Nurse Aide. We reserve the right to cancel any class due to insufficient enrollment.

Similar documents
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

Cisco College Surgical Technology Program Application for Admission and Student Health Record

Jacksonville State University Lurleen B. Wallace College of Nursing and Health Sciences Health Appraisal Form

FirstName: MiddleInitial: LastName: Student ID# LEHMAN COLLEGE DEPARTMENT OF NURSING READ ME FIRST

SOUTHWESTERN MICHIGAN COLLEGE NURSING PROGRAM

FALL Juan Carlos Castillo

Health Record Health Services 1025 North Broadway, K-254 Milwaukee, Wisconsin Phone: Fax:

Please review the information in this packet. If you have any questions, please contact me at (310) or me at

WEST LOS ANGELES COLLEGE DIVISION OF ALLIED HEALTH MEDICAL ASSISTING PROGRAM 9000 OVERLAND AVE

Health & Safety Packet for Incoming Students

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

MOUNTAIN VIEW COLLEGE Health Record

Middle Tennessee State University Master of Science in Nursing Health History and Physical Examination Form

HEALTH REQUIREMENTS AND OTHER DOCUMENTATION Required for RN Mobility Students

March Dear Student:

RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET

LONE STAR COLLEGE-TOMBALL DOCUMENTATION OF REQUIRED IMMUNIZATIONS Please Print

Initiate your background check at

Department of State Academic Exchanges Participant Medical History and Examination Form

Applicant Name (Please print) Last First MI. Northeast State Community College assigned Student ID Number: City: State: Zip Code:

Proof of current (within 1 year) Tuberculin PPD or skin test administration. If PPD result is positive a negative chest x-ray is required.

Paramedic Program Roseville, CA

2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults

Hinds Community College Nursing and Allied Health Programs Clinical Record Packet

Middle Tennessee State University MSN Program. Clinical/Student Requirements- Admission to MSN Program

Clinical Education Policies

BEFORE COMPLETING THIS PACKET

College of Sequoias Physical Therapist Assistant Program Student Health Release Form

AGE Is the student age 18 or older? (If YES, please skip to signature section below) p YES p NO

Health History and Examination Form for Children, Youth and Adults Attending Camps

Southwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM

Middle Tennessee State University MSN Program. Clinical/Student Requirements- Admission to MSN Program

MEDICAL ASSISTING CERTIFICATE PROGRAM APPLICATION PACKET

CNA CERTIFICATE PROGRAM APPLICATION PACKET

STUDENT NAME: Date Completed:

MSU-Crowder Bachelor of Science in Nursing (BSN-C) Scholars Program.

MEDICAL LABORATORY SCIENCE MANDATORIES INFORMATION

2018 SPORTS CAMP REGISTRATION FORM

Shadow-a-Professional Program 2016 Application

EL PASO COMMUNITY COLLEGE PROCEDURE

HEALTH PROFESSIONS PROGRAM Physical Examination Form

Capital Community College 950 Main Street Hartford, CT HEALTH ASSESSMENT FORM for Students participating in Clinical Activities

NURSING ASSISTANT PROGRAM REGISTRATION PACKET AND INFORMATION

Middle Tennessee State University School of Nursing Undergraduate Program Clinical Policy

Ambassador Program Application Packet

1419 Salt Springs Road Syracuse, NY (Health Office)

Golden West College School of Nursing Medical Exam Information Sheet

APPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet

MOLLOY COLLEGE Division of Continuing Education and Professional Development MRI Program. Name Home Phone. Address Work Phone ( ) NYS License # ARRT#

NORTHEAST TEXAS COMMUNITY COLLEGE Professional Education and Allied Health

NURSING ASSISTANT ADVANCED PLACEMENT PROGRAM REGISTRATION PACKET AND INFORMATION

BEFORE COMPLETING THIS PACKET

Disclosure and Release of Health History and Immunization Requirements

NORTHEAST TEXAS COMMUNITY COLLEGE Professional Education and Allied Health

Norwalk Community College 188 Richards Avenue Norwalk, CT HEALTH ASSESSMENT FORM for Students participating in Clinical Activities

WELCOME BACHELOR OF SCIENCE IN RADIOLOGICAL SCIENCE

DEPN AND GRADUATE NURSING MANDATORIES INFORMATION

Student Health Form Howard Community College Health Science Division

Davidson Campus: P.O. Box 1287, Lexington, NC Telephone: FAX:

Medication Aide. Program Application Packet. Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution.

