PRACTICAL NURSING CERTIFICATE OF PROFICIENCY PROGRAM APPLICATION

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PRACTICAL NURSING

CERTIFICATE OF PROFICIENCY

PROGRAM APPLICATION

2016-2017 Cohort

FOR QUESTIONS ABOUT THE APPLICATION OR ASSOCIATED DOCUMENTATION:

Tracy Owens, BBA 928-757-0820

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APPLICATION REQUIREMENTS

The following is a list of requirements for the Practical Nurse Certificate (PNC) program.



Applicant must be at least 17 years of age when applying and 18 years of age prior to start of

clinical rotation experience.



Graduation from a regional accrediting association as defined by the United States Office of

Education High School or other appropriate state educational agency; or a Certificate of

Equivalency (GED).



Appropriate score on MCC Compass test or successfully passing PCS 021 (Reading); and TRE

089 (Transitional English); and MAT 101 (Math Literacy for College Students) which is preferred

and recommended or TRM 091 (Beginning Algebra).



HES 113—Medical Terminology with a minimum grade of 2.0 (C).



HES 129—Allied Health Anatomy & Physiology; or, Bio 201-Anatomy & Physiology I and BIO

202—Anatomy & Physiology II with a minimum grade of 2.0 (C).



NAP 115—Nurse Assistant Program. Other Allied Health experience must be reviewed and

approved by program Director. Minimum grade of 2.0 (C) must be achieved.



Student Check—Background Check (this is a nationwide check and different from the AZDPS

fingerprint check/card).



AZDPS fingerprint check/card. (Cards and application forms are available in the Nursing office.)



Verification of Residency.



Student copy of transcripts from other educational institutions needed to verify education

requirements.

The application review process will not discriminate based on race, color, national origin, gender,

religious background, sexual orientation, age or disability.

Any official transcripts should be acquired through the issuing facilities and directly mailed to:

MCC Practical Nursing Department

PNC Program

1801 Detroit Ave.

Kingman, AZ 86401

Application for the PN Program is in addition to the application for general admission to Mohave

Community College.

Class positions are limited; therefore, students are encouraged to make early application submissions.

Application does not guarantee admission to the program.

INCOMPLETE applications will not be considered.

Application deadline April 1, 2016, at 5pm

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Admission to the program will be considered on the basis of:



Receipt of a completed PNC Program application.



Three (3) professional references from persons who have known the applicant in a supervisory or

educational setting and who are familiar with applicant’s academic and/or work ethics.



Official college transcripts, (Student copy of transcripts other than MCC, may be attached to the

application).



Complete educational and prerequisite requirements as outlined above.

Applicants will be notified of their status in 10 to 15 days after application deadline.

A completed application packet must be received by:

Mohave Community College

Practical Nursing Department

PNC Program

1801 Detroit Avenue

Kingman, Arizona 86401

NO LATER THAN 5:00 P.M. ON APRIL 1, 2016.

Applicants conditionally accepted to the PNC program must notify the Practical Nursing Department NO

LATER THAN MAY 31, 2016 that they desire to attend the program.

Applicants not accepted to the Practical Nursing Program may be given an opportunity to be considered

for the next admitting semester.

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AFTER ADMISSION TO THE PN PROGRAM

After conditional acceptance of initial application, the following must be completed per PNC Program

requirements:



CPR certification (American Heart Association-Healthcare Provider or the American Red Cross

Professional Rescuer level) and certification must be maintained during the entire program.

(Adult, child, or community CPR is not acceptable.) Online recertification IS NOT accepted.



Physical examination and health clearance indicating ability to perform all aspects of nursing, as

outlined in the Essential Skills and Functional Abilities of a Nurse, attached.



Proof of healthcare insurance.



Proof of immunizations and/or immunity to:



Hepatitis B



MMR



Varicella



Negative TB test or X-ray within six (6) months of clinical experience start in October.



Negative drug screening within twelve (12) months of start of class.



Completely filled out Degree Declaration;

Students must notify the Practical Nursing Department of any change in address or plans to attend classes.

