Umpqua Community College Practical Nursing Certificate Program Application

Transcription

1 Dear Practical Nursing Applicant: Thank you for your interest in the Practical Nursing program at Umpqua Community College (UCC)! The Practical Nursing program is both exciting and challenging; offering graduates the opportunities for employment in a variety of settings and for a lifelong career that is personally fulfilling. The practical nursing program at UCC is structured to help the nursing student build a strong foundation, thus building confidence to achieve the goal of becoming a Licensed Practical Nurse (LPN). Success in the program takes a firm commitment, and the nursing faculty members are here to help you succeed. The program focuses on the practical nursing role of providing care under the supervision of a licensed practical nurse registered nurse in long term care, outpatient clinics, and other health care settings. Curriculum includes coursework from the biological and applied sciences including anatomy and physiology, social sciences and humanities. Students study fundamental principles and procedures of practical nursing, medication administration, infection control, pharmacology, and the practical nurse s contribution to the nursing process. Theory and lab course work includes concepts that address the practical nurse role in patient teaching and the delivery of nursing skills according to current standards of practice. Practical Nursing is a demanding field and admission to nursing schools is a very competitive process. We strongly suggest you prepare well by talking with nurses in various settings, talking with an advisor in order to help you with your career plans, and by reading through the application materials thoroughly. Thanks again for your interest. If you have any questions about admission to this program, please call the Admissions Office at or admissions@umpqua.edu. Sincerely, April Myler, MSN, RN, Director of Nursing Umpqua Community College 1

2 PROGRAM OVERVIEW CAREER DESCRIPTION: The program focuses on the practical nursing role of providing care under the supervision of the registered nurse or physician in a variety of health care settings. HYBRID CURRICULUM. The Practical Nursing courses are face to face with on-line modules plus lab and clinical. Students must have access to a personal computer with a web browser and Internet connection (preferably high speed internet). LENGTH OF PROGRAM: 3 Quarters PN Program of Study FIRST QUARTER (fall) PN 101 Introduction to Practical Nursing...9 SECOND QUARTER (winter) PN102 Foundations of Practical Nursing THIRD QUARTER (spring) PN103 Foundations of Practical Nursing Credits TERM PROGRAM BEGINS EACH YEAR: Entrance is offered once a year FALL term. CREDENTIAL AWARDED WITH COMPLETION OF REQUIRED COURSEWORK: Certificate plus ability to apply for PN licensure in the state of Oregon. NEW PN STUDENT ORIENTATION: - A mandatory student orientation will be held for admitted students. Attendance is required, or the next eligible alternate will be given your assigned place in the program. Students will be informed of the orientation date, time, and location in their acceptance letter. EMPLOYMENT OUTLOOK: Employment of licensed practical and licensed vocational nurses is projected to grow 25 percent from 2012 to 2022, much faster than the average for all occupations. As the baby-boom population ages, the overall need for healthcare services is expected to increase. LPNs and LVNs will be needed in residential care facilities and in home health environments to care for geriatric patients (U. S Department of Labor/Bureau of Labor Statistics, 2014). NON-DISCRIMINATION: In compliance with state and federal laws, Umpqua Community College (UCC) does not discriminate on the basis of race, religion, color, national origin, age, gender or disability in employment, or in any of its educational programs, or in the provision of benefits to students. For information about UCC s policy of nondiscrimination, contact the Student Development & Services Department. NON-DISCRIMINATION STATEMENT ON THE BASIS OF SEX: Umpqua Community College complies with all applicable federal and state regulations that prohibit discrimination on the basis of sex. No student at UCC shall, on the basis of sex, be excluded from participation in, be denied the benefits of or be subjected to discrimination in any education, program, service or activity. Any student who believes he or she has been denied any service or benefit because of sex discrimination may 2

3 follow the steps outlined in the Sex Discrimination Grievance Procedure. In addition to utilizing the College s Grievance Procedure, a student may contact the Office of Civil Rights or the Equal Employment Opportunity Commission at the following address: Seattle Office, Office of Civil Rights, United States Department of Education ;915 Second Avenue Room 3310, Seattle, WA ;Telephone: , FAX: , TDD: ; OCR.Seattle@ed.gov ;Seattle Field Office, United States Equal Employment Opportunity Commission ;Federal Office Building, 909 First Avenue, Suite 400, Seattle, WA ;Telephone: , Fax: , TTY: ACADEMIC ACCOMMODATIONS Any student who feels that she or he may need an academic accommodation for any disability should make an appointment with the Accessibility Services Office. Once the Accessibility Services Office notifies the program director or faculty of a requested accommodation, reasonable accommodations will be made. These accommodations will not substitute for the basic requirements for entrance or academic and technical standards (i.e. essential functions) required for successful completion of the practical nursing program. 3

