VOCATIONAL NURSING PROGRAM

Transcription

1 Application for admission to: VOCATIONAL NURSING PROGRAM PLEASE SPECIFY WHICH CAMPUS SITE(S) YOU WISH TO APPLY BY RANKING EACH IN ORDER OF PREFERENCE: Cuero Gonzales Hallettsville Victoria PLEASE PRINT OR TYPE Application Date / / Name: Last First Middle Maiden Are there any other names which might appear on a transcript? If so, please list: Home Telephone #: Work Telephone #: Cell Telephone #: Address: Mailing Address: P.O. Box or Number & Street City State Zip Code County Permanent Address (if different from above): Number & Street City State Zip Code County Name, Address, and Telephone Number of person to be notified in case of an emergency: It is the student s responsibility to keep mailing address and contact information current with the program office and the Admissions office. Have you taken the DET exam? Yes No If yes, date of exam: / / If you have taken the DET prior to September 1, 2011, you will need to re-test. Have you obtained a clear criminal background check from the Board of Nursing? Yes No You are responsible for submitting the original CBC result to your first choice Program Office.

2 *Social Security No.: - - *Date of Birth: / / *This information is required to complete the BON criminal background check. Please give information concerning high school graduation or G.E.D. completion: Name of High School or GED Institution City/State Type: Diploma GED Please give information concerning college, university, vocational or allied health schools attended: Name of Institution City/State Number of Credits Earned To receive credit, students must provide course descriptions of any courses on the VN program of study taken outside of VC to the program coordinator. An official transcript must be provided to the Vocational Nursing Program Office and the Admissions Office by June 3rd. Please list any licenses or certificates held (e.g., EMT, CNA, etc.): I certify that the above statements are true and correct. Signature of Applicant It is the applicant s responsibility to: Return this application by mail or in person to the first choice VN Program Secretary s Office: Cuero VN Program (2550 Esplanade, Cuero TX 77954), Gonzales VN Program (424 E. Sarah DeWitt, Gonzales TX 78629), Hallettsville VN Program (1410 N. Texana, Hallettsville TX 77964) or Victoria VN Program (2200 E. Red River St., Victoria TX 77901). Additional information on the web: Statement of Nondiscrimination Victoria College does not discriminate on the basis of race, color, religion, national origin, gender, pregnancy, age, disability, genetic information, marital status, amnesty, veteran s status, or limited English proficiency. It is our policy to comply, fully, with the nondiscrimination provision of all state and federal rules and regulations.

3 LICENSURE ELIGIBILITY REQUIREMENTS Applicant s Name (Print): Address: PO Box or Number & Street City, State Zip Code Home Telephone #: *Social Security #: Cell #: *Date of Birth: / / *This information is required to complete the Texas Board of Nursing criminal background check (CBC). To be considered an eligible applicant, Victoria College Nursing Programs require proof of a clear Texas Board of Nursing (BON) criminal background. All licensure eligibility issues must be resolved. This form must be returned to your first choice Nursing Program Office to initiate the Texas Board of Nursing criminal background check. Completion of this process can take 4 months or longer. Eligibility issues that must be resolved in order to be qualified for nursing program admission include: 1) [ ] No [ ] Yes For any criminal offense, including those pending appeal, have you: A. been convicted of a misdemeanor? B. been convicted of a felony? C. pled nolo contendere, no contest, or guilty? D. received deferred adjudication? E. been placed on community supervision or court-ordered probation, whether or not adjudicated guilty? F. been sentenced to serve jail or prison time? court-ordered confinement? G. been granted pre-trial diversion? H. been arrested or have any pending criminal charges? I. been cited or charged with any violation of the law? J. been subject of a court-martial; Article 15 violation; or received any form of military judgment/punishment/action? (You may only exclude Class C misdemeanor traffic violations.) NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended that you submit a copy of the Court Order expunging or sealing the record in question to the BON office with your BON application. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, will at a minimum, subject your license to a disciplinary fine. Nondisclosure of relevant offenses raises questions related to truthfulness and character. NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov t Code (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may (Over)