After successful completion of the requirements for the PN certificate of proficiency, the student will be

eligible to apply to write the licensure examination offered by the National Council Licensure

Examination for PN (NCLEX-PN). Licensure requirements are the exclusive responsibility of the

Arizona State Board of Nursing and students must satisfy those requirements independently of

requirements for graduation from the college.

FINANCIAL ASSISTANCE

Financial assistance is available in the form of scholarships, and federal financial aid. The necessary

forms can be secured at the Financial Aid Office or at

http://www.mohave.edu/admission-to-mcc/financialaid/

Students are encouraged to contact the Financial Aid Director in the year preceding

admission to the nursing program. It is strongly recommended to apply for financial assistance and

scholarships along with the application process to the PN Program.

PN PROGRAM CLINICAL EXPERIENCE

Clinical experience takes place in health care facilities in Mohave County including the cities of Lake

Havasu City, Bullhead City and Kingman. Travel between clinical facilities will be required at the

student’s expense.

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TEST OF ESSENTIAL ACADEMIC SKILLS (TEAS)

MOHAVE COMMUNITY COLLEGE

WHAT IS THE TEAS TEST?

The Test of Essential Academic Skills evaluates PN Program applicants in four (4) foundational areas, which are essential to your academic success in the PN Program. The Nursing Program requires you to take the TEAS Test as an entrance examination. Basically, the test has four parts that ask you to answer multiple-choice questions covering the following:

 Reading: paragraph comprehension, passage comprehension, and inferences/conclusions.

(40 items, 50 minutes)

 Math: Whole numbers, metric conversion, fractions, decimals, algebraic equations, percentages, and ratio/proportion. (45 items, 56 minutes)

 Science: science reasoning, science knowledge, biology, chemistry, anatomy, physiology, basic physical principles, and general

science. (30 items, 38 minutes)

 English and Language Usage: punctuation, grammar, sentence structure, contextual words and spelling.

(55 items, 65 minutes)

 Total of 170 multiple choice questions.

WHO ADMINISTERS THE TEAS TEST?

The Testing centers at Mohave Community College administer the TEAS Test. The test is purchased from the Assessment Technologies Institute (ATI). Your TEAS scores are stored by ATI and are available to you and to your school via the Internet. You can also have TEAS results sent to other nursing schools at minimum cost through ATI.

HOW MUCH DOES THE TEAS TEST COST?

The cost of taking either test is $40.00 for students and $50.00 for non-students.

HOW CAN I BEST PREPARE FOR TAKING THE TEAS TEST?

A review of basic concepts and theories in mathematics, reading, science, English and language usage is recommended. ATI has two products, the TEAS Study Manual and a TEAS Online Practice Assessment, available to guide your review and provide feedback on your study progress. These products can be purchased online at the ATI website which is www.atitesting.com.

CAN I USE A CALCULATOR ON THE TEAS TEST?

Calculators are NOT allowed during the TEAS TEST.

WHAT DO I BRING TO THE TESTING CENTER?

Photo bearing identification such as a; passport, driver’s license, student identification card.

WHAT CANNOT BE BROUGHT TO THE TESTING CENTER?

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CAN YOU ACCOMMODATE STUDENTS WITH DISABILITIES?

Students with documented disabilities requiring accommodations should contact the Disability Services Office at the local campus to make arrangements to take their test. Students requiring extra time will not be able to take the computer based test because the program is self-timing and cannot be adjusted. These students will be given a paper and pencil test instead. This test cannot be scored locally, but must be sent back to ATI for scoring, requiring at least a one (1) to two (2) week turnaround. Please take this into consideration when scheduling and allow sufficient time prior to nursing program application due dates.

HOW LONG WILL IT TAKE TO GET MY TEAS TEST SCORES?

If you have taken the computer administered TEAS Test, your scores are available immediately after the examination. If you have taken the pencil/paper version of the test, your examination will be scored within 24 hours of receipt by ATI. Note that the 24-hour window is NOT 24 hours from the time you tested, but within 24 hours of ATI’s receipt of testing materials from Mohave Community College.

HOW DO I KNOW IF I PASSED THE TEAS TEST?

