read and I understand the Physical Performance Standards (functional abilities) specific to the occupation of Nurse Aide. I have the ability to meet the Physical Performance Standards as specified. Please Print Name (Signed) (Date) The Americans with Disabilities Act bans discrimination of persons with disabilities and in keeping with this law, PCC makes every effort to insure quality education for all students. It is our obligation to inform the students of the essential functions demanded by this program and occupation. Students requiring accommodations or special services to meet physical performance standards of the Nurse Aide program should contact the Disability Resources Center. I require the following accommodations to meet the physical Performance Standard as specified. (Signed) (Date) PCC is an Affirmative Action/Equal Opportunity Institution and complies will all requirements of the Americans with Disabilities Act. Accommodations for students with handicaps are made through the Disability Resources Center. This department works with the program faculty to provide appropriate accommodations for students with disabilities.

6 CONFIDENTIALITY STATEMENT PUEBLO COMMUNITY COLLEGE As a student of a health care program at Pueblo Community College and while observing or completing clinicals in any of our health care agencies, I understand that all resident care and records are to be kept confidential. This verifies that any resident information will be discussed only with my clinical instructor and, that under no circumstances, will identifiable information leave or be communicated outside the clinic sites. Any use of social media, cameras, cell phone video devices, or other recording of clinical activities in reference to any clinical activities is prohibited. Any dissemination of clinical activities outside of the classroom is prohibited. All clinical activities are to be held in the strictest confidence and any violation of this policy may result in corrective action up to and including termination from the nurse aide program. I understand that I am not allowed to photocopy any information regarding the assigned resident(s) for my clinical experience. Any pertinent information needed for my assignment will be hand-written and without reference to a resident s identity. I understand that the Health program in which I am accepted reserves the right to terminate my clinical rotation as a result of any breach of confidentiality. I understand that if there are any issues, I am to contact my clinical instructor immediately. I have read and understand the above confidentiality statement and I will abide by these guidelines. Student Name (printed) Student Signature Date

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8 Disqualifying Criminal Offenses Any conviction, plea of guilty or no contest, or deferred adjudication of the following criminal offenses (Felony or Misdemeanor) appearing on a criminal background check will disqualify an applicant for admission to a CCCS Health or Nursing Program. I II III IV V VI VII VIII IX X Crimes of violence (assault, sexual offenses, arson, kidnapping, murder, any crime against an at-risk adult or juvenile, etc.). as defined in section C.R.S. Any offense involving unlawful sexual behavior. Any crime, the underlying basis of which has been found by the court on the record to include an act of domestic violence, as defined in section C.R.S. Any crime of child abuse, as defined in section C.R.S. Any crime related to the sale, possession, distribution or transfer of narcotics or controlled substances. Crimes of theft Any offense of sexual assault on a client by a psychotherapist, as defined in section C.R.S. Crimes of moral turpitude (prostitution, public lewdness/exposure, etc.) Registered sex offenders Any offense in another state, the elements of which are substantially similar to the elements of any of the above offenses. (Students who have successfully completed the terms of their deferred adjudication agreement will not be disqualified.)

9 REGISTRATION FORM SUMMER FALL SPRING _ (CHECK THE APPROPRIATE TERM) STUDENT I.D. NUMBER _ S NAME (Last) (First) (MI) ADDRESS Street City State ZIP ADDRESS PHONE A CURRENT APPLICATION MUST BE ON FILE IN THE ADMISSIONS OFFICE BEFORE YOU CAN REGISTER FOR CLASSES. Student Intent Earn an Academic Degree (AA/AS/AGS) Earn a Vocational-Technical Degree Earn a Vocational-Technical Certificate None of the Above PREREQUISITES MUST BE FULFILLED. SEE DEPARTMENT CHAIR IF YOU HAVE QUESTIONS. NEW/TRANSFER STUDENTS ENROLLING IN SIX (6) OR MORE CREDITS, MUST MAKE AN APPOINTMENT WITH THEIR ADVISOR FOR ENROLLMENT COUNSELING. AUDITORS are NOT eligible to receive the COF STIPEND; therefore you will be charged both the tuition and the established stipend amount. Grades and credits are not assigned for audited courses EXAMPLE C I S CRN# PREFIX NUMBER SEC # # Credits N U A N U A N U A INITIAL TO REQUEST AUDIT You will not receive credit, a grade or COF INITIAL TO REFUSE COF STIPEND *Approval Signature If Needed N U A TOTAL NUMBER OF CREDITS 6.5 OVERLOAD APPROVAL STUDENT SIGNATURE IS REQUIRED YOUR SIGNATURE authorizes the COLLEGE OPPORTUNITY FUND (COF) stipend to be applied to your In-State Tuition AND holds you financially responsible for all the above registered courses. Student Signature Advisor Signature Date DATE PROCESSED BY (Clerk s ) *SIGNATURES REQUIRED: Entry into closed classes: Instructor and Department Chair Unmet Prerequisites: Department Chair Late Registration with Instructor Permission: Instructor After Late Registration with Instructor Permission: Instructor and Department Chair After the Drop Period (Census): Instructor, Department Chair and Division Dean (NO FTE OR COF - DEPARTMENT MUST PAY COF) Time Conflicts: Both Instructors Registrations in excess of 18 credit hours: Division Dean S:\A&R Forms/REGISTRATION FORM/REV 10/2006

