PRACTICAL NURSE ADMISSION INFORMATION 4/24/18

PRACTICAL NURSE ADMISSION INFORMATION 4/24/18

PRACTICAL NURSE PROGRAM Student Application Form Applicant Signature Social Security #: / / Birthdate: / / MCC ID#: Full Name: Other Name(s) Used: Mailing Address: City: State: Zip: Primary Phone Number: ( ) MCC Student Email Address: Primary Email Address: Academic History List all colleges, universities and institutions attended, including high school. High School: Location: Degree: Dates: College: Location: Degree: Dates: College: Location: Degree: Dates: Other: Location: Degree: Dates: Practical Nursing Program Prerequisite: Please state if Completed or In Progress (Official Use Only) 100 level Biology or Biology Competency Location: Completed: Grade: In Progress: Verified: BIO 201: Anatomy & Physiology I Location: Completed: Grade: In Progress: Verified: ENG 101: English Composition I Location: Completed: Grade: In Progress: Verified: PSY 101: Introduction to Psychology Location: Completed: Grade: In Progress: Verified: Work History Last (5) years, beginning with most recent: Occupation/Job Title Employer City/State Start Date End Date 1 2 3 4 5 Licensure If you have a current licensure such as Arizona CNA or MA Certificate of an Allied Health profession or current license in another state, PLEASE submit a copy with this application. Are you a current resident of the State of Arizona? YES NO

Answer the Following Question 1. Have you ever been dismissed from any course or program? YES NO If YES, please explain and state which program: NOT Required for Admission: Required for Clinicals AZ DPS Fingerprint Clearance Card StudentCheck Online PreCheck Background Check Expiration Report #: Date Completed: Licensure is the sole responsibility of the Arizona State Board of Nursing. If you have been convicted of a felony, contact the Arizona State Board of Nursing to verify eligibility to be licensed prior to submitting this application. Disclaimer & Signature I understand that if accepted into the Practical Nurse Program, I will be required to travel for class lectures and clinical experiences, and that I will be responsible for my own transportation and meals. I understand that if accepted, if a clinical agency to which I have been assigned does not accept me based on my criminal background check it may result in my inability to complete the PN Program. I also understand that MCC Nursing department may, within its discretion, disclose to a clinical agency that I have been rejected by another clinical agency. I further understand that MCC has no obligation to place me when the reason for lack of placement is my criminal background check. Since clinical agency assignments are critical requirements for completion of the PN Program, I acknowledge that my inability to complete required clinical experience due to my criminal background check will result in non-completion of the PN Program. I understand that if accepted, I will be required to meet the health requirements of the PN Program. I hereby certify that the facts set forth in this Student Application are true and complete to the best of my knowledge. I understand that if accepted into the nursing program, any falsified statements on this application shall be considered cause for suspension or dismissal. Signature: Submit Completed Application To Mail To: Mohave Community College Nursing Programs Assistant 1801 Detroit Ave. Kingman, AZ 86401 (Or) Email to: Cheryl Pike cpike@mohave.edu

TEST OF ESSENTIAL ACADEMIC SKILLS (TEAS) MOHAVE COMMUNITY COLLEGE WHAT IS THE TEAS TEST? The Test of Essential Academic Skills evaluates nursing program applicants in four (4) foundational areas which are essential to your academic success in the Practical Nurse Program. The PN Program requires you to take the TEAS Test as an entrance examination. Basically, the test has four parts that ask you to answer multiple-choice questions covering the following: Reading: paragraph comprehension, passage comprehension, and inferences/conclusions. (48 items, 58 minutes) Math: Whole numbers, metric conversion, fractions, decimals, algebraic equations, percentages, and ratio/proportion. (34 items, 51 minutes) Science: science reasoning, science knowledge, biology, chemistry, anatomy, physiology, basic physical principles, and general science. (54 items, 66 minutes) English and Language Usage: punctuation, grammar, sentence structure, contextual words and spelling. (34 items, 34 minutes) Total of 170 multiple choice questions. WHO ADMINISTERS THE TEAS TEST? The Testing Centers at Mohave Community College administer the TEAS Test. The test is purchased from the Assessment Technologies Institute (ATI). Your TEAS scores are stored by ATI and are available to you and to your school via the Internet. You can also have TEAS results sent to other nursing schools at minimum cost through ATI. HOW MUCH DOES THE TEAS TEST COST? The cost of taking either test is $65.00 for students and $75.00 for non-students. HOW CAN I BEST PREPARE FOR TAKING THE TEAS TEST? A review of basic concepts and theories in mathematics, reading, science, English and language usage is recommended. ATI has two products, the TEAS Study Manual and a TEAS Online Practice Assessment, available to guide your review and provide feedback on your study progress. These products can be purchased online at the ATI website which is www.atitesting.com. CAN I USE A CALCULATOR ON THE TEAS TEST? Calculators are NOT allowed during the TEAS TEST. WHAT DO I BRING TO THE TESTING CENTER? Photo bearing identification such as a; passport, driver s license, student identification card. WHAT CANNOT BE BROUGHT TO THE TESTING CENTER? Cell phones, textbooks, backpacks, calculators. Scratch paper and pencils will be provided.

