FALL 2016 Revised 6/09/2016 Certified Nursing Assistant Program Eligibility To become a Certified Nurse Aide you must: To help you apply I have included a checklist to guide you through the process. Meet with advisor Brandi Kerley to submit application for KRC: Certified Nursing Assistant. (Email complete application to [email protected]and call to schedule appointment 907.262.0353) Submit your Background Check information, as well as your debit/credit card payment for processing. Take a placement test to demonstrate necessary English and Math proficiency. Register and pay for the 6-credit course. Mail your fingerprint card packet to the State. Obtain proof of immunizations prior to start of class (may include blood test if you do not have your immunization records). Submit State exam application: Requires completion of an approved CNA course of 60 hours or more of classroom and lab instruction and 80 hours or more of clinical experience. NOTE: You could be eligible to take the CNA course, but not the state exam for licensing. Be sure to read the application thoroughly and answer all questions. High School Graduation or GED equivalency is not required for state licensing but may be required for employment! The HCA A105- 6 credit course is typically structured: Class and Lab 8/29-12/17 M-F 9am-3pm Clinicals 8/29-12/17 M-F 6am-3pm MANAGING COSTS Financial assistance may be available to help you manage the costs of the course. Ask your advisor to help you determine which programs you may be eligible for. Department of Labor Job Services, Alaska Job Center 907-335-3010 Department of Vocational Rehabilitation, 907-283-3133 or 1-800- 478-3136 KPC payment plan for tuition and fees. Ask about the EZ payment plan and other options at the KPC Financial Aid office. See the Estimated Cost breakdown on the following page.
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FALL 2016
Revised 6/09/2016
Certified Nursing Assistant Program Eligibility
To become a Certified Nurse Aide you must: To help you apply I have included a checklist to guide you through the process.
Meet with advisor Brandi Kerley to submit application for KRC: Certified Nursing Assistant. (Email complete application to [email protected] and call to schedule appointment 907.262.0353)
Submit your Background Check information, as well as your debit/credit card payment for processing.
Take a placement test to demonstrate necessary English and Math proficiency.
Register and pay for the 6-credit course.
Mail your fingerprint card packet to the State.
Obtain proof of immunizations prior to start of class (may include blood test if you do not have your immunization records).
Submit State exam application: Requires completion of an approved CNA course of 60 hours or more of classroom and lab instruction and 80 hours or more of clinical experience.
NOTE:
You could be eligible to take the CNA course, but not the state exam for licensing. Be sure to read the application thoroughly and answer all questions.
High School Graduation or GED equivalency is not required for state licensing but may be required for employment!
The HCA A105- 6 credit course is typically structured:
Class and Lab 8/29-12/17 M-F 9am-3pm
Clinicals 8/29-12/17 M-F 6am-3pm
MANAGING COSTS
Financial assistance may be available to help you manage the costs of the course. Ask your
advisor to help you determine which programs you may be eligible for.
Department of Labor Job Services, Alaska Job Center 907-335-3010
Department of Vocational Rehabilitation, 907-283-3133 or 1-800-
478-3136 KPC payment plan for tuition and fees. Ask about the EZ
payment plan and other options at the KPC Financial Aid office.
See the Estimated Cost breakdown on the following page.
b. Obtain fingerprints (2 sets) from VIP Alaska or Majority Arms c. Mail one set of fingerprints to:
State of Alaska: Dept. of Health & Social Services Division of Public Health Background Check Unit 4601 Business Park Blvd, Bldg. K Anchorage, AK 99503 Fax: (907) 269-3488
d. Keep second set of fingerprints for Licensing certification.
3. The advisor will verify all documents are present, input your BCP application into the
State electronic database It is your responsibility to mail the completed packet to the address listed above.
We understand that this process is unfamiliar, please call Brandi Kerley at 262-0353 if
you have questions!
A6. What records are checked by the BCP before a provisional clearance is issued? Before issuing a provisional clearance to an individual wishing to become a direct care service
provider, the BCP conducts an exhaustive background check. This background check includes
records from both Alaska and those states the individual has lived in for the past 10 years.
Records searched are:
Alaska Public Safety Information Network (APSIN) - APSIN serves as a central repository for Alaska criminal justice information. This information is also known as an “Interested Persons Report.”