4 NURSING PROGRAM COST (estimated) for Fees: Admission application and Nursing Application ~ Immunizations and physical Background History check (fingerprints are required) ~60.00 Drug Screening (10 panel) Tuition based on 27 credits Lab & clinical fees ~ Uniforms, school patch, name tag and shoes Equipment (watch w/ second hand, scissors/hemostat, stethoscope, pen lights etc.) Books CPR card current for 2 years Laptop computer/and or tablet P.N. Licensure Application and NCLEX Exam Graduation Fee Exit NCLEX Prep Testing Proctored Essay Total These costs are approximate and are subject to change. Students are responsible for transportation costs to clinical practicum sites. Costs are based on 3 terms Current tuition cost is $ per credit. A laptop computer and/or a tablet are required Does not include Nursing Assistant Class 4

5 NURSING APPLICATION / ADMISSION PROCESS Admission of all students is centralized in the Admissions Office. Admission to UCC does not guarantee admission to the Nursing Program. The following is a general outline of the Nursing Application/Admissions Process. See Application Criteria for more detailed information. 1. Sign up & attend an application information meeting. FREE 2. Submit the required documents with the ($25 Fee) (as ONE packet) to the Admissions Office (See Nursing Application Checklist Sheet) 3. Sign up, pay AND complete proctored essay exam. ($25 Fee) Must be PAID prior to the day of the exam. 4. Receive notice of acceptance or denial. INFORMATION MEETINGS Applicants will be expected to attend one of the information meetings below. Students can sign up by calling after January 2, CRN Date Day of the Week Time Location/Room Number Jan 16, 2018 Tuesday 9:00-10:00 AM SCI Jan 17, 2018 Wednesday 1:00 2:00 PM SCI Jan 18, 2018 Thursday 5:00-6:00 PM SCI 10 Due to the volume of interest in this program, applicants are expected to attend an application information meeting prior to seeking academic advising. The meetings generally last about an hour and includes time for individual questions. After attending one of the sessions below, students that need assistance filling out a planning sheet may request via at admissions@umpqua.edu. ADMISSION GUIDELINES Admission of all students is centralized in the Admissions Office. Admission to the College does not guarantee admission to this program. The Enrollment Service Office is the final authority on what constitutes equivalency for all admission criteria and has the sole authority to inform students of their admission status. WAITLIST: A qualified student should have all background checks, CPR and immunizations completed in case the student receives a call to offer them a position in the program. Spaces may become available one month after the initial acceptance/decline letters go out. Please DO NOT call Admissions regarding where you sit on the wait list. ADMISSION PROCESSING TIMELINE January 2, 2018 through February 14, 2018 Applications must be submitted to the Nursing Admission Office in Student Center by 5 pm. Applications mailed must be postmarked by deadline date. February 14, 2018, 5:00 pm Application deadline no exceptions Late May to early June, 2018 Notification of acceptance 5

6 PROPOSED PROGRAM CURRICULUM Pre-Requisites Requirements: It is your responsibility to show proof of your completed grade with an official transcript from any previous colleges attended by Fall of 2018 and must be included with application (if not previously sent). For coursework completed at Umpqua Community College, those transcripts will be ordered and placed in your application packet if it has been indicated as a college attended. Minimum courses required are: 1. MTH 95 or a higher level math course. with a grade of C or higher 4-5 Credits 2. WR 121 English Composition with a grade of C or higher. 3-4 Credits 3. BI 231, BI 232 and BI 233, Anatomy & Physiology Series completed with a grade of C or higher within the last 5 years. Applicants will be disqualified if not completed. 12 Credits Total pre-requisite credits = GPA Must be 3.00 or higher Applicant must provide a copy of a current OSBN CNA certification or proof that you completed and passed an accredited Nursing Assistant class in the last 3 years. ADMISSION CRITERIA (Total of 90 points possible) Type of Points Maximum Points Prerequisite GPA 40 Proctored Essay 30 CNA Certificate with current work experience (last 3 years) 2000 hrs. 20 Total 90 GPA ACADEMIC PERFORMANCE Maximum 40pts College Coursework applicants need a minimum of college credits completed with a C grade or better in those courses identified. Their pre-requisite GPA must be at least 3.0. MTH 95 Elementary Algebra or higher Writing WR121 English Composition BI 231, BI 232, & BI 233Human Anatomy & Physiology. These courses must be completed within the past five years (during or after calendar year) CERTIFIED OREGON NURSING ASSISTANT CERTIFICATE Maximum 20 pts Application must include completed & signed verification form. (See page 9) Applicants are awarded points for having a CNA Certificate with current work experience (last 3 years) 2000 hrs. = 20 pts CNA Certificate with current work experience (last 3 years) hours = 10pts CNA Certificate or Nursing Assistant class with no work experience (last 3 years) =0pts 6

