Marian University Leighton School of Nursing-Bachelor of Science in Nursing Program Clinical Application-Spring 2017 CAMPUS BASED ACCELERATED

Transcription

1 Marian University Leighton School of Nursing-Bachelor of Science in Nursing Program Clinical Application-Spring 2017 CAMPUS BASED ACCELERATED Only completed applications will be accepted in the Nursing Office Room EC 350 through Wednesday, December 7, 2016 at 4PM. Mailed, faxed, or ed application documents will not be considered. Please make a copy of your completed application for your records. Date: Name: (Print): Address (street, city, and zip): Phone number: I attended an application information session on September 23, 2016 Initial: Please consider the above information as my application for a place in the Campus Based Accelerated BSN Program for the class beginning Spring I certify that the information given in this application packet is accurate and complete. I also understand that misrepresentation in any statement may be considered sufficient reason for refusal of admission or cancellation of admission after acceptance. Admission is competitive and according to the current Marian University Leighton School of Nursing Decision Tree. Signature Date: Grade Credits NSG 129 BIO 214 BIO 225 BIO 226 CHE 100 Background Check Drug Screen For Office Use Only: Cumulative GPA in Pre-Requisite courses Overall Marian University GPA Transfer Student MU Student

2 Applicant Name Student ID # Release of information, Health Insurance, Criminal History RELEASE OF INFORMATION: I understand that the information regarding social security number, criminal history, contact number, immunizations and results may be released to the appropriate clinical facility where I will be placed as a student for clinical, as requested. Failure to sign consent will prevent my participation in clinical. In addition, I understand that it is my responsibility to update the Marian University Leighton School of Nursing with proper documentation if there are any changes in my health or criminal history. HEALTH INSURANCE (please attach a copy of your card or policy information): Insurance Company: Primary Policy Holder: ID Number: Group: CRIMINAL HISTORY Have you ever been convicted or pled guilty to a misdemeanor or felony other than a traffic violation? Yes No Have you ever been arrested? Yes No ONGOING HEALTH RESPONSIBILITIES: If admitted to the nursing program I understand that it is my responsibility to keep the following up to date and current according to the current addition of the Leighton School of Nursing Student Handbook: 1. Tuberculin Test (PPD) 2. CPR Certification 3. Flu Shot CERTIFICATION: I certify that all statements made in this application are true and complete Signature of Applicant: Date:

3 Applicant Name Student ID # INITIAL STUDENT HEALTH RECORD The following information must be completed by a health care provider SHOTS AND VACCINES 1. TDap-Documentation of vaccine within the last ten years. Date of vaccine: 2. Tuberculin Test (PPD)-Two Step-please make sure to do this prior to vaccines, otherwise it will interfere with tests reliability. Step 1 Date placed: Date read: Positive: Negative Step 2: (7-21 days after Step 1) Date placed: Date read: Positive: Negative -NOTE: Documentation of a chest X-ray within the last five years and results are required of any positive PPD. Thereafter, the procedure for annual follow-up involves documentation of symptom assessment by a healthcare provider. 3. Hepatitis B Vaccine Dates three part series was completed: OR Titre Date Immune Not immune 4. Flu shot Date (Attach documentation) TITRES A titre is a blood screen to verify if you have positive immunity to specific diseases. You must submit a copy of your lab results for all required titres 1. IgG Rubella Titre Date Immune Not immune My titre DID NOT SHOW IMMUNITY against rubella. 1. I received an MMR on (Date) 2. IgG Rubeola Titre Date Immune Not immune My titre DID NOT SHOW IMMUNITY against rubeola. 1. I received an MMR on (Date) 3. Mumps (IgG) Titre Date POSITIVE Negative My titre DID NOT SHOW IMMUNITY against mumps. 1. I received my first MMR vaccine on (Date) 2. I received my second MMR vaccine (min 28 days after 1 st vaccine) on (Date) 4. Varicella Titre Date POSITIVE NEGATIVE My titre DID NOT SHOW IMMUNITY against varicella. 1. I received my first varicella vaccine on (Date) 2. I received my second varicella vaccine (min 28 days after 1 st vaccine) on (Date) Signature of Health Care Provider: I verify that all information presented on this form to my knowledge is true and correct: Date: (MD,DO,NP,PA signature only)

4 Applicant Name Student ID # Report of Physical Examination (to be completed by a healthcare provider) Date of exam: Instructions for provider: 1. Complete a physical examination using this form. 2. Sign this form before returning it to the student. Physical examination must have occurred within the last six months. Age Height Weight Temperature Pulse Rate Respiration Blood Pressure Are there any abnormalities of the following systems? (Please check yes or no for each. If yes, please explain.) YES NO Explanation Head Eyes Ears Nose Throat Teeth Respiratory Gastrointestinal Cardiovascular/Hematological Genitourinary Hernia Musculoskeletal Metabolic/endocrine Neuropsychiatric Skin Is the student now under treatment for a chronic medical condition? Are there any limitations for physical activity? Healthcare provider signature: (MD,DO,NP,PA signature only) Address and phone number