Alaska Court System/Court View and Name Index – Provides civil and criminal case information and is used to assist in determination of disposition for cases in APSIN.
Juvenile Offender Management Information System (JOMIS) – JOMIS is the primary repository for juvenile offense history records for the State of Alaska, division of Juvenile Justice.
Centralized Registry (employee misconduct registry) – Includes those persons which have been investigated by a state investigator for abuse, neglect and/or exploitation, found guilty of abuse, neglect, and/or exploitation, and due process has been provided. Alaska and other states (birth and residence) as applicable.
Certified Nurse’s Aide (CNA) Registry – professional registry listing those individuals certified to perform duties as a CNA. In some states, this registry also serves an abuse registry. Alaska and other states (birth and residence) as applicable.
National Sex Offender Registry (NSOR) – The NSOR provides centralized access to registries from all 50 states, Guam, Puerto Rico and the District of Columbia.
Office of Inspector General (OIG) – A database which provides information relating to parties excluded from participation in the Medicare, Medicaid and all Federal health care programs.
And any other records/registries the Department deems are applicable.
FALL 2016
Revised 6/09/2016
STUDENT HEALTHCARE CHECKLIST
Please use this checklist to track your progress as you work to comply with these requirements. Keep all records of previous immunizations, TB skin testing and lab tests for immunities, together in a safe place. These documents will be needed as you seek employment in the health care field.
The following items are mandatory by federal and state regulations.
1. TB screening – QFT (quantiferon) TB Gold Test 2. Proof of immunity (lab test/titers) for:
Rubella
Rubeola (measles)
Mumps
Varicella zoster (chicken pox)
Hepatitis B 3. Immunizations (at any local provider)
Rubella
Rubeola (measles) or official documentation of 2 doses of MMR vaccine is acceptable. Only doses of vaccine with written documentation of date and location of receipt will be accepted as valid proof. Self-reported doses or parental report of vaccination is not considered adequate documentation.
Hepatitis B. If you don’t have documented evidence of a complete hepB vaccine series, or if you don’t have an up-to-date blood test that shows you are immune to Hepatitis B (i.e., no serologic evidence of immunity or other prior vaccination) then you should:
Get the 3-dose series (dose #1 now, #2 in a month, #3 approximately 5 months after #2)
Get anti-HBs serologic tested 1-2 months after dose #3
If unable to take a vaccine for a medical reason (e.g., allergy, previous reaction) you must provide a signed medical release from your health care provider listing the medical reason for exclusion from immunization.
4. Optional but recommended:
Mumps
Varicella zoster (chicken pox)
Hepatitis A
Flu Shot
FALL 2016
Revised 6/09/2016
Department of Health & Social
Services Background Check Program
RELEASE OF INFORMATION AUTHORIZATION FOR BACKGROUND CHECK
I, , authorize and consent to any person provided a copy or
facsimile of this Release of Information Authorization for Background Check by an authorized representative
of the Department of Health & Social Services, to disclose any information regarding me in relation to civil
court information, criminal justice, juvenile justice, protective service and licensing records. I understand
any person providing information or records in accordance with this authorization is released from any and
all claims or liability for compliance. I understand that this information may otherwise be confidential and
that I am waiving that confidentiality and any claim I may have with regard to release of these records. I
understand information obtained through this Release of Information Authorization for Background Check
will be held in confidence in accordance with DHSS guidelines.
I, , authorize and consent to the department
marking my name in the Alaska Public Safety Information Network (APSIN) under 7 AAC 10.915(e).
This form must be signed; if the individual is 16-17 years of age, a parent signature must also be included.
Applicant Printed Name Date
Applicant Signature Applicant SSN
Parent Printed Name (If applicable) Parent Signature
KPC: Kenai River Campus Certified Nursing Assistant Application
List your previous addresses for the past 10 years, beginning with the most recent.
Current STREET ADDRESS:
CITY, STATE:
ZIP CODE:
DATES AT THIS ADDRESS: *mm/yyyy - mm/yyyy
Does your mailing address differ from your physical address?