7 PROCTORED ESSAY Students can sign up by calling after January 2, Please have UCC Student ID ready and be prepared to pay the $25 fee. Payment for the Proctored Essay must be made before the test date. Students cannot pay at the testing site! Please choose from two sessions: CRN Date Day of the Week Time Location/Room Number Feb 17, 2018 Saturday 10:00 AM Student Center Feb 17, 2018 Saturday 12:00 PM (Noon) Student Center Written questions will be based on the areas listed below: Diversity The applicant expresses understanding, respect for and/or experience with varied backgrounds, cultures, ethnic groups, and lifestyles. Personal Values The applicant responds to written situations demonstrating integrity and values compatible with nursing core values and code of ethics. Communication The applicant conveys information, feelings, and opinions to others orally and/or in writing. Written information is organized and clear with appropriate grammar and punctuation. Motivational Fitness The applicant identifies expectations about nursing role and responsibilities that are congruent with reality, demonstrates professionalism. Tolerance for Stress The applicant describes strategies/behaviors that would enable maintaining stable performance under pressure. Transferable Skills The applicant responds to situation questions in a manner that demonstrates skills such as: problem solving, curiosity, leadership and critical thinking. An established scoring criteria will be used that is used by other OCNE institutions Applicants will not have access to their interview scoring or evaluation scoring criteria afterwards per OCNE guidelines. Academic and/or testing accommodations Any student who feels that she or he may need an academic accommodation for any disability should make an appointment with the Accessibility Services Office. Once the Accessibility Services Office notifies the program director or faculty of a requested accommodation, Reasonable accommodations will be made. These accommodations will not substitute for the basic requirements for entrance or academic and technical standards (i.e. essential functions) required for successful completion of the registered nursing program. UPON ACCEPTANCE Notification Upon notification of acceptance, admitted students must indicate in writing by the stated deadline their intention to enroll or their position will be given to the next eligible alternate. Mandatory Orientation A mandatory orientation will be held for admitted students. Attendance is required, or the next eligible alternate will be given your assigned place in the program. Students will be informed of the orientation date, time, and location in their acceptance letter. 7

8 History and Physical Exam This form is to be completed by a healthcare provider with CBC, UA, and Hearing Test by the first day of class. Proof of Immunizations Accepted students must submit proof of the following immunizations by the stated deadline or their space will be given to the next eligible alternate: Immunity to measles, mumps, rubella, and varicella (chicken pox) Current Tuberculin Skin Test or a chest x-ray within the last 12 months Tetanus-Diphtheria-Pertussis Toxoid within the last 10 years Hepatitis B the series must be started by the stated deadline and can be completed during the first year of the program Current CPR Card Due by the first day of class: each accepted and alternate student must provide a current Healthcare Provider CPR (BLS Provider) card approved by the American Heart Association. This is the only card that is accepted by UCC Nursing programs/courses. Background History Check Due by the first day of class: All accepted students will be required to undergo a national background history check, with fingerprinting prior to entering the program. Individuals with a criminal record may not be allowed into a healthcare facility as a student. Because it is not possible to meet the objectives of the program without having clinical experience, anyone with a positive history or abuse history may not be eligible for acceptance in the nursing program. Fingerprinting will be required. Refer to UCC website at: Oregon-Record-0215.pdf HIPAA and Blood Borne Pathogens and other Federal OSHA Safety Guidelines Training Students will be provided with training online or in the Health, Nursing, and Science Center (HNSC). Drug Screening Upon acceptance students will be required to complete and pass a Urine Analysis (UA) by a UCC selected location. An outside company will send notification of testing dates and times. (UA) fees ($45) are the responsibility of the student. Consent to Photograph and Record (Provided in acceptance packet.) Sign and turn in at orientation. 8

