1 Academic Drive Corning, New York 14830-3297 607-962-9241 800-358-7171 x 241 Fax: 607-962-9287 www.corning-cc.edu

Nurse Education Department A.A.S. Degree in Nursing

PACKET FOR FALL 2016 Welcome to the Nursing Program. The Nurse Education Faculty are happy that you have chosen to pursue a nursing career. Please be sure to read the information in this packet completely before starting to work on the required materials, in order to ensure all information is submitted. To be eligible to register for your first nursing course you MUST complete the prerequisites listed below and submit the attached Eligibility Packet when the prerequisites have been completed. It is the student’s responsibility to ensure completion of all eligibility requirements before submitting the Eligibility packet to the Nurse Education Department for review. If you have ever enrolled and attended a nursing course at CCC, please obtain a Nurse Education Petition form to complete instead of this packet. This form can be obtained from the Nurse Education Department. Class size is limited; therefore admission to NURS 1100 - Nursing I is based on meeting all eligibility prerequisites on a space available basis, so you should submit your completed packet early in the spring semester for consideration. The Nurse Education Secretary will begin to accept the Eligibility Packets starting on the first Monday in February, if this is a snow day then the next business day that the college is open.  High School Seniors Please Note – o High school seniors will be assigned to meet with the Director of Nurse Education for advisement and guidance on completion of the Eligibility packet. o You can obtain an “Eligibility Packet for Nursing I Fall 2016” on the college website under the Nursing Program OR directly from the Nurse Education Department and begin to work on completing the prerequisites noted. When all of the prerequisites have been completed and you have the required documentation, you should submit your packet as there is a history of spaces filling quickly.  If you have already completed high school Biology & Chemistry please submit official documentation of your final course numeric or letter grade.  This does not need to be the final official transcript following graduation – you can request an official transcript that your high school can prepare that will include final grades for courses completed, including your biology and/or chemistry, up to the date of your request OR you can have your High School Guidance Counselor provide signed documentation of your final course numeric or letter grade on high school letterhead for your high school biology and/or chemistry. Please remember the transcript or your Guidance Counselor’s documentation is required to be submitted in a sealed envelope.  If you are completing one of the courses in your senior year, you will need to request a final official transcript that will provide your final numeric or letter grade for your courses. This final official transcript will not be ready until after graduation and should be sent directly to the Admission’s Office at CCC OR provided to you in a sealed envelope for submission with your packet. o o o

Graduating high school seniors will be allowed to submit their packet beginning the first Monday in February. Graduating high school seniors who have already completed biology & chemistry are to submit completed packet on the first Monday of February. High school students still completing prerequisite courses may submit partially complete eligibility packets to reserve a space and will need to provide final grades in order meet the prerequisites and be approved for entry in the first nursing course. .

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Remember class size is limited, once the spaces for high school seniors are filled, if your packet is complete, the process will be the same as other prospective Nursing I students -- if there is room in the class you will be added to the approved list and if the class is full your name will be placed on the “Waiting List”.

