Associate of Applied Science in Nursing Advanced Placement (LVN to RN Transition)

THE UNIVERSITY OF TEXAS AT BROWNSVILLE AND TEXAS SOUTHMOST COLLEGE Associate of Applied Science in Nursing Advanced Placement (LVN to RN Transition) Application Deadline: May 15 th & December 15 th

ASSOCIATE DEGREE NURSING PROGRAM The University Of Texas at Brownsville and Texas Southmost College 80 Fort Brown - Brownsville, Texas 78520 - (956) 882-5072 - Fax (956) 882-5100 Dear Applicant: The nursing faculty at the University of Texas at Brownsville is pleased to learn of your interest in the Associate Degree Nursing Program. One of the most important decisions you will have to make is choosing a career. Today, nursing is one of the outstanding fields open to both men and women. Nursing has always been influenced by medical technological advances and by current scientific knowledge. Never has the demand for quantity and quality of health care been so great. Life as a registered nurse (RN) is intellectually challenging, personally satisfying, and deeply rewarding. Nursing deals with the realities of life; it satisfies the desire to make a worthwhile contribution to the care and comfort of the sick and to the promotion of health Enclosed you will find other information for this program. The admission criteria listed in the brochure must be completed and received by May 15 th for the program that begins in the Fall semester and December 15 th for the program that begins in the Spring semester. Admission into the Associate Degree Nursing Program is the sole responsibility of the Department of Nursing through the selection and concurrence of its Admission Committee. It is the responsibility of the applicant to assure that the ADN Program has received ALL required and relevant information prior to student selection activities. The Admissions Committee will send letters of notification following review of applications. The letter of notification will describe the applicant as: 1) offered admission, 2) denied admission (reason stated), or 3) assigned as an alternate (to be among those considered in the event openings develop in the entering class). In the event an applicant is not admitted, the applicant may visit with the Director of the program to determine how to improve their application status for admission into a future class. If you have any questions, please feel free to contact the Nursing Department or any member of the faculty. Sincerely, Joe R. Lacher, M.S.N., R.N., C.N.A., B.C. Program Director, Associate Degree Nursing 2

ADVANCED PLACEMENT PROGRAM FOR LICENSED VOCATIONAL NURSE This program is designed to facilitate upward career mobility for the Licensed Vocational Nurse by offering opportunity for advanced placement into the Associate Degree Nursing Program at the University or Texas at Brownsville and Texas Southmost College ADMISSION REQUIREMENTS A. Submit an application to the University of Texas at Brownsville, MEET REQUIREMENTS FOR ADMISSION, and obtain a UTB ID number. You may apply online at www.utb.edu/admissions/ or pick-up a paper application at Tandy Hall T115, Phone: 956-882-8295. B. SUBMIT THE FOLLOWING ITEMS TOGETHER IN A PACKET TO THE ADN OFFICE IN LHSB 2.720: 1. Associate Degree Nursing Application (last five pages of this packet). 2. High school transcript or GED score sheet, unofficial copies are acceptable (If you have previously attended college or university please omit this step.) 3. Transcripts, unofficial copies will be accepted (ONLY UTB TRANSCRIPTS WILL BE ACCEPTED. SCORPION ONLINE TRANSCRIPTS WILL BE ACCEPTED. If you have never attended UTB, you must submit your transcripts for evaluation to the Admissions Office, Tandy Hall 115, Phone: 956-882-8295. To acquire an unofficial transcript, please visit the Office of the Registrar at Tandy Hall 105, Phone: 956-882-8254. FOR STUDENTS WITH TRANSFERRED COURSES: TRANSCRIPTS MUST BE A PRINT-OUT FROM THE OFFICE OF THE REGISTRAR). 4. Copy of current CPR certification. ( for Health Care Provider) 5. Copy of Immunization records. 6. A minimum college GPA of 2.5 OR if no college experience, a high school average of 85. 7. Copy of CURRENT Texas LVN License. 8. Must have completed ALL Admission Prerequisite Courses (See Degree Plan) by admission deadline of May 15 th or December 15 th. As an Advanced Placement applicant, you are only allowed to be pending completion of speech and/or humanities. 9. a) ACT test scores, copies are acceptable A minimum score of 18 on the Reading, English and Composite sections is required. If score is more than five years old student will need to retake exam. Effective Fall 2010 the ACT Exam will be mandatory. -AND- b) College credit on a UTB transcript THAT INCLUDES: Anatomy & Physiology I and II with lab, Microbiology with lab, Composition I, Math for Liberal Arts (or higher), Introduction to Psychology, and Lifespan Developmental Psychology. A minimum of a C is required for each course. C. The Admissions Committee for the incoming class will only consider COMPLETE application packets that are received by the appropriate deadline. Deadline to apply is MAY 15 TH (for Fall/August) & DECEMBER 15 TH (for Spring/January) 3