9 FREQUENTLY ASKED QUESTIONS Umpqua Community College 1. Are there Pre-Requisites? Yes, there are Pre-Program Requirements (see pre-requisite planner). 2. When does the Program begin? Fall Term 2018 ending in Spring Term Do I have to have my CNA? If you have a license you must provide an unencumbered copy of OSBN CNA certification and the number of hours worked for discretionary points assigned. Or proof that you completed and passed an accredited Nursing Assistant class in the last three (3) years. 4. For College Transcripts do I need to submit transcripts from every college attended and not just the prerequisites? No, just the colleges where you took your pre-requisites. 5. How do I apply to the Practical Nursing Program? Go to OR click on Quick Links A-Z, scroll down and click on Licensed Practical Nursing, click on Practical Nursing Application. Please read the application thoroughly and follow directions to apply. 6. What Hours and Days will I be in class (clinical sites) during the course of the Program? The Program is designed to be offered face to face, online, day shift and evenings. 7. Do I need to submit a GED/High School Transcript? No. 8. Will I have to pass a background check/obtain a background history clearance? Yes. 9. Can I bridge to an RN Program from the Practical Nursing Program. There are many LPN to RN Bridge programs in Oregon for students who have completed the PN program, received their licensure, and have a specified number of hours of work experience (varies per program). 9

10 PREREQUISITE COURSE PLANNING SHEET (22-25 Credits) NAME: Student ID # THIS FORM MUST BE FILLED OUT AND SUBMITTED AS PART OF A COMPLETED APPLICATION. COURSES College Term/year completed SECTION B - MATHEMATICS: 4 or 5 credits MTH 95 or higher Math course / Grade Credits SECTION C - ANATOMY AND PHYSIOLOGY I, II, III: 12 credits BI 231 / BI 232 / BI 233 / Complete series to be completed prior to application. / SECTION D - ENGLISH COMPOSITION : 3-4 credits WR121 or higher / CNA Certificate &/or Work Experience: must complete the verification of employment form & be signed by employer. Or proof of class. 20 pts >2000 Plus Hours 10 pts hours 0 pts CNA or class For Office Use Only Total Point Calculation GPA Points CNA Points Total GPA Must be 3.0 or higher 10

11 PRACTICAL NURSING APPLICATION PACKET CHECKLIST Please complete this verification checklist as part of your Practical Nursing application. Be sure to attach all worksheets, official transcripts, and other supporting documentation as well as this checklist to your application. Applications will be notified late May. It is the responsibility of the applicant to ensure that all required documents listed below are received by the February 14, REQUIRED Signed and completed Practical Nursing Application Packet Checklist. (This Page) Prerequisite Course Planning Sheet. I have completed and attached the sheet indicating where all prerequisites have been completed and my GPA has been calculated to 3.00 or greater. Please provide your overall (uncalculated) GPA for all courses taken for informational purposes only here: Completed Umpqua Community College Practical Nursing form WITH $25.00 non-refundable Practical Nursing application processing fee; attached. DO NOT SEND CASH I understand that by making application to Umpqua Community College I am also authorizing my information to be released to the State Board of Nursing for research purposes only. Completed and signed Statement of Understanding Completed Umpqua Community College Application for Admissions. CNA Work Experience Verification Form- Complete the form with an employer signature, if applicable. OSBN CNA Certificate OR proof of Nursing Assistant Class. Attach copy of license or certificate to application. Proctored Essay. I have scheduled a time or taken the Proctored Essay and paid the fee of $ Paid / / Official (unopened) College Transcripts (Non-UCC) I understand the instructions (provided in this application) for documenting the credits of prerequisite coursework. Official transcripts from other colleges are due with application. Do Not Include UCC Transcripts. I have not attended any previous OCNE RN or Practical Nursing programs. Failure to disclose will result in immediate dismissal in the Practical Nursing Program at Umpqua Community College. I have attended an OCNE or practical nursing program at in College Date/Year Name (printed) Signature Date Please mail or bring all application materials to: Umpqua Community College, Admissions Practical Nursing Application, 1140 Umpqua College Rd, PO Box 967, Roseburg, OR

