2014-2016 TVCC/OCNE NURSING PROGRAM APPLICATION PACKET DIRECTIONS Thank you for your interest in Treasure Valley Community College (TVCC) Nursing Program. TVCC s nursing program is a member of the Oregon Consortium of Nursing Education (OCNE). Applications are evaluated on a point system. Applications will be evaluated on an initial 70-point scale, which include TVCC s discretionary points. The top applicants will be invited to sit for a proctored essay and interview, worth 30 points. Applicants not present for the proctored essay and interview forfeit their application to TVCC s nursing program. Final selection from the top applicants will be based on writing skills, answers to questions addressed in the essay, and performance during the interview. Please visit: http://www.tvcc.cc/academics/nursing/ for more information about application requirements. This application is for print only. You need to print, complete, and return to the Nursing Department, Ontario campus. APPLICATION DEADLINE: February, 17, 2014 at 5: pm MST. All items must be submitted to the Nursing Department including a non-refundable nursing application fee. It is the applicant s responsibility to ensure that all required documents listed below are received by the department deadline. Documents submitted but not requested (letters of reference, etc.) will be discarded. MINIMUM ELIGIBILITY REQUIREMENTS Applications may be mailed or hand-delivered to: TVCC Nursing Department 650 College Blvd. Ontario, OR 97914 Applicants are eligible to apply to TVCC s Nursing Program if they meet ALL of the following requirements. Completion of Biology 101 or 211, Biology 231 and 232, Writing 121, 122, and 123, Psychology 201 and 237, Math 95, and Nutrition including all labs by the end of fall quarter 2013. All pre-requisite courses for the application must be earned with a letter grade of C or better. Applicant must have a pre-program GPA of 3.0 or higher. Post-Acceptance Admission Requirements All admitted TVCC nursing students must meet the following requirements before they can begin any nursing courses: Successfully complete any outstanding pre-requisite courses with a grade C or higher by the end of spring term, 2014. Successfully pass a criminal background check and finger printing from an agency designated by TVCC*. Successfully pass a 10-panel drug screen from an agency designated by TVCC*. Submit proof of current immunizations*. Submit proof of current CPR for Health Care Providers certification by American Heart Association. 1
*After formal acceptance to the program, admitted students will receive specific instructions from TVCC s Nursing Department on how to fulfill these requirements. Failure to successfully complete any of the above requirements will result in a rescinded admissions offer. BEFORE YOU SUBMIT YOUR APPLICATION! Did you remember to: o Become a credit seeking admitted student to TVCC? (Unless already a student). o Sign and date o Application Checklist (pg. 3) o Application (pg. 4 & 5) o Pre-Requisite Planning Chart (pg. 10) o Statement Regarding Program and Licensure Requirements (pg. 6) o Proof of Health Status and Immunizations (pg. 7) o Work/Volunteer Experience Verification (pg. 8 & 9) APPLICANTS ARE RESPONSIBLE FOR COMPLETING AND SUBMITTING ALL REQUIRED FORMS AND MATERIALS. INCOMPLETE APPLICATIONS WILL BE RENDERED INELIGIBLE. 2
FALL 2014 NURSING APPLICATION PACKET CHECKLIST Completed applications will be accepted through February 17, 2014. It is the applicant s responsibility to ensure that all required documents listed below are received by the deadline. Candidates will not be notified of missing application items. Make a copy of the completed packet for your files. Documents submitted but not requested (letters of reference, etc.) will not be accepted. I attest that I have fulfilled the following requirements: (Please initial each item below) 1. I have read the Fall 2014 Nursing Program Information Packet Directions (pg. 1) and Technical Standards document found at http://www.tvcc.cc/academics/nursing/nursing_technical_standards.cfm 2. I have completed the TVCC Application for Admission and received my student ID #. Application is available at http://www.tvcc.cc/future/admissions/index.cfm 3. I have completed the TVCC/OCNE Nursing Program Application, including residency requirements, (p. 4 & 5). I understand that by applying to TVCC s Nursing Program, I am also applying for co-admission and authorizing the release of my application information to OHSU. In addition, I am authorizing my information to be released to the Oregon State Board of Nursing for research purposes only. 5. I have included is a money order for $50.00, which is a non-refundable nursing application fee. 4. I have attached are requested official (unopened) college transcripts from all institutions where pre-requisite courses have been taken through Fall term 2013 that have not yet been evaluated by TVCC s Transcript Evaluator. TVCC transcripts do not need to be attached. 5. I have completed the Pre-Requisite Planning Chart (pg. 10). I understand that I must complete Biology 101 or 211, Biology 231 and 232, Writing 121, 122, and 123, Psychology 201 and 237, Math 95, and Nutrition with a C grade or higher by the end of Fall 2013. I understand that the rest of the pre-requisite courses must be completed by the end of Spring quarter 2014. 6. I understand that the cumulative GPA for all nursing program pre-requisite courses must be 3.0 or higher. 7. I have signed the attached statements regarding: o Nursing Application (pg. 4 & 5) o Pre-Requisite Planning Chart (pg. 10 ) o Program and Licensure Requirements (pg. 6) o Proof of Health Status and Immunizations ( pg. 7) o Work/Volunteer Experience Verification (pg. 8 & 9) 8. I have signed and completed the Nursing Application Packet Checklist (this page). 9. I have attached proof of Work/Volunteer Experience Name Student ID# Signature Date 3