Patient Care Technician Certificate. Career Talk and Program Requirements

Student Health Form Howard Community College Health Science Division

The Clinical Practicum: Guidelines for Success

Phlebotomy Certificate Program. Information Guidelines

Wabash Student Health Center

WSCC Department of Nursing Clinical Portfolio

New Mexico Military Institute Medical Packet - Marshall Infirmary

PATIENT INFORMATION SHEET:

Internship Application x2645

Western MA Clinical Requirements for Nursing Students and Faculty Academic Year [UPDATED - May 17, 2017]

Guide to CastleBranch

ADN Program Application Packet

BINGHAMTON UNIVERSITY DECKER SCHOOL OF NURSING Student Health Requirements

Davidson Campus: P.O. Box 1287, Lexington, NC Telephone: FAX:

Division of Community Education Application for Certified Nursing Assistant Program CNA APPLICATION CHECK LIST

PRE-CLINICAL HEALTH REQUIREMENTS (PCHR) GRADUATE NURSING

VILLANOVA UNIVERSITY COLLEGE OF NURSING GRADUATE PROGRAM DIRECTIONS TO COMPLETING PRACTICUM APPLICATION

INDEPENDENT STUDY REFRESHER COURSE. for. REGISTERED NURSES (Minnesota & North Dakota)

ALLIED HEALTH INFORMATION PACKET

Somerset Middle School Athletic Requirements

NURSING AND HEALTH OCCUPATION PROGRAMS

Enrollment Agreement. Millicent Mucheru, RN BSN. Dear Applicant,

INDEPENDENT STUDY REFRESHER COURSE. for. LICENSED PRACTICAL NURSES (Arkansas)

*** Program Guidelines ***

MOODY BIBLE INSTITUTE HEALTH SERVICE DEPARTMENT

ZooCrew Registration Packet Summer ZooCrew

POLICY TITLE: STUDENT CLINICAL REQUIREMENTS PART ONE

Oregon State University School of Biological and Population Health Sciences KIN 344: Pre-Therapy/Allied Health Practicum.

JOHNS HOPKINS SCHOOL OF NURSING PRE-ENTRANCE HEALTH FORM

APPLICATION FOR VOLUNTEER AMBASSADOR (18 yrs and older)

Nash Health Care Junior Volunteer Application Packet

Le Bonheur Children's Hospital Child Life Clinical Internship Program

Palmetto Health Tuomey Student Volunteer Application Application to be completed by the student, NOT the parent. Full Name: Phone: (

CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018

COLUMBUS STATE COMMUNITY COLLEGE Dental Hygiene

RN Refresher Program Information Packet

Le Bonheur Children's Hospital Child Life Clinical Internship Program

USGTC Summer Camps Staff Health Form. Staff and/or Parents Please Complete Pages 1 3 & 5

ALLIED HEALTH INFORMATION PACKET

1. 2- step TST results including dates placed/read & induration amount 2. 1 additional negative TST within 12 months of your start date

Transcription:

Nurse Aide We reserve the right to cancel any class due to insufficient enrollment. **All clinical dates may vary according to site and instructor availability

ABOUT THE NURSE AIDE PROGRAM The Nurse Aide program prepares the student for employment as a nurse aide in hospitals, skilled care, home health, and hospice facilities. Basic nursing and personal care skills, legal and ethical issues for nurse aides, restorative services and recognition of the emotional, social, cultural and individual rights of patients are all competencies is in the coursework. Students will then practice these skills in the college lab and an assigned clinical setting. All students are eligible to apply. Enrollment in the clinical course is contingent upon the student passing a criminal background investigation. The Nurse Aide courses fulfill the educational requirements for students to take the Certified Nurse Assistant s (CNA) Exam. The Nurse Aide program is at Western Colorado Community College. Nurse Aide Course Descriptions NURA 101 Nurse Aide Healthcare Skills (4 Credits) This course covers the fundamental skills of the nurse aide. Basic nursing skills, communication skills, restorative services, personal care skills, safety and emergency care are covered as well as knowledge and/or principles of asepsis, OSHA and HIPAA regulations. Ethical behaviors, cultural sensitivity, principles of mental health, patient/resident rights are addressed. NURA 170 Nurse Aide Clinical Experience (1 Credit) This course applies knowledge and skills gained in NURA 101 to patient care. Students gain knowledge and skills needed to function independently within the nurse aide scope of practice. Students apply the skills needed to perform as a nurse aide in the health care setting. Enhanced communication, cultural competency, end of life care, critical thinking and organizational skills are emphasized. To schedule an advising appointment contact: Kathy Young Interim Director of Allied Health 2508 Blichmann Avenue Grand Junction, CO 81505 klyoung3@coloradomesa.edu 970-255-2661

APPLICATION PROCESS and PROGRAM ADMISSION PROCEDURES 1. Apply to Western Colorado Community College on-line at http://www.coloradomesa.edu/wccc declaring Nurse Aide as area of emphasis. (All the following steps must be completed, and all documents must be submitted before you can be registered for a class) 2. Complete a Background Check request online at American DataBank http://www.wcccbackground.com 3. Completed the Nurse Aid Application and the Health Examination Form - (see pages 4-8). Page 6 must be filled out by the student and page 7 completed by your health care provider. 4. Completed Proof of all listed Immunization Including Measles/Mumps/Rubella, Tetanus, Chicken Pox (Varicella), Hepatitis B (this is a series and you will want to begin this soon), as well as a current 2-Step TB skin test, this is the first one administered and the second within 1-3 weeks later (must be within one year, see page 8). You MUST ATTACH written proof of your vaccinations. 5. Complete Proof of Professional Liability Insurance - If you wish you may apply for insurance through the National Professional Group as a student nurse. The website is http://www.nso.com. Should you choose to go through a different company, the policy must be comprehensive general liability insurance covering bodily injury and property damage liability with minimum coverage limits of $1,000,000 per occurrence/$2,000,000 general total limit, and medical professional liability insurance with minimum coverage limits of $1,000,000 per claim/$3,000,000 annual aggregate. (Any student receiving a varicella vaccination should do so at least one month before beginning Nurse Aide classes. Students should not attend clinical rotations for 30 days after a varicella vaccination due to the rare possibility of contracting varicella after the immunization and exposing patients and faculty at clinical.) Return all materials to: Kathy Young Interim Director of Allied Health 2508 Blichmann Avenue Grand Junction, CO 81505 klyoung3@coloradomesa.edu 970-255-2661

