Nursing Assistant Program Application Checklist for High School Students Meet with your High School CTE advisor to decide on a schedule that will work for you and to obtain authorization. Determine whether you need to take a reading assessment. Testing can be waived if you can provide documentation of any of the following: TABE (8), Accuplacer (55), or DRP (65) tests taken in the last year SAT minimum scores of 400 in English (taken in the past five (5) years) ACT minimum scores of 16 in English (taken in the past five (5) years) Associate degree or higher from an accredited college or university (in the United States) College transcripts with minimum English 960 with a "C" grade or better If you need to take the reading assessment, call (801) 627-8300 or (801) 395-3742 to schedule an appointment. Bring a picture ID when you come to test. Complete the online Admissions Application. Complete the online New Student Campus Orientation. Watch the program orientation video and fill out the verification form. Visit the Enrollment office to register. You must register by the 20th of the month prior to the month you want to begin classes (e.g. register by June 20th in order to start classes the first week of July). High school students do not pay tuition. However, be prepared to pay the $32 background check fee at the time of enrollment. Obtain your TB test and immunizations or immunization/test records. TB test must have been done within the past year. Flu shots are required during the flu season (typically October thru April). Students who do not have a current flu shot, will be required to wear a mask during their clinicals. Hepatitis B vaccine series is recommended due to potential for exposure to blood borne pathogens. Have your parents sign the four forms following this checklist (Human Sexuality Instruction, Clinical Experience Consent, Hepatitis B Vaccine Declination, and OJT Agreement forms). High School Students who fail to return signed parental consent forms on the first day will be unable to participate in class until the forms are signed and turned in. On the first day of class, turn in your TB test results, immunization records, 4 consent forms and Background Notification Form.
Health Occupations Nursing Assistant Background Check Notification Students entering a Health Occupations Program at the Ogden-Weber Technical College are required to complete a background check. All Students must complete a Criminal Background Check application no later than the first day of class. Any misdemeanor or felony conviction that you have on your record may negatively impact your chances of completing the program and being placed at an externship site. An adverse finding on a criminal background check may also inhibit a student s ability to obtain employment and/or obtain certification/licensure in a health occupation. Many states including Utah, do not seal juvenile records. Any charge incurred in the last 7 years will show up on the background check. There will be no tuition or fee refund for students who are unable to complete the program due to their criminal record. Prospective students with a criminal record are strongly encouraged to contact the Program Coordinator prior to enrolling. In keeping with the program s due process policies, if a student disagrees with the accuracy of the information obtained, he/she may request a meeting with the Program Coordinator to discuss their concerns. I have read and understand the information presented above. Student Signature Parent Signature (if student is a minor) Revised 11/2017
OGDEN WEBER APPLIED TECHNOLOGY COLLEGE CONTRACT AGREEMENT FOR ON THE JOB TRAINING (OJT) This agreement is entered into this day of 20 between Ogden Weber Technology College, hereinafter referred to as COLLEGE, and, hereinafter referred to as STUDENT. NOW, THEREFORE, in accordance with the consideration provided herewith, it is agreed that: The WORKSITE will: Provide use of its facility for on the job training (OJT) also referred to as clinical to the student(s) to provide the same with practical experience and education beyond that which the COLLEGE is able to provide per specific student(s) curriculum requirements. Provide a healthy and safe work environment and proper staff to lead the student(s) throughout their OJT experience. Communicate to the coordinator of the program and instructor on-site of any unacceptable student behavior or other incidents. The COLLEGE will: Coordinate the arrangement between the WORKSITE and the student, and officially recognize the OJT received by the student(s). Provide necessary training to the student(s) prior to the student participation on any OJT. Provide an instructor to supervise the student(s) throughout and during the OJT. Recognize the importance of the onsite training and follow up with the administration of any misunderstanding or incidents. IT IS FURTHER AGREED THAT: The student is desirous of gaining said experience and education and recognize the clinical/ojt as hands on training. The student will not be paid nor provided other benefits by the WORKSITE or the COLLEGE during the training. The student will abide by all rules, procedures and policies of the WORKSITE now in effect, or placed in effect in the future, including those related to safety The student will abide by HIPAA laws and maintain patient confidentiality at all times. The student assumes all risk of personal injury and personal property loss in connection with or arising from the student s clinical training at the WORKSITE. The student waives and releases the COLLEGE and the WORKSITE for all damages or loss of personal property in connection with or arising from the student s clinical training at the WORKSITE. Both the WORKSITE and the COLLEGE shall be protected in accordance with the law (exclusive remedy) as it relates to claims for personal or property damage filed by the student. The WORKSITE will provide direct training and proper guidance to the student during the clinical. The student will be exclusively responsible for any damage caused by negligence on the student s part such as, but not limited to: property damage, equipment breakage, and physical harm to the WORKSITE property, its affiliates or third parties releasing the COLLEGE and the WORKSITE of any liability.