CAN YOU ACCOMMODATE STUDENTS WITH DISABILITIES? Students with documented disabilities requiring accommodations should contact the Disability Services Office at the local campus to make arrangements to take their test. Students requiring extra time will not be able to take the computer based test because the program is self-timing and cannot be adjusted. These students will be given a paper and pencil test instead. This test cannot be scored locally, but must be sent back to ATI for scoring, requiring at least a one (1) to two (2) week turnaround. Please take this into consideration when scheduling and allow sufficient time prior to nursing program application due dates. HOW LONG WILL IT TAKE TO GET MY TEAS TEST SCORES? If you have taken the computer administered TEAS Test, your scores are available immediately after the examination. If you have taken the pencil/paper version of the test, your examination will be scored within 24 hours of receipt by ATI. Note that the 24-hour window is NOT 24 hours from the time you tested, but within 24 hours of ATI s receipt of testing materials from Mohave Community College. HOW DO I KNOW IF I PASSED THE TEAS TEST? The applicant s adjusted individual total score must be at or above 60% to be considered for admission. CAN I RETEST TO GET A HIGHER SCORE? Tests may be retaken after a minimum of 30 days and up to 3 times a year. HOW TO REGISTER YOURSELF AS A TEST CANDIDATE FOR THE TEAS. If you are not a current user on www.atitesting.com, you need to set up a new account. This will allow you access to the testing and to complete a purchase on ATI s online store. Please follow the steps below to setup a new account: 1. Go to www.atitesting.com. Just under the Username and Password fill-in boxes, there is a small link that states, New to ATI? Create an account. Click on that link to register yourself with ATI. 2. Next, a web form will appear. Fill in all of the blue fields. Blue fields are required information necessary to create a new account. 3. You will receive an email from ATI confirming your user login and password. 4. You will need to bring your user name and password with you when you go to the testing center to take the TEAS. TO SCHEDULE THE TEAS TEST, CONTACT THE TESTING COORDINATOR AT YOUR LOCAL CAMPUS PROVIDED BELOW: Heather De Jesus: hdejesus@mohave.edu, Bullhead City Campus, 928-704-4165 Cheri Stromle: cstromle@mohave.edu, Neal Campus Kingman Campus, 928-757-4331 Kevin Smith: ksmith@mohave.edu, Lake Havasu City Campus, 928-302-5321 Kim Naylor: knaylor@mohave.edu, North Mohave Campus, 928-875-9124 MCC Toll Free: 866-664-2832 Reviewed 4/2018

PRACTICAL NURSE PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nurse Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: Please Return to: Department Of Nursing Mohave Community College 1801 Detroit Ave. Kingman, AZ 86401 Reviewed 4/2018

PRACTICAL NURSE PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nurse Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: Please Return To: Department Of Nursing Mohave Community College 1801 Detroit Ave. Kingman, AZ 86401 Reviewed 4/2018

PRACTICAL NURSE PROGRAM PROFESSIONAL REFERENCE FORM To Be Completed by Applicant (please print) Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting. Name: Address: (Street or P.O. Box) (City) (State) (Zip) The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission. I hereby waive my right of access to this letter of recommendation. Applicant s Signature: To be Completed by Evaluator This student is applying for admission to Mohave Community College Practical Nurse Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you. Please rate the applicant in each of the following areas: Excellent Good Average Poor Do Not Know Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment Overall Potential for Nursing Program *Any additional comments you feel might be of value to the Nursing Department, please state them on the back. Name: Agency Represented: Title: Address: (Street or P.O. Box) (City) (State) (Zip) Signature: Please Return To: Department Of Nursing Mohave Community College 1801 Detroit Ave. Kingman, AZ 86401 Reviewed 4/2018

TRANSCRIPT REQUEST (DO NOT SEND FOR MCC OFFICIAL TRANSCRIPTS) Institution Name Mailing Address City State Zip Please send one (1) OFFICIAL COPY of my transcript to: Mohave Community College 1971 Jagerson Ave. Kingman, AZ 86409 I do not know the Transcript fee, please bill me. I am enclosing the transcript fee of $ for (number) transcripts. PLEASE PRINT Student Name Social Security Number Mailing Address City State Zip Maiden or Previous Name(s) Address While attending your institution If there is a charge against my account, I hereby agree to clear all indebtedness before this record will be released. STUDENT is responsible for mailing this form Student Signature Reviewed 4/2018

