2022 Practical Nursing Program

APPLICATION PACKET

Full Approval Status by the Missouri State Board of Nursing

Carthage Technical Center is accredited by the Commission of the Council on Occupational Education

www.council.org

Carthage Technical Center - North Campus 609 S. RIVER STREET

CARTHAGE, MO 64836 PHONE (417)359-7095

FAX (417)359-7419 www.carthagetech.org

Application Deadline – September 24, 2021 Classes Begin – January 10, 2022

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CARTHAGE TECHNICAL CENTER PRACTICAL NURSING PROGRAM

Practical Nursing Coeta Ogle, MSN, FNP-C - Practical Nursing Coordinator oglec@carthagetigers.org (417)359-7095 extension 17031 The Carthage Technical Center Practical Nursing program, located at our North Campus, is committed to excellence in nursing education. We are very pleased that you are interested in our Practical Nursing program. Enclosed is an information packet for the class of 2022 which begins in January 2022. A brief description of each component of the application is provided. Please read the enclosed information carefully. This information has been provided for the purpose of completing the application process correctly and expediently. It is the applicant’s responsibility to make sure all components of the application process are completed before the selection committee convenes. The Practical Nursing program welcomes men and women to an exciting venture in learning. Its goal is for students to gain the knowledge and skills that will enable professional success in a career in nursing, resulting in quality patient healthcare. The program’s high standards focus on the physical and behavioral sciences, the humanities, and the nursing process. This framework prepares students to adequately meet the healthcare needs of their patients as practical nurses. The faculty is committed to mentoring students throughout their educational experience, thereby enabling them to accomplish their personal and professional goals. APPROVAL STATUS The Practical Nursing program of the Carthage Technical Center was established in 2010. It is located in the Carthage Technical Center—North Campus facility at 609 S. River Street in Carthage, Missouri. This program is under the control of the Carthage R-9 Board of Education, Carthage, Missouri, and is supervised by the State Department of Elementary and Secondary Education and the Missouri State Board of Nursing. The program is fully approved by the Missouri State Board of Nursing and is in compliance with 4 CSR 200-3.050-4 and is also approved by the Missouri State Department of Elementary and Secondary Education. Carthage Technical Center is accredited by the Commission of the Council on Occupational Education. Refer to COE website www.council.org. Approval/accreditation by these bodies confirms the Practical Nursing program’s high standards of quality, therefore properly preparing graduates for the opportunity to apply to the Missouri State Board of Nursing to sit for the NCLEX-PN licensing examination. You may contact the Missouri State Board of Nursing at: P.O. Box 656, Jefferson City, MO 65102-0656 or (573)751-0080. ADMISSION INFORMATION Admission to Carthage Technical Center Practical Nursing program is competitive. Student slots are limited to 28, but the CTC reserves the right to accept fewer students. Students must hold a High School Diploma or an original state recognized High School Equivalency Certificate. The application process consists of several steps which are outlined in this packet. Included in the process is a TEAS (Test of Essential Academic Skills) Assessment. All steps must be completed and criteria met before the application deadline in order to be considered for admission. Full acceptance to the nursing program is conditional upon negative drug testing and background check results which may be completed after acceptance into the program. All testing must be completed on or before September 24, 2021. The CTC reserves the right to accept an application after this deadline if necessary to fill the class. Please contact CTC to schedule your exam. All applications and required documents must be on file on or before September 24, 2021. MISSION STATEMENT The mission of the Carthage Technical Center Practical Nursing Program is to provide high quality nursing education empowering students to become caring, competent nurses who are able to successfully meet the expectations and challenges of the practical nursing profession with excellence.