Your packet will be stamped with date & time to keep track of submission order. Your packet will be reviewed and you will receive a letter identifying one of the following:  Your packet is complete and you have been approved to register for NURS 1100 - Nursing I and this is your next step (will be filled in)_. OR  Your packet is incomplete, (will be filled in) _ is missing. o Once the missing piece(s) is/are submitted the packet will be restamped for date & time and will be reviewed again OR  Your packet is complete but the class is full and you have been placed on the Waiting List. o If you are placed on the Waiting List, you will be notified if a spot should open. o If you are placed on the Waiting List and you are not notified by the start of the fall semester, the Waiting List is dissolved and you will need to resubmit an Eligibility Packet for the following fall using the updated packet for that fall. New Students Entering CCC  Apply to CCC, meet all admission requirements and be accepted to the college. You will be accepted into the Nursing Program as your primary program, but NOT approved to begin nursing courses until this packet is completed, submitted and approved. You will also be accepted into a Liberal Arts program as a secondary program. You will receive a letter from the Admission’s Office referring to this information and will include further instructions. Please read the information in this letter, as not following through with the instructions could impact your approval to begin nursing courses.  Complete any CCC Placement Assessment Tests that you are required to take. Please contact the Enrollment Advisement Center at 607-962-9875 to set up a testing appointment.  Submit high school and college transcripts to the Admissions Office. o If you have attended other colleges and have received college credits you will need to request an official transcript from each of the colleges attended and have them sent to the Admission’s Office. o If you are a high school senior  If you have already completed high school Biology & Chemistry please submit official documentation of your final course grade. This can be obtained by using an official high school transcript to show the final course grade OR a signed letter, on high school letterhead, obtained from your Guidance Counselor, indicating your final course grade in biology and/or chemistry.  If you are completing either biology or chemistry in your senior year, you will need to wait until the course is complete and then you can request a final official transcript. OR  Current Students –already taking classes at CCC o Please ensure that you have the nursing program listed as one of your programs. This way if we need to reach students in the nursing program you will be included in that group.  If you need to add the nursing program. You can obtain a “Program Change” form by printing the form found under the “Registration and Records” area on the “Student” tab in MyCCC, from the Enrollment Advisement Center, or your advisor. The “Program Change” form must have your signature and your advisor’s signature or it cannot be processed.  If you have never seen a Nursing Advisor to discuss the prerequisites and program requirements, you should contact Advising and Counseling to be scheduled to meet with a Nursing advisor to ensure you are on track to submit the packet. ALL students MUST meet the following prerequisites:  Successful completion of any developmental courses. 

Completion of Chemistry and Biology in high school with 75% or higher OR completion of a college course with a minimum of a “C” or better (no shelf life for either high school or college courses).

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Place into MATH 1215 College Math or higher – by Placement Assessment Tests OR by successfully passing MATH 1015 – Introductory Algebra with a “C” or higher. o PLEASE NOTE  Any prerequisite and program elective MATH course will require a “C” or higher.  Students accepted to the Nursing Program, either upon acceptance to the college or changing programs to nursing, for Fall 2014 and beyond will be required to take MATH 1215 or higher and receive a “C” or higher to meet the MATH elective for the program.  The catalog term, under which you were accepted into the Nursing Program, can be found in MyCCC under the “Student “, My banner”, “Student & Financial Aid”, then “Student Records” then “Degree Evaluation”.

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Submit the College Pre-Enrollment Health Form to the Health Office located in the Commons on the Main Campus. This form can be found in MyCCC under the “Student” tab, on the left side of the page under “Health Office”, then “Immunization Requirements”. In the verbiage you will find the sentence “A pre-enrollment health form can be downloaded here”, located in the second paragraph. This information is required by the college.

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On one of the following pages in this packet you will find how to obtain your criminal background screening and the Nursing Health Form, both through Corporate Screening. Follow the instructions to submit information for your criminal background screening and how to print the NURSING HEALTH FORM from ImmuniTrax (the link is in the Corporate Screening site). This information is required by the clinical agencies and is required for approval to enter nursing courses. o The Nursing Health Form includes a self-assessment, physical exam & all screening/ immunizations/titers required to participate in clinical lab. o Information regarding which screenings/immunizations/titers are required will be in this packet. o Physical exams and PPD results that are more than a year old, from the start date of the initial nursing course will not be accepted. YOU DO NOT NEED TO WAIT FOR NURSING PROGRAM TO APPROVE PRIOR TO PRINTING! 

Complete the attached Student Information Form, Essential Functions Form and submit along with the following to the Nurse Education Department: o a copy of a current CPR certification for the Professional Rescuer – ONLY American Heart Association or American Red Cross certification will be accepted. o a copy of the completed results of criminal background checks by Corporate Screening Services, Inc. No results from other agencies/companies will be accepted. No receipts will be accepted, only final results are to be submitted. o Further information on the process to complete background checks is included in this packet. No results that are more than a year old, from the start date of the initial nursing course, will be accepted. o a copy of the results of Pennsylvania Child Abuse screening. No receipts will be accepted, only results are to be submitted. Further information of the process to complete child abuse screening is included in this packet. No results that are more than a year old, from the start date of the initial nursing course, will be accepted. o a copy of your printout from ImmuniTrax, showing compliance with the required health information. You may see a statement indicating that the college must approve your Immunitrax information, we do not need to approve your health information at this time. You can print your form and submit in your packet, the information will be reviewed at that time. o a copy of your college transcript(s) o If you are a high school senior  If you have already completed high school Biology & Chemistry please submit official documentation of your final course grade. This can be obtained by using an official high school transcript to show the final course grade OR a signed letter, on high school letterhead, obtained from your Guidance Counselor, indicating your final course grade in biology and/or chemistry.  If you are completing either biology or chemistry in your senior year, you will need to wait until the course is complete and then you can request a final official transcript.

