CNA Application 

CNA/HHA APPLICATION

APPLICATION COMPLETION CHECKLIST APPLICATION STEPS

COUNSELOR INITIALS

DATE COMPLETED

APPLICATION COMPLETION CHECKLIST: Complete steps and bring to Counseling Appointment Counseling Appointment: Date__________________________Time____________ CERTIFIED BACKGROUND CHECK: Complete online request and bring confirmation email to Counseling Appointment (Page 3) HEALTH CAREERS PROGRAMS: Complete CNA/HHA Application and bring to Counseling Appointment (Pages 4-5) LIVE SCAN: Make an appointment at Sherriff or Police Department, and bring completed form and receipt to Counseling Appointment (Pages 6-9) HEALTH EXAM: Make an appointment with MD, PA, or NP, and bring completed form to Counseling Appointment. All Health Exam Forms must be stamped with Provider Name, Address and Phone Number. Health Care Provider must sign and should stamp the page or attach a card or blank page from prescription pad that includes the Name and License Number. (Pages 10-11) IMMUNIZATION RECORDS: Attach Proof of Vaccines and provide results of a blood titer showing immunity, and bring to Counseling Appointment (Page 12) URINE DRUG SCREEN: Must be done by first day of class and may not be older than 30 days. Please bring your receipt for the screening to the CNA Orientation. NOTE: College does not pay for the initial drug screening (Page 15) NURSE ASSISTANT AND/OR HOME HEALTH AID INITIAL APPLICATION: The California State Application will be provided at the Orientation. The Instructor will assist students to complete and will collect the Application and mail them, return receipt, to the DHS Office in Sacramento.

CNA ORIENTATION: CNA Orientation will be held according to the following schedule based on campus: IWV (Ridgecrest)................... Wednesday, two weeks prior to the first date of class, 6:00pm, East Village, Modular #10 KRV (Lake Isabella)................................................................................................................................................................. ESCC (Bishop/Mammoth) Bishop.......................................................................................................................................... Mammoth.................................................................................................................................... CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 2

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CNA/HHA APPLICATION

CNA/HHA APPLICATION READ ALL INFORMATION CAREFULLY PROGRAM APPLING FOR: CNA*_________ or HHA* _________ (Copy of current CNA Card:__________________________ Expiration Date:______________________) CAMPUS:

 IWV

 KRV

 BISHOP

*SEPARATE CCCC APPLICATIONS ARE REQUIRED FOR THE CNA AND THE HHA PROGRAM NOTE: CNA/HHA students are required to bring completed application packet to the first day of class including proof of LIVESCAN and the BLANK DHS Application, which will be completed in class. The Instructor will send to the Department of Health Services. DEADLINE:

DATE SUBMITTED:

LAST NAME: OTHER NAMES USED:

FIRST NAME: STUDENT ID: @

MIDDLE INITIAL: PHONE #:

STREET ADDRESS: CITY:

STATE:

EMAIL:

ZIP:

@email.cerrocoso.edu (or email.bakersfieldcollege.edu or email.portervillecollege.edu)

PERSONAL EMAIL: EDUCATIONAL BACKGROUND NAME OF HIGH SCHOOL, TECHNICAL SCHOOL OR COLLEGE

ADDRESS

HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OTHER THAN A MINOR TRAFFIC OFFENSE?

DATES ATTENDED DEGREE OR CERTIFICATE OBTAINED

 NO

UNITS COMPLETED

GRADUATION DATE

 YES

(A YES response does not necessarily eliminate you as a CNA/HHA candidate. Final clearance from the Department of Health Services must be obtained by the student. All DHS regulations must be met before the student will be allowed to take the state certification testing.) WORK EXPERIENCE WORK EXPERIENCE (NAME OF MOST RECENT EMPLOYER FIRST)

