The Center for Allied Health and Nursing El Centro College Perioperative Nurse Internship - Revised for Spring 2015 application - The El Centro College Perioperative Nurse Internship program offers registered nurses (RN) the opportunity to acquire additional theory and skills required for patient care in the surgical setting. The perioperative approach to patient care is employed. Principles of surgical asepsis, patient care, the use of surgical instruments, supplies, equipment, and ethical/legal aspects are presented. The emphasis of the program is on the scrub and circulating roles. A minimum of 10 students is required to offer the Perioperative Nurse Internship program and the maximum number of spaces will be determined by clinical availability. Selection of applicants is upon a firstcome, first-served basis; however, early application during the official filing period is strongly encouraged. Upon successful completion of this seven month, 15 credit hour curriculum, the registered nurse receives an Enhanced Skills Certificate. This information packet contains specific application guidelines and requirements. By submitting an application packet, an individual verifies that they have 1) read the packet thoroughly, 2) obtained all necessary documents from designated website addresses, and 3) understands the policies and procedures for application and acceptance to the program. EQUAL EDUCATIONAL OPPORTUNITY Educational opportunities are offered by the El Centro College without regard to race, color, age, national origin, religion, sex, disability, or sexual orientation. APPLICATION REQUIREMENTS TO THE PERIOPERATIVE NURSE INTERNSHIP PROGRAM Application to the Perioperative Nurse Internship program requires the following steps: Application and current admission to a Dallas County Community college. Possess current Registered Nurse ( RN ) licensure from the state of Texas OR Be a recent graduate of a Associate Degree or Bachelor s Degree nursing program and be eligible to write and pass the NCLEX-RN examination prior to the beginning of the Perioperative Nurse Internship program. Hold current CPR certification at the Healthcare Provider level. Submission of complete documentation of a current physical exam, tuberculosis screening, required immunizations and CPR certification to SentryMD. Submission of a complete application packet to the Health Occupations Admissions Office during a designated filing period. 1
A. General Admission Requirements to the College Applicants to the Perioperative Nurse Internship program must meet college admission requirements at the El Centro College as outlined in the official college catalog at http://www.elcentrocollege.edu. Applicants must have earned either a high school diploma or General Education Development (GED) certificate in addition to complying with Texas Success Initiative (TSI) requirements. All students applying or enrolled at a Dallas County Community college are required to submit their Social Security number to the Registrar s Office. Students who do not possess a Social Security number must complete a form obtained at the Registrar s Office. For more information, consult a Registrar/Admissions Office at any Dallas County Community college. Official College Transcripts Prior to application to a health occupations program, potential applicants must have submitted all of their official transcripts to the Registrar/Admissions Office at one of the seven Dallas County Community colleges. The transcripts must be current with the print date no earlier than three years of the applicant s anticipated admission to a health occupations program. If the official transcripts have not been submitted, the individual s application to a health occupations program will be voided. B. SentryMD Applicants to health occupations programs are required to have a current physical examination, specific immunizations, a tuberculosis screening, and certification in CPR at the Healthcare Provider level. The El Centro College Health/Legal Studies Division utilizes SentryMD, a medical record management company, to verify these requirements. Applicants submit this documentation directly to SentryMD which will verify whether the records are in compliance. The required immunizations are listed on item 3, page 10 of this information packet. CPR requirements are listed on item 4, page 11. NOTE: SentryMD must receive this documentation and verify that the applicant s records are in compliance no later than the January 31 st application deadline. Failure to submit the documentation AND be in compliance with these requirements by the application deadline will result in disqualification from the applicant pool. For more information on SentryMD and this process, see the Immunization Requirements link at: www.elcentrocollege.edu/healthoccadmissions If the applicant has personal healthcare coverage at the time of application, that documentation may also be submitted to SentryMD. If accepted to the program, the applicant must submit proof of coverage to SentryMD prior to attending clinical. For more information, see item 3 on page 10 of this packet. 2