The applicant’s adjusted individual total score is considered for admission as follows: 57.3% or above—1st_{priority for admission}

50% to 57.2%--2nd_{priority for admission}

40% to 49.9%—3rd_{priority for admission, if positions are available}

CAN I RETEST TO GET A HIGHER SCORE?

Tests may be retaken after a minimum of 30 days and up to 3 times a year period.

HOW TO REGISTER YOURSELF AS A TEST CANDIDATE FOR THE TEAS.

If you are not a current user on www.atitesting.com, you need to set up a new account. This will allow you access to the testing and to complete a purchase on ATI’s online store. Please follow the steps below to setup a new account:

1. Go to www.atitesting.com. Just under the Username and Password fill-in boxes, there is a small link that states, “New to ATI? Create an account.” Click on that link to register yourself with ATI.

2. Next, a web form will appear. Fill in all of the blue fields. Blue fields are required information necessary to create a new account.

3. You will receive an email from ATI confirming your user login and password.

4. You will need to bring your user name and password with you when you go to the testing center to take the TEAS.

TO SCHEDULE THE TEAS TEST, CONTACT THE TESTING

COORDINATOR AT YOUR LOCAL CAMPUS PROVIDED BELOW:

 Heather DeJesus: [email protected], Bullhead City Campus, 928-758-3926

 Cheri Stromle: [email protected], Neal Campus Kingman Campus, 928-757-4331

 Kevin Smith: [email protected], Lake Havasu City Campus, 928-505-3389

 Kim Naylor: [email protected], North Mohave Campus, 928-875-9116

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Mohave Community College

Practical Nursing Certificate Program

Technical Standards

(Functional Abilities Essential for Practical Nursing Practice)

The purpose of the Practical Nursing Certificate Program is to educate students to meet the program outcomes and to ensure that no graduate will pose a danger to the patient. Certain functional abilities are essential for the delivery of safe, effective nursing care. These abilities are essential in the sense that they constitute core components of nursing practice, and there is a high probability that negative consequences will result for patient/clients under the care of nurses who fail to demonstrate these abilities. Reference material used in the development of these standards include local health facilities job descriptions and requirements, the Arizona Nurse Practice Act, The Functional Abilities Essential for the Delivery of Safe, Effective Nursing Care (a descriptive research study conducted by the National Council of State Boards of Nursing). The Technical Standards are reflected in the Nursing Program’s performance-based outcomes, which are the basis for teaching and evaluating all nursing students.

Practical Nursing Certificate students will receive both classroom and clinical instruction in multiple nursing specialty areas (Medical/Surgical, Maternal/Child, Pediatric, Mental Health, etc.) and will be required to demonstrate competency in each area.

In order to provide safe and effective patient care in the Practical Nursing Certificate Program, the student must be able to demonstrate, with or without reasonable accommodation, physical, cognitive, and behavioral abilities required for satisfactory completion of all aspects of the program curriculum and clinical agency requirements. Any applicant who has met the necessary academic prerequisites and can, with or without reasonable accommodation, meet and/or perform the Practical Nursing Certificate Program Technical Standards will be accepted for admission. Students admitted to the Practical Nursing Certificate Program gain experience in many settings that are physically demanding, e.g., hospitals, long term care facilities, community agencies, school settings and clinics. During each clinical experience, the practical nursing certificate student is assigned clinical care which includes medication administration and direct patient care. Students will be expected to adhere to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 which safeguards patient confidentiality.

Transportation to and from health care facilities is the responsibility of the student. Please carefully read the Practical Nursing Program Technical Standards.

The practice of nursing requires the following functional abilities with or without reasonable accommodations. Functional

Ability Standards and Examples of Required Activities

Gross Motor Skills

 Gross motor skills sufficient to provide the full range of safe and effective patient care activities

 Move within confined spaces such as treatment room or operating suite  Assist with turning and lifting patients

 Administer CPR

Fine Motor Skills

 Fine motor skills sufficient to perform manual psychomotor skills

 Manipulate small equipment and containers, such as insulin syringes, vials, ampules, and pills

 and medication packages, to administer medications  Perform tracheotomy suctioning, insert urinary catheter  Safely dispose of needles in sharps containers

 Accurately place and maintain position of stethoscope for detecting sounds of bodily functions

Physical Endurance

 Physical stamina sufficient to remain continuously on task for up to a 12- hour clinical shift while standing, sitting, moving, lifting, and bending to perform patient care activities  Walk/stand for extended periods of time; turn, position, and transfer patients.