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PHILOSOPHY The Carthage Technical Center Practical Nursing Program embraces the philosophy of the Carthage R-9 School District and is committed to providing high quality career and technical education. We believe that nursing is both a science and an art. The understanding that man is a multidimensional being with physical, psychosocial and emotional needs demands health care professionals are trained in the importance of meeting the needs of the individual from more than one perspective. This requires that curriculum and preparation for the field of nursing be deliberate, focused and comprehensive in its framework utilizing a systematic approach to addressing patient needs. Our curriculum is based on the physical and behavioral sciences, the humanities and the nursing process. It is constructed with the intent to develop healthcare professionals who are competent and effective critical thinkers, with strong moral character who are empathetic to the individual and committed to responding to the varied needs of the patient. Practical nursing programs have a responsibility to provide students with excellent nursing educators who will assist the student learner to strive for excellence in his/her academic and clinical achievements while fostering an understanding of the ethical responsibility to sincerely care for the individual which is so inherent to the nursing profession. Our faculty is committed to mentoring students throughout this educational experience in order to assist them in realizing their potential, thereby enabling them to accomplish their personal and professional goals. We believe that these goals are met through a strong partnership between the student, faculty and community partners who demonstrate a commitment to the success and development of healthcare professionals. Upon graduation, the professional practical nurse will have the knowledge and skills to function as a contributing member of the health care team under the direction of a licensed registered nurse based on the standards of practice outlined in the Nurse Practice Act. CURRICULUM OUTLINE The CTC Practical Nursing program is 1325 clock hours. The following courses are required for successful completion of the Carthage Technical Center Practical Nursing program: COOPERATING CLINICAL FACILITIES Arrangements have been made with the following health care facilities to provide clinical experience opportunities for our practical nursing students. If you foresee a problem with any of the facilities listed below you must inform the Practical Nursing Coordinator. Attendance at all clinical facilities will be required. Students unable to attend certain clinicals facilities may not be able to complete clinical requirements and therefore will not able to complete the program.

• Access Family Care • Barton County Health Department • Carthage Health & Rehab • Carthage R-9 School District • Communities of Wildwood Ranch • Freeman Health Systems • Jasper County Health Department • Joplin Gardens • Joplin Health Department • Joplin Health and Rehab • Joplin R-9 Schools • Landmark

• Mercy Hospital- Joplin • National Health Care • Ozark Center • Pediatric Associates of Southwest Missouri • Phoenix Home Health • Spring River Christian Village • St. Luke’s Nursing Center • Truman Healthcare & Rehabilitation Center • Webb City Health and Rehab • Wildwood Communities

REFUND POLICY If a student wishes to withdraw from a Carthage Technical Center program, the student must notify the school of their desire to withdraw. The request for a refund must be approved by the administration. Tuition is the only expense that may be refunded. Pro-ration is used to determine the amount that may be refunded. For the students who begin classes, 100% of the textbooks and fees are considered to be expended. Applicable fees and supplies may be refunded if the expense has not been incurred. For those students leaving CTC with a balance due to the school, he/she must either pay the entire balance or make monthly installments to satisfy this debt. Weeks are defined in calendar weeks. The week the student begins, regardless of the day, from Sunday to the following Saturday is week one, and so on.

Trimester 1 Anatomy and Physiology Nursing Fundamentals Personal/Vocational Concepts Pharmacology I

Trimester 2 IV Fluid Therapy Maternal/Newborn Nursing Nursing Care of the Adult I Nursing Care of the Child Pharmacology II

Trimester 3 Community Health/Mental Health Nursing Care of the Adult II Nursing Care of the Older Adult Nursing Leadership and Management NCLEX-PN Prep