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IMPORTANT INFORMATION REGARDING STUDENT HEALTH INSURANCE: As a Nursing student, you are required to have health insurance. Corning Community College offers a comprehensive student health insurance plan underwritten by Nationwide Insurance. □ For information about this plan, visit their website at wwwchpstudent.com to view the current 2015-2016 benefits brochure. All Nursing students enrolled in NURS 1100–Nursing I, NURS 1500-Nursing II, NURS 2100–Nursing III, or NURS 2500Nursing IV are automatically enrolled in CCC’s Student Health Insurance Plan. There will be an annual premium charge automatically added to your billing statement. □ If you have your own health insurance plan, you may waive this coverage by providing documented proof of comparable coverage to the insurance company. □ Waiver information □ By completing the waiver, you are certifying that you have comparable coverage and agree that you will be responsible for your medical expenses, and that neither the college nor the Student Health Insurance Plan will be responsible for those expenses. □ When the enrollment period opens for 2015-2016 academic year – approximately July 31, 2015 you can log in to the insurance website at www.chpstudent.com to complete the waiver form. o Click on “Members tab “ o Click on “Student” o Select “Corning Community College-Resident & Nursing” o Click on “Waiver” o Complete form Please have your current health insurance ID card and a plan summary available as you will need this information to complete the form in order to waive the plan. 

Upon completion, submission, review and approval of this form, the premium charge will be removed from your account. For Advanced Placement Nursing students the request for waiver MUST be completed by Monday January 11th, 2016. □ 

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If you do not have coverage and wish to enroll, no further steps are required, as you will be automatically enrolled in the plan. This plan covers just the enrolled student. □ Additional information regarding coverage for spouse/family will be found on the insurance website AND an additional fee will be charged that will NOT be covered by financial aid. Please contact the Nurse Education Department if you have questions or need information on how to meet these prerequisites. Nurse Education Department Corning Community College 1 Academic Drive Corning, NY 14830 Phone – 607-962-9241 OR 1- 800- 358-7171 Ext 241 03/14 RH, 8/22/14 5/5/15 RH

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CRIMINAL BACKGROUND & PENNSYLVANIA CHILD ABUSE SCREENING AND HEALTH FORM – IMMUNIZATIONS/SCREENINGS/TITERS The following information is required by clinical agencies and thus will be a requirement to enter nursing courses. However, since this is required by the clinical agencies it is subject to change based on their requirements. Students will be notified of any changes as soon as the Nurse Education Department has been notified by the agencies.

Criminal Background Screening 

ALL nursing students will need to have a current criminal background screening completed prior to being approved to enter their first nursing courses. Results of the background check will need to be submitted with the Nursing I Eligibility Packet to the Nurse Education Department. The Nurse Education Department has contracted with Corporate Screening Services, Inc. to complete the required background checks. ONLY completed results from this company will be accepted. This organization is able to obtain information nationally so regardless of whether your clinical lab is scheduled in Pennsylvania or New York State, you will only need to have this one background check completed. As long as you continue to move from one nursing course to the next, consecutively, you will only need to have just this 1 check completed. o IF you should leave the nursing courses, for whatever reason, and then petition to return, you will need to repeat the background check before being approved to return.  Results will report nation-wide info  $60 (Please note this cost will include both the Corporate Screening Services - for criminal background check fee and ImmuniTrax – for required Nursing Health Form fee.)  How long before the criminal background results are ready – approximately 1 week.  How to request the screening: found on the following page.  What is to be submitted to the Nurse Education Department? – All of your completed results printed from the Corporate Screening Services, Inc. site. The Nurse Education Department is not responsible for obtaining the results – you will need to print the results and submit in your packet.