Fall 2014 Nursing Application STUDENT INFORMATION Please type or print neatly in blue or black ink. Last Name First Name Middle Initial Previous Last Name TVCC ID# Last 4-digits of Social Security # Date of Birth Place of Birth Current Mailing Address City State Zip Length of Residency at Current Mailing Address Primary Phone Alternative Phone o o Male Female EDUCATION INFORMATION LIST ALL COLLEGES WHERE YOU HAVE COMPLETED NURSING PRE-REQUISITES &/OR A DEGREE. Official transcripts will be required for all colleges and universities listed. College State Dates of Attendance Number of Credits Degree Earned RESIDENCY REQUIREMENT Residency is defined as a person s domicile, his/her true fixed and permanent home and place of habitation. It is the place where one intends to remain, and to which one expects to return when one leaves without intending to establish a new domicile elsewhere. Domicile is not established by mere attendance at the college. If you believe that you qualify for the 8 points give to applicants living in the community, reside in the TVCC taxing district (Malheur County) and/or reside within a 30-mile radius of Ontario, OR (your city of residence is used to determine the 30 mile radius), you must submit proof of physical residence by submitting the following documents: Utility receipts with your name and physical address listed showing proof of residency in the community for a 12 month period. Submit the following two receipts: 4
1. Utility receipts from Dec. 2012 and Dec. 2013 or 2. Utility receipts from Jan. 2013 and Jan. 2014. If the applicant is a dependent and resides in the community with a parent(s), the following documentation must be provided: 1. Driver s license with physical residence listed and 2. A letter from the parent verifying your place of residence and dependent status. The points for living in the community will not be given without this documentation. If there appears to be inconsistency, the nursing faculty will require further documentation. All nursing department written communication will be mailed to the address listed. I have read and understand the admission criteria for the nursing program at TVCC and OCNE. I understand that it is my responsibility to meet all program and application criteria. I verify that all statements on this application are complete and true. I understand that falsification of any information may lead to disqualification or dismissal from the program. I give my permission for release of pertinent application information to the OCNE partner schools, including OHSU and to the Oregon State Board of Nursing, as necessary to facilitate my program of study and to enhance the application process for future applicants. Signature Date 5
STATEMENT REGARDING PROGRAM AND LICENSURE REQUIREMENTS Students accepted for admission into the Nursing Program at TVCC are advised, prior to enrollment, of the following Oregon State Board of Nursing (OSBN) rules concerning Application for Licensure by Examination OARS 851-031-0006: (2) Limits on Eligibility: (a) If an applicant has a major physical or mental condition that could affect the applicant's ability to practice nursing safely, a physical or psychological assessment may be required to assist in the determination as to whether or not the applicant's physical or mental health is adequate to serve the public safely. (b) If an applicant has been arrested, charged or convicted of any criminal offense a determination shall then be made as to whether the arrest, charge or conviction bears a demonstrable relationship to the practice of nursing, in which case licensure may be denied. The college cannot be responsible for a student s physical, mental, or emotional health or ability to qualify for licensure. If you are unable to qualify under the above requirements, you may wish to reconsider your choice of program. Examples of crimes for which an individual will be denied licensure include: Crimes against another person such as murder, manslaughter, assault, rape, sexual abuse, child abandonment or neglect. Conviction within seven years for a crime against property such as first degree offenses including burglary, arson, criminal mischief, robbery, or forgery. An extended history of arrests and convictions demonstrating habitual disregard for societal rules. You will be required to complete a criminal records check after you are accepted to the nursing program. Some clinical agencies may require additional security checks. A criminal background check will also be required by OSBN when you apply for licensure. A criminal record detected in this manner will preclude your ability to complete the required clinical experience and result in dismissal from the program. I have read the above statement and I verify that I qualify for clinical experience at all clinical sites and for nursing licensure in the State of Oregon. I also agree to release any criminal background information to TVCC for use in the Nursing Program. Signature Date 6
