MATC PRACTICAL NURSING (PN) PROGRAM MOUNTAINLAND APPLIED TECHNOLOGY COLLEGE A Utah College of Applied Technology Campus SPRING 2016
P R AC TI C AL N U R S I NG AP P LI C ATI O N P AC KE T S P R I NG 2 0 1 6 Applications for the Spring 2016 Program start date will be accepted from September 1, 2015 until November 24, 2015 Please read the following information carefully. 1. Incomplete applications or those received outside the time frame given above will NOT be accepted. 2. The completed application form must be submitted along with the required supporting documents together in a manila envelope. 3. To submit your application packet, you will make an appointment with the PN Program Administrative Assistant. Call (801)753-4162 and schedule an appointment between 1100 and 1500 M-F. You will need to hand-deliver your completed application packet to the Practical Nursing Department at the Mountainland Applied Technology College Thanksgiving Point Campus, 2301 W. Ashton Blvd., Lehi, UT 84043. 4. Application does not guarantee admission to the program. 5. Entry into the program is determined by a competitive, points-based process. 6. There is no waiting list. 7. The application process will not discriminate based on race, color, national origin, religious background, sexual orientation, age, or disability. 8. Please read the application packet and the PN program webpage for information about the program and the application process at: http://mlatc.edu/programs/healthcare/practical-nursing/ 9. This is a 900 clock hour program. CNA and CPR requirements are outside of the 900 clock hours. By signing here I agree that I have read and understand the information on this page. Print Name Signature Date 1 of 10
M ATC P R AC TI C AL N U R S I NG P L AN O F S TU D Y First Semester: Nursing Foundations of Nursing Care Practice Nursing 1011 Care of the Mental Health Patient Nursing 1012 Pharmacological Nursing Care I Labs, clinicals and simulations are also conducted throughout the semester Second Semester: Nursing 1013 Pharmacological Nursing Care II Nursing 1014 Nursing Care of the New Family Nursing 1015 Nursing Care of the Adult Patient Labs, clinicals and simulations are also conducted throughout the semester M ATC P R AC TI C AL N U R S I NG P R O G R AM C OS T The cost breakdown is an approximate amount for both semesters of the program. Cost Breakdown: Tuition ($2.00 x 900 enrollment hours) $1,800.00 Fees $1,125.00 TEAS Test $61.00 PN Program Application Fee $30.00 MATC Student Application Fee $40.00 Uniforms and Shoes $200.00 Books (total) $700.00 Federal Background Investigation $42.00 Drug Screening $35.00 Immunizations $200.00 Nursing Supplies $200.00 State NCLEX-PN Exam $299.00 Total: $4,032.00 Please Note: 1. The non-refundable $30 PN Program Application Fee is paid before you turn in the MATC Application Packet. 2. The $40 MATC Student Application Fee is paid once admitted to the PN program during registration. 3. If you are accepted you will be notified by letter of the due dates for the remaining fees. 4. You are required to pay for your drug screen and background check AFTER you are admitted to the program. 5. Tuition rates generally change annually on July 1 st, and may increase from current rates. 6. The above costs are estimates only. The cost for fees, tuition and any other associated costs are subject to change at any time and without notice. By signing here I agree that I have read and understand the information on this page. Print Name Signature Date 2 of 10
M ATC P R AC TI C AL N U R S I NG R E QU IR EM E N TS All requirements must be met before you submit your application. 1. Must have Utah State CNA license. 2. Must have an American Heart Association (AHA) Health Care Provider CPR card. This CPR card must not expire during the PN program. 3. Must have high school diploma or equivalent. 4. Must be 18 years or older. 5. Must take the TEAS test before submitting application. The TEAS test scores are good for six months. If you have taken the TEAS test twice in six months, we will only count your first exam score. 6. Must have documentation of all required immunizations. 7. TOEFL is required for all students whose first language is anything other than English and must have been taken within three (3) years of the first day of class. Students must earn a total score of 75 with a minimum of 18 in any single area. If English is not your first language, it is recommended that you complete the TOEFL prior to taking the TEAS test. Prior course work, certifications, or degrees in the U.S. or any other country do not automatically exempt applicants from this requirement. HOW TO APPLY: 1. Pay the $30 non-refundable nursing application fee to Student Services. 