ADDRESS

DATES

REASON FOR LEAVING

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 4

CNA/HHA APPLICATION

NOTICE: READ AND SIGN BELOW 1. Falsification of any information may be grounds for non-selection or dismissal from the Program. 2. The student must provide the DHS with the appropriate application(s) and fingerprints PRIOR to enrolling in a CCCC CNA or HHA course. A written acknowledgment / receipt of proper procedural compliance to the regulations of the Department of Health Services must be attached to this application. (Refer to: Admission Requirements and Procedures for Certified Nurse Aide and Home Health Aide Programs.) 3. To successfully complete the course/s, the student must pass the CNA and/or HHA course with a grade of C or better in theory and a grade of Pass in all clinical components. Graduation from the nurse’s aide class does not guarantee that the student will successfully pass the state-mandated nurse’s aide certificate exam nor that the Department of Health Services will issue the graduate a certificate. 4. As a condition of admission to an Allied Health Program with a clinical component, in the Kern Community College District, all students are required to submit to and pass a designated drug and alcohol screen. (Refer to: Policy 4G - KCCD) The initial drug screen, physical exam, vaccines, and TB testing are at the student’s expense. •

I have submitted the proper application(s) and fingerprints to the Department of Health Services prior to applying to the CNA and/ or HHA Program.



I understand that once confirmed selection into the CCCC CNA or HHA Program has been announced, I must provide the College with the results of a physical exam, TB testing, and a drug/alcohol screen.



I agree to submit to monitored drug and alcohol testing prior to admission to the Program.



I understand that the Director of the Program or designee may request additional, immediate testing whenever there is reasonable cause to believe that the student is under the influence of alcohol or drugs. I agree to additional testing if requested. I understand that refusal to submit to additional testing may be grounds from dismissal from the Program. I understand that the initial testing is at the student’s expense and subsequent requested testing from the Director of the Program or designee will be at the College’s expense.



I understand that I must comply with regulations of the Department of Health Services before I will be permitted to enter into the Program and to take the State Certification Testing.



I understand that I must successfully pass both the clinical and theory portions of the CNA and/or HHA course to successfully pass the course and to be eligible to take the State Certification Testing.

THE DRUG/ALCOHOL TEST, A PHYSICAL EXAM, VACCINATIONS, AND TUBERCULOSIS TESTING ARE REQUIRED FOR ADMISSION TO THE PROGRAM. IF YOU FAIL TO HAVE THE TESTS PERFORMED BY THE DEADLINE OR YOUR TEST RESULTS DO NOT MEET ACCEPTABLE STANDARDS, YOU MAY BE DENIED ADMISSION TO THE PROGRAM AND/OR CLINICAL FACILITY. I CERTIFY THAT I HAVE READ AND UNDERSTAND ALL OF THE ABOVE INFORMATION AND THAT THE INFORMATION THAT I HAVE PROVIDED IS TRUE AND CORRECT.

SIGNATURE:_______________________________________________________ DATE:__________________________________ CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 5

Department of Justice

State of California

REQUEST FOR LIVE SCAN SERVICE BCII 8016 (3/07)

Applicant Submission

A1226

ORI:

Type of Application:

Code assigned by DOJ

Job Title or Type of License, Certification or Permit:

Certification

Certified Nurse Assistant (CNA)

Department of Health Services, L&C Fingerprint Investigation Unit 03314

Agency Address Set Contributing Agency:

Agency authorized to receive criminal history information

Mail Code (five-digit code assigned by DOJ)

1615 Capitol Ave., MS 3301, PO Box 997416 Street No.

Street or PO Box

Sacramento

CA

City

Name of Applicant: (Please print)

Alias:

State

Contact Name (Mandatory for all school submissions)

(

93899-7416 Zip Code

)

Contact Telephone No.

Last

First

Last

Driver’s License No:

First

Date of Birth:

Sex:

Male

MI

Female

Misc. No. BIL Agency Billing Number

Height:

Weight:

Misc. Number: Home Address:

Eye Color:

Hair Color:

Street No.