C. Application Packet Submission READ THE FOLLOWING INSTRUCTIONS CAREFULLY. Applicants must submit a complete application packet to the El Centro College Health Occupations Admissions Office either in person or by mail on or before the application filing deadline. Incomplete packets will not be considered in the selection process and will be returned to the applicant. The Perioperative Nurse Internship program application materials must include the following items to be considered complete and valid: 1. A completed Perioperative Nurse Internship Application form and the signed Statement of Student s Responsibility form (both available in this information packet). 2. Documentation of a current, valid Texas RN license or documentation verifying eligibility to write the NCLEX-RN prior to the start of the Perioperative Nurse Internship program. NOTE: Applicants are solely responsible for ensuring that their current official transcripts from ALL PREVIOUSLY ATTENDED COLLEGES AND UNIVERSITIES (excluding Dallas County Community colleges) are submitted to a Registrar/Admissions Office at a Dallas County Community college prior to applying to an El Centro College health occupations program. Official transcripts must have a print date no earlier than three years of anticipated entry to a health occupations program. Submitting incomplete application materials will disqualify the application and the student will not be considered further in the application process. Students are advised to retain a photocopy of all materials submitted as their application packet. D. Application Filing Period The completed application packet should be submitted to the El Centro College Health Occupations Admissions Office (Room P-101) on or before the application deadline: Official application filing period for Spring semester (late February) admission: November 1 January 31 Notification letters are mailed by February 10 th. Complete application packets may be presented in person at the Health Occupations Admissions Office during regular hours of operation or submitted in the drop box adjacent to the office door. Mailed application packets must be postmarked no later than an application filing deadline date. NOTE: In the event that the last day of a filing period falls on a holiday or a Sunday when the college is closed or when the post office does not postmark mail, complete application packets may be presented to the El Centro College Health Occupations Admissions Office in person by 5:00 p.m. the next regular business day. 3
To submit your application by mail, address your envelope to: Periop Nursing Admissions Health Occupations Admissions El Centro College/Paramount Building 801 Main Street Dallas, Texas 75202 To submit your application in person, bring your envelope to: Periop Nursing Admissions Health Occupations Admissions Room P-101 Center for Allied Health & Nursing El Centro College/Paramount Building 301 North Market Street Dallas TX 75202 E. Selection Process Qualified applicants are selected for acceptance to the Perioperative Nurse Internship program on a first-come, first-served basis. Should any available spaces remain in the program after the January 31 st application deadline, late applications may be entertained at the discretion of the Program Coordinator and the Health and Legal Studies Division administration. F. Class Schedule Perioperative Nurse Internship classes begin in the Spring semester (late February) and conclude in early August. The sample class schedule is found below: PERIOPERATIVE NURSE INTERNSHIP SAMPLE COURSE SCHEDULE Spring 2014 - Summer 2014* COURSE CLASS DAYS TIME DATES SPRING SEMESTER SRGT 1340 Perioperative Nursing I Online Online 02/17/14 05/16/14 SRGT 1167 Lab/Practicum Tuesday/Wednesday Lab 7:00 a.m. 12:00 p.m. Clinical Site 02/18/14 05/20/14 SRGT 2366 Practicum Monday Friday 7:00 a.m. 12:00 p.m. Clinical Site 04/28/14 07/25/14 SUMMER SEMESTER SRGT 1441 Surgical Procedures I Online Online 06/09/14 07/03/14 SRGT 1343 Perioperative Nursing II Online Online 06/09/14 07/18/14 SRGT 1166 Practicum (clinical) Monday-Friday 7:00 a.m. 4:00 p.m. Clinical Site 07/14/14 08/07/14 * This schedule is a sample from the previous year. 4
G. Student Considerations The surgical setting is a physically and psychologically stressful environment. In considering the Perioperative Nurse Internship program as a nursing specialty, applicants should be aware of the following: Students will be required to lift and move patients, heavy instruments, heavy and bulky equipment and supplies, and stand or sit in one place for long periods of time, often without relief. In emergency situations, a student may be required to move very quickly. Fine hand-eye coordination skills are needed in certain situations while gross hand-eye coordination skills are needed in others (i.e., threading small-eyed needles or handing large orthopedic drills to surgeons). Students will be required to anticipate quickly and adequately the needs of the patient, physician, and other health workers. Students will be required to develop and utilize interpersonal relationship skills and be able to function in highly stressful situations. Students may be subjected to various gases, chemicals, and radiation which may be harmful to them, their