2. Pay $61 for the TEAS test and register for the exam: Students need to go to www.atitesting.com and create an account Make certain while creating the account that Mountainland Applied Technology College (MATC) is selected as the institution Once registered students will be able to pay the $61.00 test fee and can schedule the date they wish to take the exam, which will be held at the Testing Center, MATC Thanksgiving Point Campus Please note that it is approximately a four (4) hour test. The TEAS test includes sections on Science, Math, English and Language Usage, and Reading Comprehension. Your scores on each section will be multiplied by a factor to determine the final score. 3. Make an appointment with the PN program Administrative Assistant according to the instructions given on page 1 to turn in your completed application packet. By signing here I agree that I have read and understand the information on this page. Print Name Signature Date 3 of 10
IM M U N I ZA TI O N R E QU IR E M E N T I N FO R M ATI O N Students will be required to show proof of current immunizations in order to apply for the MATC PN program. The following immunizations are required: 1. Evidence of immunity to rubella as demonstrated by either a. Documentation of two MMR immunizations at least 28 days apart after the age of 1 or b. Documentation of a positive antibody titer for measles/rubella 2. Immunity to Varicella (chickenpox) verified by a. Immunization record (1 immunization if vaccinated before age 13, 2 if vaccinated after age 13) b. Positive titer for varicella 3. Tdap Immunization a. Tdap only. (This is not the same as a DTaP, a DPT, a Td, or a Tetanus shot) 4. Hepatitis B Vaccine (3-dose series) a. Or Twinrix (3 dose series) b. Or positive titer for Hepatitis B 5. Seasonal flu vaccine is required. Immunizations can be obtained from a private physician or from the Utah County Health Department. Utah County Health Department Closed Holidays 151 S. University Ave. Provo, UT 84601 801-851-7025 Monday, Tuesday, Friday: 0800-1630 Wednesday: 0800-1900 Thursday: 0800-1900 American Fork Immunization Clinic Call for appointment 599 S. 500 E. #2 American Fork, UT 801-851-7331 Monday Friday: 0800 1200 or 1300-1630 Payson Health Department 910 E. 100 N. #125 Payson, UT 84651 Tuesdays: 1600 1900 (Walk-in) **Additional immunizations will be required if you are accepted into the PN program.** By signing here I agree that I have read and understand the information on this page. Print Name Signature Date 4 of 10
Name: Date of Birth: The following tests/immunizations/titers are required in order to participate in clinical rotations. Please submit a copy of your immunization records with this completed form and submit with your Practical Nursing application. Copies will be maintained in your student file. Tdap (Tetanus, Diptheria, Pertussis) MMR (Measles, Mumps, Rubella) Two doses required (both doses received after 12 months of age) Rubella/Measles titer *MMR immunizations are contraindicated for pregnant females Hepatitis B Vaccine (3-dose series) Twinrix ( 3 dose series) Positive Titer for Hepatitis B Varicella (Chickenpox): Document history of disease and vaccine titer Influenza Vaccine (Seasonal) *Required every year Date received: Tdap MMR: Date of 1 st dose Date of 2 nd dose Rubella titer: Date: Result: Measles titer: Date: Result: Date of 1 st dose: Date of 2 nd dose: Date of 3 rd dose: Date of 1 st dose: Date of 2 nd dose: Date of 3 rd dose: Titer: Date: Result: History: Yes No If yes, date/year of exposure: Date of varicella booster(s): Varicella titer: Date: Result: Date: 5 of 10
WHAT TO INCLUDE IN YOUR APPLICATION PACKET: (Required) Your completed and signed application for admission form. A photocopy of your current Utah State CNA license or recertification letter. Copy of receipt for the $30.00 PN Program Application Fee. Copy of your TEAS test results, showing date and time of testing. If applicable, proof of TOEFL, with in the last three (3) years, or proof of registration with date. Documentation of all required immunizations Copy of high school diploma or equivalent A copy of your American Heart Association Health Care Provider CPR/AED Card. (Must be good through the entire program. You will NOT be allowed to recertify during the MATC Practical Nursing Program) WHAT HAPPENS AFTER YOU APPLY: Once the application period is closed, all applications will be scored on a point system used to select candidates based on TEAS test score, work experience, etc. The top 35 best scores will be selected to go through a second application process which will consist of an interview. Students will be selected following the interview and offered a seat in the program. The PN Faculty reserves the right to interview additional qualified applications. If additional applications are interviewed the faculty will interview the next 10 qualified applicants in the order they are ranked on the alternate list. This process may continue, if the faculty deems it necessary until the top 24 students are selected. A maximum of 24 students will be conditionally accepted into