Place of Birth:

Street or PO Box

City, State and Zip Code

Social Security Number:

Your Number:

OCA No. (Agency Identifying No.)

Level of Service:

If resubmission, list Original ATI Number:



DOJ

FBI

Employer: (Additional response for agencies specified by statute)

Employer Name

Street No.

Street or PO Box

City

State

Mail Code (five digit code assigned by DOJ)

Zip Code

Live Scan Transaction Completed By:

Transmitting Agency

(

Name of Operator

ATI No.

)

Agency Telephone No. (optional)

Date

Amount Collected/Billed

ORIGINAL – Live Scan Operator; SECOND COPY - Applicant; THIRD COPY (if needed) - Requesting Agency

CNA/HHA APPLICATION

DISQUALIFYING PENAL CODE SECTIONS If they have been convicted of any of the penal codes listed, CNA/HHA applicants will be automatically denied certification or ICF/DD, DDH, or DDN applicants will be denied employment. All CNA/HHA applicants should review this list carefully to avoid wasting their time, effort and money by training, testing and submission of fingerprints since they cannot receive the required criminal background clearance if they have been convicted of any of these violations. Section 187 Murder 192(a) Manslaughter, Voluntary 203 Mayhem 205 Aggravated Mayhem 206 Torture 207 Kidnapping 209 Kidnapping for ransom, reward, or extortion or robbery 210 Extortion by posing as kidnapper 210.5 False imprisonment 211 Robbery (Includes degrees in 212.5 (a) and (b)) 220 Assault with intent to commit mayhem, rape, sodomy, oral copulation 222 Administering stupefying drugs to assist in commission of a felony 243.4 Sexual battery (Includes degrees (a) - (d)) 245 Assault with deadly weapon, all inclusive 261 Rape (Includes degrees (a)-(c)) 262 Rape of spouse (Includes degrees (a)-(e)) 264.1 Rape or penetration of genital or anal openings by foreign object 265 Abduction for marriage or defilement 266 Inveiglement or enticement of female under 18 266a Taking person without will or by misrepresentation for prostitution 266b Taking person by force 266c Sexual act by fear 266d Receiving money to place person in cohabitation 266e Placing a person for prostitution against will 266f Selling a person 266g Prostitution of wife by force 266h Pimping 266i Pandering 266j Placing child under 16 for lewd act 266k Felony enhancement for pimping/pandering 267 Abduction of person under 18 for purposes of prostitution 273a Willful harm or injury to a child; (Includes degrees (a)-(c)) 273d Corporal punishment/injury to a child (Includes degrees (a)-(c)) Section CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 7

CNA/HHA APPLICATION

Section 273.5 Willful infliction of corporal injury (Includes (a)-(h)) 285 Incest 286(c) Sodomy with person under 14 years against will (d) Voluntarily acting in concert with or aiding and abetting in act of sodomy against will (f) Sodomy with unconscious victim (g) Sodomy with victim with mental disorder or developmental or physical disability 288 Lewd or lascivious acts with child under age of 14 288a(c) Oral copulation with person under 14 years against will (d) Voluntarily acting in concert with or aiding and abetting (f) Oral copulation with unconscious victim (g) Oral copulation with victim with mental disorder or developmental or physical disability 288.5 Continuous sexual abuse of a child (Includes degree (a)) 289 Penetration of genital or anal openings by foreign object (Includes degrees (a)-(j)) 289.5 Rape and sodomy (Includes degrees (a) and (b)) 368 Elder or dependent adultabuse;theft or embezzlement of property (Includes (b)-(f)) 451 Arson (Includes degrees (a)-(e)) 459 Burglary (Includes degrees in 460 (a) and (b)) 470 Forgery (Includes (a)-(e)) 475 Possession or receipt of forged bills, notes, trading stamps, lottery tickets or shares (Includes degrees (a) - (c)) 484 Theft 484b Intent to commit theft by fraud 484d-j Theft of access card, forgery of access card, unlawful use of access card 487 Grand theft (Includes degrees (a)-(d)) 488 Petty theft 496 Receiving stolen property (Includes (a)-(c)) 503 Embezzlement 518 Extortion 666 Repeat convictions for petty theft, grand theft, burglary, carjacking, robbery and receipt of stolen property Certification of applicants with convictions on this list MAY be reconsidered by ATCS only if misdemeanor actions have been dismissed by a court of law or a Certificate of Rehabilitation has been obtained for felony convictions. Any other convictions, other than minor traffic violations, must also be reviewed by ATCS.

