A & L Home Care and Training Center, LLC. ***Important Information***

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1 ***Important Information*** Physical Competed physical form must be submitted to A & L Home Care and Training Center, LLC by the first day of class. **Your Physical cannot be more than 6 months old.** TB Mantoux/PPD test Evidence of TB test must be submitted to A & L Home Care and Training Center, LLC by the first day of class, unless performed in house. Recombivax-HB Vaccine Evidence of HB vaccine must be submitted to A & L Home Care and Training Center, LLC by the first day of class I understand that Recombinvax-HB is a non-infectious subunit viral vaccine and has shown 80-90% efficiency in preventing infection of Hepatitis B in susceptible persons and that I must complete a series of three doses (initial, 1 month, and 6 month)in order to obtain the full benefits of the immunization. I assume all responsibility for completing the series and the development of any potential side effects or reactions upon receiving the vaccine. INDIVIDUALS WITH HYPERSENSITIVITY TO MOLDS AND/OR YEAST SHOULD NOT TAKE THIS VACCINE. I have read the above information and have determined to take the vaccine without coercion or duress and agree to hold A & L Home Care and Training Center, LLC free and harmless from any claims, demands, actions or suits from damages resulting from any injuries or complications that may result from the administration of the Hepatitis B vaccine. I have obtained the initial vaccine and intend to complete the series as suggested to obtain full benefits. Signature: I have obtained the vaccine in the past and will provide documentation of its administration. I have read and understood the above information regarding the benefits and potential side effects of the HB vaccine and decline to complete the suggested series of vaccines. I hold A & L Home Care and Training Center, LLC free from any claims, demands, actions or suits from damages resulting from any injuries or complications that may result from declining to be vaccinated with the HB series. Criminal Background Check Completed background check must be submitted to A & L Home Care and Training Center, LLC by the first day of class **Your background check cannot be more than 1 year old.** The agency can perform Bureau of Criminal Investigation (BCI) and (FBI) fingerprinting in-house at the following cost $35.00 for BCI fingerprinting and $69.00 if both BCI and FBI fingerprinting is required (required if one has not been an Ohio resident for at least 5 years). I swear and affirm that I am not currently on parole or probation. I swear and affirm that I have not committed or have been convicted of a violent, crime, theft, or exploitation of the elderly. I state that I have not pled guilty to, been formerly charged with, or been convicted of a disqualifying offense, as outlined in Title 29 of the Ohio Revised Code. I acknowledge that I have not been convicted of a felony or had a felony reduced to a misdemeanor conviction by any court. You may omit conviction of a misdemeanor while under the age of 18 if the record was sealed under penal Code or any minor traffic violation with a fine imposed of $ or less. I understand that Senate Bill 160 will not permit individuals with certain misdemeanors and felonies to work in Long-Term Care Facilities and/ or home health. I understand that it is my responsibility to notify the agency at which time items in the above paragraph change. Yes No Signature: I understand that completion of the S.T.N.A training program does not guarantee me employment with the agency. If desired, I must go through the application, interview, and hiring process. Signature Property of A & L Home Care and Training Center, LLC June 2014 All Rights reserved

2 Name : A & L Home Care and Training Center, LLC P. o. Box County Road 107 Proctorville, Ohio Phone: (740) / Fax: (740) Student Health Form Cellular Number: Address: Phone Number: Class runs Monday through Friday for 3 consecutive weeks. Evening and Part-Time Classes pending. Requirements for Clinical Participation (All sections for TB test, HB immunization, and Verification of health must be completed) Release for 2-Step TB Mantoux/PPD Test A 2 step TB is required to participate in clinical practice. A second test is given 7 days after the initial test. Each result must be read hours after the test is received. An induration of greater than 5mm will be considered a positive result. A chest x-ray will be required for a positive result. Positive TB Test Before? Yes No Pregnant? Yes No Allergies to prescribed medications? Yes No MMR within last 2 months? Yes No Family history of TB? Yes No Were you born in the US? Yes No Known exposure to TB? Yes No Serum Lot # Date Given Forearm Given By Date Read Results Read By mm mm ***If a positive skin test reaction is noted and a chest x-ray is required, a copy of the x-ray results must accompany this form. Comments: Signature/Title of Individual Administering Test and Date Agency Address and Phone Number Where the Test was Administered Recombivax-HB Vaccine Evidence of HB Vaccine must be submitted to A&L Home Care and Training Center, LLC by the first day of class. Submit copy of vaccination if obtained with health form. PHYSICAL EXAM Each student participating in the nursing assistant/home health aide training program is required to successfully pass a completed physical examination and be certified as physically fit to participate. The Physical Exam for must be submitted by the first day of class. After reviewing the above named individual's medical history and current health status, I certify that he/she is able to fully participate in the nursing assistant / home health aide training program without restriction. After reviewing the above named individual's medical history and current health status, I certify that he/she is not able to participate in the nursing assistant / home health aide training program without restriction. Comments: Name / Address / Phone Number of Agency: Signature/Title: (Physician's Assistant or Nurse Practictioner : Date Completed: Property of A & L Home Care and Training Center, LLC June 2014 All Rights Reserved