PROOF OF HEALTH STATUS AND IMMUNIZATIONS Listed items are to be completed once you have been notified that you are accepted into the nursing program. However, this signed form is to be turned in with application as acknowledgement of student responsibility. I understand that once accepted to the TVCC Nursing Program, I must complete the following and provide proper documentation by the deadline stated in the acceptance letter. 1. A physical examination by a licensed health care professional. 2. A tuberculosis skin test, with follow-up chest x-ray if skin test is positive. Note: This test must be repeated each year in the program. 3. Immunizations or titers, as appropriate, for Measles, Mumps, Rubella, and Chicken Pox. 4. Tetanus immunizations within the last 10 years. 5. As a nursing student you may be at risk for contracting Hepatitis B. Therefore, you are required to obtain the Hepatitis B vaccination. This is a series of three injections given over a six month period. Only the first dose must be completed prior to the start of the program. 6. It is required that you obtain the Influenza immunization. This immunization is required for your safety and the safety of your patients. It is recommended that you obtain this immunization no earlier than October 1 st. 7. I further understand that I will be required to take a drug test at my expense prior to the start of the nursing program. Results of the testing will remain confidential. Signature Date 7
HEALTH CARE EXPERIENCE DOCUMENTATION FORM Applicant Name Student ID# Date TO BE COMPLETED BY THE APPLICANT Please check one of the following that best describes your work/volunteer experience. o I have a CNA, LPN, EMT, Paramedic or CMA (Certified Medical Assistant) certification and have 400 or more, 300-399, 200-299, 100-199, 0-99 post-certification patient care hours. Provide the following documentation: A copy of state or national license with original date of issue (must be issued on or prior to Dec. 31, 2013) A copy of the certification card or printed verification from the state board website which are both acceptable forms of documentation. Certificates of training completion, diplomas, or transcripts from health care training programs are NOT acceptable forms of documentation. ALL HEALTH CARE EXPERIENCE DOCUMETATION MUST BE SUBMITTED FOR THE APPLICANT TO RECEIVE POINTS. Health care experience must be completed by Dec. 31, 2013. Health care experience completed after Dec. 31, 2013 will not be considered. Points will not be awarded if forms are incomplete or if documentation is missing. All required documentation must be received in the Nursing Department office no later than Feb. 17, 2014 at 5:00 pm, MST. If you have questions regarding this form, please contact the Nursing Department Administrative Assistant at 541-881-5940. 8
HEALTH CARE EXPERIENCE DOCUMENTATION FORM Applicant Name Student ID# Date TO BE COMPLETED BY THE EMPLOYER Name of Company/Facility City State Job Title of Applicant Certification held by Applicant Employment Status (please check) Full Time Part Time Volunteer Beginning Date End Date Total Number of Hours Completed or Average Weekly Hours Completed (only count hours completed through Dec. 31 st, 2013) Attach a current position description or provide a detailed description of the position duties in the space provided below: Please provide the following information. Contact information will only be used to verify information provided on this document. Supervisor name and title: Telephone number: Email address: Supervisor Signature: Thank you for taking the time to complete this form. All health care experience documentation forms and other documentation must be submitted by February, 17, 2014 by 5:00 pm MST for applicants to receive work experience points. If you have any questions regarding this form or the TVCC Nursing application process, please contact the Nursing Department office at 541-881-5940. 9
TVCC/OCNE Pre-Requisite Planning Chart A minimum of 41 credits of the 51 credits listed below must be completed by the end of Fall term 2013, see starred* items. Official transcripts from other schools must be submitted by the Feb. 17 th, 2014 deadline. Classes taken at other colleges can only be deemed equivalent by TVCC s Transcript Evaluator based on curriculum content. All 51 credits must be earned with a C grade or higher to be considered as an applicant. All Fields Must Be Completed TVCC Required Pre-Requisites Grade Earned Credits Term/Yr Earned at College/University (Official transcripts must be attached if taken outside of TVCC) Course # Course Title Intermediate Algebra Math095* or higher Biology w/ Genetics Component BIOL101* or 211 A & P including lab BIOL231* A & P including lab BIOL232* A & P including lab BIOL233 Microbiology including lab BIOL234 English Composition WR121* English Composition WR122* English Composition WR123* or 227 Nutrition FNUT* General Psychology PSYC201* Seasons of Life PSYC237* or 235 & 236 Soc. Science Electives Signature Date 10