PROGRESSION A C is required in all General Education courses that are part of the degree plan. Students must pass all Nursing courses (RNSG) with a minimum course grade of 74.50. Students must pass all courses at one level/semester before progressing to the next level/semester. Complete information on grade requirements can be found in the ADN Student Guide and/or course syllabi. Achievement tests are given throughout the program. If a student falls below the established standard, the student will be assigned remedial work that is required to be completed prior to enrollment in the following course(s). The student is responsible for the testing fees of approximately $120.00 over the two-semester course of study. TUITION COSTS Tuition for nursing student, enrolled in nursing courses will be the same as for other UTB/TSC students. Uniforms, books, various school fees and health/accident and liability insurance are additional. Students arrange for their own living quarters, laundry and transportation between the college and clinical facilities. Uniforms will cost approximately $223.00 and must be purchased prior to the first nursing course. Books will average $1200.00 for the entire program. Liability and heath/accident insurance must be purchased at registration annually. The Student Financial Assistance programs provide financial assistance to eligible student who, without such aid, would be unable to attend college. Financial assistance for eligible students is available in the form of grants, loans, college work-study, veterans benefits, and scholarships. ELIGIBILITY TO TAKE NCLEX-RN EXAMINATION The Board of Nurse Examiners has identified certain circumstances that may render a potential candidate ineligible for licensure as a registered nurse in the State of Texas. The Board provides individuals with the opportunity to petition the Board for a Declaratory Order as to their eligibility in accordance with Article 301.257 of the Nursing Practice Act. If you are required to answer YES to any of the following questions please request a Declaratory Order Petition in writing by contacting the Education/Examination Department, Board of Nurse Examiners for the State of Texas, P.O. Box 430, Austin, Texas 78767-0430. Processing your Petition may take 6 to 12 month, or longer, after you provide all required documentation and depending on you circumstance. Once all requested documents have been received, you will be notified that the Petition has been transferred to the Enforcement Department for review. 1. Have you been convicted, adjudged guilty by a court, plead guilty, no contest or nolo contendere to any crime in any state, territory or country, whether or not a sentence was imposed, including nay pending criminal charges or unresolved arrest (excluding minor traffic violations)? This includes expunged offenses and deferred adjudications with or without prejudice of guilt. Please note that DUI s, DWI s, PI s must be reported and are not considered minor traffic violations. (One minor in possession [MIP] or minor in consumption [MIC] do not need to be disclosed, therefore, you may answer No. If you have two or more MIP s or MIC s, you must answer Yes.) 2. Do you have any criminal charges pending, including unresolved arrests? 3. 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 or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? 4. Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug? 4