reproductive system and/or unborn fetus. In order to protect the student, a physician's release form must be obtained by the student indicating the student is able to fully participate in the surgical setting. The surgical setting is a high-risk area for contracting human immuno-deficiency virus (HIV), acquired immune deficiency syndrome (AIDS), and hepatitis B (HBV). Students are taught protective and precautionary procedures which must be followed in the clinical setting. Perioperative Nurse Internship courses are taught only during daytime hours due to surgical schedules. SURGICAL CAREERS PROGRAMS MISSION STATEMENT The Surgical Careers programs strive to provide the cognitive, affective, and psychomotor (kinetic) skills necessary for the graduate to function in a diverse community as a perioperative nurse or a perioperative nurse. 5
SURGICAL CAREERS PROGRAMS PHILOSOPHY The Surgical Careers faculty accepts the philosophy, mission, and objectives of the college of which we are a part. We believe that Surgical Careers are a service to the community. The graduate of a surgical careers program utilizes the humanistic application of scientific principles concerning knowledge of anatomy, physiology, sterile technique, and external control forces to meet and protect the physiological and emotional needs of the patient. We further believe that the education of the perioperative nurse and perioperative nurse is a dynamic teaching-learning process that involves modification of cognitive, psychomotor, and attitudinal potentials of the student. We consider learning to be an active process contingent upon the student and facilitated by the instructor. Upon graduation, we expect the perioperative nurse to be prepared to write the National Certifying Examination for Perioperative nurses. It is recognized that there is an increasing body of knowledge dealing with new, complex surgical procedures and that the perioperative nurse will gain competency in these areas through his/her active participation in continuing education and professional organizations. The faculty accept the responsibility for planning, implementing, and evaluating the teaching-learning process in order to ensure the delivery of safe, competent surgical performance. We also believe that through periodic review and revision, the curriculum shall continue to reflect the philosophy of the Surgical Career program as related to the needs of the community. SURGICAL CAREERS PROGRAMS STUDENT WORK POLICY All student activities associated with the curriculum, especially while students are completing his or her clinical rotations, will be educational in nature. Students will not be receiving any monetary remuneration during this educational experience, nor will he or she be substituted for hired staff personnel within the clinical institution, in the capacity of a perioperative nurse. Clinical facility personnel must be available to assist or replace the student to prevent the patient or student from being placed in a compromising position. 6
EL CENTRO COLLEGE SURGICAL CAREERS PROGRAM PROGRAM GOALS AND LEARNING DOMAINS COGNITIVE DOMAIN GOAL: OBJECTIVE: To prepare competent entry-level perioperative nurse in the cognitive (knowledge), psychomotor (skills), affective (behavior) learning domains, and to meet the needs of the health care industry by providing qualified, well-trained Perioperative nurse. The graduates of the Surgical Career program will complete the following objectives during their course of study: AFFECTIVE DOMAIN 1. Identify the role of the Perioperative nurse as a member of the health care team. 2. Utilize theoretical knowledge base while caring for patients. 3. Exhibit competence in all roles of the Perioperative nurse by performing safe, skilled technical practice. 4. Utilize effective communication skills while interacting with all members of the health-care team, patients and their families, faculty, and other groups in the health care setting. 5. Display legal and ethical behavior in the practice of technical skills. 6. Assume responsibility for continuing educational growth. 7. Demonstrate the ability to comprehend, apply and evaluate knowledge of anatomy, physiology, sterile technique, and external control forces to meet and protect the physiological and emotional needs of the patient. GOAL: OBJECTIVE: To prepare competent entry-level perioperative nurse in the cognitive (knowledge), psychomotor (skills), affective (behavior) learning domains and to meet the needs of the health care industry by providing qualified, well-trained Perioperative nurse. Upon completion of the program, students will demonstrate professional behavior consistent with employer expectations as a registered nurse with an enhanced skills certificate in Peroperative nursing. PSYCHOMOTOR DOMAIN GOAL: To prepare competent entry-level perioperative nurse in the cognitive (knowledge), psychomotor (skills), affective (behavior) learning domains and to meet the needs of the health care industry by providing qualified, well-trained Perioperative nurse. OBJECTIVE: Upon completion of the program, students will demonstrate the technical proficiency in all the skills necessary to fulfill their roles as a certified Perioperative nurse. 7
