American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Nursing Assistant I Admissin Requirements 1. Only prvide ne riginal transcript f: 1. High Schl Transcript 2. GED Transcript; r 3. Cllege Transcript 2. Driver s License r State ID 3. Scial Security Card (nn-laminated) 4. Physical Examinatin ($40.00, can be dne n premises) 5. Criminal Backgrund Check ($20.00, dne n premises) 6. CPR Certificatin ($40.00, dne n premises during class) 7. TB Test ($20.00), (dne n premises prir t clinical rtatin) 8. Verificatin f the Immunizatin: (must have immunizatin verificatin frm cmpleted and attached t applicatin) Tetanus r Diptheria (within 10 years) Varicella (Chicken Px) (psitive histry r titer dcumented) Rubella r psitive titer (German Measles) Rubela (Measles) 1 dse and (2 dses after 1 st birthday fr any persn brn after 1957) r psitive titer Mumps (1 st dse fr any persn brn n r after January 1, 1957) r psitive titer PPD Skin Test (TB) (have ne dne each year) Chest X-Ray and INH if PPD is psitive Chest X-Ray if knwn t be PPD psitive in the past 1 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Enrllment Agreement Name: Address: City: State: Zip: DOB: Scial Security #: Hme Phne #: Cell: Alternate Cntact #: Emergency #: _ E-mail Address: Prgram Infrmatin: Nursing Assistant I Nursing Assistant II Medicatin Aide Phlebtmy Wund Care Prgram Start : Maintaining a Hme Care Agency Telemetry Technician Medical Assisting Dialysis Technician End : A class schedule fr which yu enrlled (meets n day f week): A Certificate f Cmpletin will be awarded at the end f the prgram and successful students will be recmmended fr listing as a CNA I by the NC Nurse Aide Registry. Educatin: SCHOOL NAME AND ADDRESS START MO/YR END DATE MO/YR DID YOU GRADUATE? DEGREE Cllege/University: SCHOOL START MO/YR END DATE MO/YR DID YOU GRADUATE? DEGREE Other Educatin: 2 f 14
Other Certificatins: Emplyment Histry: (mst recent emplyment first) Emplyer Name and Address START MO/YR END DATE MO/YR POSITION Fees and Charges: Yu are respnsible fr paying the fllwing Fees and Charges: Registratin Fee Tuitin Text Bk Criminal Check Unifrm TB Test Drug Screen CPR Ttal $ 25.00 $ 500.00 $ Incl. (laned) $ 20.00 (mandatry prir t clinical rtatin $ 20.00 (mandatry purchase) $ 20.00 (must have within the last year $ 40.00 (mandatry prir t clinicals) $ 40.00 (mandatry within 2 years, r if expired $ 665.00 (requirements will be deducted) Ttal charges fr Registratin and the Nursing Assistant I Curse is due and payable n r befre the first day f class, if yu chse t make a payment plan, yu are still respnsible t cmplete the payment even if yu did nt cmplete the prgram. Terms and Understanding: As a Student f American Academy f Healthcare, I understand that: 1. The schl des nt guarantee emplyment fllwing graduatin. 2. The schl deserves the right t terminate a student s training fr failure t abide by the Attendance Plicy, failure t maintain satisfactry academic prgress, failure t abide by the schl rules and regulatins and fr ther reasns as detailed by the schl catalg. 3. All fees such as tuitin, unifrms, stethscpes, bks, CPR and ther miscellaneus items are t be paid prir t clinical rtatin in a facility, r the schl Initials deserves the right t terminate a student s training fr failure t abide by the Payment Plicy. Initials 3 f 14
4. The textbk is prvided by the schl and I am paying fr it under the heading textbk, all ther materials that I will use in the lab and in the prcess f learning des nt belng t me and shuld nt be remved frm the classrm. 5. The schl des nt guarantee the transfer f credit t any ther institutin. 6. Any ntificatin f withdrawal r cancellatin must be in writing. 