5 Health Record Information Hepatitis B Nursing students in need of the Hepatitis vaccine series may choose to use Marian University Student Health Center (if registered in courses at Marian). 1. If you have completed the series, indicate the dates on the initial student health record 2. If you have never received the Hepatitis vaccine, complete the series (three parts). 3. If you do not have medical documentation of the series, but are sure you have had it, you can opt to have a titre drawn to show immunity. If the titre shows you are not immune, then you will need to start the Hepatitis B series. Tdap vaccine The required tetanus is the Tdap vaccine and is available at the Marian University Student Health Center. If you have had the Tdap vaccine within the last 10 years you are covered. PPD The required 2-step TB test can be placed at the Marian University Student Health Center as well: Step-2 must be read/interpreted 7-21 days after Step 1 (no test on Thursday due to Sat/Sun read). County Health Departments are another option for all of your immunizations. Physical: Marian University Leighton Student Health Center can provide the necessary physical at no charge for students currently taking classes at Marian please call to schedule an appointment as availability will be limited. To make an appointment with the Marian University Student Health Center please call: (317) Rubeola, Mumps, Rubella and Varicella Titres: Lab test results are mandatory for students to prove you are immune Vaccines alone do not meet this requirement. Your proof of immunity is confirmed by checking IgG titres. You must provide the School of Nursing with a copy of the lab results. If previously pregnant, your obstetrician may have a Rubella Titre test result from your initial blood work. You may obtain your titres from either your primary health care provider or at the following location. You do NOT need an appointment for the Madison Ave. Lab. Your results will be faxed to the Marian University Student Health center on campus. It is responsibility to pick up the results and include them in your application packet. Madison Avenue Medical Laboratory 8523 Madison Avenue; (317) Please schedule an appointment if you need a health care provider to sign the immunization form; Marian University Student Health Center ( ) The Marian University Student Health Center does not send results to the Leighton School of Nursing Websites and Phone numbers for CPR Classes: The American Heart Association: Visit the American Heart Association website to find a CPR class. Remember there is a significant turnaround time on receiving your CPR card. Please complete this early to ensure you will have a card by the application deadline. Marian University School Leighton of Nursing requires American Heart Association CPR/BLS for the Healthcare Provider or BLS Instructor only. No other organization s card will be accepted.

6 Instructions for Obtaining Criminal Background Check 1. Go to website 2. Select state 3. Select online scheduling 4. Welcome page-enter name 5. Under agency name choose All Others 6. Under Applicant type, select NCPA Volunteer Background Check 7. Under NCPA, choose Marian University School of Nursing (INAP00316) 8. Appointment details-choose region or closest fingerprinting location for your appointment 9. Choose location and day for your appointment 10.Fill out application information and submit It will take approximately 7-10 days (after you are fingerprinted) for your report to be sent to Marian University.

7 Drug Screen Information Marian University School of Nursing requires a 10-panel drug test for all students. 1. Each student must have a 10-panel drug test completed as part of the application process. If you have questions please contact your Advisor. 2. Students must use one of the approved sites listed below. The prices are subject to change. Each site has a standing order for nursing students at Marian University. No other physician order is required. 3. Each of the below sites will report the results directly to Marian University School of Nursing. 4. Results of the testing, or a receipt proving that the test was completed, must be received by Marian University School of Nursing by the application deadline. It generally takes 3-4 business days for results to be reported. 5. Picture identification is required at the time of testing. 6. Students should take all prescription medications in their original containers to the testing site, since some prescription medications will alter the results of the 5-panel drug test. Approved testing sites are listed below: FACILITY ADDRESS CONTACT INFORMATION APPROX. COST OF DRUG SCREEN Medcheck 1011 Main Street Speedway, IN Brigid Gedig $50 IU HEALTH Occupational Health Madison Avenue Lab 7301 Georgetown Road Suite 109 Indianapolis, IN Madison Avenue Indianapolis, IN Reba Petty *Georgetown local # Linda Taylor $58 $40 Out-of-State Applicants If you cannot get the screening done at one of the Sites listed above because you are located out of the area, then you can get screened at an Occupational Health lab/facility near where you live. The facility must complete a 10-panel drug screen; follow chain of custody requirements; and send your results directly to: Marian University 3200 Cold Spring Road Indianapolis, IN Attn: Becky Goss Fax: Please go to to find a testing location in your state.