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In the event the Carthage Technical Center cancels the class before the start of the program, CTC will refund 100% of the tuition/fees collected. This includes tuition fees as well as application and acceptance fee. Full refund will be given when a student withdraws on or before the first day of class, less $100 cancellation fee. Refund will be given within 45 days of the class start date. Application and acceptance fess are not included in refund. Withdrawing during week one of the program, after the first day, makes the student eligible for a refund of 75% of the tuition of his/her program they are withdrawing. Refund will be given within 45 days of the start date for the class. Withdrawing during week two of the program makes the student eligible for a refund of 50% of the tuition of his/her program they are withdrawing. Refund will be given within 45 days of withdrawal/termination. Withdrawing during week three of the program makes the student eligible for a refund of 25% of the tuition of his/her program they are withdrawing. Refund will be given within 45 days of withdrawal/termination. Beginning week four of the program, no refund will be given. Students who have not visited the school facility prior to enrollment will have the opportunity to withdraw without penalty within three days following either attendance at a regularly scheduled orientation or following a tour of the facilities and inspection of the equipment. PERFORMANCE STANDARDS Students seeking admission and graduation from Carthage Technical Center’s Practical Nursing program are required to meet specific academic and performance standards. Critical Thinking—Student will demonstrate sound clinical judgment. Student will exhibit the reasoning skills sufficient to perform deductive/inductive critical thinking in the clinical setting. Interpersonal/Communication Skills—Student will demonstrate the ability to interact with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds, the ability to establish rapport with patients and colleagues, the ability to use therapeutic communications and function as part of a team, the ability to explain treatment procedures, initiate health teaching, document and interpret nursing actions and patient responses, and the ability to identify cause and effect relationships in clinical situations, along with developing nursing care plans, calculating medication dosage accurately, evaluating patient responses, and promoting patient safety. Communication abilities sufficient for effective interactions with others both in verbal and written form; ability to operate information technology systems, i.e. teach patient and family, explain procedures, give oral reports, interact with others, speak on the telephone, influence people, and explain information through writing. Motor Skills—Physical stamina sufficient to perform the complete range of required patient care activities for the entire length of a work day. Physical fitness to move from room to room and maneuver in small spaces; full ROM; manual and finger dexterity; and hand-eye coordination sufficient to provide safe and effective nursing care. Administer CPR procedures, stand/walk for extensive periods of time, use equipment, transfer patients, and lift 50 pounds. Sensory Skills: Hearing Abilities—Sufficient to monitor and assess health needs, hear heart monitor alarms, emergency signals, auscultatory sounds, and cries for help. Visual Abilities—Sufficient for observation and assessment necessary in nursing (can be corrected to 20/40). Observe patients responses, secretions, and color. Read manometers, charts, computer screens, digital printouts, labels, graphs, gauges, and syringes. Tactile Abilities—Sufficient for physical assessments and interventions when necessary in nursing. Ability to perform functions of physical examination and/or those related to therapeutic intervention, e.g. insertion of a catheter or IV, etc. Olfactory Abilities—Sufficient for maintaining environmental and patient safety (smell). Distinguish smells which are contributory to assessing and/or maintaining the patient’s health status or environmental safety. Reading Abilities—understand written documents. Read and understand policies, procedures, and patient charts. Reading ability will be tested on the TEAS pre-entrance test. Mathematical Skills—Perform computations including counting, measuring, and performing calculations. Math abilities tested on the TEAS pre-entrance test.

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Professional Attitude and Demeanor—Present professional appearance and skills required to maintain physical, mental and emotional boundaries. Assume responsibility and accountability for own actions. Show stability and work under stressful conditions. React calmly in emergency situations. Show concern for others. ENGLISH AS A SECOND LANGUAGE/FOREIGN STUDENTS Applicants for whom English is a second language and/or applicants that are non U.S. citizens must take the TABE CLAS-E and obtain a required program passing score. Applicants are responsible for making their own arrangements for testing. International students must have proper documentation that allows participation in post-secondary education in the United States, to be admitted to the CTC Program. International students must meet the same requirements for admission and must qualify for licensure and/or certificate per program. Once this process is complete, the TEAS Entrance Exam is required as per the application criteria. For more information, contact AEL Coordinator, Bonnie Schaeffer, at (417)359-7095 ext. 17017 or by email schaefferb@carthagetigers.org. ADMISSION CRITERIA Students shall be selected on the basis of the philosophy and objectives of the practical nursing program and the ability of the student to carry the program toward completion. Applicants must:

• Be a High School graduate or hold an original state recognized High School Equivalency Certificate. Official documentation must be presented to the admissions office.

• Show evidence of good moral character (three letters of reference are required). • Be eighteen years of age. • A criminal background check clearance. • Negative Family Care Safety Registry background screening • Negative Drug Testing Results • Be eligible to participate in all clinical rotations. If eligibility changes at any point prior to or during the program,

the student must notify the program coordinator. Failure to do so may result in program dismissal. • Recommended TEAS score of 56% or higher • Have a physical examination by a physician or nurse practitioner utilizing the form provided in the acceptance

packet. • American Heart Association BLS CPR Certification valid through the completion of the Practical Nursing

program. • Provide your immunization records with proof of the following:

o Annual influenza vaccine 2021-2022 season vaccine will need to be received in the office by October 28, 2021 2022-2023 season by October 28, 2022

o Hepatitis B series or positive titer o Tdap vaccine or Td booster if Tdap is past 10 years o Immunity for measles, mumps and rubella - 2 doses of MMR (if born in 1957 or later) or positive titers

for each o Immunity for varicella vaccine (2 shot series) or positive titer o TB Skin Testing

New to Healthcare: Negative Manitou TB 2-step testing after December 1, 2021. Second TB test must be received within 30 days of first TB test. Or other initial screening method such as Quantiferon Test - TB Gold blood will be accepted.