4 become a character and fitness issue. Pursuant to other sections of the Gov t Code chapter 411, the Texas Nursing Board is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board discovers a criminal matter that is the subject of an order of nondisclosure, even if you properly did not reveal that matter, the Board may require you to provide information about that criminal matter. 2) [ ] No [ ] Yes Are you currently the target or subject of a grand jury or governmental agency investigation? 3) [ ] No [ ] Yes Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license, certificate or multi-state privilege held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? 4) [ ] No [ ] Yes *Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug? 5) [ ] No [ ] Yes *Within the past five (5) years have you been diagnosed with, treated, or hospitalized for schizophrenia and/or psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder? If YES indicate the condition: [ ] schizophrenia and/or psychotic disorders, [ ] bipolar disorder, [ ] paranoid personality disorder, [ ] antisocial personality disorder, [ ] borderline personality disorder *Pursuant to the Occupations Code , information regarding a person s diagnosis or treatment for a physical condition, mental condition, or chemical dependency is confidential to the same extent that information collected as part of an investigation is confidential under the Occupations Code If you answered YES to any of the questions listed above, submit a letter of explanation to the Texas Board of Nursing (333 Guadalupe, Ste , Austin TX ) that is dated and signed indicating the circumstance(s) you are reporting before you will be eligible for program admission. Telephone number: (512) , website: Applicant s Signature: Date: Revised 9/27/12

5 NAME: DATE: Vocational Nursing Program Checklist Dear Vocational Nursing Program Applicant, Thank you for your interest in the Vocational Nursing Program. The program begins every fall semester. It is the responsibility of the applicant to furnish all necessary documentation (as stated below) by June 3rd of the current year. In order to be considered for admission to the program you must complete the following checklist: *Applicants need to bring this form into the office when submitting documents.* (VC staff will initial, check box, and date when documents have been submitted) 1. Criminal Background Check (CBC) Complete the Licensure Eligibility Requirement form and submit it to the nursing program office. This form will not be accepted after March 1 st for fall admission. It can take 4 months or longer for the Texas Board of Nursing (BON) to complete this process. Without resolution of all licensure eligibility issues including a clear criminal background check (CBC), you are not eligible for admission to the Vocational Nursing Program. Once you have received a completed, clear CBC result from the BON, it is your responsibility to submit the original document to the program office by June 3rd. For applicants with a declaratory issue, please submit the letter indicating Board order. (Faxed or scanned copies will not be accepted.) 2. Vocational Nursing Program Application Submit a completed Vocational Nursing Program Application for VN Admission. Vocational Nursing Program Applications are not retained from year to year so in order to be eligibile for admission, a new application must be submitted each year (October 1 June 1). 3. TSI Complete (Texas Success Initiative) Applicants must be TSI (Texas Success Initiative) complete to qualify for admission. Please contact Advising and Counseling Services for more information at (361) It is the applicant s responsibility to validate their TSI status with the Advising/Counseling and the Admission/Records Office. Official transcript(s) from all colleges attended (other than Victoria College) must be provided to the Victoria College Admission/Records Office and Vocational Nursing Program by June 3rd to be eligibile for program admission. 4. Record of Immunization Form Submit completed Victoria College Record of Immunization form. Hepatitis B series must be completed or in progress on or before March 1 st of the

6 current year or earlier OR proof of seroligic immunity. The two-step PPD skin test for tuberculosis is required. 1. The first PPD must be within one year of second PPD. This is submitted on the Record of Immunization form. 2. The date of the second PPD should be no earlier than July 22, 2013 and no later than August 7, The 2 nd PPD test results must be submitted no later than August 12, 2013 and will be submitted separately. 5. Diagnostic Entrance Test (DET) A qualifying Diagnostic Entrance Test (DET) result of 45% or higher in English AND 45% or higher in Math on the same test date are required to be eligible for admission to the program. You may only take this test twice in a testing year. If taking the DET more than one time in a testing year, the most recent score will be used to meet the admission criteria. Contact the Victoria College Testing Center at (361) for further information regarding the DET. 6. Victoria College Application Complete an online application for admission to Victoria College. More information is located at It is the applicant s responsibility to validate with the Admission and Records Office that their Victoria College application has been processed by calling (361) or (877) EDUC 1300 or SDEV 0301 Applicants who have earned less than 13 hours of college credit must complete EDUC 1300 or SDEV 0301 with a C or better prior to June 3rd to be eligible for admission. 8. BIOL 2404 OR BIOL 2401 and BIOL 2402 Submit official transcript which includes completion within the past 5 years of BIOL 2404 OR BIOL 2401 and 2402 (Anatomy & Physiology) with a C or better. Applicants are responsible for submitting college transcripts to the Admissions/Records Office and Vocational Nursing Program by June 3rd. PRIOR TO ENROLLMENT: Qualified applicants who have been ACCEPTED into the Vocational Nursing Program must submit a current and completed: 1. CPR Health Care Provider card (American Heart Association only) 2. Victoria College Allied Health Physical Examination form (completed no more than 6 months prior to program enrollment). Please call or our office if you have any questions regarding the Vocational Nursing Program. We look forward to assisting you in becoming a Licensed Vocational Nurse. Most sincerely, Vocational Nursing Program Coordinators

