ADN Program Application Application for: Spring Admission Due by 3:00 pm on September 10 th Fall Admission Due by 3:00 pm on May 10 th DIRECTIONS: Please type or print. Submit electronically to nursing@dixie.edu. Incomplete applications will not be processed. 1. Personal Information Legal First Name MI Last Name DixieID (Student Number) Birthdate Name I Prefer to Be Called Address City State Zip Cell Phone Other Phone Personal Email 2. Emergency Contact Name Relationship Address City State Zip Primary Phone Rachel K Student D00110103 07-01-1988 Rachel 144 N Student Blvd #202 St George UT 84791 435-680-0000 nursingrocks@yahoo.com Kristi Student Secondary Phone Mother 984 E 700 S St George UT 84790 435-628-3939 435-229-3939 3. Program Application Requirements & Legal Signature By electronically submitting this application packet and signing below, I agree to the following: I have read and understand the ADN Program Application Packet. I will abide by all program requirements and due dates listed. By the due dates given: I will have met the Minimum Eligibility guidelines (page 2) I will have a CNA Certificate or LPN License (page 3) Rachel K Student I will have completed all mandatory vaccinations and/or titers (page 3) Applicant s Signature (Typed / E-signatures Accepted as Legally Binding) Revised 201630 ADN Application Page 4
4. Prerequisite Course Completion Required Courses List ALL attempts for ALL prerequisites. Use additional line if necessary. Do NOT use midterm grades. DSU Course Number Human Anatomy BIOL 2320 HIGHEST GRADE - (USED IN SCORING) PRIOR ATTEMPT - (NOT USED IN SCORING) NOTES (Retake in Progress, etc.) Semester Grade College or University Repeated Semester Grade College or University Fall 2015 A- DSU Spring 2015 C+ DSU Human Anatomy Lab BIOL 2325 Human Physiology BIOL 2420 Fall 2015 B+ DSU Spring 2015 A DSU Spring 2015 C- DSU Human Physiology Lab BIOL 2425 Spring 2015 A- DSU Elem Gen / Organic Chemistry CHEM 1110 Fall 2014 A- WSU Elem Gen / Org Chem Lab CHEM 1115 Fall 2014 A- WSU Intro to Writing ENGL 1010 Intermediate Writing ENGL 2010 Spring 2014 A WSU Fall 2014 A- DSU College Algebra, or Intro to Statistics, or Quantitative Reasoning MATH 1030 MATH 1040 MATH 1050 PSYC 1010* Spring 2016 A- DSU Human Development/ Lifespan PSYC 1100 FCS 1500 **Higher level Math or Chemistry may be used *PSYC 1010 for Spring 2017 applicants only Fall 2015 A- DSU Revised 201630 ADN Application Page 5
Acknowledgement of Program Requirements for Personal Effort and Commitment The nature of the Dixie State University Nursing Programs, as with most nursing programs, requires a substantial time commitment to fulfill the intensive requirements of the program in the classroom, nursing arts laboratory, and clinical settings. Student success in the nursing program is dependent upon the creation and maintenance of a collaborative, working partnership between students and faculty. The nursing program faculty recognizes its responsibility as facilitators of your learning and is committed to helping you succeed in the program. However, it is important that you are aware of the responsibilities you will hold for your own learning while in the nursing program. As part of your application to the program, please read the following and sign below. Your signature is an acknowledgement of your understanding of the expectations of the program. 1. There is a minimal study expectation of two hours of study per week for each credit enrolled. For example, a 5 credit nursing course requires a minimal expectation of 10 hours of study per week. Most students spend more time than the minimal study expectation. 2. Although we hold an appreciation for your possible need to work to support yourself and/or a family, most students find it difficult to work full time and still achieve the grades they may have earned in non-nursing courses. Reducing your work schedule to part-time, if possible, will be helpful for success in the nursing program. 3. In general and given the same amount of student effort, nursing students may not achieve the high grades they earned in non-nursing courses. You will be learning a new language in the first semester of your program. Additionally, you will be exposed to in-depth, comprehensive nursing concepts and principles that may require more effort on your part to learn and understand. 4. You are expected to be prepared for class, lab, and clinical. This may include extensive reading and completion of concept maps or other assignments prior to your attendance. 5. Most exams given in nursing courses are structured similarly to the nurse licensing exam. This means that most of the items on the exams are application type questions rather than simple knowledge and recall. These questions require a higher-order of thinking to answer correctly. We provide you with strategies for learning and test-taking that help you take the nursing course exams. 6. You will find the nursing program different and more difficult than your past educational experiences. The nursing program is designed this way to facilitate the quality of the program, prepare you to pass your licensing exam, and ensure you become a safe and competent nurse. I certify that all of the statements in this application and all of the documents submitted with this application are true and accurate to the best of my knowledge. I acknowledge that I have read and understand the above statements and, if I am accepted into a Dixie State University s Nursing Program, I agree to manage my time and personal affairs in order to meet the commitment necessary to succeed. Rachel K Student Print name of Applicant D00110103 DixieID May 1, 2019 Signature of Applicant Date Revised 201630 ADN Application Page 6