If the student is injured while on the WORKSITE premises, performing the normal tasks that are required of the position, the COLLEGE will provide assistance to the student. The student will NOT perform any task for which he or she was not trained, or if the task being asked to be performed by the student is not congruent with the way the student was trained, increasing the risk for unsafe performance. The COLLEGE will exercise reasonable care in selecting and forwarding student(s) to the WORKSITE for OJT training. By signing below all parties have read, understand, and agree to the terms of this agreement as written. Student signature Parent signature Ogden-Weber Technology College Representative signature *both pages of the OJT contract should go in the student s file
Hepatitis B Vaccine Declination I understand that occupational exposure to blood or other potentially infectious materials, may put me at risk of acquiring Hepatitis B virus, (HBV) infection. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I may be at risk of acquiring hepatitis B, a serious disease. I have previously completed Hepatitis B vaccination series I have just started the Hepatitis B vaccination series. Antibody testing reveals that I am immune to Hepatitis B For medical reasons, the Hepatitis B vaccine is contraindicated I am declining to have the Hepatitis B vaccination knowing that I have a chance to contract it at any time throughout this program. Yes No Yes No Yes No Yes No Yes No As a result of my decision to decline Hepatitis B vaccination, I hereby release Ogden-Weber Technology College, as well as any and all officers, directors, employees, agents or associates from any and all liability for any injury, illness, damage, claim or cause of action which arises or may arise in association with this decision and my work. Student Signature Parent or Guardian if younger than 18 years of age Students Printed Name / Parent or Guardian Name Printed Witness Medical Assisting, Dental Assisting, Certified Nurse Assisting, EMT, Surgical Technician 2007
Utah State Office of Education Clinical Experiences Consent Form Clinical experiences are vital in the preparation of health care workers who will work with patients. This course has a required clinical experience component in which the student will observe and/or perform specific health care procedures in direct contact with patients that may include: o personal care o patient bathing o bathroom assistance o questioning patients about bodily functions o specimen collection o assistance with procedures such as a pap smear o other types of personal contact between student and patient Each high school student who participates in a course-required clinical experience must have the signature of a parent or legal guardian in order to participate in and complete the clinical experience. I give permission for my student to (student s name) participate in discussions, study, and experiences regarding personal care. I acknowledge that these are duties and responsibilities of health care providers. I also understand that if I do not consent to have my student participate in these discussions and experiences, my student may not be eligible to become licensed or certified in the program in which they are enrolled. Student Signature: : Parent Signature: : Instructor Signature: : Medical Assisting, Dental Assisting, Certified Nurse Assisting, EMT, Surgical Technician 2007
Utah State Board of Education Parent/Guardian Consent Form Human Sexuality Instruction Name of Student Parents must receive this form no later than two weeks prior to the beginning of instruction. Course:_NURSING ASSISTANT Teacher(s):CHERIE CREZEE, PROGRAM COORDINATOR School: OWTC Telephone Number: 801-612-4179 Dear Parent/Guardian: As part of your child s education, he/she has enrolled in a course that includes instruction on topics related to human sexuality. You are receiving this consent form because instruction and/or discussion of human sexuality topics are controlled by state law and/or Utah State Board of Education rule. Please read the form carefully, select one option, sign, and return to the teacher identified above. Your student will not be allowed to participate in class activities without this completed and signed form on file. Thank you. INFORMATION All instruction related to human sexuality and/or sexual activity will take place within the context of Utah State Law (53A-13-101) and Utah State Board of Education rule (R277-474) as follows: $ The public schools will teach sexual abstinence before marriage and fidelity after marriage. $ There will be prior parental consent before teaching any aspect of contraception and/or condoms. $ Students will learn about communicable diseases, including those transmitted sexually, and HIV/AIDS. Program materials and guest speakers supporting instruction on these topics have been reviewed and approved by the local district review committee. The following are NOT approved by the State Board of Education for instruction and may not be taught: $ The intricacies of intercourse, sexual stimulation or erotic behavior; $ The advocacy of homosexuality; $ The advocacy or encouragement of the use of contraceptive methods or devices; $ The advocacy of sexual activity outside of marriage. In accordance with Utah State Board of Education Rule R277-474-6-D, teachers may respond to spontaneous student questions for the purposes of providing accurate data or correcting inaccurate or misleading information or comments made by students in class regarding human sexuality. Please choose one option for instruction listed on the reverse side of this page.
