NURSE EDUCATION PROGRAM ADMISSIONS QUESTIONNAIRE For Returning Applicants Spring & Fall 2018

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1 NURSE EDUATION PROGRAM ADMISSIONS QUESTIONNAIRE or Returning Applicants Spring & all 2018 This questionnaire is to be completed with the attached Application for Admission. Instructions Page 1: Please complete this page by word processing all of your answers. Attach additional sheet(s) if needed or submit a resume (make sure your name is on each additional sheet). Name: Student ID #: Last irst MI (I AVAILABLE) Address: Day Time Phone:_( ) Evening Phone:_( ) ell Phone: _( ) Are you applying as a returning applicant to the Nurse Education Program? No Please PRINT all answers (or attach a word processed resume): Your current job: Employer: Dates: Duties and Responsibilities: Prior job(s) Dates: Employer/acility: Duties and Responsibilities: Employer/acility: Duties and Responsibilities: Health Related Experiences or Site Visits Dates: Employer/acility: Duties and Responsibilities: Please proceed to the next page and follow the instructions. 5

2 NURSE EDUATION PROGRAM Returning Student QUESTIONNAIRE SPRING & ALL 2018 (ontinued) Instructions page two: Please answer all following questions. Evaluation of the answers includes but is not limited to grammar, spelling, as well as overall content and quality of the answer s (e.g. accuracy, thoroughness, and relevance to the question asked). Handwritten applications will not be accepted. Make sure your name is on each of the page(s) submitted. 1. Why have you decided to re-apply to the Nurse Education Program? What changes have you made to help you succeed with your academic goals? 2. What have done to enhance your nursing knowledge since you left the Nurse Education Program? Nurse Education This Program prepares interested students for a career in nursing as a Registered Nurse. Graduates of the Program receive an Associate in Science degree and are eligible to enter the licensure process for Registered Nurses. The Program is approved by the Board of Registration in Nursing and is accredited by the National League for Nursing Accreditation ommission. Please be advised that students accepted to this program will be required to fully participate in patient simulation scenarios designed to closely replicate the healthcare workforce environment, which will prepare students to perform required competencies and care for patients. These scenarios are video recorded and viewed in debriefing sessions that allow for reflective learning, peer-to-peer learning, and evaluation by faculty/staff. Students are expected to respect and care for the patient simulators as if they were live patients, as well as to respect their fellow classmates during scenarios and debriefing sessions. The Program is organized as a competency-based curriculum with modified self-pacing. Nursing courses include clinical practice experiences in a variety of clinical settings, where students develop nursing skills based on theoretical concepts. To participate in clinical practice experiences and take the National ouncil of State Boards Licensure Examination (NLEX-RN), students are required to under go a riminal Offense Record Information check. Depending upon information in the ORI check students may be denied placement in the clinical area and will not be able to participate in the Program. Readmission applications for the Spring of 2018 must be post marked by November 1, Readmission applications for the all of 2018 must be postmarked by ebruary 9,

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9 Revised: 9/12/17 TEHNIAL STANDARDS OR NURSE EDUATION To the student: As you complete this form please consider your physical and mental/attitudinal ability to meet the Technical Standards associated with the health professions program that you are about to enter. Please carefully consider the General Job Description as you evaluate your ability to meet the Technical Standards specified. ontact the Nurse Education Program at (978) , if you require more specific information about the physical and mental/attitudinal requirements of the program. Throughout the performance of your duties as a healthcare provider, you will be exposed to infectious diseases in all practice settings. Although you will learn practices and procedures to minimize the risk of exposure, you should be aware of the risk and take it into consideration when deciding to enter this program and profession. General Job Description: Assess patients using critical thinking in decision-making. Provide physical and emotional care to patients. Apply principles of therapeutic communication and teaching appropriately. Accepted Students: PHYSIAL Please sign and return to Health Professions Main Office DH318 Performance Level* LIT: patients, equipment up to 25 lbs safely ARRY/MOVE: equipment, objects up to 25 lbs safely KNEEL: STOOP/BEND/ TWIST: BALANE: to perform PR, work with patients, assist patients who fall assist in ADL; perform transfers, operate low level equipment safely maintain while assisting patients in ambulation, and transfer ROUH: to locate and plug in equipment O REAH: WALK: STAND: to adjust equipment, to guard patient, to reach supplies for extended periods of time and distances over an eight (8) hour period for extended periods of time over an eight (8) hour period O HANDLE: equipment such as syringes, Bp cuffs, IV infusions, buttons, switches and touch pads DEXTERITY: to perform fine motor skills, manipulate and fine tune knobs, dials, blood pressure cuffs, equipment, scales and stretchers. Don and remove protective clothing. Safely handle sterile supplies to prevent contamination. PUSH/PULL: wheelchairs, stretchers, patients, Hoyer lifts