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Physical Strength

 Physical strength sufficient to perform full range of required patient care activities  Push and pull up to 300 pounds (with assistance) as well as emergency carts;

stretchers and wheel chairs with and without patients; medication carts; wheel chairs; and other equipment

 Lift/move heavy objects up to 50 pounds without assistance

Mobility

 Physical ability sufficient to move from room to room and maneuver in small spaces; full range of motion to twist/bend,

 stoop/squat, reach above shoulders and below waist and move quickly;

 manual and finger dexterity; and hand-eye coordination to perform nursing activities  Move around in work area and treatment areas.

 Position oneself in the environment to render care without obstructing the position of other team members or equipment.

Hearing

 Auditory ability sufficient for physical monitoring and assessment of patient healthcare needs

 Hear normal speaking level sounds

 Detect sounds related to bodily functions using a stethoscope  Hear auditory alarms (monitors, fire alarms, call bells)

 Hear cries for help

 Hear in noisy environments

Visual

 Normal or corrected visual ability sufficient for accurate observation and performance of nursing care.

 See objects up to 20 feet away

 Visual acuity to read calibrations on 1 ml syringe  Assess skin color (cyanosis, pallor)

Tactile

 Tactile ability sufficient for physical monitoring and assessment of health care needs  Feel vibrations (pulses);

 Detect temperature changes;  Palpate veins for cannulation;

 Able to work with hands in water and wash hands frequently, Smell

 Olfactory ability sufficient to detect significant environmental and patient odors.  Detect abnormal odors from patient (foul smelling drainage, alcohol breath);  Detect smoke. Emotional/ Behavioral Professional Attitudes Interpersonal Skills

 Emotional stability and appropriate behavior sufficient to assume responsibility/accountability for actions.

 Present professional appearance and demeanor; demonstrate ability to communicate with patients, supervisors, coworkers to achieve a positive and safe work environment. Follow instructions and safety protocols;

 Honesty and integrity beyond reproach;

 Establish rapport with patients, instructors and colleagues;

 Respect and care for persons whose appearance, condition, beliefs and values may be in conflict with their own;

 Deliver nursing care regardless of patient’s race, ethnicity, age, gender, religion, sexual orientation or diagnosis;

 Conduct themselves in a composed, respectful manner in all situations and with all persons;

 Work with teams, workgroups, and other disciplines;  Establish and maintain therapeutic boundaries;

 Demonstrate emotional skills to remain calm and maintain professional decorum in an emergency/stressful situation;

 Demonstrate prompt and safe completion of all patient care responsibilities;  Adapt rapidly to changing environment/stress;

 Exhibit ethical behaviors and exercise good judgment;

 Function effectively under stress, to work as a part of a team and to respond

appropriately to supervision; to adapt to changing situations, to respond appropriately to patients and families under stress, and to follow through on assigned patient care responsibilities.

 Abilities sufficient to demonstrate competencies such as:  Ability to arrive to a clinical on a timely basis;

 Meet the demands for performance of duties;

 Meet organizational requirements to perform these duties in a professional and competent manner.

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Communicatio n

 Oral communication skills sufficient to communicate in English with accuracy, clarity and efficiency with patients , their families and other members of the healthcare team including non-verbal communication, such as interpretation of facial expressions, affect and body language.

 Give verbal directions to or follows verbal directions from other members of the health care team, and participate in health care team discussions of patient care;

 Elicit and record information about health history, current health state and responses to treatment from patients or family members;

 Convey information to patients and others as necessary to teach, direct and counsel individuals in an accurate, effective and timely manner;

 Recognize and report critical patient information to other Caregivers;  Communicate clearly in telephone conversations;

 Ability to speak, comprehend, read, and write English at a level that meets the need for accurate, clear, and effective communication.