Pennsylvania Child Abuse Screening 

All Nursing students will also need Pennsylvania Child Abuse screening. Because Pennsylvania does not allow a 3rd party access to this information, you will need to contact Pennsylvania directly. In the box marked “Purpose of Clearance Check one box only” CHECK "EMPLOYMENT WITH A SIGNIFICANT LIKELIHOOD OF REGULAR CONTACT WITH CHILDREN.   

Results – will report ONLY Pennsylvania child abuse information. Cost - $10 How long before results are ready – it can from 1 to 6 weeks for processing depending on how the information is submitted – on-line or sent via mail. o Required results – Results are expected to be clear Contact Information – by using www.compass.state.pa.us/cwis/public/home you can request your Pennsylvania Child Abuse Screening and print out the result to be submitted with your packet.

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NURSING PROGRAM STUDENT INSTRUCTIONS

Before Starting: 

A valid email is REQUIRED

1. Getting Started: Have your credit card/debit card (Visa/MasterCard/American Express/Discover) information ready in order to process payment. Your credit card will be charged $60.00 for the service. 2. Log onto our website at www.VerifyStudents.com 3. Use this special promotional code: CCCNBGIMM 4. Complete profile & e-sign forms as they appear 5. After completing steps 1-4 as identified above, you will receive an e-mail from [email protected] containing instructions for submitting your health and immunization documents (via fax or electronic upload). [Please Note: This part of the process is administered by ImmuniTrax powered by Medicat. You will be able to log in at http://corning-cc.medicatimmunitrax.com If you do not receive an email with instructions on how to log in to this site, email [email protected].]

*Please note that this information is for the sole purpose of background screening for this school only. Unauthorized use of our service is prohibited*

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PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE INSTRUCTIONS (from the Pennsylvania Website) Effective December 31, 2014 THE PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE APPLICATION CAN BE SUBMITTED ONLINE. ONCE YOU ENTER THE LINK BELOW YOU WILL BE DIRECTED TO THE CHILD WELFARE PORTAL WHERE YOU MUST CREATE AN ACCOUNT OR LOG IN IF YOU ALREADY HAVE AN ACCOUNT. NOTE: YOU WILL NEED AN EMAIL ADDRESS TO CREATE AN ACCOUNT. THE PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE CERTIFICATE WILL NO LONGER BE ISSUED ON IVORY MARBLE SECURITY PAPER. ALL CHILD ABUSE HISTORY CLEARANCE RESULTS WILL BE ISSUED ON PLAIN WHITE PAPER AS OF DECEMBER 31, 2014. VOLUNTEERS ARE NO LONGER REQUIRED TO SUBMIT A COPY OF THE PROCESSED RESULTS OF THEIR “REQUEST FOR CRIMINAL RECORDS CHECK (SP4-164) FROM THE PENNSYLVANIA STATE POLICE OR A COPY OF THEIR FBI RESULTS WITH THEIR PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE APPLICATION. IF WE RECEIVE COPIES ATTACHED TO THE PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE APPLICATION WE WILL NOT RETURN THOSE COPIES TO THE APPLICANT.

ELECTRONIC SUBMISSION Child Abuse History Clearance Online: https://www.compass.state.pa.us/CWIS Creating an account and submitting your clearance application online will give you immediate access to your results or the status of your results if your results cannot be processed immediately. Organizations who want to set up business accounts must first register for a Business Partner User account using the “Organization Account Access” link on the Child Welfare Portal. Organization accounts will allow businesses and organizations to purchase child abuse history clearance payment codes and distribute those codes to applicants. When an applicant uses a code given to them by an organization, the organization will have access to the applicant’s child abuse history clearance results once those results are processed.

For questions related to the Pennsylvania Child Abuse History Clearance, please contact the ChildLine Verification Unit at 717-783-6211 or toll free at 1-877-371-5422.

