Baton Rouge Community College

Nurse Assisting (HCNA 1215) Course – Acadian Campus

APPLICATION PACKET All students enrolling in HCNA 1215

must complete this application packet

Contact Mary Stewart, Course Manager, Before Completing This Packet

RETURN COMPLETED APPLICATION IN PERSON TO

BRCC FRAZIER CAMPUS – Room 201 – 4, 555 Julia Street, Baton Rouge, LA, 70802

Contact: Mary Stewart, Course Manager 225. 359. 9427 stewartm2@mybrcc.edu

Applications returned through the mail will not be accepted

For additional information please contact:

Rosalind Martin – 225.359.9233 – BRCC Frazier Campus

It is the policy of Baton Rouge Community College not to discriminate on the basis of age, sex, race, color, religion, national origin or disability in its educational programs, activities or employment policies.

Rev- 3-2019

INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED

Application Packet Deadline to enroll in

Summer 2019: Thursday, May 9, 2019 by 3:00 pm Fall 2019: Thursday, July 25, 2019 by 3:00 pm

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COURSE INFORMATION

HCNA 1215 Nurse Assisting HCNA 1215 Nurse Assisting prepares students for employment in long-term care facilities, home health agencies, and hospitals where basic bedside care is needed as a Certified Nurse Assistant (CNA). Classroom instruction includes an introduction to health care, essential OBRA skills required for certification, body structure and function, and the job-seeking process, with an introduction to computer skills as it relates to the health care industry. Students participate in clinical activities at approved facilities under the supervision of the instructor. Upon successful completion of this nurse aid training and competency evaluation program (NATCEP) the student will qualify to take the national exam to obtain CNA certification through the testing organization identified by the state of Louisiana.

COURSE: HCNA 1215 Nurse Assisting is a 4 credit hour course that includes 80 hours of classroom and laboratory training and 45 hours of external clinical.

APPLICATION PROCESS

STEP 1 COMPLETE THE BATON ROUGE COMMUNITY COLLEGE ADMISSION PROCESS

In order to enroll into the HCNA 1215 Nurse Assistant course the student must complete the BRCC admission requirements.

STEP 2 MUST OBTAIN REQUIRED TEST SCORE BEFORE PRECEDING TO STEP 3

One of the following admission scores are required:

Type of Assessment ACCUPLACER ACT COMPASS* College Level English

Reading 53 14 62 Pass

*COMPASS, scores, if applicable, cannot be more than three years older than the date of admission

STEP 3 COMPLETE AND SUBMIT, IN PERSON, ALL COMPONENTS OF THE REQUIRED ADMISSION APPLICATION

All components of the required application must be submitted in person. Applications submitted via the mail or electronically will not be accepted.

STEP 4 ENROLLMENT

1. Approval will be granted to the student to enroll in HCNA 1215 when the application is complete. 2. The student must enroll themselves into HCNA 1215 after approval has been granted.

STEP 5 HCNA 1215 COMPLETION

1. Students must satisfactorily complete all components of HCNA 1215 (lecture, lab, clinical and the final exam)

with a minimal passing grade of (C) to be submitted for Nurse Assistant (CNA) Certification.

2. Students will follow the process to contact the testing company approved by the Louisiana Department of

Health and Hospitals in order to complete the CNA National Certification Test.

3. Students planning to pursue Practical Nursing (LPN) at BRCC must attain a "B" or higher in HCNA 1215.

4. Completion of HCNA 1215 does not guarantee admittance to a BRCC Practical Nursing program nor does

completion guarantee certification as a CNA.

CRIMINAL BACKGROUND CHECK Applicants to HCNA 1215 must submit to a criminal background check, through the Louisiana State Police Department, with all costs borne by the student. Complete the RIGHT TO REVIEW form and take it to the Louisiana State Police Department for processing. Applicants who have been charged with, pled guilty or nolo contendere to, been convicted of, or committed a criminal offense that involves a crime of violence or distribution of drugs, abuse, neglecting or mistreating the elderly or infirm, or misappropriating property may be denied the right to enroll in the course.