5. Within the past five (5) years have you been diagnosed with, treated, or hospitalized for schizophrenia and/or psychotic bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder? Students that have obtained a Declaratory Order Petition must notify the Director and inform them of the outcome of their petition. ESSENTIAL ELIGIBILITY REQUIREMENTS FOR PROFESSIONAL NURSING STUDENTS PARTICIPATION IN CLINICAL PRACTICE The Associate Degree Nursing Applicant and/or student would be considered ineligible to participate in the Associate Degree Nursing Program when his/her physical, emotional, and/or intellectual disability and/or incapacitated state: 1. Hinders the student from being able to achieve the cognitive knowledge and/or dexterous skills required for the Associate Degree Nursing student nurse and expected of the Registered Nurse in the performance of the functions of which he/she is preparing to be employed. 2. Creates a potential health hazard to the student and/or recipient of health care services by the respective student. It assumed that a student will independently be able to: 1. Functionally use the senses of vision, hearing, smell and touch with or without technical (mechanical) compensation. Observe a patient accurately at a distance and close at hand. Observation necessitates the functional use of the sense of vision and somatic sensation. It is enhanced by the functional use of the sense of smell. 2. Execute functional psychomotor activities to provide general nursing care and emergency treatment. Such actions require coordination of both gross and fine muscular movements, equilibrium and functional use of the senses of touch and vision. 3. Hear, observe and speak to patients in order to elicit information, describe changes in mood, activity and posture, and perceive non-verbal communications. A student must be able to communicate with patients and others effectively and with sensitivity. Communication includes not only speech but also reading and writing. 4. Utilize intellectual abilities, exercise responsible judgment and complete task. Comprehend threedimensional relationships and understand the spatial relationships of structures. 5. Demonstrate the emotional health required for full utilization of intellectual abilities and exercise of good judgment. The student must be able to promptly complete all responsibilities attendant to the care of the patients, families, and groups from a variety of social, emotion, cultural, and intellectual backgrounds and develop mature, sensitive and effective relationships with them. A student must be able to tolerate physically taxing workloads and function effectively under stress. The student must be able to adapt to changing environments, display flexibility and learn to function in the face of uncertainties inherent in the clinical problems of many patients. Compassion, integrity, concern, other interpersonal skills, interest and motivation are all personal qualities that will be assessed during admission and the educational process. A student who cannot function in any of the abilities mentioned above may receive individual consideration for admission or retention. For consideration, request must be submitted to the Director. 5

ADA Guidelines apply to all qualified disabled persons. A qualified disabled person is a person with a disability who, with or without reasonable modifications to rules, policies, or practices, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of services, or the participation in programs or activities provide by a public entity and who can perform the essential eligibility requirements of the position. Any student who, because of a disabling condition, may require some special arrangements in order to meet course requirements should contact the Director as soon as possible to make necessary accommodations. Students should be prepared to present a disability verification form from their physician and update that information periodically. HEALTH REQUIREMENTS A current up-to-date immunization record is required prior to entering the program. Immunizations include Measles/Mumps/Rubella (MMR or confirmation of Immunity/protective titer), varicella, Tetanus/Diphtheria (TD Immunization received within the last 10 years), Tuberculin Test (PPD administered and read within the last 12 month) and Hepatitis B Series (or confirmation of Immunity/protective titer). Prior to starting the program, the student must provide documentation of current C.P.R. for the Health Care Provider. Students are encouraged to carry health insurance and must carry professional liability insurance. Students needing health insurance may obtain information in the Student Health Services Office. Professional liability insurance coverage in at least a minimum amount of $1 million limit each claim and $3 million aggregate is required. Cost for the professional liability insurance in included in the fees ($18.78) paid during each fall semester. The professional liability insurance is only applicable to students in their student role, not in their employment role. 6