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COMPLETION OF REQUIRED HEALTH INFORMATION

PLEASE NOTE that some Health Form immunization/screening information will be needed in the CCC Health Office (Pre-Enrollment Health Form) in order to meet NYS Public Health Law requirements. If you haven’t already submitted a Pre-Enrollment Health Form to the CCC Health Office, please do so as soon as possible. There are consequences if you delay submitting the form to the Health Office. From the Health Office Web Site: “All students that remain non-compliant following a 30-day grace period, risk being removed from the campus until compliance can be proven. HOLDS will be placed on all student accounts following the end of the grace period that have not provided the Health Office with a Health Questionnaire, adequate vaccine history, and evidence of meningitis education. HOLDS prevent students from registration, schedule changes, transcript request, obtaining grades, and could result in delays with graduation. In the event of a campus outbreak, all susceptible students will be removed from campus until public health officials declare it is safe to return to campus or until proof of vaccination history has been determined.”

Beginning Fall 2015 the Nurse Education Department will begin to use ImmuniTrax, a corporate screening company, to maintain required clinical Nurse Education Health Form data for students. On the following pages you will find general information regarding the required clinical Immunizations/Screenings/Titers. Please refer to the instructions on how to enter Corporate Screening in order to obtain the ImmuniTrax Nurse Education Health Form via the link provided.  The Nursing Health Form includes a self-assessment that you can complete; the remainder will need to be completed by your health care provider. 1. Once all of your information has been submitted to ImmuniTrax, you will have access to a print a document showing that you have met all of the requirements needed for clinical and be able to submit this document with your Eligibility Packet. The college does not need to review your information before you can print the document.

Information regarding Immunizations/Screenings/Titers 

The mandatory immunizations/screenings are noted on the ImmuniTrax Nursing Health Form for Nursing Students. Those are: 1. PPD* If you have never had a PPD OR if you have had a PPD previously BUT it has been more than 12 months – you will need a 2 Step PPD and you will submit your results to ImmuniTrax  Individuals who are not annually tested for tuberculosis could have been exposed and not know it. A 2 step PPD is given to detect individuals who may have been exposed to tuberculosis, but when tested initially may show a negative result, however when tested again, a short time after the initial testing, the results may confirm the initial negative result or may show a positive reaction that would result in the need for further testing.  IF you have never had a PPD – you must have a 2 Step PPD o You MUST have your initial PPD placed and have the site assessed 2-3 days later and then REPEAT the PPD at least 1-3 weeks following your initial PPD but less than 12 months. The results of BOTH tests should be submitted to ImmuniTrax. along with the signature of the Healthcare Provider interpreting the results of the tests. Then you must have a PPD done annually with results submitted to ImmuniTrax.  IF you have had a PPD previously BUT it has been more than 12 months– you must have a 2 Step PPD o You MUST have a PPD placed, have the site assessed 2-3 days later and then REPEAT the PPD at least 1-3 weeks later but less than 12 months. The results of BOTH tests should be submitted to ImmuniTrax. along with the signature of the Healthcare Provider interpreting the results of the tests. Then you must have a PPD done annually with results submitted to ImmuniTrax  If you have a positive PPD, the student must follow up with their Healthcare Provider in order to receive further testing. Testing could include a chest x-ray, a QuantiFERON-TB Gold test and/or other testing. Results of follow up testing will need to be submitted to ImmuniTrax to be included in your account.

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Measles, Mumps, Rubella  What is required: o Evidence of vaccines received OR o Reliable medical history of disease that includes a date of the disease OR o Documentation of a blood test showing a positive titer, indicating immunity.

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Tetanus/Diphtheria  What is required: o Evidence of receiving vaccine within last 10 years. o If never received vaccine or it has been more than 10 years – you must receive a current vaccine and submit documentation to ImmuniTrax.