DISCLOSURE: The curriculum for this course includes instructions and/or discussions about the topics checked in this box: **Teacher Use Only** reproductive anatomy and health contraception, including condoms* human reproduction HIV and AIDS (including modes of transmission) information on self-exams sexually transmitted diseases date rape (terms of a sensitive/explicit nature may be defined) *Factual, unbiased information about contraception and condoms may be presented as part of this course (only if the box above is checked). Demonstrations on how to use condoms or any contraceptive means, methods, or devices are prohibited and are NOT authorized. Name of Student: OPTIONS: Please read and check only one of the following: Option 1 I GRANT permission for my child to participate in the scheduled activities/discussions as described above. Option 2 I GRANT permission for my child to participate in the scheduled activities/discussions as described above, with the exception of. I understand that my child will receive an alternative assignment of equal value and will not attend the regularly scheduled class on the day of this instruction. My child will be provided a safe, supervised place within the school during the class period(s). It will be his/her responsibility to report to the pre-arranged location, check in with the teacher or supervisor, and submit the completed assignment to the appropriate person. Option 3 Prior to making a decision, I will contact you at the school within the next two weeks to arrange a time to discuss the planned curriculum and/or review the materials. Option 4 I DENY permission for my child to participate in any of the scheduled activities/discussions as checked in the above box. I understand that while my child is not involved in the exempted portion of the curriculum, he/she will be provided a safe, supervised place within the school during the class periods and will receive an alternative assignment related to other elements of the course. I shall take responsibility, in cooperation with the teacher and the school, for the student learning the required course material identified on this form (State Board of Education Rule 277-474-5-D). This consent form may be sent to parents within 2 weeks after the beginning of the course, but not less than 2 weeks prior to instruction of the identified topics. Under state law, your child cannot participate in the scheduled instructional activity specified above unless and until this signed letter of permission is returned to the teacher identified on this form. Signed forms will be kept on file at the school for a minimum of one year. PLEASE SIGN AND RETURN I have read this form and have chosen one option from the preceding list. Parent/Guardian Signature: Telephone Number: : Curriculum or Board Rules may be read at, or printed from, at: www.schools.utah.gov/curr/healthpe
Nursing Assistant Class Information All Students: All students must complete a Criminal Background Check application on the first day of class. Any felony or misdemeanor conviction that you have on your record may negatively impact your chances of completing the program and being placed at an externship site. There will be no tuition or fee refund for students who are unable to complete the program due to their criminal record. Prospective students with a criminal record are strongly encouraged to contact the Program Coordinator, Cherie Crezee, at 801-612-4179 to discuss their record prior to enrolling in the program. Please note, many states including Utah, do not seal juvenile records. Any charge incurred in the last 7 years will show up on the background check. Tuberculosis (TB)** test results indicating a negative reading must be provided within 2 weeks of your program start date. (Test can be completed at the Health Department, Workmed, or any Health Provider of your choice) Proof of current TB test results (within 1 year) acceptable..high School students must pay for the background check at time of enrollment. High School Students will have a Curriculum Packet provided at no cost and classroom access to all other items below marked with a single asterisk. Items without an asterisk will be your responsibility to purchase. You are strongly encouraged to purchase your own textbook, workbook, stethoscope, and blood pressure cuff for after school use. Adult students are responsible for all costs listed below: Approximate Associated Costs in addition to tuition and fees: Textbook* $46.00 o Hartman s Nursing Assistant Care Long Term Care, 3rd ed. ISBN 978-1-60425-041-1 Curriculum Packet* $19.25 Ceil Blue Scrubs $36.00 (required at end of course for clinical prep and clinicals) Stethoscope* $15.00 Blood Pressure Cuff* $25.00 TB testing** $20.00 (health provider of your choice) CPR Supplies $11.00 Flu shot during flu season $30.00 (health provider of your choice) Total $202.25 High School Students are responsible for all costs listed below: Approximate Associated Costs: Background check fee $32.00 Ceil Blue Scrubs $36.00 (required at end of course for clinical prep and clinicals) TB testing** $20.00 (health provider of your choice) CPR Supplies $11.00 Flu shot during flu season $30.00 (health provider of your choice) Total $129.00 Workbook Hartman s Nursing Assistant Care- Long Term Care, 3rd ed. is not required but is recommended for all students. ISBN 978-1-60425-042-8 (Updated January 2018)