THE UNIVERSITY OF TEXAS AT BROWNSVILLE and TEXAS SOUTHMOST COLLEGE ASSOCIATE DEGREE NURSING PROGRAM Associate Degree Nursing Program requires you to take the courses listed below in addition to the nursing courses. In order to be accepted in to the Associate Degree Nursing Program, you must have completed Math, English, Anatomy and Physiology I and II with lab, Microbiology with lab., Introduction to Psychology, and Lifespan Developmental Psychology, prior to application. MATH 1332 MATH FOR LIBERAL ARTS -OR- MATH 1314 COLLEGE ALGEBRA -OR- ANY MATH HIGHER THAN MATH 1314 ENGLISH 1301 COMPOSITION I BIOLOGY 2301 ANATOMY & PHYSIOLOGY I BIOLOGY 2101 ANATOMY & PHYSIOLOGY I LAB BIOLOGY 2302 ANATOMY & PHYSIOLOGY II BIOLOGY 2102 ANATOMY & PHYSIOLOGY II LAB BIOLOGY 2321 MICROBIOLOGY BIOLOGY 2121 MICROBIOLOGY LAB PSYCHOLOGY 2314 LIFESPAN DEVELOPMENTAL Psychology PSYCHOLOGY 2301 INTRODUCTION TO PSYCHOLOGY SPEECH 1318 INTERPERSONAL COMMUNICATION -OR- SPEECH 1315 APPLIED COMMUNICATION HUMANITIES 3 hr. course (i.e. ART, MUSIC, PHILOSOPHY, FOREIGN LANGUAGE OR ANY 2000 ENGLISH LITERATURE COURSE) 7

A.A.S. - Associate Degree Nursing - LVN Advanced Placement Program Class Beginning in August with May 15 th Deadline: Admission Prerequisite Lecture Lab Clin Contact Hours Credit BIOL 2301 Anatomy and Physiology I 3 0 0 48 3 BIOL 2101 Anatomy and Physiology I 0 4 0 64 1 BIOL 2302 Anatomy and Physiology II 3 0 0 48 3 BIOL 2102 Anatomy and Physiology II 0 4 0 64 1 MATH 1332 Math for Liberal Arts 3 0 0 48 3 PSYC 2301 Introduction to Psychology 3 0 0 48 3 BIOL 2321 Microbiology 3 0 0 48 3 BIOL 2121 Microbiology Lab 0 4 0 64 1 ENGL 1301 Composition 1 3 0 0 48 3 PSYC 2314 Lifespan Development 3 0 0 48 3 Total Hours 21 12 0 528 24 LEVEL II Fall Semester Lecture Lab Clin Contact Hours Credit *RNSG 2207 Transition to Nursing Practice 2 0 0 32 2 *RNSG 1327 Transition from Vocational to Professional Nursing Practice 3 0 0 48 3 *RNSG 2260 Clinical: Nursing RN: Transition to Nursing Practice 0 0 8 128 2 SPCH 1318 Interpersonal Communication 3 0 0 48 3 Total Hours 8 0 8 256 10 LEVEL III Spring Semester Lecture Lab Clin Contact Hours Credit *RNSG 2341 Advanced Concepts of Clinical Decision Making 3 0 0 48 3 *RNSG 2263 Clinical: Nursing RN: Advanced Concepts of Clinical Decision Making 0 0 6 96 2 *RNSG 2121 Management of Client Care 1 0 0 16 1 *RNSG 2361 Clinical: Nursing RN: Preceptor 0 0 9 144 3 ELCT Humanities (Art, Music, Philosophy, Foreign Language or any 2000 English) 3 0 0 48 3 Total Hours 7 0 15 352 12 Nursing Hours Total 9 0 23 512 16 Grand Total 1248 46 Class Beginning in January with December 15 th Deadline: Admission Prerequisite Lecture Lab Clin Contact Hours Credit BIOL 2301 Anatomy and Physiology I 3 0 0 48 3 BIOL 2101 Anatomy and Physiology I 0 4 0 64 1 BIOL 2302 Anatomy and Physiology II 3 0 0 48 3 BIOL 2102 Anatomy and Physiology II 0 4 0 64 1 MATH 1332 Math for Liberal Arts 3 0 0 48 3 PSYC 2301 Introduction to Psychology 3 0 0 48 3 BIOL 2321 Microbiology 3 0 0 48 3 BIOL 2121 Microbiology Lab 0 4 0 64 1 ENGL 1301 Composition 1 3 0 0 48 3 PSYC 2314 Lifespan Development 3 0 0 48 3 Total Hours 21 12 0 528 24 LEVEL II Spring Semester Lecture Lab Clin Contact Hours Credit *RNSG 2207 Transition to Nursing Practice 2 0 0 32 2 *RNSG 1327 Transition from Vocational to Professional Nursing Practice 3 0 0 48 3 *RNSG 2260 Clinical: Nursing RN: Transition from Vocational to Professional Nursing Practice 0 0 8 128 2 SPCH 1318 Interpersonal Communication 3 0 0 48 3 Total Hours 8 0 8 256 10 LEVEL III Fall Semester Lecture Lab Clin Contact Hours Credit *RNSG 2341 Advanced Concepts of Clinical Decision Making 3 0 0 48 3 *RNSG 2263 Clinical: Nursing RN: Advanced Concepts of Clinical Decision Making 0 0 6 96 2 *RNSG 2121 Management of Client Care 1 0 0 16 1 *RNSG 2361 Clinical: Nursing RN: Preceptor 0 0 9 144 3 ELCT Humanities (Art, Music, Philosophy, Foreign Language or any 2000 English) 3 0 0 48 3 Total Hours 7 0 15 352 12 Nursing Hours Total 9 0 23 512 16 Grand Total 1248 46 Upon satisfactory completion of RNSG 2207, RNSG 1327 and RNSG 2260 the LVN Transition student will receive 21 semester credit hours for RNSG1205, RNSG 1215, RNSG 1413, RNSG 1160, RNSG 1201, RNSG 1331, RNSG 1347, RNSG 1261 & RNSG 1262. *All WECM Courses Underline all General Education Courses CREDIT HOUR SUMMARY: Nursing 37 Credit Hours; General Education 30 Credit Hours; Total 67 Credit Hours. 8

1 st Semester Tuition The University of Texas at Brownsville and Texas Southmost College School of Health Sciences Nursing Department Associate of Applied Science LVN-RN Track Estimated Cost RNSG 1110 Intro to Community-Based Nursing RNSG 2307 Transition to Nursing Practice RNSG 2260 Clinical: RN: Transition to Nursing Practice RNSG 1327 Transition from Vocational to RN RNSG 2207 Transition to Nursing Practice Estimate for 11 credit hours (for resident in-district) $ 1510.56 HESI Exams (included w/tuition stmt) PEDI, PSY & MAT ($19.00/each) $ 57.00 Fees Parking Fees (optional) $ 20.00 Liability Insurance (included with tuition statement) $ 18.00 Health provider CPR course $ 40.00 Immunizations (price listed is from UTB Student Health Services) CBC $ 15.00 RPR $ 15.00 Urinalysis (UA) $ 10.00 FBS $ 2.00 Annual TB (PPD) Test $ 10.00 Chest X-Ray (if positive TB) Not available at UTB MMR #1 $ 50.00 MMR #2 $ 50.00 Tetanus (TD) Booster $ 20.00 Varicella Vaccine (if never had disease) Not available at UTB Hepatitis B Vaccine Series $ 45.00 Physical Exam $ 15.00 Books RNSG 1210 Intro to Community-Based Nursing 1 book $ 46.00 RNSG 2307 Transition to Nursing Practice 3 books $ 190.00 RNSG 2461 Clinical: RN: Transition to Nursing Practice No text Uniforms 2 tops (regular sizes) $ 86.00 2 bottoms (regular sizes) $ 48.00 1 clinic coat $ 54.00 Nurse Packs $ 95.00 Name Tag & Patches (name tag $5.25/each; 5 patches $4.00 each) $ 25.25 Meds Publishing Learning software $ 92.50 Estimated Total for Semester $2514.31 2 nd Semester Tuition RNSG 2341 Advanced Concepts of Clinical Decision Making RNSG 2360 Clinical: RN: Adv Concepts Clinical Decision Making RNSG 2121 Management of Client Care RNSG 2166 Practicum (Capstone) Estimate for 9 credit hours (for resident in-district) $ 1510.56 Fees Parking Fees (optional) $ 20.00 HESI Exams (included w/tuition stmt) Exit Exam 1 st time testers ($35 each time you take exam) $ 35.00 Books RNSG 2341 Advanced Concepts of Clinical Decision Making 4 books $ 232.00 RNSG 2360 Clinical: RN: Adv Concepts Clinical Decision Making No text RNSG 2121 Management of Client Care 1 book $ 48.00 RNSG 2166 Practicum (Capstone) No text Meds Publishing Learning software $ 92.50 Graduate Pin Prices range from $35.00 to $250.00 $ 35.00 UTB Graduation Application Fee $ 25.00 Graduate Nurse Cap $ 8.00 NCLEX Exam $ 200.00 BNE Application Fee (Board of Nurse Examiners) $ 139.00 Estimated Total for Semester $2345.06 Estimated Total for the LVN-Transition Program $4859.37 9

Name: I.D. #: A.D.N. ADMISSION POINT GRID CATEGORY POSSIBLE POINTS POINTS AWARDED ACT Composite 18-21 1 22-25 2 26-29 3 30+ 4 ACT Reading Score 18-21 1 22-25 2 26-29 3 30+ 4 ACT English Score 18-21 1 22-25 2 26-29 3 30+ 4 Overall GPA College: High School: 2.5-2.8 1 85-89 2.9-3.2 2 90-92 3.3-3.6 3 93-96 3.7-4.0 4 97+ Certificates/ Degrees Earned LVN/1 yr Certificate 1 Associates 2 Bachelors 3 Masters & above 4 Grand Total: Revised: 10/2008 9//2008 6/2005 2/2005 4/2003 3/2003 4/2002 5/2000 6/2009 2/2010 10

THE UNIVERSITY OF TEXAS AT BROWNSVILLE and TEXAS SOUTHMOST COLLEGE SCHOOL OF HEALTH SCIENCES APPLICATION FOR ADMISSION DEPARTMENT OF NURSING APPLICATION FOR READMISSION Mark box corresponding to the program of application: Vocational Nursing 956-882-5072 Part-time Vocational Nursing 956-882-5072 Associate Degree Nursing 956-882-5073 LVN Advanced Placement 956-882-5073 Bachelor of Science in Nursing (Full-Time) 956-882-5070 Bachelor of Science in Nursing (Part-Time) 956-882-5070 Master of Science in Nursing 956-882-5070 BSN to MSN Bridge Program 956-882-5070 Note: See individual programs for application requirements and processes. PLEASE TYPE OR USE BLACK INK. DO NOT USE NICKNAMES. FAILURE TO ANSWER ALL QUESTIONS COMPLETELY MAY DELAY PROCESSING OF YOUR APPLICATION. Date of Application: - - Mo. Day Yr. UTB Student ID # This application is for admission into the program beginning: / Semester Full legal name: Last First Middle Maiden name: Current mailing address: Street E-mail address: (Required) Year City State Zip Telephone #: ( ) - Alternate #: ( ) - (Please give a number where you can be reached weekdays between 8 a.m. and 5 p.m.) Permanent address: Note: This address should be a constant one where you can be reached now and in future years. Street City State Zip Telephone: ( ) - If you have previously attended any school under a name other than that given above, specify on line below. PERSONAL INFORMATION The following voluntary information is needed for affirmative action purposes. The information you provide will not affect your admission to the ADN program. Male Female Date of Birth: / / (mm) (dd) (yyyy) Race/Ethnicity: Hispanic Black Asian white/caucasian American Indian/Alaskan Puerto Rican Other Spanish Surname Pacific Islander Are you an International / Non United States Citizen applicant? Yes No If yes, see Admission of International Student in the UTB/TSC Undergraduate Catalog for additional requirements. 11

IN CASE OF AN EMERGENCY, PLEASE NOTIFY: Name: Address: Telephone: ( ) Relationship: City, State, Zip: DISABILITIES In order to provide better services for people with disabilities, the following voluntary information is needed. This is for affirmative action purposes. The information you provide will not affect your admission to the School of Health Sciences and will be kept confidential. Please check all that applies to you: physical disability learning disability other disability: Will you need special accommodations in order to succeed in the program for which you are applying? No Yes, please specify: EDUCATIONAL BACKGROUND If you have not attended college/university, list the high school you graduated from on the line below and request that an OFFICIAL TRANSCRIPT (showing your rank in the class & GPA) be sent directly to: Associate Degree Nursing Program, School of Health Sciences, University of Texas at Brownsville, 80 Fort Brown, Brownsville, Texas 78520. High School: Name City/State Graduation Date Please list each college or university that you have attended or will attend prior to enrolling at UTB/TSC. Be sure to submit a transcript from each institution to the ADMISSIONS OFFICE in TANDY 115 for evaluation. NAME OF SCHOOL CITY STATE DATES OF ATTENDANCE Mo./Yr. TO Mo./Yr. DIPLOMA/DEGREE or Sem. Hours If you have attended more than four colleges, please list on a separate sheet. Please list all college or university COURSES which DO NOT PRESENTLY APPEAR on your transcript, but in which you are currently enrolled or will have completed before enrolling at UTB. Final official transcripts must be sent DIRECTLY to UTB ADMISSIONS OFFICE in TANDY 115 from the institution you are attending when course work is completed for evaluation. COLLEGE OR UNIVERSITY COURSE NO. COURSE TITLE SEM HRS TERM/YR 12

Note: All ADN and VN students must complete the following eligibility questions. Please review the Eligibility to take the NCLEX-RN Examination in the information packet to answer these questions. If you answer yes to any of the following questions you must provide a written explanation. 1. Yes No 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? 7 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 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 our office with your 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. Non-disclosure of relevant offenses raises questions related to truthfulness and character. NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov t Code 552.142(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 nondisclosure may 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 non-disclosure, even if you properly did not reveal the matter, the Board may require you to provide information about that criminal matter. 2. Yes No Are you currently the target or subject of a grand jury or governmental agency investigation? 3. Yes No 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. Yes No Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug? 5. Yes No 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 If you answered YES to any of the questions listed above, attach a letter of explanation that is dated and signed indicating the circumstances(s) you are reporting to the Board. *If you are licensed as an LVN in the State of Texas and are currently participating in the Texas Peer Assistance Program for Nurses you may answer NO to questions #4 and #5. 13

APPLICATION CHECKLIST A. Submit an application to the University of Texas at Brownsville, MEET REQUIREMENTS FOR ADMISSION, and obtain a UTB ID number. B. SUBMIT THE FOLLOWING ITEMS TOGETHER IN A PACKET TO THE DEPARTMENT OFFICE, LHSB 2.720, BEFORE THE DEADLINE DESCRIBED BELOW. H : Completed Nursing Application (last four pages of this packet). High school transcript or GED score sheet, unofficial copies are acceptable (If you have previously attended college or university please omit this step.) UTB Transcripts, unofficial copies will be accepted (ONLY UTB TRANSCRIPTS WILL BE ACCEPTED, if you have never attended UTB you must submit your transcripts for evaluation to the Admission s Office). Proof of Immunizations for Measles/Mumps/Rubella (MMR or confirmation of Immunity/protective titer); Tetanus/Diphtheria (TD Immunization received within the last 10 years); Hepatitis B Series (or confirmation of Immunity/protective titer); Tuberculin Test (PPD administered and read within the last 12 months); and Varicella. Proof of CPR for the Healthcare Provider. Program Required test scores required (ACT, TEAS, TASP, GRE*) * These vary by program C. Students are encouraged to carry health insurance. Students needing health insurance may obtain information in the Student Affairs website. Students must carry professional liability insurance. Professional liability insurance coverage in at least a minimum amount of $1 million limit each claim and $3 million aggregate is required. Cost for the professional liability insurance in included in the fees paid during each fall semester. The professional liability insurance is only applicable to students in their student role, not in their employment role. NOTE: All VN applicants must demonstrate graduation from high school or completion of a GED. List the high school you graduated from on the line below and request that an OFFICIAL TRANSCRIPT (showing your rank in the class & GPA) be sent directly to: Vocational Nursing Program, School of Health Sciences, University of Texas at Brownsville, 80 Fort Brown, Brownsville, Texas 78520. High School: Name City/State Graduation Date If you did not graduate from high school include a copy of GED certificate with this application. NOTE: All ADN applicants who have not attended university must complete the following. List the high school you graduated from on the line below and request that an OFFICIAL TRANSCRIPT (showing your rank in the class & GPA) be sent directly to: Associate Degree Nursing Program, School of Health Sciences, University of Texas at Brownsville, 80 Fort Brown, Brownsville, Texas 78520. High School: Name City/State Graduation Date 14