the program. All other qualified applicants will be placed in rank-order on the alternate list. Applications are only good for one application period. If you apply, but are not accepted you must reapply. Admission to the program is not guaranteed. ADDITIONAL INFMATION YOU WILL NEED IF YOU ARE ACCEPTED: Interview and alternate notices will be sent out no later than December 4, 2015. Acceptance notifications will be made available after the interviews are conducted and scored. If you are an alternate you can be notified of an available seat as late as the beginning of the first week of class. NOTE: Admission to the program is contingent on: a. Negative drug screen b. Satisfactory background check c. Evidence of fulfillment of additional immunization requirements d. Attendance of the mandatory PN program orientation and the entire first week of class I understand that if all the items listed above are not received by the due date listed in my acceptance letter and/or I do not attend the mandatory PN program orientation, I will be dropped from the program and I understand that my seat in the program will be lost to me for this term. I may reapply for another class at a later date. I further agree that I have read and understood all of the information on this page. Print Name Signature Date 6 of 10
Name: Date of Birth: By signing here I commit to keeping my CNA license current during the MATC PN program. Signature Date Satisfactory progress through the Practical Nursing Program requires attendance in both theory and clinical sections and may require long days, nights and weekends. By signing here I commit to the hours and policies outlined in the Practical Nursing Student Handbook. Signature Date Please Note: In order to be licensed as a practical nurse in the State of Utah, the application must be in conformity with the Utah Nurse Practice Act. Applicants who have been convicted of a felony or treated for mental illness or substance abuse should discuss their eligibility status for licensure with the Utah State Board of Nursing. Acceptance and completion of the nursing program does not assure eligibility to take the PN licensure exam. The Utah State Board of Nursing makes the final decision as to whether a license will be issued to practice nursing in Utah. If you have questions regarding this, please contact the State Board of Nursing, 160 East 300 South, P.O. Box 146741, Salt Lake City, UT 84114-6741, Phone number 801-530-6628. I hereby certify that the statements in this application are true to the best of my knowledge. I understand that this form is to be used for application to the Spring 2016 MATC Practical Nursing Program only. Signature Date 7 of 10
P E RS O N AL I N FO R M ATI O N Please print neatly. Please complete all information requested. Application Date: Name: Last First Date of Birth: Home Address: Street City State Zip Code Telephone: Home Cell Email: Please list name, address, and phone number of your nearest relative or friend NOT living with you who will always know how to reach you: Name: Last First Home Address: Street City State Zip Code Telephone: Home Cell 8 of 10
WO R K H IS TO R Y List all places of health-related employment where you provided direct patient care beginning with the most recent: (use additional sheets if necessary) (i.e. CNA, RT, PT/aide, EMT, etc.) Company Name: Supervisor: Company Address: Phone Number: Occupation: No. of Months Reason for leaving: Your role at work: Company Name: Supervisor: Company Address: Phone Number: Occupation: No. of Months Reason for leaving: Your role at work: Company Name: Supervisor: Company Address: Phone Number: Occupation: No. of Months Reason for leaving: Your role at work: Company Name: Supervisor: Company Address: Phone Number: Occupation: No. of Months Reason for leaving: Your role at work: 9 of 10
P R AC TI C A L N UR S I N G P R OGR AM AD M IS S IO NS AC C E P TAN C E P O I N T S YS TE M MATC OFFICE USE ONLY CRITERION: Required TEAS test points... / 217 Work History: Direct health care experiences... / 5 Experience Points 3-6 Months +1 7-12 Months +2 13-24 Months +3 >24 Months +5 Current resident of Utah, Wasatch or Summit Counties... / 2 Previous Qualified Applicant... / 2 Attended MATC PN Information Session... / 2 Total Points... / 228 The Mountainland Applied Technology College accepts 24 applicants for each of the two annual sessions. All remaining qualified applicants will be ranked in order, according to their score, and will be placed on the alternate list. See page 6 for details The total points needed to be admitted to the PN Program may change with every applicant pool. If a seat becomes available after primary applicants are admitted for any reason, the next most qualified applicant on the alternate list will be offered the open seat. This process will continue until all seats are filled or the supply of qualified alternates has been exhausted. 10 of 10