NATIONAL SEX OFFENDER PUBLIC REGISTRY CHECK The name of each applicant to the Nurse Assistant course will be submitted to the National Sex Offender Public Registry for verification.

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RETURN COMPLETED APPLICATION IN PERSON TO: BRCC Acadian Campus, Baton Rouge, LA Room 209

Do Not Mail DEADLINE

Summer 2019: May 9, 2019 by pm 3:00 pm Fall 2019: July 25, 2019 by 3:00 pm

INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED AND THE APPLICATION PERIOD WILL NOT BE EXTENDED

NURSE ASSISTING (HCNA 1215) APPLICATION – BRCC Acadian Campus You must print & complete this application page

INDICATE STATUS APPLICATION REQUIREMENTS

_____ Complete

1. Registered as a BRCC student. Include your L# or B#

_____ Complete Score/_____Date:_______

2. Reading Accuplacer score "53" /ACT of 14"/COMPASS of “62” or College English

_ Complete Exp. Date: _________

3. American Heart Association (AHA) Basic Life Support (BLS) provider card

__ Complete

4. Background check from Louisiana State Police – Right to Review

__ Complete

5. Physical Exam - Personal Attestation form

_ Complete

6. Physical Exam - Physician form

_____ Complete

7. Immunization record (flu immunization required in season); If no immunization record, need Titer for Rubella, Mumps, Hepatitis B)

_____ Complete

8. Urine drug screen with complete printed results

__ Yes __ No

9. Are you currently on the Nurse Aide or Direct Service Worker Registry?

__ Yes __ No ______ N/A

10. Have you ever had a healthcare credential/ certification revoked?

______Yes ______No

11. Have you been the subject of disciplinary action by any state agency?

PERSONAL INFORMATION

Last Name First Name Middle Name

Mailing Address City / State Zip Code

Home Phone Number

( )

Cell Phone Number

( )

E-Mail Address Student ID Number

OTHER REQUIRED INFORMATION Are you a licensed/certified healthcare provider?

❏ Yes ❏ No

License Number

Exp. Date

Are you applying to the LPN track?

❏ Yes ❏ No

HCNA 1215 is a pre-requisite course for BRCC Practical

Nursing program

Did you complete high school?

❏ Yes ___diploma ___ GED ❏ No

Do you have additional post-secondary degrees?

❏ Yes ❏ No

Please list additional degrees earned

I would like to apply for the HCNA 1215, Nurse Assisting course. I understand that any attempt on my part to falsify or

exclude information is cause for disqualification of my application and / or dismissal from the program. I hereby certify that all information presented is true to the best of my knowledge. I understand completion of HCNA 1215 does not guarantee admission to a BRCC Practical Nursing program nor certification as a CNA.

Student Signature Date . Received by Date Time .

OFFICE USE ONLY

DATE PACKET APPROVED: __________

DATE NOTIFIED: _____________

COURSE SECTION: ______________

CNA REGISTRY CHECK: ___________

DSW REGISTRY CHECK: ___________

SEX OFFENDER REGISTRY: ___________

BATON ROUGE COMMUNITY COLLEGE NURSING DEPARTMENT

Health History and Physical Examination

HEALTH HISTORY to be completed by applicant

Last Name First Name Middle Name

Banner # Date of Birth

(Month / Day / Year)

Gender M ❏ Male F ❏ Female

Racial / Ethnic Group

A ❏ Asian A.I. ❏ American Indian B ❏ Black H ❏ Hispanic/Latino P.I. ❏ Pacific Islander W ❏ White O ❏ Other

Mailing Address City / State Zip Code

Home Phone Number

( )

Cell Phone Number

( )

E-Mail Address

Emergency Contact

(Name / Relationship)

Emergency Contact Number

( )

Have you ever been treated, or are you receiving treatment for any of the following conditions -mark all that apply and comment below.