Cognitive/ Quantitative

Abilities

 Reading comprehension skills and mathematical ability sufficient understand written documents in English and solve problems involving measurement, calculation, reasoning, analysis and synthesis.

 Calculate appropriate medication dosage given specific patient parameters;  Analyze and synthesize data and develop an appropriate plan of care;  Collect data, prioritize needs and anticipate reactions;

 Transfer knowledge from one situation to another;

 Accurately process information on medication container, physicians’ orders, monitor and equipment calibrations, printed documents, flow sheets, graphic sheets,

medication, administration records, other medical records, and policy and procedure manuals.

 Ability to collect, analyze, and integrate information and knowledge to make clinical judgments and manage decisions that promote positive patient outcomes

Conceptual/Sp atial Abilities

 Conceptual/spatial ability sufficient to comprehend three-dimensional and spatial relationships

 Comprehend spatial relationships in order to properly administer injections, start intravenous lines, assess wounds of varying depths etc.

Clinical Reasoning

 Ability to reason across time about a patient’s changing condition and/or changes in the clinician’s understanding.

 Evaluate patient or instrument responses, synthesize data, and draw sound conclusions.

Flexibility

 Adapt to Nursing Department course scheduling policy

 Available to work the hours of an assigned schedule which could include any shift and day of the week.

Once the program is in receipt of application and student receives letter of contingent acceptance to the Practical Nursing Certificate Program, the student is responsible for notifying the Director of the Practical Nursing Certificate Program of conditions that impact the student’s ability to meet the Practical Nursing Certificate program Technical Standards. Any change in the student’s ability to meet and/or perform the Practical Nursing Certificate Program Technical Standards would require the student to provide the Director with documentation that they once again meet Technical Standards for functional abilities essential to practical nursing practice.

If an accommodation is necessary to participate in the Practical Nursing Certificate Program, participation is dependent on the identification of a reasonable accommodation. Students should seek accommodation advising as soon as possible so that a plan for accommodation can be in place at the beginning of the program. Applicants seeking admission to the Nursing Program who may have questions about the Technical Standards and appropriate reasonable accommodations are invited to discuss their questions with the Office of Disability Services. Reasonable accommodation will be directed toward providing an equal educational opportunity for students with disabilities while adhering to the standards of practical nursing practice for all students. Registration with Disability Services is required before any accommodation requests can be granted. Under no circumstances will any course requirements or technical standards be waived for any student, with or without a disability. Reasonableness is determined by the office of student disabilities and Student Services and the Practical Nursing Certificate Program on a case-by-case basis utilizing the Practical Nursing Certificate Program Technical Standards. Mohave Community College provides reasonable accommodations to those students who qualify under the Americans with Disability Act, as amended (ADA). Appropriate documentation will be required to determine eligibility to receive accommodations. It is the student’s responsibility to contact the office of student disabilities and request accommodations in a timely manner.

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INSTRUCTIONS FOR OBTAINING YOUR BACKGROUND CHECK FOR A

CLINICAL EDUCATION PROGRAM

Mohave Community College-Practical Nurse Program

Background checks are required on incoming students to insure the safety of the patients treated by students in the clinical education program. You will be required to order your background check in sufficient time for it to be reviewed by the program coordinator or associated hospital prior to starting your clinical rotation. A background check typically takes 3-5 normal business days to complete. The background checks are conducted by PreCheck, Inc., a firm specializing in background checks for healthcare workers. Your order must be placed online through StudentCheck.

Go to

www.mystudentcheck.com

and select your School and Program from the

drop down menus for School and Program. It is important that you select your

school worded as

Mohave Community College-Practical Nurse.

Complete all required fields as prompted and hit Continue to enter your payment information. The payment can be made securely online with a credit or debit card. You can also pay by money order, but that will delay processing your background check until the money order is received by mail at the PreCheck office. Texas residents will pay $53.58 and New Mexico residents will pay $53.27. Residents in all other states will pay $49.50. For your records, you will be provided a receipt and confirmation page of the background check performed through PreCheck, Inc.