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04/04/2019 CASHNet Receipt Number: 191 160 Web payment location Current Date: 04/04/2019 Email Address: @dmail.dixie.edu Full Name (First Last): Rachel K Student DixieID Number: Ph Num (XXX-XXX-XXXX): 4356800000 Description 1 ADN Nursing Application Student's First Name: Rachel Street Address: City: St George State: UT Zip Code: 84791 Email Address: @dmail.dixie.edu Service Charge Total Amount $50.00 $0.96 $50.96 Payments Received Credit Card Web Trans NCC Visa XXXXXXXXXXXX1234 Authorization # 143233 Credit Card Web Trans NCC Visa XXXXXXXXXXXX1234 Authorization # 4 70724 Total Amount $50.00 $0.96 $50.96 Thank you for the payment. Please print your receipt and show it for receipt of your item. https://commerce.cashnet.com/cashnetg/selfserve/printablereceipt.aspx?ixds=o&z=pp 1/1
WEBER STATE UNIVERSITY 3885 West Campus Drive Department 1102 Ogden, Utah 84408-1102 TRANSCRIPT OF ACADEMIC RECORDS All credits recorded in semester hours. STUDENT ID#: W0123456789 SSN: DOB: CURRENTPGM:NRSG: Health Sciences DATEISSUED: 04-MAY-2018 PAGE: 1 Rachel K Student Rachel K Student Course Level: Under raduate SUBJ NO. COURSE TITLE CRED GRD PTS R SUBJ NO. COURSE TITLE CRED GRD PTS R TRANSFER CREDIT ACCEPTED BY THE INST1TUTI0N: NONE Institution Information continued: HLTH 1030 SS Healthy Lifestyles HTHS 1110 LS Int Human Anat/Physiology 3.00 A 4,00 A 12.00 16. 00 INSTITUTION CR.EDIT; Ehrs, 17.50 GPA-Hrs: 17.00 QPts: 63. 80 GPA: 3. 75 Spring 2016 CHEM 1050 PS Intro Gen, Organic, & Bio 5. 00 B+ 16.5-0 Fall 2014 COMM 2110 NTM 1700 UNIV 1105 Ehn;: Spring 2015 CHF 1500 HIST 1700 MICR 1113 THE/', 10;23 Ehl::s: HU CeL Intrprsnl/Sm Group Comm 3. oo A TE Intro to Computer Applicatn 3. 00 A Foundations of College Success 3. 00 A 9.00 GPA Hra: 9.00 QPts: 36.00 GPA: ss Human Development Al American Civilization LS Intro to Microbiology CA Int:rodUctJon to F:i.lm 12. oo GPA-11rs: 12. 00 QPts: 3. 00 A 3.00 A '.l. 00 A- J.00 A- 46.20 GPA: 12. 00 12. 00 12. 00 4. 00 12. 00 12. 00 11.10 11.10 3.85 HTHS 1111 Integ i;uman P,nat/Phyi;iology II 4.00 A PSY 1010 ss Introductory Psychology Ehrs: 18. 00 GPA Hrs: 18. 00 QPts: 3. 00 A 68.50 GPA: * * * 1'RANSCRI PT TO'.fALS Earned Hrs GPA Hrs Points GPA TOTAL INSTITUTION 62. 50 59. 00 224.40 3.80... ENP OF TRANSCRil?T 16. 00 12. 00 3. 81 Fall 2015 ENGL 1010 CA Introduction to visual Arts EN Introduce colle9e Writing J.QO B+ 3.00 A 9. $10 12.00
UTAH NURSING ASSISTANT REGISTRY 550 East 300 South ville, Utah 84037 Phone (801) 547-9947 -FAx (801) 5,93-2584 website: utahcna.com February 01, 2019 Rachel K Student ---C--or\grafUFcitionsT You have-rnet therequifem ts c for UfaffNursfng Assisfann ertffication. Certificate information is printed below. It is your responsibility to renew certification every two years. Note the expiration date listed. The Registry will mail a renewal notice to you, as a courtesy, to the last known address in the database approximately 45 days prior to expiration date. To remain certified during the renewal period, you must be actively employed in' a health care setting providing nursing-related services, a minimum of 200 hours,, within the two-year period immediately preceding the".cert'.ificate :exp1ration date shown. If you do not meet renewal requirements, you must complete another nursing assistant training program and /or competency testing. To help maintain accurate information, please notify the registry of any change in mailing address. Failure to do so may result in expired certification and repeating the training and/or testing would be necessary to reactivate. VerirJ certificatior.,-vww_utah-::na.com..... ' '. -..,: '-- l I" -,: t;.:_': -.: 1 _: '. ' : :,.:. :- # UTAH CERTIFIED NURSING ASSISTANT Awarded to _Rachel K Student ", Certificatet f tjt00050001234 Issued Jan26,20119 Expires Jan-31,2028
Employee Record of Immunizations Name: Organization: Request Date: Student, Rachel K Person Type: Job Title: Birth Date: Active Employee Latest 5 Flu Shots You currently have no flu shot information saved in the Employee Health system. Immunizations Immunization Exempt Test Date Status Shots Hepatitis B 06/22/16 Reactive 02/27/98-04/30/98-08/28/98-05/11/16 MMR Complete 03/02/99-07/18/03 Tdap Complete 07/20/10 Varicella Complete 03/02/99-07/20/10 TB Testing You currently have no TB test information saved in the Employee Health system. If this information appears incorrect, please contact your Employee Health Nurse.