CURRICULUM OVERVIEW PERIOPERATIVE NURSE INTERNSHIP CERTIFICATE PREREQUISITES Applicants to the Perioperative Nurse Internship program must hold a current license from the Texas Board of Nursing, or be a recent graduate of a Associate Degree or Bachelor s Degree nursing program and be eligible to write and pass the NCLEX-RN examination prior to the beginning of the Perioperative Nurse Internship program. Applicants must hold a current BLS Healthcare Provider level CPR certification. SEMESTER I Spring Lec Lab Ext Cont Cr Hrs Hrs Hrs Hrs Hrs SRGT 1340 Perioperative Nursing I 3 0 0 48 3 SRGT 1167 Practicum - Surgical/OR Technician 0 0 10 160 1 SRGT 2366 Practicum Surgical Technology/Technologist 0 0 21 336 3 Total Hours: 3 0 31 544 7 SEMESTER II Summer SRGT 1441 Surgical Procedures I 4 0 0 64 4 SRGT 1343 Perioperative Nursing II 3 0 0 48 3 SRGT 1166 Practicum Surgical Technology/Technologist 0 0 10 160 1 Total Hours: 7 0 10 272 8 TOTAL CREDIT HOURS FOR CERTIFICATE: 816 15 SRGT 1343 - Perioperative Nursing Internship II contains the capstone for this program. SRGT 1166 - Practicum Surgical Technology/Technologist is the external capstone for this program. The total contact hours are equivalent to 5.1 months training in a hospital-based internship. 8
ESTIMATED EXPENSES FOR THE PERIOPERATIVE NURSE INTERNSHIP PROGRAM * PRIOR TO APPLICATION Dallas County Resident Out of County Texas Resident Out of State/ Country Resident Physical Exam and Immunizations $ 225.00 $ 225.00 $ 225.00 CPR Certification 65.00 65.00 65.00 SentryMD 15.00 15.00 15.00 Total $ 305.00 $ 305.00 $ 305.00 SEMESTER I Spring Tuition (7 credit hours) $ 413.00 $ 777.00 $ 1,218.00 Textbooks/Syllabi 392.00 392.00 392.00 Professional Liability Insurance 11.00 11.00 11.00 SentryMD 20.00 20.00 20.00 Name Badge 8.00 8.00 8.00 Uniform (ceil blue/black scrubs w/ ECC logo) 40.00 40.00 40.00 Blank DVD 3.00 3.00 3.00 Background Check/Drug Testing 86.00 84.00 84.00 Total $ 973.00 $ 1,337.00 $ 1,778.00 SEMESTER II Summer Tuition (8 credit hours) $ 472.00 $ 888.00 $ 1,392.00 TOTAL ESTIMATED PROGRAM EXPENSE $ 1,750.00 $ 2,530.00 $ 3,475.00 * All fees are subject to change. Please refer to the tuition table in the current course schedule for current tuition rates. Tuition above is current for January 2015. ** Liability insurance is prorated to $11.00 and covers both spring and summer semester. The above estimate does not include additional expenses such as parking feel and transportation to the College and clinical site, good support shoes, lab coat per clinical affiliate s requirements, or CST exam after graduation. Students may contact the College Accounting Office for information regarding the tuition payment plan. 9
GENERAL INFORMATION 1. The Perioperative Nurse Internship program accepts a class of approximately 10 students. The El Centro College Health and Legal Studies Division reserve the right to make changes in program enrollment capacity. Program guidelines are subject to change. Students are advised to obtain the latest program information from the Health Occupations Admissions Office (Room P-101) 2. The Perioperative Nurse Internship courses are offered during daytime hours only. The program involves online class hours and 10-12 hours of clinical experience every week. A student will need to plan 2-3 hours of studying and preparation time for each hour of class and clinical experience. The demands of surgical technology/perioperative nurse internship courses suggest that students may not be able to work full time while enrolled in these courses. 3. Applicants to the health occupations programs at El Centro College must comply with physical examination and immunization requirements and submit the documentation to SentryMD no later than the program application deadline. The physical examination must be on the official El Centro Health Form downloaded from http://sentrymd.com/student-immunization-forms/ and must have been documented no earlier than 12 months prior to the application deadline. Tuberculosis screening and immunization requirements are outlined below: Tuberculosis screening - A negative PPD or Quantiferon screening is required with millimeters of induration recorded. If the screening is positive, documentation of a chest x-ray is required and must be negative for active disease. Both the positive screen and the negative x-ray report must then be submitted. If an applicant has tested positive in the past, documentation must be submitted of the positive screen. In the event that an applicant has received the BCG injection, documentation of the injection and a negative x-ray report must be submitted. MMR (measles/mumps/rubella combination) - Two (2) doses of measles/mumps/rubella ( MMR ) or a positive titer report with indicated lab values for each. Varicella - Two (2) doses of varicella or a positive titer report with an indicated lab value (NOTE: Statement or documentation of disease history is not accepted). Tdap (tetanus/diphtheria/pertussis) - One dose of tetanus/diphtheria/pertussis (Tdap) within the past 10 years ( Td injection is not accepted without the pertussis). Hepatitis B - Series of three injections (recommended schedule: first injection, second injection one month after the first, third injection six months after the second) or a positive titer report with an indicated lab value. 10