Nurse Aide Program Fee Schedule Matriculation Fee (if applicable) $ 125 In-State Tuition and Fees (approximate) $ 1399 Textbook (available at CMU Bookstore) (approximate) $ 100 Supplies/Uniforms (approximate) May be purchased at Uniform Junction 256-1600 Watch w/second Hand $ 20 Shoes - White closed toe, no holes in shoes $ 50 Other (Paid to American DataBank online at http://www.wcccbackground.com) Background Check payment is not refundable $ 21 Professional Liability Insurance (may be purchased at www.nso.com) $ 40 Colorado Nurse Aide Certification Test $ 123 Total Estimated Cost $ 1878 Costs are approximate and subject to change

Nurse Aide Application 2508 Blichmann Ave. Grand Junction, CO 81505 (970) 255-2600 www.coloradomesa.edu/wccc Submit application along with all required paperwork to Kathy Young, WCCC, 2508 Blichmann Avenue, Grand Junction, CO 81505. Or fax to (970) 255-2690. Contact Information: Full legal name Last First Middle Initial Maiden Name of Birth / / CMU ID # Permanent home address: City, State, Zip Present mailing address: (if different from above) City, State, Zip Email address (please print clearly): Phone number with area code: ( ) Cell: ( ) Are you a current WCCC/CMU student? Yes No Is this the first time you have applied to the Colorado Mesa University Nurse Aide program? Yes No Are you an EMT? Yes No

Employment Experience: s employed From To Name and location where employed Duties (briefly) Healthcare Experience: From To Any other healthcare experience not previously defined Duties (briefly) Acceptance into this program is contingent upon receipt of the completed application and required documents. I certify that all the information stated on this application form is accurate and complete. Concealment of facts or false statements may result in dismissal from the program. Applicant Signature

Western Colorado Community College Nurse Aide Program Name Health Examination Form Last First Middle (Maiden) Local Address Birthdate CMU ID # Notify in case of emergency: Name Address Telephone Number Personal History (to be completed by student): Allergies (please specify) Yes No Drugs Foods Other Communicable Diseases: Yes No Scarlet fever Chicken pox Malaria Mononucleosis Surgery (please list): Accidents (please list): Health Problems: Yes No Eye problems Ear, nose, throat trouble Insomnia Recurrent headache Head injury w/unconsciousness Tuberculosis Chest, pain/pressure Chronic cough High blood pressure Diabetes Rheumatic fever/heart murmur Problems with muscles and joints Back problems Seizures Stomach or intestinal problems Gallbladder problems Recurrent diarrhea Hernia Weakness, paralysis Psychiatric problems Hepatitis, A, B, etc. Other (The college encourages students to obtain a vaccination for bacterial meningitis.) Student Signature

Health Exam (to be completed by physician or certified nurse practitioner): Height Weight Visual Status, with correction: L = 20/ R = 20/ Hearing Status: Normal Deficits Blood Pressure Pulse Review of Systems (please check): Normal Abnormal Comments, if abnormal 1. Head, neck 2. Lungs 3. Heart 4. Gastrointestinal 5. Genitourinary 6. Musculoskeletal 7. Neurological 8. Other Immunization Record (required): Negative two-step tuberculin test or negative chest x-ray within last year. Result Diphtheria/Tetanus within past 10 years. Yes No Please attach proof of two MMR immunizations (if you were born before 1957, provide proof of a positive rubella laboratory titer): Measles (red/rubeola), Mumps and Rubella (initial immunization received on or after 1 st birthday) and or or or Measles (a second immunization of rubeola/red measles) Physician-diagnosed measles and rubella Positive laboratory titer for measles and rubella Birth date of 1957 or earlier, rubella immunity only (requires documentation of a positive rubella laboratory titer) Please check below activity you recommend: All forms of physical activity Activity restrictions. Please comment: Summary of general health status: Signature Address: Examining Health Professional

N u r s e Ai d e P r o g r a m Vaccination Program for Hepatitis B Health care personnel are at risk of acquiring Hepatitis B in direct relation to their degree of exposure to blood and blood products and to the degree of their exposure to patients with Hepatitis B. Western Colorado Community College requires this vaccination for Nurse Aide students. Schedule of Immunization Shot #1 Shot #2 Shot #3 Please print student name Program CNA Student signature Signature of health care provider who administers the vaccination