Baton Rouge Community College Nurse Assisting (HCNA 1215) Program APPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED Application Deadline to enroll Spring 2018 is: Thursday, December 14, 2018 by 3:00 pm Contact Mary Stewart, Program Manager Before Completing This Packet RETURN COMPLETED APPLICATION IN PERSON TO BRCC ACADIAN CAMPUS Room 209, 3250 N. Acadian Thruway E., Baton Rouge, LA, 70805 Contact: Mary Stewart, Program Manager 225.359.9427 stewartm2@mybrcc.edu Deborah Henderson 225.359.9233 smith-hendersond@mybrcc.edu Applications returned through the mail will not be accepted For additional information please contact: BRCC Acadian Campus 225.359.9427 or 225.359.9233 It is the policy of Baton Rouge Community College not to discriminate on the basis of age, sex, race, color, religion, national origin or disability in its educational programs, activities or employment policies.
PROGRAM INFORMATION Certified Nursing Assistant (CNA, Technical Competency Area) The Certified Nursing Assistant Program prepares students for employment in long-term care facilities, home health agencies, and hospitals where basic bedside care is needed. Classroom instruction includes an introduction to health care, essential OBRA skills required for certification, body structure and function, and the job-seeking process, with an introduction to computer skills as it relates to the health care industry. Students participate in clinical activities at approved facilities under the supervision of the instructor. Upon successful completion of this nurse aid training and competency evaluation program (NATCEP) the student will become a certified nursing assistant with the state of Louisiana. COURSE: The HCNA 1215 Nurse Assisting is a 4 credit hour course that includes 80 hours of classroom and laboratory training and 45 hours of external clinical. APPLICATION PROCESS STEP 1 BATON ROUGE COMMUNITY COLLEGE ADMISSION In order to enroll into the BRCC Nursing Assistant (HCNA 1215) program the student must complete the BRCC admission requirements. STEP 2 MUST OBTAIN REQUIRED TEST SCORE BEFORE PRECEDING TO STEP 3 One of the following admission scores are required for acceptance into the program Type of Assessment ACCUPLACER ACT COMPASS* College Level English STEP 3 STEP 4 STEP 5 Reading 53 14 62 Pass *COMPASS scores cannot be more than three years older than the date of admission SUBMIT, IN PERSON, ALL COMPONENTS OF THE REQUIRED ADMISSION APPLICATION. All components of the required application must be submitted in person. Applications submitted via the mail or electronically will not be accepted. ENROLLMENT 1. Approval will be granted to the student to enroll in HCNA 1215 when the application is complete. 2. The student must enroll themselves into HCNA 1215 after approval has been granted. HCNA 1215 COMPLETION 1. Students must satisfactorily complete all components of HCNA 1215 (lecture, lab, clinical and the final exam) with a minimal passing grade of (C) to be considered for Nurse Assistant Certification. 2. Students receiving a "C" or better names will be submitted to the Certified Nurse Aide Registry at the Louisiana Department of Health and Hospitals. 3. Students planning to pursue Practical Nursing (LPN) at BRCC must attain a "B" or higher in HCNA 1215. 4. Completion of HCNA 1215 does not guarantee admittance to a BRCC Practical Nursing program. CRIMINAL BACKGROUND CHECK Applicants to the Nurse Assistant course must submit to a criminal background check, through the Louisiana State Police Department, with all costs borne by the student. Complete the RIGHT TO REVIEW form and take it to the Louisiana State Police Department for processing. Applicants who have been charged with, pled guilty or nolo contendere to, been convicted of, or committed a criminal offense that involves a crime of violence or distribution of drugs, abuse, neglecting or mistreating the elderly or infirm, or misappropriating property may be denied the right to enroll in the course. NATIONAL SEX OFFENDER PUBLIC REGISTRY CHECK The name of each applicant to the Nurse Assistant course will be submitted to the National Sex Offender Public Registry for verification. Page 2 of 7
RETURN COMPLETED APPLICATION IN PERSON TO: BRCC Acadian Campus, Baton Rouge, LA Room 209 NURSE ASSISTING (HCNA 1215) APPLICATION You must print & complete this application page INDICATE STATUS APPLICATION REQUIREMENTS Do Not Mail DEADLINE 12/14/2017 by 3 pm INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED AND THE APPLICATION PERIOD WILL NOT BE EXTENDED Complete 1. Registered as a BRCC student. Include your L# or B# Complete Score/ Date: 2. Reading Accuplacer score "53" /ACT of 14"/COMPASS of 62 or College English _ Complete Exp. Date: 3. American Heart Association (AHA) Basic Life Support (BLS) provider Complete 4. Background check from Louisiana State Police Complete 5. Physical Exam - Personal Attestation form _ OFFICE USE ONLY DATE PACKET APPROVED: DATE NOTIFIED: COURSE SECTION: CNA REGISTRY CHECK: DSW REGISTRY CHECK: SEX OFFENDER REGISTRY: Complete 6. Physical Exam - Physician form Complete 7. Immunization record (flu immunization required in season) If no immunization record Titer for Rubella, Mumps, Hepatitis B) Complete 8. Urine drug screen with complete printed results Yes No 9. Are you currently on the Nurse Aide or Direct Service Worker Registry? Yes No N/A 10. Have you ever had a healthcare credential/ certification revoked? Yes No 11. Have you been the subject of disciplinary action by any state