ATCS 98-4 (4/02) CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 8

CNA/HHA APPLICATION

PHYSICAL EXAM QUESTIONNAIRE Name:

Date Of Birth:

Directions: Check “yes” or “no” to the following questions and/or fill in the appropriate blanks. Allergies:

YES

NO

Food: (i.e. bananas, nuts, etc.) Please list: Medications: Please list: Latex: (gloves, balloons, etc.) Please list:

Surgery (type): Chronic disease (list): Current prescribed medications (list): Social habits:

Coffee (amount): Alcohol (amount): Smoking (amount):

Head:

History of migraines History of dizziness History of sinus problems

Neck:

Frequent swollen glands

Chest:

Have you ever had TB? Frequent chest or lung pain Frequent shortness of breath

Abdomen:

Frequent abdominal pain History of liver problems Recent changes in bladder or bowel habits

Extremities:

History of joint pain Stiffness or arthritis

Back: History of back pain, injury or surgery. If yes, explain: Skin:

Rashes Shingles Itching

Urinary:

Frequent urinary tract infections

History of Mental Health Problems. If yes, list: Have you ever been rejected or discharged from employment because you could not perform the essential physical functions of the position? Explain: I acknowledge that all statements and answers to this questionnaire, or any supplement thereto, are true and complete to the best of my knowledge and belief, and that any falsification of this record may be considered cause for termination from the health careers program. Signature:__________________________________________________________________________Date:_______________________________________

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 9

CNA/HHA APPLICATION

PHYSICAL EXAMINATION FORM Date: Height:

Weight:

Glasses:

Vision: R eye:

Vital Signs:

Blood Pressure:

L eye:

Pulse: Temperature: Respirations: Neck: Chest: Lungs: Abdomen: Extremities: Back: Skin: Neuro-Muscular: Abnormalities: Social Habits: Remarks:

Recommendations: Reasons:

 Unlimited

Limited

 Rejected

Doctor’s Signature:__________________________________________________________________________Date:_______________________________

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 10

CNA/HHA APPLICATION

VACCINATION REQUIREMENTS Students enrolled in any of the health career programs may be at risk for exposure to serious, and sometimes deadly, diseases. If you work directly with patients or handle material that could spread infection, you should get appropriate vaccinations to reduce the chance that you will get or spread vaccine-preventable diseases. Protect yourself, your patients, and your family members. You must have the required vaccinations prior to attending any clinical component for any of the health careers programs/courses at Cerro Coso Community College. All records are to be submitted on first day of your program/course for review process. Failure to submit records in timely manner may lead to dismissal from that program or course. Titer results of immunity is the preferred and recommended preference for Cerro Coso Community College Health Careers programs and courses. A titer is a laboratory test that measures the presence and amount of antibodies in blood. A titer may be used to prove immunity to disease. A blood sample is taken and tested. •

If the test is positive (above a particular known value) the individual has immunity.



If the test is negative (no immunity) or equivocal (not enough immunity) you need to be vaccinated.

A Titer Lab Report is generated by the lab that tested the blood sample. The Titer Lab Report must include the test type, exact values, signature, and date.

Immunization

Vocational Nursing

Medical Assistant

Certified Nursing Aid

R R R R R *r

R R R R R *r

R R R R R *r

Measles, Mumps, Rubella Hepatitis B Tdap Varicella Tuberculosis test Flu vaccine R = Required

r = recommended

Emergency Medical Technician R R R R R *r

*May be required by clinical site

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 11

CNA/HHA APPLICATION

VACCINATION REQUIREMENTS The following serves as the approved sources for verifying immunizations: •

High School Records: Your immunization records do not transfer automatically, you must request a copy.