10 TATILE Performance Level* PALPATE: pulses, skin texture, bony landmarks DIERENTIATE: between temperature and pressure variations VISUAL READ: DETET: OBSERVE: SEE: accurately read numbers, letters, cursive writing in fine and other print in varying light levels changes in skin color, patient s facial expressions, swelling, atrophy, forms of nonverbal communication (gestures) patient and environment in order to assess conditions or needs BP manometer, small print on vials, syringes, dials, gauges and computer screens Performance Level* OMMUNIATION Performance Level* SPEAK: in English language in clear, concise manner; to communicate with patients, families, significant others and the health care team RESPOND: to patient with communication disorders (aphasia, hearing loss), or those who use ELL OMPREHEND: oral and written language, including health care terminology in order to communicate with patients, families, significant others, health care providers, and community WRITE/WORD PROESS: AUDITORY HEAR: in English, clearly, legibly; for charts, computer input of data heart sounds, breath sounds, patient distress sounds, machine timer bells and alarms; verbal directions and requests from health care team and patients Performance Level*

11 MENTAL/OGNITIVE/BEHAVIORAL unction safely, effectively, and calmly under stressful situations. Remain alert to surroundings, potential emergencies; respond to patient situations, i.e. falls, burns, pain, change in physical status. Integrate information, and make decisions based on pertinent data, in a collaborative manner. Interact effectively, appropriately and exhibit respect for cultural and ethnic differences of clients, peers and individuals in the classroom setting. Interact effectively and appropriately with patients, families, supervisors, and co-workers of the same or different cultures with respect, politeness, tact, collaboration, teamwork, and discretion in both the clinical and classroom settings. ommunicate an understanding of basic principles of supervision, ethics, and confidentiality. Display effective interpersonal skills necessary to interact in situations requiring close, personal contact. Display attitudes/actions consistent with the ethical standards of the profession. Maintain personal hygiene consistent with close personal contact associated with patient care. Maintain composure while managing multiple tasks simultaneously. Prioritize multiple tasks. Remain free from alcohol and/or chemical impairment in the clinical and classroom settings. Performance Level* IMMUNIZATIONS Health science students must meet immunization requirements under state law, MGL hapter 76, Section 15 and its regulations at 105 MR Students must also meet any additional immunization requirements required by clinical affiliates. According to MGL hapter 76, Section 15, a health science student who is in contact with patients may be exempt from the immunization requirements imposed under state law pursuant to a medical or religious exemption. Submission of documentation will be required and, if sufficient to qualify for a medical or religious exemption, it will be granted. PLEASE BE ADVISED that, while the college will make a reasonable effort to place you in a clinical facility, clinical placement cannot be guaranteed in light of an un-immunized status. If a clinical placement cannot be secured, then you will be unable to complete the program's clinical requirement. Thus, you will be unable to progress and will fail out of the program. *Performance Level: O = occasionally 50-74%; = frequently 75-89%; = constantly %

12 *Applicants who are offered admission must document their ability to perform all essential tasks with or without reasonable accommodation in order to begin the professional courses. If you are an otherwise qualified individual with a disability who seeks a reasonable accommodation, you need to contact the Office of Accessibility for eligibility determination for reasonable accommodation(s). or those applicants offered admission into the program, you will be asked to self-certify by signing the Technical Standards form which is included in the Health orm packet that will be mailed to you and that you are required to complete no later than July 5, 2018.