agency? PERSONAL INFORMATION Last Name First Name Middle Name Mailing Address City / State Zip Code Home Phone Number E-Mail Address Cell Phone Number Student ID Number Are you a licensed/certified healthcare provider? Yes No Are you applying to the LPN track? Yes No Did you complete high school? Yes diploma GED No Do you have additional post-secondary degrees? Yes No OTHER REQUIRED INFORMATION License Number Exp. Date HCNA 1215 is a pre-requisite course for BRCC Practical Nursing program Please list additional degrees earned I would like to apply for the HCNA 1215, Nurse Assisting course. I understand that any attempt on my part to falsify or exclude information is cause for disqualification of my application and / or dismissal from the program. I hereby certify that all information presented is true to the best of my knowledge. I understand completion of HCNA 1215 does not guarantee admission to a BRCC Practical Nursing program. Student Signature Date. Received by Date Time. Page 3 of 7
BATON ROUGE COMMUNITY COLLEGE NURSING DEPARTMENT Health History and Physical Examination HEALTH HISTORY to be completed by applicant Last Name First Name Middle Name Banner # Date of Birth (Month / Day / Year) Gender M Male F Female Racial / Ethnic Group A Asian A.I. American Indian B Black H Hispanic/Latino P.I. Pacific Islander W White O Other Mailing Address City / State Zip Code Home Phone Number Emergency Contact (Name / Relationship) Cell Phone Number E-Mail Address Emergency Contact Number Have you ever been treated, or are you receiving treatment for any of the following conditions -mark all that apply and comment below. Y E S* NO Condition YES* NO Condition YES* NO Condition Alcohol/Substance Abuse Diabetes Orthopedic Disorder Allergies: Food Eating Disorder Seizure Disorder Allergies: Medication Emotional Disorder Social Disorder Asthma Heart Disorder Trauma Back Injury / Disorder Hearing Disorder Tuberculosis Blood Disorder Intestinal Disease Vision Disorder Explanations / Other: Cancer Kidney Disease Pregnancy *Provide dates and an explanation for yes responses in the space provided below. * Please use additional paper if needed to fully explain your yes answers. List Surgical History: List Routine Medications: Do you have any disorder or disability that limits cognitive awareness? All pre-existing medical conditions require a medical release from your health care provider. Attached? Yes N/A My signature indicates I have no injury or illness and amble to meet technical performance standards. I will notify the program head of health changes. I understand that falsification, omission, or misrepresentation of my health and abilities may result in dismissal from BRCC nursing and allied health programs. APPLICANT SIGNATURE DATE
BATON ROUGE COMMUNITY COLLEGE NURSING DEPARTMENT Health History and Physical Examination PHYSICAL EXAMINATION to be completed by physician/licensed prescriber Last Name: First Name: Middle Initial: System NORMAL ABNORMAL COMMENTS General Health Cardiovascular Endocrine Extremities HEENT Gastrointestinal Neurologic Respiratory Reproductive Pregnant students: Can the student meet technical performance standards including the ability to lift 20 lbs? Yes No Skeletal Skin Urinary B/P Pulse Resp Temp Weight Height CBC IMMUNIZATION DOCUMENTATION Please attach copies of immunization records and/or lab results* REQUIRED IMMUNIZATION / LABS DATE RESULTS / COMMENTS MMR and Rubella Immunization or Titer* Hepatitis B Vaccine Series* Dates of vaccination #1 #2 #3 Or Date and result of Hepatitis B Vaccine Titer* TB Skin Test*(administered by ) Neg Pos Date read Read by If (+) TB skin test treatment received? If (+) TB attach copy of most recent Chest x-ray VDRL / RPR* Page 5 of 7
HIV*Screening dated within last 5 years. Flu Vaccine (as per seasonal requirements) Urine Drug Screen* 9 Panel (Printed Results) Does the student have any physical, medical, or mental conditions that would impede their ability to provide safe and compl care of patients in a health care environment? No Yes (please comment below) Examining Health Care Physician/Provider: Date: TECHNICAL PERFOMANCE STANDARDS Students enrolled in the nursing assistant (CNA) program must demonstrate the ability to meet the following technical/performance standards while receiving classroom and clinical instruction as outlined in the course syllabus. 1. Read and communicate orally and in writing using the English language. 2. Hear with or without auditory aids to understand normal speaking voice without viewing the speaker's face. 3. Visually, with or without corrective lenses, observe changes in resident/patient/client's condition and actively participate in the learning process. 4. Utilize stamina, strength and psychomotor coordination necessary to perform routine nurse assistant/aide procedures at floor and bed level. 5. Demonstrate use of gross and fine motor skills necessary to provide independent, safe and effective nurse assistant/aide care. 6. Solve basic care problems and apply critical thinking skills while providing safe and efficient patient care. 7. Interact with individuals/families/groups from various socioeconomic and cultural backgrounds. 8. Function in a multi-stressor environment while adhering to legal/ethical guidelines of the college, program, regulatory, and clinical agencies. Comments: I attest this student can meet the technical/performance standards: Examining Health Care Physician/Provider: _ Date: Page 6 of 7
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