3 Refund/Transfer/Dismissal Policies Refund Policy No refunds will be made to students who withdraw or are dismissed from classes regardless of the reason for withdrawal/dismissal. All tuition paid is non-refundable. When you reserve space in a class, others may have been denied placement in the training program due to lack of space. Enrollment Acceptance is on a first come, first serve basis and as determined by interview. As a result, once you reserve a spot in a class the monies paid cannot be refunded. Transfer Policy If you need to transfer from a class, please let us know at least five (5) full business days in advance so that we may fill your space. Please be sure to call during regular business hours. A $15.00 processing fee will be assessed for all transfer requests. A re-registration fee of $50.00 will be assessed if you cancel 5 or more days before the first day of class. A re-registration fee of $ will be assessed if you cancel within 4 business days of the start of the scheduled class. A re-registration fee of $ will be assessed if you cancel on the 1 st day of class or later. **Failure to show up for the first day of class constitutes an automatic withdraw and all transfer/re-registration fees will apply. **All transfer/withdrawal requests must be received in writing. Dismissal Policy A & L Home Care and Training Center, LLC reserves the right to dismiss a student based on classroom/clinical behavior, performance, grades, attendance, non-adherence to the rules and regulations of this program, or non-adherence to the scope of practice for a Certified Nursing Aide Student. All funds paid prior to the dismissal date are non-refundable. Disciplinary action, including expulsion from class could occur for, but is not limited to the following reasons: Cheating, profanity, sleeping in class, falsification of records, theft, illegal possession or use of any drug or Intoxicant, careless or willful destruction of property, smoking in unauthorized areas, disruptive or distractive behavior, committing unlawful acts, etc. Book Refund Policy I understand that the book fees are required. I understand that the $17.00 work book fee is non-refundable. I understand that I may keep my book at the cost paid or that I may receive a refund of $60.00 if my textbook is returned in given condition on the last day of class. I further understand that I forfeit my $60.00 deposit if my workbook is lost or damaged. By signing below, I understand and agree to the above Refund, Transfer, and Dismissal Policies. Signature Date Witness Signature Date

4 P. o. Box County Road 107 Proctorville, Ohio Phone: (740) / Fax: (740) State Tested Nurse Aide (STNA) Training Program Overview and General Information Course Description A 75-hour State approved course covering Basic Nursing Skills, Personal Care Skills, Mental Health, and Social Service Needs, Basic Restorative Services, Resident s Rights, Communication and Interpersonal Skills, Infection Prevention and Control, Safety and Emergency Procedures, Promoting Resident s Independence, and Respecting Resident Rights. To receive a Certificate of Successful Completion, the student must pass written exams with an overall score of 80% or greater and demonstrate proficiency in all skills learned. The student must also complete 16 hours of mandatory hands-on clinical in a long term care facility. Admission Guidelines Diploma or GED is not required, but candidate must be able to read and perform basic math skills. Student must be at least 16 years old to begin training. Good physical health exam, TB test, HB Vaccine consent or decline, and background check must be submitted to A & L Home Care before the first day of class. The Role of the Nurse Aide The Nurse Aide is an important member of the nursing team. The individual is instrumental in providing residents/patients with basic nursing and personal care, as well as providing emotional and physical support. Employers There is a high demand for State tested Nurse Assistants in Nursing homes, Hospitals, Home Health Care, Hospice, and Assisted Living Facilities. Note We train students with the information that is required to take the Ohio Department of Health s Nurse Aide competency test, a multiple choice written/oral test and skills test to become a State-Tested Nurse Aide (STNA). The State Exam is scheduled after the completion of classes & clinical experience. A & L Home Care and Training Center, LLC is not responsible for exams not completed proficiently by the student. Uniform Requirement S.T.N.A. Class Any classroom appropriate clothing can be worn and name badge. No short-shorts, short-skirts, half-shirts, revealing items, or clothing with inappropriate writing will be permitted. CLINICAL Attendance- Royal blue scrub top, white scrub pants, white shoes, white socks, and name badge. Appropriate undergarments must be worn that cannot be seen through your uniform. Student must be clean, neat, and professional looking at all times. ** Any student not dressed appropriately will be sent home. (No exceptions). DUE TO THE LENGTH OF THE PROGRAM 100% ATTENDANCE IS REQUIRED FOR COURSE COMPLETION. CLINICALS CANNOT BE MADE UP UNTIL THERE IS SPACE AND AVAILABILITY IN THE NEXT SCHEDULED CLASS. S.T.N.A TRAINEES ARE ALSO GRADED ON PUNCTUALITY! A STUDENT MORE THAN 15 MINUTES LATE FOR CLASS WILL BE COUNTED AS ABSENT AND THE DAY WILL HAVE TO BE MADE UP. IF LATE FOR CLINICAL, STUDENT IS NOT ALLOWED OR ADMITTED ON THE FACILITY FLOOR. Property of A & L Home Care and Training Center, LLC June 2014 All Rights reserved