PreCheck will not use your information for any other purposes other than the services ordered. Your credit will not be investigated, and your name will not be given out to any businesses.

FREQUENTLY ASKED QUESTIONS:

 Does PreCheck need every street address where I have lived over the past 7 years? No. Just the city and state.

 I selected the wrong school, program, or need to correct some other information entered, what do I do? Please email [email protected], with the details.

 How long does the background check take to complete? Most reports are completed within 3-5 business weekdays.

 Do I get a copy of the background report? Yes. Log into www.mystudentcheck.com and click on “Check Status”, and enter your SSN and DOB. If your report is complete, you may click on the application number to download and print a copy. This feature is good for 90 days after submittal. After 90 days, you will be charged $14.95 for a copy of your report, and will need to contact PreCheck directly to request this.

 I have been advised that I am being denied entry into the program because of information on my report and that I should contact PreCheck. Where should I call? Call PreCheck’s Adverse Action hotline at 800-203-1654. Adverse Action is the procedure established by the Fair Credit Reporting Act that allows you to see the report and to dispute anything reported.

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MCC

MOHAVE

COMMUNITY

COLLEGE

PRACTICAL NURSING PROGRAM

Student Application Form

All qualified applicants are considered for admission, and students are treated without regard to race, color, religion, sex, national origin, age, or marital status. Information related to these areas will be used for statistical analysis and not as criteria for admission to the nursing program. All information will be kept confidential.

APPLICANT INFORMATION

Date: Social Security #: MCC ID #:

Full Name:

(Last) (First) (Middle)

Mailing Address:

Street (Apt #)

HOME PHONE:

City ST Zip (Area Code) Phone Number

Email Address: Cell Phone:

(Area Code) Phone Number

ACADEMIC HISTORY

List all colleges, universities and institutions attended, including high school.

High School: Location: Degree: Date(s):

College: Location: Degree: Date(s):

Other: Location: Degree: Date(s):

Practical Nursing Program PREREQUISITES: Please state if Completed or In Progress COMPASS READING:  Score 74 or above; or PCS 021  Completed  In Progress

COMPASS WRITING:  Score 70 or above; or TRE 089  Completed  In Progress

COMPASS NUMERICAL MATH: TRM 091  Completed  In Progress or MAT 099  Completed  In Progress TEAS  Completed  Retaking to improve score

HES 113—Medical Terminology Location:  Completed  In Progress

HES 129—Allied Anatomy & Physiology Location  Completed  In Progress

or

BIO 201—Anatomy & Physiology I Location:  Completed  In Progress

And

BIO 202—Anatomy & Physiology II Location:  Completed  In Progress

WORK HISTORY

Last five (5) years, beginning with most recent:

Occupation/Job Title Employer City/State Start Date End Date

1 2 3 4 5

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Personal Demographic Information

Responses to Gender, Birth Date, Marital Status, and Ethnicity/Race are voluntary and will be kept confidential. Failure to furnish this information will not adversely affect the status of this application; it is for statistical purposes only.

Date of Birth: Gender:  Male  Female Marital Status:  Single  Married Divorced  Widowed

MM/DD/YYYY

Maiden Name: Other Name(s) Used: Number of Children:

Ethnicity/Race

 American Indian or Alaskan Native  Asian or Pacific Islander  Hispanic

 Black/Non-Hispanic  White/Non-Hispanic  Other/Unknown

ANSWER THE FOLLOWING QUESTIONS 1. Have you ever been addicted to habit-forming drugs:  Yes No

If YES, please explain:

2. Do you have any physical or mental limitations:  Yes No If YES, please explain

3. Have you ever been convicted of a felony:  Yes No If YES, please explain

Licensure is the sole responsibility of the Arizona State Board of Nursing (AZBON). If you have been convicted of a felony, contact the Arizona State Board of Nursing to verify eligibility to be licensed prior to submitting this application.

DISCLAIMER AND SIGNATURE

 I have read all associated documentation contained within this admission packet and fully understand the functional skills and requirements as outlined in the Technical Standards document included.