12 CNA WORK EXPERIENCE VERIFICATION FORM CNA experience must qualify the individual for renewal of CNA certification by the Oregon State Board of Nursing (OSBN). In other words, the individual must have been performing authorized duties as defined by the OSBN and must have received ongoing or regular supervision by a licensed nurse, and must have been in a position that required CNA certification. Please verify the amount of hours this applicant has worked as a CNA using the scale provided: <2000 hours in a year (within last 3 years) = 20 Points hours in a year (within last 3 years) =10 Points I have a current certification by the Oregon State Board of Nursing (OSBN) (No signature needed - 0 Points) but have not worked. Clinical class hours do not count. I have never worked as a CNA, but have attended a Nursing Assistant class. (No Supervisor signature needed - 0 Points) Please note: Employment Beginning Date: and Employment End Date: Does a licensed nurse regularly supervise this individual? Yes No Name/ Signature of Supervisor: Printed Name of Supervisor: Supervisor s phone number: Facility Position/Title: Name of Facility: Permission for verification of Employment Hours: I give my consent to release information verifying my hours of employment the school officials at Umpqua Community College. Student Signature Date 12

13 g Practical Nursing $25.00 Application Fee (Required for the Practical Nursing Application to be processed) DO NOT SEND CASH Please type or print neatly in blue or black ink. Providing your social security number is voluntary. If you provide it, the college will use your social security number for keeping records, doing research, aggregate reporting, extending credit and collecting debts and providing the Internal Revenue Service with the information required under the Taxpayer Relief Act of Your SSN will not be given to the general public. If you choose not to provide your SSN, you will not be denied any rights as a student. Please refer to the disclosure statement in the college catalog and schedule of classes. However, providing your SSN is required to receive Federal Financial Aid. Ethnic data information is required for institutional compliance with the Civil Rights Act of Your cooperation is appreciated. Applicant Demographics: for information only. Last Name First Name Middle Initial Previous Last Name(s) Social Security Number Date of birth (mm/dd/yy) Male Female Current mailing address number and street City State Zip Physical address if different from mailing address City State Zip Daytime phone Evening phone Message/Cell phone address Ethnicity (optional): American Indian/Alaskan Native Asian/Pacific Islander Black/Non-Hispanic Hispanic White/Non-Hispanic High school diploma or college degree earned? Yes No GED earned? Yes No English is my: Primary Language Secondary Language Education Information List all colleges where you have completed nursing prerequisites and/or a degree and attach sealed official transcripts College State Dates of attendance Degree earned/number of credits I have read and understand the admission criteria for the nursing program at Umpqua Community College. I understand that it is my responsibility to meet all program and application criteria. I verify that all statements on this application are complete and true and I understand that falsification of any information may lead to disqualification or dismissal from the program. Signature Date MAIL TO: UCC ADMISSIONS PRACTICAL NURSING APPLICATION P.O. BOX 967 ROSEBURG, OR Date Received: Initial Affirmative Action: It is the policy of Umpqua Community College to provide equal educational and employment opportunities and to provide service benefits to all students and employees without regard to sex, race, color, religion, national or ethnic origin, age, sexual orientation, marital status, disability or any other status or characteristic protected by applicable state or federal law. This policy is in accordance with the laws enforced by the Department of Education and Department of Labor, including Presidential Executive Order 11246, as amended by the Civil Rights Act of 1991, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Acts of , the Americans with Disabilities Act of 1990 and Oregon Revised Statute Questions or complaints may be directed to Lynn Johnson, Affirmative Action: Administration, P.O. Box 967, Roseburg OR 97470, (541) r a c t i c a l N u r s i n g A p p l i c a t i o n P r a c t i c a l N u r s i n Applic P atio n