5 Cellular Phones are Prohibited CELL PHONES ARE TO BE TURNED OFF PRIOR TO CLASS & CLINICAL! (NO RINGING, NO VIBRATING, NO BEEPING, NO TEXTING, NO SOCIAL MEDIA SITES, ETC.) Telephones may ONLY be used during your break times or scheduled lunch. RECORDING AND/OR VIDEOTAPING ANY PORTION OF THIS PROGRAM IS PROHIBITED. State Requirements Course length is 59 hours of classroom training plus 16 hours of clinical training. See attached calendars for class times and dates. Clinical The State of Ohio mandates at least 16 hours of clinical training. Failure to attend all 16 hours (due to absence or tardiness) will result in an incomplete. Training must be completed within 60 days of the earliest of any missed time or the last day of your program. Make-up training will be completed based on space and availability in the next scheduled class. What do I do once I have completed the course? You will receive your certificate of completion for nurse assistant training and you will be eligible to register for the Ohio State Test. Are the class times flexible? No. You must be on time for each and every class. Anyone arriving 15 minutes past the class start time will be counted as absent. What happens if I miss a day? We have a 100% attendance policy. If you are unable to complete the program with 100% attendance because of a catastrophic event, you may be allowed to transfer to a future available class. This will be at the discretion of the Program Coordinator. See Transfer Policy. What else do I need for the class? You will need a physical, 2 step TB Mantoux/PPD test and/or negative chest x-ray, HB vaccine documentation or decline, criminal background check(s), Uniform scrub pants, T-shirt, name badge, supplies, and books. **(You will need to have all required documentation before the first day of class). How old can the physical & TB Test (or chest x-ray) be? Your physical cannot be more than 6 months old from the start of class. Your 2 Step TB test cannot be more than one year old from the end date of the course. Your chest x-ray cannot be more than one (1) year old from the end date of the course. Where can I get a physical or TB test done? A & L Home Care and Training Center, LLC can provide the 2 step TB Mantoux/PPD test at no charge in-house or you can get it done at your local health department or physician s office. A chest x-ray must be completed at a medical facility that provides it. You can obtain a physical at your local clinic or physician s office. You can also schedule one at Med Express at 3120 Route 60 East, Huntington, West Virginia or by phoning (304) Where can I obtain a Criminal Background Check? You can obtain a Criminal Background check at your local sheriff s office or in-house from A & L Home Care and Training Center, LLC at 6129 County Road 107, Proctorville, Ohio for applicable a cost of $35.00 for BCI and $69.00 if BCI and FBI both are required. Non-Discrimination Policy: A & L Home Care and Training Center, LLC is committed to provide equal training opportunities to all qualified candidates, regardless of race, color, religion, sex, sexual orientation, age, national origin, marital status, pregnancy, or disability according to Federal and State Civil Rights Law.

6 P. o. Box County Road 107 Proctorville, Ohio Phone: (740) / Fax: (740) Authorization to Release Information Form I hereby AUTHORIZE and request any law enforcement agency to furnish the bearer with criminal history and identity check information in their possession regarding me in connection with class and clinical training. I am willing for a photocopy of this authorization be accepted with the same authority as the original. I understand that this Authorization is to be part of my student application, which I sign. I understand that A & L Home Care and Training Center, LLC and State guidelines mandate that background information be obtained prior to beginning the program. I hold A & L Home Care and Training Center, LLC free from any liability resulting from the results/information obtained. Print Name: Other Names used: Last, First Middle (maiden, previous marriages, etc.) Date of Birth: Home Phone: Social Security Number: Cellular Phone: Driver s License Information: License # Expiration Date State of Issue Have you lived in the State of Ohio for at least Five Years? Yes No Current Address: Address City State Zip Criminal Background Disclaimer You may omit conviction of a misdemeanor while under the age of 18 if the record was sealed or any minor traffic violation with a fine imposed of $ or less. Have you been background checked by A & L Home Care and Training Center, LLC is the past year? Yes No Are you currently on parole or probation in any state? Yes No Have you ever committed, pled guilty to, been formerly charged with a violent crime, theft, or exploitation of the elderly or a disqualifying offense as outlined in Title 29 of the Ohio Revised Code? Yes No Have you ever been convicted of a felony or had a felony reduced to a misdemeanor conviction by any court? Yes No I understand that Senate Bill 160 will not permit individuals with certain misdemeanors and felonies to work in Long-Term Care Facilities and/ or HOME HEALTH. Yes No I understand that it is my responsibility to notify the agency at which time items in the above paragraph change. Yes No If yes was answered to any of the above, please provide the date, location, and an explanation. I further certify that all statements and information provided on this application is correct to the best of my knowledge and belief. I understand that A & L Home Care and Training Center, LLC solicits this information so as to be informed on my previous record and character. I understand that my enrollment with the agency depends upon successful completion of the application process and its components, a criminal background check, and course criteria. I also understand that any misrepresentations, falsifications, or omission of the facts herein may be ground for disqualification or dismissal from the program. Signature Date Property of A & L Home Care and Training Center, LLC June 2014 All Rights reserved