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Varicella (Chicken Pox)  What is required is either: o Reliable medical history of disease that includes a date of the disease OR o Documentation of a blood test showing a positive titer, indicating immunity. OR o If no medical history is provided or lab test fails to document immunity to Varicella, documentation of the Varivax vaccination series (2 injections) is required

The recommended immunizations/screenings are noted on the ImmuniTrax Nursing Health Form for Nursing Students. Those are: 2. Hepatitis B  Information regarding Hepatitis B and the vaccine is found on the following pages  What is required:  Evidence of receiving the 3 vaccines (or starting the series of vaccines) submitted to ImmuniTrax OR  Signing the declination form and submitting to ImmuniTrax 3. Meningococcal Meningitis  Information regarding Meningococcal Meningitis and the vaccine is found on the following pages  What is required:  Evidence of receiving the vaccine submitted to ImmuniTrax OR  Signing the declination form and submitting to ImmuniTrax

PLEASE NOTE: Additional immunization / screenings may be required by an individual clinical agency. This information will be provided to you once the Nurse Education Department has been notified and you are registered for your first nursing course. 5/5/15 RH

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OSHA FactSheet Hepatitis B Vaccination Protection Hepatitis B virus (HBV) is a pathogenic microorganism that can cause potentially lifethreatening disease in humans. HBV infection is transmitted through exposure to blood and other potentially infectious materials (OPIM), as defined in the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030. Any workers who have reasonably anticipated contact with blood or OPIM during performance of their jobs are considered to have occupational exposure and to be at risk of being infected. Workers infected with HBV face a risk for liver ailments which can be fatal, including cirrhosis of the liver and primary liver cancer. A small percentage of adults who get hepatitis B never fully recover and remain chronically infected. In addition, infected individuals can spread the virus to others through contact with their blood and other body fluids. An employer must develop an exposure control plan and implement use of universal precautions and control measures, such as engineering controls, work practice controls, and personal protective equipment to protect all workers with occupational exposure. In addition, employers must make hepatitis B vaccination available to these workers. Hepatitis B vaccination is recognized as an effective defense against HBV infection. HBV Vaccination The standard requires employers to offer the vaccination series to all workers who have occupational exposure. Examples of workers who may have occupational exposure include, but are not limited to, healthcare workers, emergency responders, morticians, first-aid personnel, correctional officers and laundry workers in hospitals and commercial laundries that service healthcare or public safety institutions. The vaccine and vaccination must be offered at no cost to the worker and at a reasonable time and place. The hepatitis B vaccination is a non-infectious, vaccine prepared from recombinant yeast cultures, rather than human blood or plasma. There is no risk of contamination from other bloodborne

pathogens nor is there any chance of developing HBV from the vaccine. The vaccine must be administered according to the recommendations of the U.S. Public Health Service (USPHS) current at the time the procedure takes place. To ensure immunity, it is important for individuals to complete the entire course of vaccination contained in the USPHS recommendations. The great majority of those vaccinated will develop immunity to the hepatitis B virus. The vaccine causes no harm to those who are already immune or to those who may be HBV carriers. Although workers may desire to have their blood tested for antibodies to see if vaccination is needed, employers cannot make such screening a condition of receiving vaccination and employers are not required to provide prescreening. Employers must ensure that all occupationally exposed workers are trained about the vaccine and vaccination, including efficacy, safety, method of administration, and the benefits of vaccination. They also must be informed that the vaccine and vaccinations are offered at no cost to the worker. The vaccination must be offered after the worker is trained and within 10 days of initial assignment to a job where there is occupational exposure, unless the worker has previously received the vaccine series, antibody testing has revealed that the worker is immune, or the vaccine is contraindicated for medical reasons. The employer must obtain a written opinion from the licensed healthcare professional within 15 days of the completion of the evaluation for vaccination. This written opinion is limited to whether hepatitis B vaccination is indicated for the worker and if the worker has received the vaccination.

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Declining the Vaccination Employers must ensure that workers who decline vaccination sign a declination form. The purpose of this is to encourage greater participation in the vaccination program by stating that a worker declining the vaccination remains at risk of acquiring hepatitis B. The form also states that if a worker initially declines to receive the vaccine, but at a later date decides to accept it, the employer is required to make it available, at no cost, provided the worker is still occupationally exposed.

Additional Information For more information, go to OSHA’s Bloodborne Pathogens and Needlestick Prevention Safety and Health Topics web page at: https://www.osha.gov/ SLTC/bloodbornepathogens/index.html. To file a complaint by phone, report an emergency, or get OSHA advice, assistance, or products, contact your nearest OSHA office under the “U.S. Department of Labor” listing in your phone book, or call us toll-free at (800) 321-OSHA (6742).