14 P r a c t i c a l N u r s i n Applic P atio n g STATEMENT OF UNDERSTANDING Please indicate that you have read each paragraph by initialing each line, then sign below and date. I have read and understand the admission criteria for the Practical Nursing Program at Umpqua Community College. I understand it is my responsibility to meet all program and application criteria. I verify that all statements on this application are complete and true and I understand that falsification of any information may lead to disqualification or dismissal from the program. I understand that if I am accepted into the program I will be expected, with or without accommodation, to demonstrate the UCC Practical Nursing Program academic and technical standards outlined in the program information (available from UCC Nursing website or nursing office) to successfully complete the program. I understand that students accepted into the practical nursing program must show proof of a current Oregon State Board of Nursing CNA Card or Nursing Assistant class by application deadline. Certain clinical facilities may require a background history check be completed while the student is enrolled in the practical nursing program. I understand that if I am accepted into the program, for the purposes of public safety and health, if I have or develop any type of psychological, medical, drug or alcohol problem that impairs my ability to provide safe client care, or if I have an arrest or conviction history that would disqualify me from patient care in a clinical facility or licensure by the Oregon State Board of Nursing (OSBN), the practical nursing faculty/selection committee may consult with legal counsel and/or the OSBN and reject or dismiss me from the program. (Upon application for licensure, applicants will be subject to a history background check performed by the Oregon State Board of Nursing (OSBN). Certain crimes may disqualify an applicant from licensure. Any individual who supplies false or incomplete information to the Board regarding the individual's criminal conviction record will be denied licensure. Specific questions regarding these issues should be directed to the OSBN at SW Upper Boones Ferry Road, Portland, OR 97224, (971) , or I understand that the college uses a learning management system called Canvas which is an integral part of all practical nursing courses and have access to a computer with software that includes Microsoft Word and Power Point. Internet access will be required on a daily basis. Student Signature r a c t i c a l N u r s i n g A p p l i c a t i o n Date 14

15 g Umpqua Community College Application for Admission Disclosure Statement: Providing your social security number is voluntary. If you provide it, the college will use your Social Security number for keeping records, doing research, aggregate reporting, extending credit and collecting debts. Your SSN will not be given to the general public. If you choose not to provide your SSN, you will not be denied any rights as a student. Please refer to the disclosure statement in the college catalog and schedule of classes which describes how your number will be used. Providing your social security number means that you consent to use of the number in the manner described. Intended Term & Year of Enrollment: Fall 20 Student Information Social Security Number: - - Date of Birth: (month/day/year) / / Last Name: First Name: M.I. Maiden Name: Current Mailing Address: Number & Street/PO Box City County State Zip/Postal Code Home Phone: ( ) Work / Cell Phone: ( ) Previous Home Address: (If at present address less than 90 days) Number & Street/PO Box City County State Zip/Postal Code General Information Citizenship: USA Other* Country of citizenship: *(Must complete the International Student Application.) Gender: (optional) Male Female Race/Ethnicity: (optional) Caucasian Black Hispanic American Indian Asian Other Are you a U.S. veteran? Yes No Will you receive veteran benefits? Yes No Did your parent(s) (natural or adopted) receive a Bachelor s Degree from a 4-year college/university? Yes No High School Information Check one and provide date of completion/or Expected date of Completion: HS Diploma GED Adult HS Diploma Date Completed: (month/day/year) / / School attended or currently attending : City State Enrollment Information Enrollment Status: (check one): Enrolling at UCC for the first time Returning student (absent for more than one full year) Approx. term of last attendance / / Intended Program: Practical Nursing (AAOT-NUR) College background: Please list ALL colleges and universities attended. Official college transcripts should be requested from each school and sent to Umpqua Community College. College/University Name City & State Dates Attended What is your goal at UCC? What is the highest degree you have attained beyond high school? 1. Two year program 6. Transfer to 2-year school 1. Some college credits 5. Masters Degree 3. Certificate 7. Transfer to 4-year school 0. None 4. Bachelors Degree 4. Job Preparation 8. Personal Interest 2. Certificate 6. PhD/Professional 5. Skill Improvement 9. Adult High School diploma 3. Associates Degree Affirmative Action It is the policy of Umpqua Community College to provide equal educational and employment opportunities and to provide service benefits to all students and employees without regard to sex, race, color, religion, national or ethnic origin, age, sexual orientation, marital status, disability or any other status or characteristic protected by applicable state or federal law. This policy is in accordance with the laws enforced by the Department of Education and Department of Labor, including Presidential Executive Order 11246, as amended by the Civil Rights Act of 1991, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Acts of , the Americans with Disabilities Act of 1990 and Oregon Revised Statute Questions or complaints may be directed to: Affirmative Action: Administration, P.O. Box 967, Roseburg OR 97470, (541) By signing this form, certify that the information on this form is correct and I understand that if it is later found otherwise, it is sufficient cause for rejection or dismissal. I authorize the use of my social security number as my student identification number and in follow-up studies. Signature Date 15 r a c t i c a l N u r s i n g A p p l i c a t i o n P r a c t i c a l N u r s i n Applic P atio n