7. This agreement is legally binding instrument when signing by yu and accepted by the schl. Yur signature n this agreement acknwledges that yu have been given reasnable time t read and understand it and that yu have been given the schl catalg including a descriptin f this prgram, including all material facts cncerning the schl and the prgram f instructin which are likely t affect yur decisin t enrll. Students Right t Cancel: Yu may cancel this enrllment agreement fr the schl at any time up t the first day f class. If yu cancel this agreement, any payment yu have made will be refunded t yu within 60 days. T cancel the enrllment agreement fr the schl yu must mail r deliver a signed and dated cpy f the cancellatin ntice r any written ntice t the schl at its fficial address. Fr all ther refunds, please see the refund plicy. Acknwledgement: D nt sign this cntract befre yu read it r if it cntains blank spaces. Yu are entitled t an exact cpy f the cntract that yu sign. Keep it t prtect yur legal rights. My signature certifies that I have read, understd and agreed t my rights and respnsibilities, that the institutin s cancellatin and refund plicies have been clearly explained t me and that I have a cpy f this agreement. I hereby accept this agreement with the schl. Student Signature Return the fllwing items: *Cmpleted Applicatin *Backgrund Cnsent Frm *Student Interview Frm *Immunizatin Recrd *Physical Examinatin *Driver s License (Clr Cpy) *$26.06 Nn-refundable Registratin Fee *Scial Security Card (Clr Cpy) MAIL TO: American Academy f Healthcare, LLC 4822 Albemarle Rad Charltte, NC 28205 Accepted Frms f Payment Cash Mney Order (NO CHECKS) 4 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 STUDENT ACKNOWLEDGEMENT Name: : I hereby acknwledge that I have received the American Academy f Healthcare Orientatin Plicy Manual and I have reviewed the plicies in this bklet with the Instructr assigned. Attendance and Unifrm Plicy Privacy Acknwledgement and Nn-Disclsure Cmpetency Evaluatin Skills Testing Prcedures Initials I have been given the pprtunity t ask any questins needed t clarify the infrmatin cntained within. I als understand that I may request additinal infrmatin r explanatin at any time while I am a student with American Academy f Healthcare. Initials I als understand that all students fees have t be paid in full prir t clinical rtatin. If my clinical file is incmplete prir t clinical rtatin, I will nt be attending the rtatin at the assigned facility and will nt be able cntinue in the prgram. Immunizatin Recrd TB Results Hepatitis B and Flu Declinatin Frm Physical Examinatin Request, Authrizatin, Cnsent and Release fr Backgrund Check Criminal Backgrund Check Initials I als understand that if any part f my student file is incmplete at the time f cmpletin f the curse, I will nt receive Transcripts and/r a Certificate f Cmpletin. Educatin Criteria Driver s License Scial Security Card CPR Certificatin Quizzes/Final Exam/Mck Skills Exam Initials Student Signature 5 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Attendance Plicy All students are expected t attend required class, labratry and related experiences, shw evidence f preparatin fr learning and activity and be punctual. Students must cmplete 119.0 hurs (ne hundred and nineteen hurs) which includes 87.0 hurs (eighty seven hurs f classrm) instructin/skill practicum and 32.0 hurs (thirty tw hurs f clinical) experience in the apprved lng-term care facility as apprved by the prgram. Absences shuld ccur nly in situatins f persnal illness, immediate family illness, military leave r death. It is the respnsibility f the student t arrange fr a make up which is at the discretin f the Prgram Directr. Excessive absences mre than sixteen hurs will result in failure t meet prgram requirement and the student may be asked t withdraw r jin the next class. A Physician s verificatin fr illness may be required at the prgram directr s discretin. Unifrm Plicy American Academy f Healthcare, LLC believes that prper dressing is essential fr the student t present themselves in a prfessinal manner t prmte a psitive envirnment. Therefre, students are expected t dress in an apprpriate and acceptable manner fr class, fr clinical and any activity related t training. Students are required t wear ID badges at all times while at the academy fr clinical rtatin. CLINICAL: Students will wear ryal-clred scrub unifrms with natural r white hse fr wmen and white scks fr men. White r ryal-clred crew neck tee shirt r white r ryal-clred mck turtle necks may be wrn under the scrub tps fr warmth. White lab cats r jackets may als be wrn. White r black shes/tennis shes and name badge. N