personal support worker (psw) diploma program- blended ... · immunization and physical fitness...

Name:____________________Program:____________________ Date:____________________

SE Health Career College & First Nation, Inuit, and Metis Programs October 2019

Admission Criteria for the program are as follows:

1. Complete and submit the PSW Program- Blended Delivery admission Application form.2. Have Grade 12 Secondary School Diploma or equivalent, or a General Educational

Development (GED) certificate or have Advance Standing documentation OR be of MatureStudent Status (Be 19 years of age or older and attain a passing score on the College EnglishLiteracy Test)

3. Successful completion of an English Literacy Test provided by the College.4. Complete and up to date Immunization and Physical Fitness Form (to be completed by a

licensed physician, nurse (RN) or a nurse practitioner). Immunization for Hepatitis B andInfluenza is recommended: The student may not be able to complete the clinical or practicumplacement unless immunization for Hepatitis B and Influenza is documented.

5. All students must obtain and submit a Police Check (Clearance) of Criminal Record withVulnerable Sector check. These checks will be accepted if dated within 6 months of theapplication deadline.

6. All students must obtain and submit a Child Registry Check. This check will be accepted ifdated within 3 months of the application deadline.

7. Completion of the Evidence of Community Support section of the Application form on page3 by the community’s Health Director/HCC Coordinator. This section providesdocumentation of community support for the applicant to participate in the training andsupport to attend the in-person weeks (Maximum of 8 weeks) of the training in thedesignated location.

Please do NOT send in your original certificates or documentation.

Personal Support Worker (PSW) Diploma Program- Blended Delivery ADMISSION CRITERIA & REQUIRED DOCUMENTATION



Required Documentation: Failure to submit required documentation within the required time-lines will result in your application being canceled. You must submit the following by the application deadline: • High School or General Educational Development (GED) - High school or GED transcripts

may be submitted by you and must be originals printed on school letterhead, signed by a school official, and sealed with the school seal.

• Police Check (Clearance) of Criminal Record with Vulnerable Sector check- the record must be recent (dated within 6 months of the application deadline).

• Child Abuse Registry Check- the record must be recent (dated within 3 months of the application deadline).

• Immunization and Physical Fitness Form- completed by a licensed physician, nurse (RN) or a nurse practitioner.

• Evidence of Community Support- the Evidence of Community Support section Pg. 3 of the Application form is to be reviewed, completed and signed by the Health Director or Home and Community Care Coordinator.

• CPR and First Aid Training and Food Handlers training will be provided by SE health during the training sessions. If a student chooses to opt out of the training, due to having already completing the certificates, proof of the certificates are required prior to the start date of the program. If a student does not attend the scheduled training and does not have the certificates, the student will be required to schedule the training on his/her own time and at the expense of the student.


Personal Support Worker (PSW) Diploma Program- Blended Delivery ADMISSION CRITERIA & REQUIRED DOCUMENTATION



HOW TO APPLY Please submit the following by the application deadline:

• Completed Application Form• Required documentation.• Refer to the Submission of Required Documentation section on page 2 & 3.• Evidence of Community Support section reviewed, completed and signed by the Health Director on page 3.

Please mail, e-mail or fax to: Program Administrator Dilico Anishinabek Family Care, Health Services 200 Anemki Place Fort William First Nation, ON P7J 1L6 E-mail: [email protected]: 1-807-626-7999

If you have any additional questions or concerns please contact Yolanda Wanakamik at 1-807-632-5781 or by calling 1-855-632-8511.

PERSONAL INFORMATION (All information is required)

Name: (First Name, Middle Name, Last Name) Previous Last Name: (if applicable)

First Nation/Community Name:

Mailing Address: (First Nation, Province, Postal Code)

Phone Number: Home: Work: Cell: Other:

Email Address: (must include) Date of Birth (mm/dd/yyyy):

APPLICATION FORM Personal Support Worker (PSW) Diploma Program- Blended Delivery

mailto:[email protected]



EDUCATIONAL AND WORK EXPERIENCE BACKGROUND

Did you graduate from a Grade 12 Secondary School Diploma or equivalent, or a General Educational Development (GED) certificate?

Yes

No

If yes, what school and program did you graduate from and date you graduated?

*If no, please note, you have the option to apply as a Mature Student(Be 19 years of age or older and attain a passing score on the CollegeEntrance Test).

Are you a Mature Student?

Yes

No

If yes, you will be required to take a College Entrance Test.

Are you currently employed as a Personal Support Worker (PSW)?

Yes

No

If yes, how long have you been employed as a PSW? If yes, which programs are you employed in (example Home and Community Care)?

. Do you require a flight from your community?