7 Cuero Campus 2550 Esplanade, Cuero TX (361) Rebecca Barfield, Program Coordinator Sheryl Mueller, Program Secretary Gonzales Campus 424 E. Sarah DeWitt, Gonzales TX (830) Karen Bauer Smith, Program Coordinator Helen Hahn, Program Secretary Hallettsville Campus 1410 N. Texana, Hallettsville TX (361) Joyce Harper, Program Coordinator Tricia Grahmann, Program Secretary Victoria Campus 2200 E. Red River St., Victoria TX Rebecca Barfield, Program Coordinator (361) Sheryl Mueller, Program Secretary (361) Victoria College Vocational Nursing Programs

8 Arnett Development Corporation Diagnostic Entrance Test DET The Arnett Development Corporation, Diagnostic Entrance Test is a 148 multiple choice item content test, divided into four major parts which consist of English, Reading/Comprehension, Critical Thinking and Math. The DET test was designed to be a diagnostic instrument to evaluate your knowledge level in specific areas and pinpoint strengths and weaknesses. This test is designed to assess your ability to incorporate material learned throughout your education and use principles, rules, concepts and facts that have been built on throughout your educational life. Categorization of Major Areas of Coverage English Spelling Grammar Contextual Words Sentence Structure Math Integers, -, +, x, / whole number Fractions Decimals Percents Pattern Recognition Word Problem Reading Paragraph & Passage comprehension Drawing inferences & conclusions Graph & Chart interpretation Critical Thinking (core competency) Analysis Explanation Inference Interpretation Evaluation (This section is based on your ability to solve problems.) There are 88 questions in the English category and 60 questions in the Math category for a total of 148 questions. The time allotted to take this test is two hours and 30 minutes. Study Materials Recommended study material (study guide) for the DET is provided. Purchasing of this study material is not required. It is optional. The study guide can be purchased at the Victoria College Bookstore or on-line at Test Taking Tips 1. Do not cram. 2. Get a good night s sleep the night before the test. 3. Eat breakfast. 4. Dress comfortably. 5. Follow all directions during the test.

9 DET-LVN Program Exam Schedule Test Fee-- Cost $30 Reschedule Fee-- $15 (must be paid in-person at Payment Center by 4PM the day of the test) No refunds on testing Please Note: You may only take this exam TWICE between September and June 1, Walk-In testing is NOT available. Registration fee can be paid in person at the VC-Payment Office or online at testingcenter. Payment guarantees your seat. Retain your payment receipt for your records. Photo ID and Paid Receipt are required to sign-in on test day. Be familiar with the computer. Computer knowledge is needed to take this exam. Tests will not be administered during Final Exam testing, spring & Christmas breaks, and government holidays. Because of the difficulty of the exam and the limited number of attempts allowed, students are strongly encouraged to study for the exam. If you wish to purchase a Study Guide, please go to the Victoria College Bookstore website: bookstore VC Testing Center-Main Campus Exams scheduled will start promptly at 8:30 a.m. on the following test dates: October 3, 2012 October 17, 2012 November 7, 2012 January 15, 2013 January 23, 2013 January 30, 2013 February 6, 2013 February 20, 2013 February 27, 2013 March 6, 2013 March 20, 2013 March 27, 2013 April 3, 2013 April 17, 2013 April 24, 2013 May 15, 2013 May 17, 2013 May 31, 2013 VC Gonzales Center Exams scheduled on FRIDAYS on the following test dates: October 19, :30 PM November 9, :00 AM February 8, :30 PM February 22, :00 AM March 22, :30 PM April 12, :30 PM April 26, :00 AM Test will be administered at: Main Campus Continuing Education Center 2200 E. Red River, Room 201 Victoria, TX (unless otherwise noted) (driving directions) Gonzales Center 424 E. Sarah DeWitt Drive Gonzales, TX (driving directions) Please call in advance to check test date availability if you are traveling from outside Victoria County. Scheduled dates are subject to change as needed. Please bring your Paid Receipt and PHOTO ID to testing session. Please arrive at least 15 MIN BEFORE test is scheduled to start Students who are late WILL NOT be allowed to test and will have to reschedule. All fees apply. Revised