Hepatitis A - Series of two injections (recommended schedule: first injection, second injection six months after the first) or a positive titer report with an indicated lab value Influenza Due to variances in availability, a current flu shot is not required to apply to the program; however, the documentation must be received and documentation by SentryMD before the student accepted to a health occupations program is allowed to attend clinical rotations. 4. All applicants must be certified in cardiopulmonary resuscitation (CPR) at the Healthcare Provider level as designated by the American Heart Association and a photocopy of the front and back of the card must be submitted to SentryMD no later than the program application deadline. The CPR certification must not expire prior to the anticipated program entry date and must not expire during a semester when enrolled in the program. CPR classes are available through the El Centro College Continuing Education Division, the American Heart Association, American Red Cross, various hospitals, independent instructors, etc. Online CPR certification classes are not valid for application to health occupations programs. 5. Proof of current personal healthcare insurance coverage is required for all health occupations students, If documentation of coverage is not submitted to SentryMD with immunization records, proof of coverage must be submitted by the first day of the semester if a student is accepted to the program. Students must secure their own coverage and the insurance policy must cover the student at any hospital facility. Information on college student policies and rates can be found at https://www1.dcccd.edu/catalog/ss/sd/insurance.cfm. The National Student Nurses Association also partners with United Healthcare which offers a student policy for their members. See the following link for more information: https://www.uhcsr.com/nsna 6. It is necessary to consider transportation to and parking costs at the college, as well as the clinical sites throughout the city. Clinical rotations vary from among the facilities listed below: Baylor Surgicare Baylor University Medical Center Baylor University Medical Center at Garland Baylor University Medical Center at Irving Baylor University Medical Center at Waxahachie Children s Medical Center Doctors Hospital Medical Center of Mesquite Medical Center of Plano Medical City Dallas Hospital Methodist Charlton Medical Center Methodist Dallas Medical Center North Texas Veterans Affairs Healthcare System Parkland Memorial Hospital RHD Memorial Medical Center Richardson Medical Center Trinity Medical Center UTSW University Hospital at St. Paul UTSW University Hospital at Zale Lipshy 7. Hospitals and clinical facilities require students to undergo a criminal background check and drug testing prior to admittance to their facility for a clinical/practicum rotation. Students are responsible for any cost incurred and will receive further information regarding this screening after admission to the program. 11
8. Please contact the following individuals for further assistance: Joan Becker, M.A., R.N. Dean of Nursing Room P-715 El Centro College/Paramount 301 North Market Street Dallas, TX 75202 Telephone: 972-860-5098 Email: JBecker@dcccd.edu Periop Admissions Health Occupations Admissions Office El Centro College 301 North Market Street Dallas TX 75202 Telephone: 972-860-5001 Email: ECCHOAO@dcccd.edu Serina Davenport Academic Advisor/Retention Specialist Health/Legal Studies Division Room P-202 El Centro College/Paramount 301 North Market Street Dallas, TX 75202 Telephone: 972-860-5037 Email: SMDavenport@dcccd.edu The official mailing address for all application materials, transcripts, and correspondence is: Periop Admissions Health Occupations Admissions Office El Centro College/Paramount 801 Main Street Dallas TX 75202-3604 Program guidelines are subject to change. Students are advised to obtain the latest program information packet from the El Centro College Health Occupations Admissions Office or the printable information packet on the website below. www.elcentrocollege/edu/health-information-packets Visit the Perioperative Nurse Program webpage: https://www1.dcccd.edu/catalog/programs/degree.cfm?degree=es.nurs.periop.intern Health Occupations webpage: www.elcentrocollege.edu/healthcareers Health Occupations Admissions Office webpage: www.elcentrocollege.edu/healthoccadmissions 12