Date: 04/13/2019-10:42 AM CERTIFICATE OF IMMUNIZATION Page: Southwest Utah Public Health Department 620 S 400 E # 400 St. George, UT 84770-7063 Patient: Address: City/St: Student, Rachel K www.swu health.org Client#: Birth Date: Age: Gender: Female CMMR) Measles Mumos And Rubella Shot Sea Desc *DMMR 1 MMR *DMMR 2 MMR Svc Date 11/02/2015 11/30/2015 Lot# L007216 L004656 Stat Provider Southwest Utah Public Health Department Southwest Utah Public Health Department CHPB) Heoatitis B Shot Sea Desc XHBA 1 Hep B Adult *DHBA 2 Hep B Adult *DHBA 3 Hep B Adult Svc Date 10/01/2014 11/02/2014 04/13/2015 Lot# C3TY3 Y9424 Stat H Provider Southwest Utah Public Health Department Southwest Utah Public Health Department I GENERAL COMMENTS:
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STUDENT, RACHEL K 07-01-1988 A-M1234567 Step 1 of 2 FEMALE HLS 090909F STUDENT, RACHEL K 07-01-1988 A-M1234567 Step 2 of 2 FEMALE HLS 090909F
ILabCorp Ubaratory C01J1oration ot America Specimen ID: 196-612-2201-0 Control ID: 800444674 Rachel K Student I IPatient Specimen Details DOB: Age(y/m/d): General Comments & Additional Information Alternate Control Number: B0044467 490 Total Volume: Not Provided Details Date collected: 07/14/2016 1636 Local Date entered: 07/14/2016 Date reported: 07/16/2016 0808 Local Phone: (440) 717--0440 Patient Report Request A Test, LTD. 7027 Mill Road Suite 201 BRECKSVILLE OH 44141 1l 1 1 1 hl l,li11l1 1 l 1 l1h1l 11 llh11 1 l1hlhlll 1 l 1 l11 1 l IIMl 1 l 11 II I Physician Details Ordering: Referring: ID: NPI: Alternate Patient ID: Not Provided Fasting: No Rte: MA Ordered Items Varicella-Zoster V Ab, lgg; Venipuncture TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB Varicella-Zoster V Ab, IgG Varicella Zoster IgG 2338 index Immune >165 01 Positive >165 A positive result generally indicates exposure to the pathogen or administration of specific immunoglobulins, but it is not indication of active infection or stage of disease. 01 BN LabCorp Burlington 1447 York Court Burlin ton NC 27215-3361 For inquiries, the physician may contact Branch: 800-762-4344 Lab: 800-795-3699 Dir: William F Hancock, MD Date Issued: 07/16/2019 FINAL REPORT This document contains private and confidential health Information protected by state and federal law. If you have received this document in error, please call 800-542-7708 Page 1 of 1 1995-2016 Laboratory Corporation of America Holdings All Rights Reserved- Enterprise Report Version: 1.00
INTERMOUNTAIN LABORATORIES - DIXIE REGIONAL MEDICAL CENTERS 1380 East Medical Center Drive, St. George, UT 84790 Phone: (435) 688-5022 Client/Event Report 05/01/2019 07,00 Student, Rachel K Home Phone#: F Hosp #, 570 Bill #, Hos MR #, IDX MR #, Workmed Provider 1: B Provider 1 Phone#: 4 Test Performed Results Reference Range Units PerfLab ------------------------------------------------------------------------------------------------------- F6389504 Coll, 04/29/2019 12,54 Recv, 04/29/2019 15,43 Ord by: B HEPATITIS B SURFACE AB Hepatitis B Surface Ab Reactive NR HBSAB, quantitative H 30.79 <8.00 Comments: See Note: (NOTE) INTERPRETIVE TEXT FOR: HEPATITIS B Su:.:tFACE ANTIBODY NONREACTIVE result (<8.00 miu/ml) mea s patient is Not Immune REACTIVE result (>=12.00 miu/ml) means patient is Immune GRAY ZONE results (8.00-11.99 miu/ml) means that the immune status of this patient should be further assessed by considering other factors, such as clinical status, follow up testing, associated risk factors, and the use of additional diagnostic information. miu/ml {IM} {IM} {IM} This assay should not be used for screening of donors for blood/blood products, solid organs, tissues, bone marrow and/or stem cells. {IM} Perform.ed at Intermountain Central Laboratory, Murray, Utah END OF REPORT Page, l
If you have questions about your immunization or titer documentation, you may contact the DSU Nursing Department Secretary via email at nursing@dixie.edu.