March 2011 Dear Student: Thank you for your interest in applying for our Certified Nursing Assistant Program. Completion of this program will enable you to apply for work in one of the largest growing occupations in response to the increasing need for senior care. Opportunities exist in long-term care facilities, rehabilitation centers, senior housing, adult medical day care and in some hospitals. This 90 hour course is approved by the NJ Department of Health and Senior Services and provides 50 hours of classroom and 40 hours of clinical instruction to prepare you for the New Jersey State Certified Nursing Assistant Certification Exam. TO ENROLL IN OUR PROGRAM Attend a mandatory free information session. The next session is Thursday, February 3, 2011 at 6pm in the Conference Center. Please call 609-570-3311 to reserve a space. Other dates will be posted on www.mccc.edu/ccs Initiate your background check at www.mercercollegecx.com - after we notify you of clearance you may register. Make payment in full of the $1195 tuition which includes a non-refundable registration fee of $100 for application review and processing Please supply us with the following paperwork upon registration: o Continuing Studies Application Form Completely Filled Out o Contract initialed and signed stating that you understand course requirements see page 4 o Proof of Personal Health Insurance Classes will begin on Saturday, April 30, 2011 through August 13, 2011 and meet once a week on Saturdays from approximately 7:30 am to 4pm. It is possible that some of our clinical sessions may take place on Sunday mornings. The program runs for 15 weeks and the hours vary slightly each week. Total cost is $1195 and must be paid in full at time of registration. There are no classes on holidays. Applicants will be entered into the program on a first-come first-served basis. Class size is limited. 1
The rest of this paperwork can be completed after registration but received no later than March 28, 2011 Copy of HS Diploma/Transcript Physical Examination Report signed by your physician with proof that you have had all required shots and tests (see page 4 & 5). Shots and tests must have been done within the past year. Proof that you purchased CNA Liability insurance (see page 6) Additionally, all applicants are required to wear during each class: Hunter green scrubs available at uniform shops retail stores and sometimes at thrift stores. Lightweight white nursing shoes with backs to your first class and ALL clinical practice sessions A watch with a second hand A stethoscope (optional cost under $15) available at college bookstore If you have questions or need assistance, please contact Nancy Nicholson at 609-570-3574, or nicholsn@mccc.edu. Carol Desmond Clark Director, Continuing Studies Mercer County Community College Nancy Nicholson Coordinator, Community Education C.N.A. Program Manager File: sp2011cnastudentapp.docx 2
STEPS TO COMPLETE YOUR CERTIFIED NURSE AIDE APPLICATION PROCESS STEP 1 Attend a CNA Information Session STEP 2 - Fill out and submit the CNA Application Form see Page 4 STEP 3 - Sign and Initial and submit the CNA Contract see Page 5 STEP 4 Provide proof of personal health insurance STEP 5 Initiate your background check and notify Nancy Nicholson UPON APPROVAL FROM NANCY NICHOLSON YOU MAY REGISTER. $1195 IS DUE AT REGISTRATION. If you drop the course or do not complete the rest of the paperwork you will forfeit the $100 application review fee. The last day to drop this course is April 20, 2011. If you drop after that you will lose the full $1195. STEP 6 Immediately go to your doctor or clinic for your physical exam, shots and first PPD shot. You must have the second PPD shot before classes begin or you will not be permitted to attend the clinical sessions. Bring the original signed receipt to the Conference Center addressed to the attention of Nancy Nicholson. The medical forms will be complete after your second PPD shot is administered and comes back negative OR you provide a report of a clear chest X-ray. STEP 7 Purchase your Student Liability Insurance online and send a copy of the email confirmation to Nancy Nicholson at Nicholsn@mccc.edu or fax to 609-570-3883. STEP 8 Send a photocopy of your High School or College Diploma or GED to Nancy Nicholson. We do not need original copies or certified transcripts. YOUR APPLICATION PROCESS IS NOW COMPLETE Please purchase your scrubs, shoes and supplies. You need to also purchase the textbook/workbook/dvd package which is available at the College bookstore. You should have all of this the first day of class. 3
CENTER FOR CONTINUING STUDIES MERCER COUNTY COMMUNITY COLLEGE ALLIED HEALTH PROGRAM APPLICATION FORM DATE NAME MCC ID NUMBER: ADDRESS STREET CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL DO YOU HOLD A COLLEGE DEGREE? NO YES IF YES, AS BS MS PhD COLLEGE NAME ADDRESS CITY/STATE PROGRAM OF STUDY DATE OF GRADUATION / DATES ATTENDED HIGH SCHOOL NAME ADDRESS CITY/STATE DATE OF GRADUATION ARE YOU OVER 18 MALE FEMALE EMERGENCY CONTACT NAME RELATIONSHIP PHONE NUMBER WORK EXPERIENCE (MOST RECENT FIRST OR ATTACH RESUME) DATES EMPLOYED NAME OF EMPLOYER POSITION HELD IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY QUESTIONS, PLEASE USE THE BACK OF THIS FORM. 4