Essential Skills & Functional Abilities for Nursing Mohave Community College Individuals who apply for admission to the Mohave Community College Nursing Program must be able to perform essential skills. Any applicant who has met the necessary prerequisites and who can perform the essential functions will be considered for admission. If a student believes that he or she cannot meet one or more of the standards without accommodations, the nursing program must determine, on an individual basis, whether a reasonable accommodation can be made. Functional Ability Standard EXAMPLES of required activities Motor Abilities Skills Gross Motor Skills Manual Dexterity Fine Motor Skills Physical abilities and mobility sufficient to execute gross motor skills, physical endurance, and strength, to provide patient care. Demonstrate fine motor skills sufficient for providing safe nursing care. Mobility sufficient to carry out patient care procedures such as assisting with ambulation of clients, administering CPR, assisting with turning and lifting patients, providing care in confined spaces such as treatment room or operating suite etc. Motor skills sufficient to handle small equipment such as insulin syringe and administer medications by all routes, perform tracheotomy suctioning, insert urinary catheter, etc. Perceptual Sensory Ability Visual Tactile Smell Sensory / perceptual / Auditory ability to monitor and assess clients Normal or corrected visual ability sufficient for accurate observation and performance of nursing care. Tactile ability sufficient for physical monitoring and assessment of health care needs. Olfactory ability sufficient to detect significant environmental and client orders. Sensory abilities sufficient to hear alarms, auscultatory sounds, cries for help, hears normal speaking levels sounds, etc. Visual acuity to read calibrations on 1cc syringe, assess color, see objects up to 20 ft. away (cyanosis, pallor, etc.) Tactile ability to feel pulses, temperature, palpate veins, etc. Olfactory ability to detect smoke or noxious odor, foul smelling drainage, alcohol, etc. Behavioral Interpersonal Emotional Emotional/Behavioral Ability to relate to colleagues, staff and patients with honesty, integrity, and nondiscrimination. Capacity for development of mature, sensitive and effective therapeutic relationships. Establish rapport with clients, instructors and members of health care team. Work with teams and workgroups. Professional Attitudes and Interpersonal Skills Interpersonal abilities sufficient for interaction with individuals, supervisors, members of health care Establish and maintain therapeutic boundaries.

team, families and groups from various social, emotional, cultural and intellectual backgrounds, achieve a positive and safe work environment. Ability to work constructively in stressful and changing environments with the ability to modify behavior in response to constructive criticism. Follow instructions and safety protocols. Capacity to demonstrate ethical behavior, including adherence to the professional nursing and student honor codes. Emotional skills sufficient to remain calm in an emergency situation and maintain behavioral decorum in stressful situations. Behavioral skills sufficient to demonstrate the exercise of good judgment and prompt completion of all responsibilities attendant to the diagnosis and care of clients. Honesty and integrity beyond reproach. Adapt rapidly to environmental/stress changes and multiple task demands. Exhibit ethical behaviors and exercise good judgment. Communication Ability to communicate in English with accuracy, clarity and efficiency with patients, their families and other members of the healthcare team (including spoken and nonverbal communication, such as interpretation of facial expressions, affect and body language.) Required communication abilities, including speech, hearing, reading, writing, language skills and computer literacy. Gives verbal directions to or follows verbal directions from other members of the healthcare team and participates in healthcare team discussions of client care. Elicits and records information about health history, current health state and responses to treatment from clients or family members. Conveys information to clients and others as necessary to teach, direct and counsel individuals in an accurate, effective and timely manner. Establishes and maintain effective working relations with clients and co-workers. Recognizes and reports critical client information to other caregivers. Cognitive Conceptual Quantitative Abilities Ability to read and understand written documents in English and solve problems involving measurement, calculation, reasoning, analysis and synthesis. Calculates appropriate medication dosage given specific client parameters. Analyzes and synthesize data and development of an appropriate plan of care.

Ability to gather data, to develop a plan of actions, establish priorities and monitor and evaluate treatment plans and modalities. Ability to comprehend three-dimensional and spatial relationships. Ability to react effectively in an emergency situation. Collects data, prioritize needs and anticipate reactions. Comprehend spatial relationships adequate to properly administer injections, start intravenous lines or assess wounds of varying depths. Recognizes an emergency situation and responds effectively to safeguard the client and other caregivers. Transfers knowledge from one situation to another. Accurately processes information on electronic medical records (EMR), medication container, physicians orders, and monitor equipment calibrations, printed documents, flow sheets, graphic sheets, medication administration records, other medical records and policy and procedure manuals. Safe environment for patients, families, and co-workers Ability to accurately identify patients. Ability to effectively communicate with other caregivers. Ability to administer medications safely and accurately. Ability to operate equipment safely in the clinical area. Prioritizes tasks to ensure client safety and standard of care. Maintains adequate concentration and attention in inpatient care settings. Seeks assistance when clinical situation requires a higher level or expertise/experience. Ability to recognize and minimize hazards that could increase healthcare associated infections. Ability to recognize and minimize accident hazards in the clinical setting including hazards that contribute to patient, family, and co-worker falls. Responds to monitor alarms, emergency signals, call bells from clients, and orders in a rapid and effective manner.

Computer and Internet Use Ability to use a computer, including common software applications. Ability to access the community college s intranet programs. Ability to access and use the Internet. Proficient in using word processing software to prepare assignments. Use computer to access Mohave Community College s student email system, College Learning Management System (Schoology) and other software programs as assigned by instructor. Use computer to access websites on the Internet/World Wide Web to obtain references, take tests, access learning materials and other assigned uses. Revised 4/2018