PERIOPERATIVE NURSE INTERNSHIP APPLICATION CHECKLIST This checklist is provided to assist you in following the steps toward program application. It is not part of the application packet which is submitted with transcripts, etc. 1. Obtain Perioperative Nurse Internship program information packet. 2. Complete an application for college admission. 3. Submit official transcripts from all previously attended colleges and universities to the El Centro College Registrar s Office or any other Dallas County Community college Registrar Office. 4. See a physician or healthcare clinic for a physical examination and obtain all required immunizations, and TB screening; obtain CPR training at the Healthcare Provider level. 5. Submit physical exam form, immunization and TB screening documentation with photocopy of front and back of CPR card to SentryMD prior to the application filing deadline. 6. Compile the following materials as your complete Perioperative Nurse Internship application packet: Completed Perioperative Nurse Internship application form (from this information packet). Signed Statement of Students Responsibility form (from this information packet). Documentation of a valid Texas RN license or documentation verifying eligibility to write the NCLEX-RN prior to the start of the Perioperative Nurse Internship program. 7. Place above materials in a 9 x 12 envelope for submission either in person or by mail to: MAILING ADDRESS: PHYSICAL ADDRESS: Periop Admissions Periop Admissions Health Occupations Admissions Office Health Occupations Admissions El Centro College/Paramount Room P-101 801 Main Street El Centro College/Paramount Dallas, TX 75202-3604 301 North Market Street Dallas TX 75202 13
EL CENTRO COLLEGE PERIOPERATIVE NURSE INTERNSHIP PROGRAM APPLICATION PLEASE PRINT: SOCIAL SECURITY NO. STUDENT ID NO. NAME Last First MI Maiden/Other ADDRESS Number and Street Apartment Number City State Zip Code PHONE Home Cell/Other EMAIL TX RN LICENSE NO EXPIRATION DATE OR NCLEX-RN EXAM ELIGIBILITY DOCUMENTATION? HOAO Initials LIST ALL PREVIOUS COLLEGES ATTENDED FOR ACADEMIC CREDIT, INCLUDING DALLAS COUNTY COMMUNITY COLLEGES. (Transcripts must be on file in Registrar s Office.) I certify that the information given on this application is complete and accurate. Applicant s Signature Date Educational opportunities are offered by El Centro College without regard to race, color, age, national origin, religion, sex, disability or sexual orientation. 14
STATEMENT OF STUDENTS RESPONSIBILITY Review and initial each section as verification that you have read and understand this information: I acknowledge that this information packet contains policies, regulations, and procedures in existence at the time this publication went to press. I also acknowledge that El Centro College reserves the right to make changes at any time to reflect current Board policies, administrative regulations and procedures, and applicable State and Federal regulations. Furthermore, I understand that this packet is for information purposes only and does not constitute a contract, expressed or implied, between any applicant, student, or faculty member and El Centro College. I have read and understand the admission process for the Perioperative Nurse Internship program and acknowledge that it is a competitive selection process with a limited number of spaces available. I understand that meeting eligibility requirements and submission of complete application packet materials does not guarantee acceptance to the program. I understand that I must submit all of my current official transcripts to the Registrar/Admissions Office at El Centro College or one of the other Dallas County Community colleges prior to applying to an El Centro College health occupations program and that failure to do so will void my application to the program. I understand that in order to be considered a qualified applicant to the program, I must submit the official physical exam form and documentation of required immunizations, tuberculosis screening, and Healthcare Provider level CPR certification to SentryMD and receive notification from them that I am compliant with these requirements no later than the application filing deadline for the program. I further understand that if I am not compliant by that deadline, my application to the program will be disqualified. I accept full responsibility for submitting a complete Perioperative Nurse Internship application packet prior to or by the designated application filing deadline and understand incomplete materials will disqualify my application. I also accept the responsibility to inform the El Centro College Health Occupations Admissions Office of any change in my status, address, telephone number, or any other information that would affect my entrance into the Perioperative Nurse Internship program. I acknowledge that if admitted to the Perioperative Nurse Internship program, I may be assigned to clinical rotations at area healthcare facilities which may require additional proof of immunity to required inoculations/immunizations for program admission and additional inoculations. I also acknowledge that I am required to have my own personal health care insurance coverage and submit documented proof either to SentryMD with my immunization records or, if I am accepted to the program, by the first day of class for the program. I am aware that I will be required to undergo a criminal background check and mandatory drug screening prior to being allowed to attend a clinical rotation. I understand that should I be prohibited from attending a clinical rotation at a clinical facility due to findings on my drug screen or criminal background check, I may be dismissed from the El Centro College Perioperative Nurse Internship program. Applicant s Signature Date 15