Certified Nursing Assistant Student Agreement I,, understand that my admission to the Certified Nursing Assistant program is provisional based upon the completion of the following. Initial I am present at the mandatory CNA orientation on date: at the conference Center at MCCC or have attended a previous session. I am required to submit proof of a high school diploma, GED or college transcript by March 28, 2011 I am required to have all current laboratory tests and required shots and submit a medical release form signed by my physician by March 28, 2011 I am required to provide proof of liability insurance for Certified Nursing Assistants by and by March 28, 2011 and proof of personal health insurance upon registration. I understand that I am responsible to purchase the required uniform, shoes and equipment and textbook and workbook prior to the first day of the class. I understand that I must obtain a MCCC Student ID badge prior to the first day of clinical practice. Students who fail to purchase the required items will not be allowed to attend clinical and will be dismissed from the program. I am informed of the requirement to undergo a criminal background check by Mercer County Community College for clearance to attend the clinical portion of this course and the additional NJ State requirement for a criminal background checks and fingerprinting prior to certification. A positive criminal history may preclude a student s ability to complete clinical education and/or obtain certification from the State of NJ. Application to American Databank for the criminal background check must be initiated by the student and received by the college before the student is permitted to register. Please read attached addendum for additional information. I understand that I will be admitted to the program and pay my registration only after my background check and application are completed and approved. The registration fee of $1195 includes a non-refundable $100 application review fee. If I withdraw from the program or am not admitted due to failure to complete the application procedures listed above I will forfeit the $100 fee. The last day to drop this course is April 20, 2011. I have read and understand the requirements set within this document. I understand I will not be able to complete the C.N.A. program unless the above requirements have been met. Student Signature Date 5
STUDENT CERTIFIED NURSING ASSISTANT APPLICATION DETAILED INSTRUCTIONS Physical Examination Report Instructions The Physical Examination Report located at the end of this document must be completed by your healthcare provider. The form must be submitted to the Center for Continuing Studies office no later than March 28, 2011. Students who do not submit this information will be unable to begin the Certified Nursing Assistant program and may lose all or part of their registration fee. The Robert Wood Johnson Health Center is a recommended and convenient local clinic for your immunizations but you may go to any hospital or doctor s office. Many walk-in minute clinics do give PPD shots. All immunizations and medical testing required for admission to this course is done at the student s own expense and must be done within the past 12 months. Immunizations Hepatitis B A series of three (3) vaccinations is highly recommended for healthcare professionals. If you have completed the series, the dates need to be indicated and a blood test (titer) is required to show immunity status. If you have not begun the series, you may do so now and we will accept you into the program. If you chose not to be immunized for Hepatitis B, you must sign a declination form. Please contact us if you need this form. Mantoux (PPD) A current two (2) stage PPD is required for your initial health record. Copies of the PPD results must be submitted. For students who have received a BDG or have a positive PPD, a chest x-ray report must be submitted. A single stage PPD or chest x-ray must be submitted annually, while enrolled. You will also need a CBC, Urinalysis and Drug Screening as well as your doctor s signature stating that you are physically able to perform the duties assigned in the class and clinical settings. Student Liability Insurance Instructions All students are required to purchase student liability insurance. A copy of your certificate of insurance must be submitted to the Continuing Education Office no later than March 28, 2011. You may purchase this insurance on-line at www.hpso.com. 1-800-982-9491. It is not required that student purchase their insurance from NSO. You may find a comparable company, as long as it has the appropriate coverage for a Nursing Assistant/Aide. You need to purchase insurance in the state that you reside. 6
Background Check Instructions You will not be admitted to our program until your background check is completed and approved. The Joint Commission of Accreditation of Healthcare Organization (JCAHO), which accredits healthcare facilities across the country, enforced background screening since September 2004 and has set requirements mandating that students in a healthcare field must now complete the same background check as hospital employees. A background investigation must be completed prior to your clinical experience at Mercer County Community College. Students are responsible for payment of their background investigation, and American Databank must conduct the investigation. The basic cost is $15 and an additional $15 for each maiden name or alias. To initiate your background clearance, go to the website www.mercercollegecx.com and follow the step by step process. You need to print out their authorization form and fax it into them to authorize the process: Please also check the box that says Certified Nurse Aide so that your information is reported to our office. Their phone number is 1-800-200-0853. The profile information you input will be sent directly to the school upon completion. If you would like a copy sent to you, you must indicate that when you apply. The following search is required for students attending facilities for clinical instruction through Mercer County Community College: Criminal History Record Search (7 years) Maiden/Alias Names PLEASE CONTACT NANCY NICHOLSON AT 609-570-3311 OR EMAIL NICHOLSN@MCCC.EDU IMMEDIATELY WHEN YOU INITIATE YOUR BACKGROUND CHECK THIS WILL ENABLE US TO VERIFY YOUR RESULTS QUICKLY. 7