This is one in a series of informational fact sheets highlighting OSHA programs, policies or standards. It does not impose any new compliance requirements. For a comprehensive list of compliance requirements of OSHA standards or regulations, refer to Title 29 of the Code of Federal Regulations. This information will be made available to sensory-impaired individuals upon request. The voice phone is (202) 693-1999; teletypewriter (TTY) number: (877) 889-5627. For assistance, contact us. We can help. It’s confidential.

Occupational Safety and Health Administration www.osha.gov 1-800-321-6742

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1 Academic Drive Corning, New York 14830-3297 607-962-9241 800-358-7171 x 241 Fax: 607-962-9287 www.corning-cc.edu

Nurse Education Department A.A.S. Degree in Nursing

STUDENT INFORMATION for a student entering NURSING I I plan to enter Nursing I Fall 2016 Please attach a copy of the following to this information form prior to submitting the packet:  Current Professional CPR card  Criminal Background Screening results  Pennsylvania Child Abuse Screening results  Unofficial college transcripts

Name: Last

First

Middle Initial

Mailing address: House# / Apt# / P.O. Box / Rural route

City

Street name

State

Birthdate:___________________

Zip code

CCC CID#___C_________________________

County of Residence: Chemung_____ Schuyler_____ Steuben_____ Other - please identify____________ Previous name(s) under which your academic records are listed?__________________________________ High School Name & Graduation Date / GED Date ____________________________________________ Previous degrees obtained:_________________________________________________________________ HAVE YOU EVER ATTENDED NURSING I AT CCC? ______ If yes, please provide date(s)_______ Phone # Daytime ______________________________ Home Phone:______________________________ Cell ______________________________ Work Phone ______________________________ Personal e-mail:___________________________ College e-mail address:___________________________ HAVE YOU EVER BEEN CONVICTED OF A FELONY: __________________________________ Release and Signature: The information provided in this application is correct to the best of my knowledge. Signature of Applicant:_________________________________Date:_________________

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Please read, sign, and submit the Essential Functions form included on next page.

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ESSENTIAL FUNCTIONS FOR NURSING STUDENTS I,___________________________________________, a prospective nursing student, verify that I am able to: Maintain emotional stability, accept responsibility, and be accountable for my own actions. Signature:_____________________________________________ See:

Initial here_____

Must possess near clarity of vision at 20 inches or less and far clarity of vision at 20 feet or more. Hear:

Initial here______

Must be able to hear verbal communication, as well as sounds that indicate changes in a person’s condition (for example: breathing sounds, heart sounds, heartbeat, blood pressure…). Speak:

Initial here______

Speak to clients and members of the health team utilizing understandable English. Feel:

Initial here______

Possess sufficient sense of touch to determine a person’s condition (for example: changes in skin temperature, pulses…). Read and Understand:

Initial here______

Read and understand English. Write:

Initial here______

Use the English language to write legibly, thoroughly, concisely and appropriately. Utilizes Informatics:

Initial here______

Perform basic functions including use of a word processing program to cut/paste/copy/format documents; create/respond/attach documents to an e-mail; search the internet; and download assignments, save, complete assignments and return to sender.

Calculate:

Initial here______

Use mathematical functions to accurately calculate (for example: add, subtract, multiply, and divide - whole numbers, decimals, and fractions and use basic algebraic equations). Move:

Initial here______

Move freely to perform safe client care with both gross and fine motor skills. Lift:

Initial here______

Lift and/or support a person in order to safely assist that person to change position, move and ambulate. Think:

Initial here______

Successfully complete the pre-requisites of the Nurse Education program. Have the ability to learn, assess, analyze, and solve problems. Transport:

Initial here______

Transport self (for example: travel to college, community assignments, clinical facilities, and community agencies…). If any of the above information changes, it is the responsibility of the student to notify the Nurse Education Director. I verify that the above information is true. Student Name - Printed ___________________________________ Student Name – Signature __________________________ Date _________ word/applicationpacket/essentialfunctions

revised 5/13

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