visible bdy piercing is allwed ther than earrings. Limited jewelry, earrings are t be nly small tack r small hp. Artificial nails r nails that are lng may nt be wrn by any student wh prvides direct resident care. Signature 6 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 PRIVACY ACKNOWLEDGEMENT AND NON-DISCLOSURE AGREEMENT The facility is cmmitted t prtecting the privacy f all Residents and prtecting the cnfidentiality f their health care infrmatin. The fllwing specific principles are applicable t all f the facility emplyees, independent health care prfessinals invlved in the care f Residents at the facility, vlunteers, students, faculty, vendrs and cntractrs regardless f their jb classificatin r psitin. While wrking with Residents at/r the facility, I realize that I may have access t/r becme aware f cnfidential Resident medical infrmatin, whether r nt I am directly invlved in prviding care t that Resident. I understand that I must keep this infrmatin n the strictest f cnfidence. As a cnditin f my emplyment r wrk at the facility, I agree that I: be disclsed t thse authrized t receive it. I cmmit t: Respect the wnership f prprietary sftware, by nt making any unauthrized cpies f sftware even when the sftware is nt physically prtected Respect the finite capability f the systems and limit my wn use s as nt t interfere unreasnably with the activity f ther users. Respect the prcedures established t manage the use f the system. Prevent unauthrized use f any infrmatin in files maintained, stred r prcessed by the facility. Will nt verbally r in any written frm disclse cnfidential Resident infrmatin t any unauthrized persn. Will nt permit any unauthrized persn t examine r make cpies f any Resident s recrds, reprts, ther dcuments, r data files prepared, cntrlled, r accessible by me at any time during r after my emplyment r wrk at the facility. Will nt examine, use, r disclse cnfidential Resident medical infrmatin except as needed t perfrm the duties f my jb. Nt perate any nn-licensed sftware n any cmputer prvided by the facility. Nt utilize anyne else s authenticatin cde r device in rder t access any f the facility system. Respect cnfidentiality f any reprts printed frm any infrmatin system cntaining Resident/member infrmatin and handle, stre and dispse f these reprts apprpriately. Nt release my authenticatin cde. Understand that all access t the system will be mnitred. Will nt knwingly include r cause t be included in any recrd r reprt, a false, inaccurate, r misleading entry. Understand that my cmputer system privileges hereunder are subject t peridic review, revisin and if apprpriate renewal. Will nt remve r cpy any recrd r reprt frm the ffice where it is kept except in the perfrmance f my duties. Will reprt any vilatin f this plicy. If I have access t cmputerized infrmatin r prgrams at the Nursing Hme, I understand that the infrmatin accessed thrugh all facility infrmatin systems cntains sensitive and cnfidential Resident care, business, financial and Nursing Hme emplyee infrmatin that shuld nly I understand that a vilatin f this agreement may result in crrective actin up t and including discharge r terminatin f my student enrllment at American Academy f Healthcare, LLC and that my bligatins under this agreement will cntinue after terminatin f my student enrllment. By signing this, I agree that have read, understand and will cmply with the facility s plicies cncerning cnfidentiality f infrmatin and use f cmputerized infrmatin systems and the statements made in this Agreement. Student Signature 7 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Student Interview Frm : Student: 1. What d yu think it takes t be a gd Nurse Aide? 2. What are (3) three wrds yur friends wuld use t describe yu? 3. Give me an example f a time when yu had t learn smething new i.e. task r prcedure. Hw did yu learn the new task r prcedure? 