YES NO
Current MAILING ADDRESS:
CITY, STATE, ZIP CODE:
CITY:
STATE:
COUNTRY:
DATE AT THIS ADDRESS: *mm/yyyy- mm/yyyy
CITY:
STATE:
COUNTRY:
DATE AT THIS ADDRESS: *mm/yyyy -mm/yyyy
CITY:
STATE:
COUNTRY:
DATE AT THIS ADDRESS: *mm/yyyy mm/yyyy
Education
List your Education starting with most recent
NAME OF SCHOOL:
CITY, STATE:
DATES ATTENDED: mm/yyyy-mm/yyyy
GRADUATED:
NAME OF SCHOOL:
CITY, STATE:
DATES ATTENDED: mm/yyyy-mm/yyyy
GRADUATED:
NAME OF SCHOOL:
CITY, STATE:
DATES ATTENDED: mm/yyyy-mm/yyyy
GRADUATED:
Application Questions
WHY DO YOU WISH TO BECOME A CNA?
DESCRIBE ANY PREVIOUS HEALTHCARE EXPERIENCE YOU MAY HAVE: specify type and number of years
Are you presently taking health care courses toward a degree?
YES NO
Are you planning to take other courses during the duration of the CNA course:
YES NO
Do you have any problems with walking or standing for prolonged periods of time, including stooping and sitting?
YES NO
If yes, please explain
Are you currently BLS-CPR Certified: YESNO
What Date did you receive certification:
Barrier Crimes
Has a certificate ever been denied, revoked, suspended, on probation, or disciplined in any jurisdiction?
YES NO
Have you been in Treatment for mental illness in the last five years?
YES NO
Have you had any problems related to habitual use of drugs or alcohol within the last five years?
YES NO
Do you have any physical disability which may impair or interfere with your ability to practice as a nurse aide?
YES NO
Have you ever been convicted of any criminal offense other than minor traffic violations?
YES NO
I understand that marking yes to any of the above may disqualify me from the State Licensing Exam and it is my responsibility to contact the Alaska State Department of Health to determine eligibility. Refunds will not be issued from KPC for failure to do so.
YES NO
MEMORANDUM OF UNDERSTANDING
I am expected to purchase the required textbook/workbooks prior to the start of classes. I am expected to complete all reading and assignments.
I am expected to supply a copy of my American Heart Association BLS or First Aide Certification (If I have one) to my instructor. I understand that the BLS/First Aide Certification required must include 2-person, infant, child and adult resuscitation techniques.
Attendance requirements and absentee policies are strictly adhered to. A student cannot miss more than 12 total hours of class time, including time missed due to tardiness. Absolutely NO clinical time may be missed.
I will be expected to complete all written quizzes and the final tests.
I am expected to maintain a minimum average grade of "C": on all graded assignments.
I am expected to be able to move or lift 50lbs or 25% of my body weight, whichever is less, and be able to lift over my head.
I am expected to assume responsibility for my own learning with guidance from the instructor.
I am expected to wear clean, comfortable and appropriate clothing to class.
I am expected to wear Scrubs in class labs and other clinical training sites.
I understand the use of drugs or alcohol is unacceptable while caring for an individual and will disqualify me from the program.
I understand it is my responsibility to verify with the Alaska State Board of Nursing, whether I am eligible to apply for certification through the State of Alaska as a nursing assistant; and to become certified I must personally submit state test, application and certification fees.
I understand that being convicted of a crime does not prevent me from registering for the class, but may prevent me from attending the clinical portion of the course; and could therefore prevent me from completing the required clinical hours according to State certification standards.
I understand that no refund will be given for students who have taken the course but are ineligible for state licensing or examination, or are unable to complete the class due to criminal history.
I understand that I must drop this course before the published drop deadline in order to receive a 100% refund. After the deadline, there will be no refund.
The campus assumes no responsibility for illnesses and/or injuries experienced by students in conjunction with their CNA clinical experience; students who are injured while completing clinical assignments are responsible for all associated medical costs. It is strongly recommended that students maintain personal medical insurance. Students may purchase student insurance through UA's Student Health Service. Students are not covered by workers compensation through the University or medical facilities.
I have read the attached CNA Eligibility criteria and application requirements.
YES NO
I fully understand that I am responsible to follow the provisions and conditions set forth during the course.
YES NO
ALL INFORMATION CONTAINED IN THIS APPLICATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. Please print this form then sign and date on the line below.