 I understand that if accepted into the Practical Nursing Program, I will be required to travel for clinical experience and that I will be responsible for my own transportation and meals.

 I understand that if accepted, I will be required to meet the health requirements of the Practical Nursing Program.

 I hereby certify that the facts set forth in this Student Application are true and complete to the best of my knowledge. I understand that if accepted into the Practical Nursing Program, any falsified statements on this application or within any of the associated documentation shall be considered cause for suspension or dismissal.

Signature: Date:

MAIL COMPLETED APPLICATION TO: Practical Nursing Program Mohave Community College

1801 Detroit Ave. Kingman, AZ 86401

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TRANSCRIPT REQUEST

This form is for Transcripts from other institutions, not for MCC- the PN Program is able to view your MCC

Transcripts there is no need to order one.

Institution Name

Mailing Address

City

State

Zip

Please send one (1) OFFICIAL COPY of my transcript to:

Practical Nursing Program

Mohave Community College

1801 Detroit Avenue

Kingman, AZ 86409

____I do not know the Transcript fee, please bill me.

I am enclosing the transcript fee of $_ for

(number)

_____ transcripts.

PLEASE PRINT

Student Name

Social Security Number

Mailing Address

City

State

Zip

Maiden or Previous Name(s)

Address While attending your institution

If there is a charge against my account, I hereby agree to clear all indebtedness before this record will be released.

“STUDENT is responsible for mailing this”

Student Signature

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PRACTICAL NURSING PROGRAM

PROFESSIONAL REFERENCE FORM

To Be Completed by Applicant

(please print)

Complete the following section and give this form as soon as possible to someone who has observed you in a professional setting for a reasonable period of time. This should be an employer or community leader for whom you have worked or volunteered, or an instructor who has had the opportunity to view your accomplishments in a classroom setting.

Name:

Date:

Address:

(Street or P.O. Box)

(City) (State) (Zip)

The Family Educational Rights and Privacy Act of 1974 permits a matriculated student to have access to his/her file unless a waiver of that right has been signed. If you wish to waive your right to access your file, sign your name in the space provided. The waiver is NOT required as a condition of admission.

I hereby waive my right of access to this letter of recommendation.

Applicant’s Signature:

Date:

To be Completed by Evaluator

This student is applying for admission to Mohave Community College Practical Nursing Program. Evaluations are invaluable to the decision making process. Please include any information that you feel is pertinent, and remember that the sooner you return this form to MCC, the sooner we can give this student our admission decision. Thank you.

Please rate the applicant in each of the following areas: _Excellent _Good _Average _Poor _{Do Not Know}

Ability to work with others Conceptual ability Dependability Leadership ability Integrity / Honesty Initiative / Motivation Maturity Empathy / Caring Judgment

Overall Potential for Nursing Program

*Any additional comments you feel might be of value to the Practical Nursing Department, please state them on the back.

Name:

Agency Represented:

Title:

Address:

Signature:

Date:

PLEASE RETURN TO

Practical Nursing Program

Mohave Community College

1801 Detroit Avenue

Kingman, AZ 86401

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PRACTICAL NURSING PROGRAM

PROFESSIONAL REFERENCE FORM

To Be Completed by Applicant

(please print)

Name:

Date:

Address:

I hereby waive my right of access to this letter of recommendation.

Applicant’s Signature:

Date:

To be Completed by Evaluator

Please rate the applicant in each of the following areas: _Excellent _Good _Average _Poor Do Not _Know

Name:

Agency Represented:

Title:

Address:

Signature:

Date:

PLEASE RETURN TO

Practical Nursing Program

Mohave Community College

1801 Detroit Avenue

Kingman, AZ 86401

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PRACTICAL NURSING PROGRAM

PROFESSIONAL REFERENCE FORM

To Be Completed by Applicant

(please print)

Name:

Date:

Address:

I hereby waive my right of access to this letter of recommendation.

Applicant’s Signature:

Date:

To be Completed by Evaluator

Please rate the applicant in each of the following areas: _Excellent _Good _Average _Poor Do Not _Know

PRACTICAL NURSING CERTIFICATE OF PROFICIENCY PROGRAM APPLICATION