Personal Shot Records: Must be verified by a doctor’s stamp or signature and by a clinic or health department stamp.



Military Records: Must be verified by a doctor’s stamp or signature.



Previous College: Your immunization records do not transfer automatically, you must request a copy. Required Immunization

Measles

Mumps German Measles (Rubella) Hepatitis B

Minimum Requirement Two (2) doses of measles vaccine if born after January 1, 1957 administered on or after your birthday and at least 30 days apart; or lab report of positive rubeola titer. One (1) dose of mumps vaccine administered on or after first birthday; or lab report of positive mumps titer. One (1) dose of rubella vaccine administered on or after first birthday; or lab report of positive rubella titer. HepB Surface Antibody titer (blood test) is required for CCCC students enrolled in health programs. If you have not received prior to this you must complete a three (3) dose serie (second dose one [1] month and third dose six [6] months after first dose). The titer will be followed by the six month dose to confirm immunity. A positive titer indicates immunity.

A negative titer indicates no immunity and you will need to repeat the series. Tetanus Diphtheria and Pertussis (Tdap) The Tdap vaccination includes Tetanus, Diphtheria, and Pertussis (Whopping cough).

Varicella (Chickenpox) Series Tuberculosis (TB) test

One (1) dose within the past 10 years. Two (2) dose series (second dose one [1] month after first dose); or a physician validated history of the disease; or lab report of positive varicella titer. Within the past 12 months, even for those who have received BCG vaccine as a child. If skin test or IGRA is positive, a chest x-ray documenting no active tuberculosis must be submitted with immunization form. A TB questionnaire may be required from the clinical site.

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 12

CNA/HHA APPLICATION

VACCINATION REQUIREMENTS Influenza vaccine

Current with flu season. May be required/mandatory by the clinical site. Students are strongly encouraged to receive the flu vaccination when available.

NOTE: Reports specifying immunization information MUST include the name of the healthcare provider and facility providing the information. Exemptions permitted by law are for: •

Students who can provide proof that a healthcare provider has determined that it would be a health risk for the student to have the vaccine.

Upon negative or non-immune results: 1. Booster doses are required if titer results for MMR are “non-immune”, “negative”, or “equivocal”. 2. Repeat Hepatitis B series of three (3) injection for a “non-reactive” result. A repeat Hepatitis B titer is required 6-8 weeks after the final injection. 3. 2 doses of Varivax vaccine for a “negative” or “equivocal” Varicella result.

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 13

CNA/HHA APPLICATION

DRUG SCREEN Check with Counseling at your location, as your drug screen must be done through the designated provider. You may write the number and your appointment information in the space below. Program Start Date:____________________________________ Clinical Rotation Start Date:_____________________________ Drug Screen Provider:_________________________________________Phone: (_____)_________________________________ Drug Screen Appointment: Date:_________________________________Time:_________________________________________ Drug Screen may NOT be done more than 30 days prior to Clinical Rotation Start Date. If you have completed your drug screen prior to submitting this application, you may exceed the 30 day window. Cerro Coso will not reimburse for first required drug screen (or repeated screens due to being outside the 30 day window). CNA students are subject to random drug screen testing at any time (in or out of class) for the duration of class (including clinical rotations). These screens may be done at the college’s expense. The instructor MUST verify the screen report prior to clinical rotations. Students failing to complete the screen or with positive results will be dropped from the course. For your records (cost is a tax deductible Educational Expense) you may attach your receipt below after you have completed your drug screen.

CERRO COSO COMMUNITY COLLEGE 3000 College Heights Blvd.  Ridgecrest, CA 93555  Online: www.cerrocoso.edu  Phone: 760-384-6100  Fax: 760-384-6270 14