4. Describe yur best learning experience. What made the experience a gd ne? 5. Where d yu see yurself in 3-5 years? Results f Interview: Eligible fr Enrllment Nt eligible fr Enrllment Other Representative Signature 8 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 EMERGENCY NOTIFICATION INFORMATION Name: Address: _ Apt N: City: State: Zip: Phne Number: [ ] - HOSPITAL PREFERENCE: ALLERGIES: NEW ADDRESS INFORMATION Address: Apt N: City: State: Zip: Phne Number: [ ] - Mbile Number: [ ] - Pager Number: [ ] - Fax Number: [ ] - Other Cntact Number: [ ] - E-Mail Address: Cntact Name: Phne Number: [ ] - 9 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Immunizatin Recrd Name: DOB: Scial Security #: Prf f Immunizatin is required fr admissin int any Health Educatin Prgram that includes a Clinical Experience. Hepatitis B (series must have been cmpleted) (s) f Immunizatin: 1. 2. 3. Measles, Mumps, Rubella (individuals brn befre 1957 are nt required t have prf f MMR Immunizatin) (s) f Immunizatin: 1. 2. Tetanus (within the last 10 (ten) years f last Bster: Tuberculin Skin Test (PPD) within the last year: given: read: Results: Alternative: Chest X-Ray within the last 5 years given: read: Results: Varicella (Chicken Px) (s) f Varicella Immunizatin: 1. 2. 3. Alternative: Histry f disease r Psitive Titer Results Histry f Disease: : f Titer: Results: Signature f Examining Medical Prfessinal Print Name f Examining Medical Prfessinal (MD, PA r NP) Telephne Number Address City State Zip 10 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 HEPATITIS B AND FLU DECLINATION STATEMENT THIS STATEMENT is nt a waiver. I UNDERSTAND that due t my educatinal expsure t bdy fluids, bld r ther ptentially infectius materials r substances I may be at risk f acquiring Hepatitis B Virus (HBV) infectin. I UNDERSTAND that by declining the HBV vaccine, I cntinue t be at risk f acquiring Hepatitis B, a serius disease. I UNDERSTAND I can btain the Hepatitis B vaccinatin frm my physician in the future if I cntinue t have educatinal expsure t bdy fluids, bld r ther ptentially infectius materials r substances. I UNDERSTAND if I remain educatinally at risk and I want t be vaccinated with Hepatitis B vaccine, as an active American Academy f Healthcare student I can receive the vaccinatin series frm my physician. MY SIGNATURE als acknwledges that I d nt have a knwn sensitivity t yeast r a previus reactin t the vaccine that is knwn. My affiliated health facility, American Academy f Healthcare, has recmmended that I receive influenza vaccinatin t prtect the patients I serve. I acknwledge that I am aware f the fllwing facts: Influenza is a serius respiratry disease that kills an average f 36,000 persns and hspitalizes mre than 200,000 persns in the United States each year. Influenza vaccinatin is recmmended fr me and all ther healthcare wrkers t prtect ur patients frm influenza disease, its cmplicatins, and death. If I cntract influenza, I will shed the virus fr 24 48 hurs befre influenza symptms appear. My shedding the virus can spread influenza disease t patients in this facility. If I becme infected with influenza, even when my symptms are mild r nn-existent, I can spread severe illness t thers. I understand that I cannt get influenza frm the influenza vaccine. The cnsequences f my refusing t be vaccinated culd have life-threatening cnsequences t my health and the health f thse with whm I have cntact, including my patients and ther patients in this healthcare setting, my cwrkers, my family, my cmmunity. Despite these facts, I am chsing t decline influenza vaccinatin right nw fr the fllwing reasns: Print Name Student Signature 11 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Physical Examinatin : Must be within 12 mnths f the start f Clinical Experience Student Name: Print Clearly T the Medical Prfessinal: In rder t ensure the safety f students and patients, a recent physical Examinatin is required fr all students entering a healthcare prgram. Students wrk in all envirnments where the sick and injured may be cared fr. They are required t sit, stand and walk fr extended perids f time as well as lift, turn and care fr patients in a clinical setting. Students are physically challenged thrugh ut this curse. Yur signature certifies that the fllwing statements are true: This individual has been examined and fund t be fit t participate withut restrictin in the strenuus activities demanded f a Healthcare Prfessinal. This individual has been fund t be free f any cntagius disease, which may cause a threat t patient safety. This individual is physically and mentally cmpetent t perfrm the duties required in a rigrus, perfrmance based educatinal experience. Signature f Examining Medical Prfessinal Print Name f Examining Medical Prfessinal (MD, PA r NP) Address City State Zip Telephne Number 12 f 14