� YES

� NO



SUBMISSION OF REQUIRED DOCUMENTATION Failure to submit required documentation within the required timelines will result in your application being cancelled. You must submit the following by the application deadline. • High School or General Educational Development (GED) - High school or GED transcripts

may be submitted by you and must be originals printed on school letterhead, signed by a school official, and sealed with the school seal.

• Police Check (Clearance) of Criminal Record with Vulnerable Sector check- the record must be recent (dated within 6 months of the application deadline).

• Child Abuse Registry Check- the record must be recent (dated within 3 months of the application deadline).

• Immunization and Physical Fitness Form- completed by a licensed physician, nurse (RN) or a nurse practitioner.

• Evidence of Community Support- the Evidence of Community Support section below is to be reviewed, completed and signed by the Health Director or Home and Community Care Coordinator.

• CPR & First Aid Certification as well as Food Handlers must have proof of completion.




EVIDENCE OF COMMUNITY SUPPORT

***Required document MUST be completed by the Health Director or Home and Community Care Coordinator***

I have been provided with the background information on the PSW Diploma Program- Blended Delivery and I fully support the applicant in attending this training. Supports will include time to attend Virtual Gatherings (2-3 hours a week), complete course work (3-4 hours a week) on average. I am also confirming the community will support the applicant to attend the in-person weeks (Maximum of 8 weeks).

Name of Student (Print):_____________________________________

Name (Print):______________________________________________

Title:______________________________________________________

Community Name:__________________________________________

Address:___________________________________________________

Phone:____________________________________________________

E-mail:____________________________________________________

Signature: X_______________________________________________



APPLICANT DECLARATION PLEASE AFFIRM THE FOLLOWING BEFORE YOU SUBMIT YOUR APPLICATION. I have read, understood, and agree to the following declaration:

• I have read and understood the program admission requirements and application instructionsincluding the section regarding use of personal information.

• I am prepared to submit required documentation within the next 30 days.• I understand my application will be cancelled if I fail to submit required documentation or

fail to respond to College communications within the deadlines specified.

• I understand that misrepresentation, falsification of documents, or the withholding of requestedinformation with respect to my application may result in cancellation of my application,acceptance, and registration, or dismissal from the College.

• I accept that any information on falsified documents may be shared with the Association ofRegistrars of the Universities and Colleges of Canada.

• I understand that the start date I am applying to may change, and that the College cannotguarantee admittance into a specific start date.

I have read, understood, and agree to the following declaration:

• I understand it is my responsibility to notify the College of changes to my personalinformation including my name, address, phone number, and e-mail address. Therefore, Iunderstand College communication returned as undeliverable will result in my applicationbeing cancelled.

APPLICANT SIGNATURE After the processing of your application, you will be sent an e-mail confirming receipt of your application.

Date:____________________________________________________

Signature: X _____________________________________________



ADMISSION CRITERIA

Admission Criteria for the program are as follows:

1. Complete and submit the PSW Program- Blended Delivery admission Application form.2. Have Grade 12 Secondary School Diploma or equivalent, or a General Educational

Development (GED) certificate or have Advance Standing documentation OR be of MatureStudent Status (Be 19 years of age or older and attain a passing score on the College EnglishLiteracy Test)

3. Successful completion of an English Literacy Test provided by the College.4. Complete and up to date Immunization and Physical Fitness Form (to be completed by a

licensed physician, nurse (RN) or a nurse practitioner). Immunization for Hepatitis B andInfluenza is recommended: The student may not be able to complete the clinical or practicumplacement unless immunization for Hepatitis B and Influenza is documented.

5. All students must obtain and submit a Police Check (Clearance) of Criminal Record withVulnerable Sector check. These checks will be accepted if dated within 6 months of theapplication deadline.

6. All students must obtain and submit a Child Registry Check. This check will be accepted ifdated within 3 months of the application deadline.

7. Completion of the Evidence of Community Support section of the Application form on page3 by the community’s Health Director/HCC Coordinator. This section providesdocumentation of community support for the applicant to participate in the training andsupport to attend the in-person weeks (Maximum of 8 weeks) of the training in thedesignated location.




IMMUNIZATION AND PHYSICAL FITNESS FORM INSTRUCTIONS

As part of the admission requirements for the PSW Diploma Program and the CHR Certificate Program students are required to provide medical evidence completed by a licensed physician or nurse practitioner which states the applicant is in good physical and mental health. Proof of up-to- date immunization for preventable diseases and negative TB test are also a requirement.

No student will be able to commence practice education placements or practicums until the following medical documents have been obtained and submitted to the College. For immunizations, please see your local Health Centre/Office, Nursing Station or your family doctor.