10 PUEBLO COMMUNITY COLLEGE GRADUATION PLANNING SHEET NAME: ID #: LAST FIRST MI Graduation Term (check one) Fall 20 Spring 20 Summer 20 Catalog Year Are all transfer and/or prior learning credits posted to the student s record? Yes No N/A Will the student receive a degree or certificate? (check one) Certificate Degree: AA AS AGS AAS Indicate the student s major AND concentration, if appropriate: Certified Nursing Assistant (Certificate) Applications must be received in Records by the deadline date for the requested graduation semester. Late applications will be automatically processed for the next semester. All summer applications will be included in the preceding commencement ceremony. To graduate in: Application must be submitted by: Please PRINT the student s name as it should appear on the diploma. FIRST/MIDDLE LAST Address where student s diploma should be mailed: Check here if this is an address change for all of the student s records Street City State Zip INPROGRESS COURSES IDENTIFIED SHOULD ONLY RELATE TO COMPLETION OF DEGREE Course # Course Title Term Final Grade or Comment NUA 101 NUA 170 NUA 171 NUA 102 Nurse Aide Hlth Care Skls Nurse Aide Clinical Exp Adv Nurse Aide Clinical Nurse Aide Cert. Exam Prep. Graduation is dependent upon satisfying all academic requirements as stated in the PCC Catalog and meeting all PCC financial obligations. (Student ) Student: Dean s signature indicates ALL substitutions, waivers, and modifications are approved. Date: Advisor: Department Chair: Dean: Date: Date: Date:

11 Curriculum Sheet Nursing Aide Student Name: Certificate Student ID #: Until Modified Phone Number: 6.5 Credit Hours Catalog Year: Entrance requirements: High school diploma or GED, ENG 030, REA 030, MAT 045 or equivalent assessment test score. To succeed in this program, you must have a sincere concern for people, good physical and emotional health, an excellent attendance record, an ability to communicate effectively with other health care personnel, residents, and their families, and a neat, well-groomed appearance. This program IS NOT eligible for financial aid. Note: Clinical agencies used during the program require that you successfully complete a background check, drug screening, immunization series, and CPR training; you must also carry malpractice insurance. Nursing Assistant PREREQUISITES Core Curriculum SEM CRS SEM COM GRADE Transfer Credit or Course Substitution CR SS 50-69, RD 40-61, EA NUA 101 Certified Nurse Aide Health Care Skills 4 SS 50-69, RD 40-61, EA 30-84, CORQ: NUA 101 NUA 170 Nursing Assistant Clinical Skills 1 SS 50-69, RD 40-61, EA 30-84, CORQ: NUA 101, NUA 170 NUA 171 Advanced Nurse Aide Clinical 1 Refer to College Catalog for Prerequisites NUA 102 Nurse Aide Certification Exam Prep 0.5 I have checked the record of the student shown above and found it qualifies him/her for a degree at the completion of spring semester, Student Advisor Date ESTIMATED COSTS *Tuition/Fees (6 ½ Credits) $ Books $56.99 Uniform $25.00 to $40.00 Shoes $25.00 to $75.00 Gait Belt $10.00-$20.00 Watch with sweep second hand $20.00 CPR Certification $35.00 Background /Drug Screen Check $66.20 Immunizations $75.00 to $ State Board of Nursing written and practical test $ Total $1, to $1, *Tuition estimate is the Colorado Resident tuition rate; those designated as non-residents will pay a substantially greater tuition. These costs are estimates and are subject to change without notice.

12 NURSING ASSISTANT Flowchart 6.5 Credit Hour Certificate College Admission Process Assessment Testing Program Entry Prerequisites: RC 40-61, EA 30-84, SS or CCR 092, MAT 050 or CCPT exemptions 1. Successfully pass a background check and drug screen 2. Immunizations are current 3. Complete CPR Training Pass your classes and Certification exam! GRADUATE!

13 Pueblo Community College: Health Professions Division Health Certification Legal Name: Student ID: Birthdate: Phone: Address: City/State: Zip: Cell: Instructions: Complete the immunization and signature sections on this form as well as the Essential Functions page specific to your program. All information/test results must be complete before you submit this form. Questions may be directed to the PCC Health (719) You MUST make a copy of your completed health form and retain it. You may need to provide it to a clinical agency. DO NOT RETURN THIS FORM TO THE CLINICAL COORDINATOR UNTIL ALL RESULTS AND SIGNATURES ARE COMPLETE. DATE TYPE OF TEST/VACCINE RESULTS AUTHORIZED SIGNATURE / MEDICAL TITLE #1 #2 OR QFT CXR PPD/TB (Tuberculin Skin Test): You are required to show proof of 2 consecutive, annual TB skin tests (one in the last 12 months). If you ve never had a TB skin test or haven t had one within the last 2 years, you must complete a two- step TB Skin Test OR Quantiferon TB Gold (QFT-G) blood test. Chest X-Ray: If you have a positive PPD or QFT-G blood test, a Chest X-ray report must be submitted. #1 #2 QFT CXR Tetanus: Must provide proof of (1) Tdap vaccination in lifetime and Td booster within 10 years of program entry; Tdap may substitute for Td (Dtap will not be accepted) #1 #2 T B MMR #1 MMR # 2 MMR Titer MMR Booster Proof of (2) MMR (Measles,Mumps,Rubella) vaccinations in lifetime OR laboratory evidence of immunity with MMR Titer (MMR vaccine booster given if titer results are negative and/or equivocal) T #1 #2 #3 Hepatitis B: Proof of 3-dose Hepatitis B series in lifetime OR laboratory evidence of immunity with Hepatitis B Titer. Influenza: Required annually for all clinic/hospital site based clinicals. May also be required for other clinical sites (please check with your instructor). (If allergic, you must provide physician explanation. If allergic or refuse influenza vaccination, you will be required to wear a mask, at all times, during clinical studies) T The following lab tests may be required by clinical sites: (Please check with your instructor) Hepatitis B Titer T T I give permission to release information on this health form to the professional college and clinical affiliate staff if it s deemed necessary for the benefit and/or safety of myself and others. Signature of Immunization Recipient Date: Date Due Program Name Semester Start Rev: