ADN Admission Procedures 2015-16

ADN Admission Procedures 2015-16 Application period is September 2, 2014 through February 20, 2015. Only applications showing completion of all nursing pre-requisites and degree classes will be evaluated. Application Process: 1. Read complete Application and website information 2. Student applies to attend COS and receives an S number. Go to the main webpage and click on the Navigator button. Apply to be a student. 3. Application must include all items on Checklist. 4. Mail complete application and official transcripts from all college coursework to the Nursing Office. COS transcripts do not need to be official. 5. If official transcripts have already been sent to COS, include a note in the application with that information, including approximate date they were sent, and include a copy (or unofficial) with application. College of the Siskiyous Nursing Program 2001 Campus Dr. Yreka, CA 96097 TEAS testing Dates are: Thursday, September 25, 2014; Wednesday, October 24, 2014; Thursday November 6, 2014; Tuesday, January 20, 2015. Call 530-841-5929 to make an appointment

Career & Technical Education LVN RN Step-Up Program (530) 841-5929 Fax (530) 841-5214 APPLICATION INSTRUCTIONS 2015-16 Thank you for your interest in the 2015-16 Associate Degree Nursing (LVN-RN Step-Up) program; a 27 unit LVN to RN step-up program spanning the Summer, Fall & Spring semesters of an academic year. The application period for the 2015-16 cohort will start Tuesday, September 2, 2014 at 8:30 a.m., and end Friday, February 20, 2015 at 4:00 p.m. Students seeking admission to the ADN program must have all pre-requisite and associate degree classes completed before an application will be considered. Incomplete applications will not be returned. Completed applications must be received in the Nursing Program office, 2001 Campus Drive, Yreka, CA 96097, no later than February 20, 2015 at 4:00 p.m. It is the applicant s responsibility to verify that applications materials have been received. To confirm receipt of a completed packet, call the Yreka Nursing Office at 530-841-5929 thirty days after mailing. All applicants are strongly encouraged to meet with Counseling Services prior to submission of application package. Students will receive official notification of acceptance before they can register for the Summer Role Transition Class. If the applicant does not accept placement into the current program, the applicant must re-apply for a subsequent program. Applicants who accept the position and later withdraw their name from the list are also required to re-apply for a subsequent class. NOTE: Special accommodations are available for any phase of the application or testing process for individuals with disabilities. Contact the Disabled Student Services office at 530-938-5297. We are pleased you are considering the College of the Siskiyous Nursing Program and wish you all the best. Janis Laiacona, MSN, RN Director of Nursing

REGISTERED NURSING -- APPLICATION INSTRUCTIONS I. General Information: The Associate Degree Nursing (LVN-RN Step-Up) Program admits a new cohort annually. The program is a one year course of instruction. Classroom instruction is offered concurrently with clinical experience. The Associate Degree Nursing (LVN-RN Step-Up) curriculum is designed to prepare students for the National Council Licensure Examination-Registered Nursing (NCLEX- RN). Upon successful completion of the examination, the student becomes a Registered Nurse (RN). II. Program Prerequisites: To be considered for admission to this program, you must meet the following minimum qualifications: High school graduate or equivalent Completion of Human Anatomy (BIO 2700) with a grade of "C" or higher* Completion of Human Physiology (BIO 2800) with a grade of "C" or higher* Completion of Microbiology (BIO 2600) with a grade of "C" or higher* Completion of College Composition (ENGL 1001) with a C grade or better Copy of current LVN license (kept valid through May 2016)and official transcript showing graduation from an approved VN program or equivalent as determined by the school Official verification of completed T.E.A.S. V (Test of Essential Academic Skills) with a composite score of 62% or better. If a 62% is not achieved, student must show evidence of remediation for no less than 30 days before retaking the T.E.A.S. Students must pay for any retakes. Only two retakes are allowed. Proof of immunizations, meeting health and physical requirements, background clearance and drug screening as mandated by the Nursing program *Please note: Applicants must have a minimum GPA of 2.5 for Human Anatomy, Human Physiology, and Microbiology, with no grade less than a C for each course. One repetition of one science class is allowed, if the first attempt is a C, D, F, FW. A minimum cumulative GPA of 2.5 for all college coursework is required. III. Additional Degree Requirements: To be considered for admission to this program, these requirements must also be completed: A minimum cumulative GPA of 2.5 for all college coursework is required. Please confirm that courses taken meet the COS degree requirement. Quarter system courses are not equivalent to semester courses. Completion of one Associate Degree General Education Mathematics course with a C grade or better (MATH 0980, or BA 0959) Completion of Sociology (SOC 1001-Introduction to Sociology, or SOC 1002-Social Problems) Completion of Psychology (PSY 1001-General Psychology, or PSY 1033-Personal & Social Adjustment)

Completion of Speech Communication (COMS 1100-Public Speaking, COMS 1200- Small Group Communication, COMS 1300-Interpersonal Communication,) Completion of one non-studio Humanities course (courses listed on the IGETC Area 3 Arts & Humanities) Completion of a one unit PE course Students with a previously earned Bachelor s Degree are only required to take nursing prerequisites plus select other courses. Please contact Counseling Services for additional information. IV. Selection of Associate Degree Nursing (LVN-RN Step-Up) Class: Applications will only be accepted for evaluation during the application period Associate degree classes must also be completed before submitting application. Incomplete applications will not be evaluated. Selection criteria include TEAS test score, Science GPA, and Overall GPA. Students are allotted points in each area. Those with highest overall totals are admitted first. Those who meet admission criteria but are not admitted due to space availability will be placed on a wait list for admission to the next cohort. V. Notification of Acceptance: Only applicants with complete applications will be considered for admission to the program. Applicants will be accepted, placed on a waiting list, or denied, based on a point-by-point evaluation of qualifications. The Nursing Program office will send students notification of acceptance into the program, placement on a waiting list or denial, by the week of April 30, 2015. VI. Costs: Up): Approximate cost, per student, for the Associate Degree Nursing (LVN-RN Step- * Tuition:....$ 1242.00 Books:... 1500.00 Equipment: (Stethoscope, penlight, goggles, patches)... 500.00 Uniforms: (Shoes, ID badges, watch, scissors).... 400.00 Assessment testing package (approx)........ 700.00 Drug Screen & Background check:... $99.00 CPR certification:... 50.00 Immunizations/Physical (varies)... 150.00 BRN application fee:.. 150.00 Interim Permit:.. 50.00 NCLEX testing fee:...$ 200.00 Fingerprinting fee: varies... $ 55.00 Photo ID Application:... $ 10.00 Travel to remote clinical sites:... Varies Approximately 448 miles per week based on distance from Yreka to Redding Approximate cost (California residents) for the RN Step-Up program $5,000.00-$6,000.00 *Tuition is based on the proposed 2013-14 rate, established by the California State Legislature. *Out-of-state tuition is $276.00 per unit. These fees are to be considered an estimate and are subject to change.

VI. Misc.: A. General Class Information: Lecture/theory classes are in the RHSI building, on the Yreka campus. Summer Session Tuesday, Wednesday, Thursday Fall and Spring Semesters: Theory days: Monday and Tuesday - Fall Semester Wednesday and Thursday - Spring Semester Clinical assignments will be in Redding (8 hrs/day), with the exception of three to six weeks of clinical agency rotations in Siskiyou County. There may also be one trip to Sacramento during the Spring semester. Clinical days: Wednesday and Thursday Fall Semester Monday and Tuesday Spring Semester Dates may change based on availability of clinical sites. Students must provide their own transportation to the clinical facilities. B. Financial Aid: Financial aid is available for students in the form of Pell Grants, EOPS Grants, and nursing scholarships. For more information regarding financial aid, contact the Financial Aid Office at (530) 938-5209. STEP (Siskiyou Training & Employment Agency) may also provide financial assistance. C. Background Clearance & Drug Screening Requirements Background check and drug screening are required by the clinical facilities prior to student placement. An additional background check is also a requirement during the licensure application process. Students must notify school immediately if there are any legal issues. Failure to do so will result in dismissal. Legal history may preclude student acceptance or continuing in program.

COLLEGE OF THE SISKIYOUS ASSOCIATE DEGREE NURSING PERSONAL DATA FORM 2015-16 CLASS PLEASE PRINT CLEARLY Full Name of Applicant: COS student # (S) S000 Address: (Street, PO) (City, State, Zip) Phone Number: Cell Phone Number: Email address: LVN License # Expiration Date Name of LVN school Emergency Contact Other Names Used

COLLEGE OF THE SISKIYOUS Associate Degree Nursing LVN to RN Step-Up Program Application 2015-16 Class Check list for a complete packet: o Official Transcripts for all colleges attended showing completion of prerequisite classes and degree requirements. COS transcripts can be unofficial. o A 2.5 overall GPA for all college coursework taken o A 2.5 GPA for Human Anatomy, Human Physiology & Microbiology o Official transcripts showing completion of an approved vocational nursing program or the equivalent as determined by the school o Proof of high school graduation or equivalency. (GED certificate, CHSPE transcript or a CHSPE Certificate of Proficiency) o Copy of active LVN license (valid thru May 2016) o Official proof of completed TEAS (Test of Essential Academic Skills) with a composite score of 62% or better. o Completion of self-evaluation form o Completed Personal Data Form o Completed Confidential Application for Clinical Practice Form o Signed Drug Screen Policy o Note stating that transcripts have already been sent to Enrollment Services, if applicable. Signature: Date:

Name Student # Self-Evaluation Form I. LVN to RN Program Prerequisites Yes No High School graduate or equivalent Proof of active LVN license (copy) Graduate of an approved vocational nursing program or the equivalent as determined by the school TEAS V Test Score of 62% or better Minimum cumulative GPA of 2.5 for all college coursework Completion of the LVN to RN Course Prerequisites listed below Statement of Understanding: I understand that any question answered no under items I & II means I have not met a necessary criterion for enrollment to the program. I hereby acknowledge that failure to follow enrollment procedures or omission of required materials will result in disqualification of my enrollment packet. Date Signature of Applicant II. LVN to RN Course Prerequisites COURSE TITLE COLLEGE BIO 2700 Human Anatomy* (4 units) SEM./QTR. AND YEAR GRADE REPEAT BIO 2800 Human Physiology (5 units) BIO 2600 Microbiology* (4 units) ENGL 1001 College Composition* (3 units) III. Courses Required for Degree Completion Sociology Complete one (3 units) SOC 1001 or SOC 1002 COURSE TITLE COLLEGE SEM./QTR. AND YEAR GRADE Psychology Complete one (3 units) PSY 1001 or PSY1033 Speech Communication (complete one) (3 units) COMS 1100, COMS 1200, COMS 1300 Mathematics* (minimum 3 units) Arts & Humanities** (3 units) PE/Wellness One unit of PEAC or PEFI *Complete one Associate Degree General Education Mathematics course. The COSGE list of approved math courses is at http://www.siskiyous.edu/counseling/handouts/aa.pdf **Complete one IGETC Area 3 Arts & Humanities course. The IGETC list of approved Arts and Humanities courses is at http://www.siskiyous.edu/counseling/handouts/igetc.pd

Applicant Information: Program: X ADN VN CNA Career & Technical Education Nursing Program (530) 841-5929 Fax (530) 841-5214 CONFIDENTIAL Application for Clinical Practice 5/15/12 Page 1 of 2 Last Name First Name MI Maiden Address City State Zip Email Birth Date Gender M Phone( Day) Phone ( Eve) Phone (Cell) F Person to notify in case of emergency: Full Name Relationship Address- Number & Street City State Zip Home Phone Work Phone Cell Criminal Public Record Check Yes Have you ever been convicted *of any crime*under your current name or any other name? If the above answer is yes, please detail information for each conviction on the back of this form No Yes No Yes No Yes No Yes No Do you have a criminal case now pending? Clinical assignments are in health facilities that allow you to access to drug and medications. Have you ever been arrested for an offence involving controlled substances? (Cal labor Code 432.7f, Cal Health and safety Code 11590) Clinical assignments are in the health facilities that allow you regular access to patients. Have you ever been arrested for a sex offense for which registration as a sex offender would be required upon conviction? (Cal labor code 432.7f, Penal Code 290) Do you understand that a background check; reference verification; and drug screening is a part of the enrollment decision making process, and if you are invited to participate in the program that you consent to a complete background investigation. * Convicted means plea, verdict of finding of no contest or guilt, regardless of whether sentence was imposed by the court. * Any Crime means misdemeanors or felonies including motor vehicle/ driving violations excluding minor traffic infractions, conviction for marijuana more than two years ago, and convictions for which the records has been sealed, expunged, eradicated, or judicially dismissed. *Please schedule an appointment with the Director of Nursing if you have questions/concerns regarding the information required in this document. Signature of Applicant: Date:

Program: ADN VN CNA Career & Technical Education Nursing Program (530) 841-5929 Fax (530) 841-5214 CONFIDENTIAL Application for Clinical Practice Applicant s Name (Print) Page 2 of 2 *Existence of convictions will not necessarily disqualify an applicant from enrollment. However, failure to fully disclose may be considered falsification, and will result in offer of enrollment being rescinded and is grounds for immediate termination upon discovery at any time during enrollment. Students accepted into the nursing program are required to disclose * any crime incurred prior to the program start date through program graduation. Such offenses may be grounds for immediate dismissal. The student must discuss any potential issue with the Director of the Nursing Program. Failure to disclose will result in immediate dismissal. A student will be excluded from participation in clinical rotations and therefore unable to complete the College of the Siskiyous Nursing programs for the following background check/drug screen findings: Information Regarding Criminal History Date Conviction Court Name City / County Exclusion from Clinical Placement In collaboration with the clinical agencies used by College of the Siskiyous, a student will be excluded from participation in clinical rotations and therefore unable to complete the College of the Siskiyous Nursing programs for the following background check/drug screen findings: Capitol felony conviction at any time in student s past. Felony conviction within the past 7 years* Misdemeanor convictions within the past 3 years* Medicare Fraud Any crime that results in requirement to register as a sex offender Positive Drug Screen CNA students with a Criminal History are required to provide their own Live Scan Clearance prior to acceptance into the CNA Program. There are some specific restrictions imposed by the state for nursing students that require additional clearance, a criminal record may disqualify you from state licensure testing. Applicant Statement I hereby certify that all statements made on this form are true and correct and I authorize investigation of all statements herein recorded. I release from liability persons and organizations reporting information required by this application. I understand that any misrepresent or falsification of material facts in this application may be cause for immediate disqualification and removal from program. Signature: Date:

ADN DRUG SCREEN AND BACKGROUND CHECK POLICY/PROCEDURE The Joint Commission requires hospitals to have a process to ensure that a person s qualifications are consistent with his or her job responsibilities (standard H.R. 1.20). As a result, hospitals are required to have the same standard for students as they would for their staff. To meet this requirement, all students who participate in clinical rotations must submit proof of their drug screening and background check prior to starting the ADN Program. Students are provided information for obtaining their Corporate Screening background check and drug screening at Orientation, forms are also available in the Nursing Office. The background check must be completed no later than 6 weeks prior to the start of class in order for the Nursing Office to receive results 2 weeks prior to the first day of class. If this requirement is not completed within this timeframe, students may be dropped from the program. Convictions will be addressed on an individual basis between the student and the Director of Nursing. Students accepted into the nursing program are required to disclose * any crime incurred prior to the program start date through graduation of the ADN Nursing Program. Such offenses may be grounds for immediate dismissal. The student must discuss any potential issue with the Director of the Nursing Program. Failure to disclose will result in immediate dismissal. A student will be excluded from participation in clinical rotations and therefore unable to complete the College of the Siskiyous Nursing programs for the following background check/drug screen findings: Capitol felony conviction at any time in student s past. Convicted of Abuse: Elder or Child at any time in student s past Felony conviction within the past 7 years Misdemeanor convictions within the past 3 years Medicare Fraud Any crime that results in requirement to register as a sex offender Positive Drug Screen * Convicted means plea, verdict of finding of no contest or guilt, regardless of whether sentence was imposed by the court. * Any Crime means misdemeanors or felonies including motor vehicle/ driving violations excluding minor traffic infractions, conviction for marijuana more than two years ago, and convictions for which the records has been sealed, expunged, eradicated, or judicially dismissed. If you have any questions, please contact the Director of Nursing. A fingerprinting and background check is required by the BRN before you are able to sit for licensure. A positive criminal history does not disqualify a candidate from taking the licensure examination. However, should the candidate pass the exam, issuance of licensure will be delayed pending the Board's investigation of the candidate's criminal history and a decision rendered relative to the candidate's eligibility for licensure. Anyone who has a criminal history may be denied licensure by the Board of Registered Nursing. This is confidential information declared to the BRN at the time of examination application. Felony convictions that may jeopardize licensure include, but are not limited to: elder abuse, child abuse, sexual abuse, and possession of drugs for sale. If you have specific questions or concerns you may contact the BRN at (916) 322-3350. www.rn.ca.gov/enforcement/convictions.shtml www.cdph.ca.gov/certlic/occupations/documents/atcs%2098-4.pdf I have read and understand the drug screen and background check requirements for the ADN program. Printed Name Signature