The following list is the required vaccinations for preventable diseases: 1. Diphtheria/Tetanus2. Proof of basic immunization and booster in past 10 years3. Poliomyelitis4. Proof of basic immunization series of polio vaccine plus single booster dose after 10 years of

primary series5. Those with no basic series should have the series completed regardless of interval of last dose6. Measles, Mumps and Rubella (MMR)7. For those born after 1957, proof of two doses of MMR vaccine or reactive serology test for

immunity8. Varicella (chicken pox)

• Proof of vaccination or a positive history9. Hepatitis B

• Proof of Hepatitis B vaccine series10. Influenza Vaccination

• Proof of annual vaccine11. Tuberculosis (TB)

• A negative skin test dated within 6 months of the first placement12. For those with a positive skin test (10 mm or more) a negative chest x-ray is required within a

year of the first practice placement

Please submit the completed form by mail, e-mail or confidential fax to:

Program Administrator Program Administrator Dilico Anishinabek Family Care, Health Services 200 Anemki Place Fort William First Nation, ON P7J 1L6 E-mail: [email protected]: 1-807-626-7999

If you have any additional questions or concerns please contact Yolanda Wanakamik at 1-807-632-5781 or by calling 1-855-632-8511.

mailto:[email protected]



PERSONAL SUPPORT WORKER (PSW) DIPLOMA PROGRAM

PRE-ADMISSION MEDICAL HEALTH RECORD Program Name: Program Start Date:

Last Name: First Name:

Telephone Number: e-mail address:

Address (Community Name, Province, Postal Code)

IMMUNIZATION

TO COMPLETE THIS FORM Check with your family doctor or local health unit (Nursing Station, Health Centre) for your childhood

immunization records. Take your immunization records and this form to your doctor or nurse practitioner to review and complete.

*Dates to be in DD/MM/YYYY format

TETANUS/DIPHTHERIA Tetanus, Diphtheria Tetanus, Diphtheria and Polio

Yes □ No □ No Record □

Date of last Tetanus Vaccination: __________________

POLIO Childhood primary series Yes □ No □ No Record □

Date of last Polio Vaccination: __________________

MEASLES, MUMPS AND RUBELLA Mandatory: 2 documented MMRs Yes □ No □ No Record □

MMR #1 Date: :__________________ MMR #2 Date: :__________________



VARICELLA (CHICKEN POX) History of disease or herpes zoster? Yes No

If Yes, Date:

*If yes, no titre is required.*If no, titre is required and Adult Primary Series of 2 doses required if there is inadequate immunity

Immunization:

Yes □ No □ No Record □Date of Varicella Vaccinations: Dose #1 Date: __________________ Dose #2 Date: __________________

Hepatitis B (Recommended) Primary Series (3 doses) completed Yes □ No □ No Record □

Dates of Hepatitis B Vaccinations: Dose #1 Date: __________________ Dose #2 Date: __________________ Dose #3 Date: __________________

Influenza (Recommended) Yes □ No □ No Record □Date of last Flu Vaccine:

TESTS REQUIRED (Before starting the Personal Support Worker Certificate Program)

Tuberculosis Tests (Required) TB Skin Test (Two Step Mantoux) required. Note: If the TB Skin Test is positive (≥10 mm), it must be followed up with an x-ray. If the x-ray is positive for TB the individual will not be admitted into the PSW Certificate Program.

Test Date: 1st Step Date:___________________________

1st Step Result:____________________ 2nd Step Date: ______________________

2nd Step Result:___________________

Chest X-RAY (if Mantoux positive) Result Date:__________________

Rubella Titre (if not immunized) Result Date:__________________

Varicella Titre (if not immunized) Result Date:__________________

Hepatitis B surface Antigen (post- immunization or not immunized)

Result Date:__________________

Hepatitis B surface Antibody (if antigen is positive)

Result Date:__________________



CHECK LIST OF ESSENTIAL PHYSICAL ABILITIES

Physical Demand Sample Duties Demonstrated Ability Yes No

Lifting (up to 25 kg) Laundry, groceries, use of equipment (lifts, vacuum, etc.)

Carrying and shifting weight (up to 25 kg)

Client transfers and positioning, assisting with personal care, groceries, laundry

Mobility: 1. Limbs/back2. Bending3. Crouching4. Kneeling5. Balancing6. Sitting7. Standing (possibly for long

periods)8. Climbing stairs (leg and knee

flexibility)9. Pushing and pulling10. Reaching11. Hand/arm and shoulder dexterity

• Housekeeping duties• Client transfers and repositioning• Assisting with personal care

Hearing • Assisting with personal care• Client safety• Conversations and other sounds

Vision: • Color• Depth• Spatial

• Client safety• Medication• Meal preparation



PHYSICIAN OR NURSE PRACTITIONER COMPLETING THE REPORT Is the applicant fit physically? Yes No I certify that the information contained within this report is accurate and up-to-date.

(Name: Please Print) (Telephone)

(Address) X____________________________________ (Signature) (Date)

personal support worker (psw) diploma program- blended ... · immunization and physical fitness...

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