YE S*

NO Condition YES* NO Condition YES* NO Condition

Alcohol/Substance Abuse Diabetes Orthopedic Disorder

Allergies: Food Eating Disorder Seizure Disorder

Allergies: Medication Emotional Disorder Social Disorder

Asthma Heart Disorder Trauma

Back Injury / Disorder Hearing Disorder Tuberculosis

Blood Disorder Intestinal Disease Vision Disorder

Cancer Kidney Disease Pregnancy

*Provide dates and an explanation for “yes” responses in the space provided below. * Please use additional paper if needed to fully explain your ‘yes’ answers.

Explanations / Other:

List Surgical History:

List Routine Medications:

Do you have any disorder or disability that limits cognitive awareness?

All pre-existing medical conditions require a medical release from your health care provider. Attached? ❏ Yes ❏ N/A

My signature indicates I have no injury or illness and amble to meet technical performance standards. I will notify the program head of health changes. I understand that falsification, omission, or misrepresentation of my health and abilities may result in dismissal from BRCC nursing and allied health programs.

APPLICANT SIGNATURE_______________________________________________________________ DATE_________________

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BATON ROUGE COMMUNITY COLLEGE NURSING DEPARTMENT Health History and Physical Examination

PHYSICAL EXAMINATION to be completed by physician/licensed prescriber

Last Name: First Name: Middle Initial:

System NORMAL ABNORMAL COMMENTS

General Health

Cardiovascular

Endocrine

Extremities

HEENT

Gastrointestinal

Neurologic

Respiratory

Reproductive

Pregnant students: Can the student meet technical performance standards including the ability to lift 20 lbs? Yes ______ No ______ N/A _______

Skeletal

Skin

Urinary

B/P

Pulse Resp Temp Weight Height

IMMUNIZATION DOCUMENTATION Please attach copies of immunization records and lab results*

REQUIRED IMMUNIZATION / LABS DATE RESULTS / COMMENTS

CBC

MMR and Rubella Immunization or Titer*

Hepatitis B Vaccine Series* Dates of vaccination #1 #2 #3

Or Date and result of Hepatitis B Vaccine Titer*

TB Skin Test*(administered by _________________)

Neg Pos Date read _______ Read by________________

If (+) TB skin test treatment received?

If (+) TB attach copy of most recent Chest x-ray

VDRL / RPR*

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Last Name: First Name: Middle Initial

Flu Vaccine (as per seasonal requirements)

Urine Drug Screen* 9 Panel (Include copy of Printed Results)

Does the student have any physical, medical, or mental conditions that would impede their ability to provide safe and complete ent care

of patients in a health care environment? ❏ No ❏ Yes (please comment below)

Examining Health Care Physician/Provider: Date: ___________________

TECHNICAL PERFOMANCE STANDARDS

Students enrolled must demonstrate the ability to meet the following technical/performance standards while receiving classroom and clinical instruction as outlined in the course syllabus.

1. Read and communicate orally and in writing using the English language.

2. Hear with or without auditory aids to understand normal speaking voice without viewing the speaker's face.

3. Visually, with or without corrective lenses, observe changes in resident/patient/client's condition and actively participate in the learning process. 4. Utilize stamina, strength and psychomotor coordination necessary to perform routine nurse assistant/aide procedures at floor and bed level.

5. Demonstrate use of gross and fine motor skills necessary to provide independent, safe and effective nurse assistant/aide care. 6. Able to lift at least 20 lbs during the performance of nursing care duties in the skills lab and clinical setting

7. Solve basic care problems and apply critical thinking skills while providing safe and efficient patient care.

8. Interact with individuals/families/groups from various socioeconomic and cultural backgrounds.

9. Function in a multi-stressor environment while adhering to legal/ethical guidelines of the college, program, regulatory, and clinical agencies.

Comments: I attest this student can meet the technical/performance standards: Examining Health Care Physician/Provider: _ Date:

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BATON ROUGE COMMUNITY COLLEGE SITE LOCATONS