If you have any questions, please contact our office. This is what the online application looks like: 8
BACKGROUND CHECK ADDITIONAL INFORMATION All students will also be required to complete a MCCC criminal background check prior to beginning the Certified Nursing Assistant Course. While enrolled, you will need to undergo fingerprinting and an additional background check instituted by the Department of Health and Senior Services. This will be done during the class. An applicant whose criminal background check discloses a conviction or unresolved arrest for a crime or misdemeanor that could jeopardize the health, safety or welfare of any patient, employee, student or visitor may also be barred from entrance to the school. If your MCCC background check is flagged, you will be required to provide a written statement indicating the specific details of each conviction you have on your criminal record, the outcome of any trial/hearing and what you have done since the offense to better yourself. Letters of reference may also be required. You are advised that if you are admitted to the program, MCCC cannot guarantee that you will be licensed by the New Jersey Department of Health and Senior Services pending their independent review of your criminal history. If your application is under review you will not be admitted to the program until any background check issues are resolved. In order to take part in the educational program an applicant must not have been convicted of, or pled guilty to: Homicides Assaults Kidnapping or criminal coercion Sexual offenses Robbery Thefts, larceny and fraud Endangering the welfare statues Drug offenses Information on background check results and conditions may be located on pages 5-9 in the New Jersey Nurse Aide & Personal Care Assistant Candidate Handbook which is distributed at the information session. Financial Aid The following list represents a small number of lending institutions that may offer alternative loans. There are many other lending institutions that may offer similar or better loan programs. Our college does not endorse any lending institution. The list is provided for quick reference only and students are encouraged to shop and secure the best terms from any lending institution on their own. Chase 866-661-3877 Citibank 800-967-2400 Nelnet 800-922-6352 Sallie Mae 888-272-5543 Wells Fargo 800-658-3567 Wachovia 877-689-0763 9
The individual presenting this form has been accepted into a Health Professions Program at Mercer County Community College. Nursing assistant students are required to meet the same health requirements mandated by the NJ Department of Health and JCAHO as employees of any health care facility. MERCER COUNTY COMMUNITY COLLEGE PHYSICAL EXAMINATION REPORT FOR Certified Nursing Aide Program The individual presenting this form has been accepted into a Health Professions Program at Mercer County Community College. Nursing assistant students are required to meet the same health requirements mandated by the NJ Department of Health and JCAHO as employees of any health care facility. NAME: PROGRAM: Certified Nurse Aide MCCC PERSONAL IDENTIFICATION NUMBER: IMMUNIZATIONS Tetanus/ Diphtheria booster (Must be within 10 yrs.) Date Hepatitis B Series-Dose 1 Dose 2 Dose 3 Date Date Date Screening/Titer Date* Immune Non immune NOTE: ONCE SERIES IS COMPLETED, TITER* MUST BE DRAWN AND RESULTS SUBMITTED. IF CLIENT IS NON-IMMUNE, SERIES MUST BE REPEATED. STUDENT WILL BE ACCEPTED AS LONG AS Hepatitis B SERIES IS INITIATED OR A DECLINATION FORM IS SUBMITTED. *Quantitative test results required LABORATORIES CBC DATE: Within Normal Limits? Yes No Urinalysis DATE: Within Normal Limits? Yes No Drug Screening DATE: Negative? Yes No 10 TWO STEP MANTOUX (PPD) #1 STEP ADMIN DATE #1 STEP RESULTS #2 STEP ADMIN DATE #2 STEP RESULTS NOTE; IF POSITIVE OR CLIENT RECEIVED BCG, A CHEST X-RAY MUST BE TAKEN AT THIS TIME UNLESS ONE WAS PERFORMED WITHIN THE PAST TWO MONTHS. THE RADIOLOGY REPORT MUST BE SUBMITTED. The tine or multiple puncture tests are not sufficient
PHYSICAL EXAMINATION Pulse: Blood Pressure: Height: Weight: Hearing Normal Abnormal Corrected Vision Normal Abnormal Color Blind Corrected with Glasses ARE THERE ANY ABNORMALITIES IN THE FOLLOWING? EENT Cardiovascular Pulmonary Gastrointestinal Hernia Endocrine Musculoskeletal Neurological Genitourinary Emotional Physical Handicap If yes, please explain Yes No PHYSICIAN S STATEMENT Upon review of the physical exam and lab results, I certify that this student is medically able to perform all clinical activities without restrictions. MD/NP Signature: Date: Print Name: License # Address: Telephone # 11