Please Type r Print Request, Authrizatin, Cnsent and Release fr Backgrund Check I, Last Name First Name Middle Name (Include Jr., Sr., II, III Etc.) Understand that in cnjunctin with my applicatin fr emplyment, American Academy f Healthcare, LLC, will use the services f an utside agency t research and verify the infrmatin I have prvided n my applicatin fr patient cntact including my persnal backgrund and character. This agency will prvide a reprt t American Academy f Healthcare, LLC. American Academy f Healthcare, LLC uses a screening agency, as an agent t perfrm backgrund verificatins. These agencies will utilize varius surces f infrmatin it deems apprpriate including but nt limited t: credit reprting agencies, Wrkers Cmpensatin recrds, Department f Mtr Vehicle recrds, criminal cnvictin recrds, current and frmer emplyers, military recrds, educatin recrds, prfessinal and persnal references. I request, authrize and cnsent t the release and disclsure f any and all infrmatin including but nt limited t the abve t American Academy f Healthcare, LLC. I request, authrize and cnsent t the prcurement f an Investigative Cnsumer Reprt and understand that it may cntain infrmatin abut my backgrund, mde f living, character, persnal characteristics and general reputatin. This authrizatin in riginal r cpy frm shall be valid fr ne year frm the date indicated next t my signature. Accrding t the Fair Credit Reprting Act, I will be ntified by American Academy f Healthcare, LLC if enrllment is denied because f infrmatin btained frm a Cnsumer Reprting Agency. Additinally, I understand that if requested within 60 days, I will be given a full and accurate disclsure as t the nature and substance f all infrmatin prvided t American Academy f Healthcare I further understand that when requesting a cpy f the reprt, prper identificatin will be required and I shuld direct my request t: BIB LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES. I HEREBY RELEASE AMERICAN ACADEMY OF HEALTHCARE AND ITS AGENTS, BACKGROUNDS ONLINE AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR REPORTS ABOUT ME FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE ABOVE MENTIONED INFORMATION OR REPORTS. Signed Printed Name Nurse Aide I Student Psitin Applied Fr Scial Security Number f Birth Driver s License Number State Other names yu have used r are als knwn as: Residential Addresses fr last 7 Years: Current Address: Street Apt. # City State Zip Cde Hw lng here? Frmer Address: Frmer Address: Street Apt. # City State Zip Cde Hw lng here? Street Apt. # City State Zip Cde Hw lng here? 13 f 14
American Academy f Healthcare, LLC Prviding Excellence in Healthcare Educatin 4822 Albemarle Rad Charltte, NC 28205 Phne: 704-525-3500 Cmpetency Evaluatin Skills Testing Prcedures T successfully pass the clinical and skills cmpetency evaluatin, the student must demnstrate unassisted, 100% mastery f all skills based n identified critical elements as utlined in the Nrth Carlina Nurse Aide I curriculum. The skills evaluatin will be cmpleted in the clinical setting as well as the classrm, but the student must cmplete a simulatin practice test and shw cmpetency befre clinical demnstratin in a skilled facility. The student has tw ther pprtunities t prve 100% mastery f skills t be allwed t cntinue with the prgram, which is nt mre than three ttal attempts. If the student fails n the third attempt, they will be asked t withdraw frm the prgram. NO REFUND WILL BE MADE. It is the RN instructrs respnsibility t ensure that the skills the cmpetency skills the student s demnstrate are signed ff n an apprpriate dcumentatin as necessary are made. The RN instructr is respnsible fr the students training and evaluatin thrugh ut the prgram. Print Student Name Last 4-digits f S.S. # Student Signature 14 f 14