10 ***READ THIS FIRST*** INSTRUCTIONS TO RECORD OF IMMUNIZATIONS Submit Record of Immunizations by June 3, 2013, regardless of whether or not the Hepatitis B series is completed. The 2 nd PPD test will not have been given. The complete Hepatitis B series (or confirmation of serologic immunity test) must be submitted no later than September 1, Immunizations must be current. This includes the DT (diphtheria, tetanus) booster within the last 10 years, and MMR (measles, mumps, rubella). The two-step PPD skin test for tuberculosis is required. 1. The first PPD must be within one year of second PPD. This is submitted on this form. 2. The date of the second PPD should be no earlier than July 22, 2013 and no later than August 7, The 2 nd PPD test results must submitted no later than August 12, 2013 and will be submitted separately. EXCEPTIONS TO IMMUNIZATION REQUIREMENT (Verification of Immunity/History of Illness) (a) Serologic confirmation of immunity to measles, rubella, mumps, Hepatitis A, Hepatitis B, or varicella, is acceptable. This confirmation of immunity must be validated by a qualified healthcare provider and must include the laboratory report that confirms immunity. (b) A parent or physician validated history of varicella disease (chickenpox) or varicella immunity is acceptable in lieu of vaccine. A written statement from a physician, or the student s parent or guardian, or school nurse, must support history of varicella disease. Please turn to other side of page to complete form. Revised 4/20/11

11 Print Name: DOB: RECORD OF IMMUNIZATIONS Note: Please provide dates for each requested blank unless otherwise specified and proof of immunity, if applicable. TETANUS/DIPHTHERIA: Booster date: (One dose of tetanus-diphtheria toxoid (Td) is required within the last ten years.) MEASLES/MUMPS/RUBELLA: Two doses of MMR are required: Dose #1 (Immunization received as infant may be used as first dose.) Dose #2 OR Proof of immunity to Rubella by Rubella titer: Immune Status/Date: Proof of immunity to Measles by Measles titer: Immune Status/Date: Proof of immunity to Mumps by Mumps titer: Immune Status/Date: 2 STEP PPD TB TEST Note: TINE TESTS ARE NOT ACCEPTABLE 1. Date of first skin test: (NOTE: must be within one year of second test) Reaction: mm induration 2. Students must provide evidence of second TB skin test results to program secretary prior to enrollment. If candidate has a positive PPD, has he/she been evaluated for/received INH chemoprophylaxsis? If previous positive PPD, date of chest x-ray within 6 months of admission date: Chest x-ray report: HEPATITIS B SERIES: Date of First Dose: Date of Second Dose (One (1) month after 1st dose): Date of Third Dose (Six (6) months after 1st dose): OR Serologic confirmation of immunity to hepatitis B virus: Date: Immune Status: VARICELLA: Date of 1st dose: Date of 2nd dose: (Required if 1st dose was given after 13 years of age.) OR Serologic confirmation of immunity to Varicella virus: Date: Immune Status: OR Complete form Documenting History of Illness: Varicella (Chickenpox) Date of Illness: By signing this document, you, the Healthcare Provider, are validating immune status on any titers reported above. Please attach laboratory results of all titers completed. ***Healthcare Provider signature required.*** Signature of Healthcare Provider Date Revised 9/27/12

12 Ben Wilson U X E9 Victoria College CAMPUS MAP Victoria College and the University of Houston-Victoria 1 Museum of the Coastal Bend 2 Academic Building (AB) 3 Johnson Hall (JH) 4 Fine Arts (FA) 5 Allied Health (AH) 6 Johnson Symposium (JS) 7 Library (LIB) 8 Welcome Center/ Student Services 9 Building A 10 Health Sciences Center (HSC) 11 Language Building (L) 12 Sports & Fitness Center (SPCTR) 13 Student Center/Bookstore 14 Continuing Education Center (CECTR) 15 Technology Center (TC) 16 William Wood Vocational Building (WB) 17 College Services & Training Building (CST) T 19 S 17 C 18 Q 16 R 10 E1 A D 14 F E2 B G 7 E J K 13 3 I L 4 E6 P O M Red River 5 6 V E7 Main Entrance E8 W University of Houston-Victoria UHV West UHV Center Parking A X Student, Employee, and Visitor Parking Student and Visitor parking is allowed in any unmarked space. No permit is required. Reserved spaces (Yellow curb) require employee permit ($25 fine per violation) Students and visitors may use reserved spaces after 5:00 p.m. Ben Jordan H 1 E5 Handicap spaces (Blue curb) require state-issued permit. ($50 fine per violation) I E - Entrances E3 E4 Exit Only