Note: All students must sign the following disclaimer question. I understand that the Department of Nursing will not regard this application as "complete" until all supporting papers have been received; therefore, it is to my interest to see that these are submitted as promptly as possible. It is also my understanding that official transcripts must be sent directly from each school to the ADMISSIONS OFFICE in TANDY 115 to a Transcript Evaluator. If selected for admission to this program I will at all times conduct myself in accordance with the rules and regulations of the College, Program and its clinical affiliates. I certify that the information in this application is complete and correct and understand that the submission of false information is grounds for rejection of my application, withdrawal of any offer of acceptance, cancellation of enrollment, or appropriate disciplinary action. I certify that I can perform the essential eligibility requirements for participation in clinical nursing with or without reasonable modifications to rules, policies, or practices, the removal architectural, communication, or transportation barriers, or the provision of auxiliary aids and services as described in the information packet. I hereby grant permission to UTB/TSC to verify any and all information submitted/stated. I understand that my acceptance to any nursing program is only conditional, until such time as I have cleared a criminal background/security clearance screening. NOTE: All applicants must submit a complete application package in order to be considered for admission. No application package will be accepted if incomplete. If there are circumstances that may have an influence on your admission that you would like for those reviewing your application to know about, please describe on a separate sheet and attach. Signature of Applicant Date DEADLINES FOR RECEIPT OF APPLICATION AND ALL REQUIRED DOCUMENTS: ASSOCIATE DEGREE NURSING PROGRAM ASSOCIATE DEGREE NURSING PROGRAM LVN ADVANCED PLACEMENT VOCATIONAL NURSING PROGRAM BACHELOR OF SCIENCE IN NURSING PROGRAM BSN TO MSN BRIDGE PROGRAM MASTER OF SCIENCE IN NURSING PROGRAM - MAY 15 TH - MAY 15 TH - DECEMBER 15 TH - JUNE 1 ST - NOVEMBER 1 ST -JULY 1ST -NOVEMBER 1ST -JULY 1ST -NOVEMBER 1 ST -SEE GRADUATE CALENDAR DEADLINES Application, transcripts, and supporting documents should be turned in a packet together to respective programs. Program Name The University of Texas at Brownville and Texas Southmost College Life & Health Science Building, 2.720 80 Fort Brown Brownsville, TX 78520-4993 15

DEPARTMENT OF NURSING THE UNIVERSITY OF TEXAS AT BROWNSVILLE AND TEXAS SOUTHMOST COLLEGE 80 Fort Brown Brownsville, Texas 78520 (956) 882-5071 Fax (956) 882-5100 Immunization Record Name: ID# Program: (circle program): VN ADN BSN MSN TB (Tuberculosis or Chest X-Ray) (To be completed once accepted into the program) Date Result MMR#1 MMR#2 Tetanus(TD) Booster Varicella Vaccine 1# 2# Illness Hepatitis B Vaccine 1# 2# 3# Hepatitis B Waiver signed Comments: Please bring a copy of this form to your physician/health care provider and have them fill out and sign. Return with your completed application. Health Care Provider Signature Date Address 16