Currently in Healthcare: Negative Manitou TB 1-step test after December 1, 2021 with proof of previous TB skin tests

If there is a past history of a positive TB skin test, a chest x-ray and a release statement from the physician will be required.

o COVID-19 Vaccine

**Carthage Technical Center’s admission requirements offer reasonable expectations for successful completion of the occupational programs offered regardless of delivery mode. Selection Process—Applicants are reviewed and selected by the Admission/Selection Committee without consideration of age, marital status, sex, national origin, race, color, creed, disability, and/or religion to the extent required by the law. Applicants will be selected based on whose records indicate the most potential for success in the nursing program, this is determined by applicants score on the selection tool. The TEAS score, reference responses, and background checks are evaluated for acceptance to the program. TEAS scores weigh heavily in the applicant selection process. It is to your advantage to score as high as possible. All applicants scoring a 56 or higher on their TEAS will be considered first in the selection process. Therefore, a TEAS score of 56 or above is recommended but CTC reserves the right to accept lower scores. Evidence of previous college course work (official college transcript required) and active or inactive healthcare certifications may add points to an applicant’s selection tool score. The top 28 applicants per the selection tool will be accepted for the upcoming school year as long as the application process is completed, all required documents have been provided by the applicant and admission criteria has been met.

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ACCOMMODATIONS FOR STUDENTS WITH SPECIAL NEEDS Notification and Assessment Requirements: Students requesting accommodations for special needs must notify the school of their needs prior to the first day of class. In order for the school to make appropriate accommodations, students must provide current (less than one year old) assessments identifying their needs. The assessment is to be accompanied with recommendations for accommodations that are made by the agency performing the assessment. Such assessments are at the expense of the student. American with Disabilities Act of 1990 If you have special needs as addressed by ADA, please discuss this with Mark Sponaugle, Career and Adult Accommodations Coordinator, at the Carthage Technical Center. You may reach Mr. Sponaugle at (417)359-7026. Reasonable efforts will be made to accommodate your special needs. TRANSFER/ADVANCE PLACEMENT POLICY: Carthage Technical Center does not accept clock or credit hours to be transferred from outside institutions or within this institution. Carthage Technical Center does not allow transfers between programs within this institution and does not offer advanced placement. This program must be completed start to finish to be eligible to sit for the NCLEX-PN licensure exam. GRADUATE COMPETENCIES During three trimesters, the school curriculum and practicum prepare students to demonstrate the achievement of the program’s objectives by learning to:

1. Demonstrate effective communication to clients, members of the family and the healthcare team throughout the nursing care process.

2. Utilize competent clinical judgement in nursing care as evidenced by utilization of nursing principles, skills, and assessment techniques when addressing the physiological, psychosocial, and emotional needs of the client and members of the family.

3. Demonstrate appropriate therapeutic interventions when providing nursing care to clients and members of a family with knowledge of appropriate safety and infection control techniques.

4. Provides patient-centered care across the life span utilizing the principles of growth and development for clients and members of the family.

5. Utilize evidence-based practice to provide appropriate nursing care to clients and members of the family.

6. Assume a professional role as evidenced by displaying responsibility and accountability for his/her nursing care utilizing ethical and legal principles within the licensed practical nurse scope of practice.

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APPLICATION PROCESS CHECKLIST Step 1

� Review the application and application process very carefully. � Review tuition and fees sheet and financial commitments. � Review for ATI TEAS test.

Step 2 Turn in application to the CTC office. The following items must be submitted at one time:

� Complete application forms (pages 9-12) � $35 non-refundable application fee � Official High School Transcript/High School Equivalency Certificate � Birth Certificate for office to copy � Photo ID for office to copy � Social Security Card for office to copy � Complete the Free Application for Federal Student Aid (FAFSA) at www.fafsa.ed.gov for

2021-2022 and 2022-23 (available10-1-2021) using school code 041522. *Refer to https://ctc.carthagetigers.org/financialaid for additional financial aid information.

Step 3

� Schedule ATI TEAS by calling the CTC office at 417-359-7095. o View the TEAS testing calendar on our website for specific dates. o The $65 testing fee is due at the time of registration. o An ATI account must be created before testing date. Go to www.atitesting.com to register. o If you need to cancel, the CTC must be notified at least 24 hours in advance in order to

qualify for a refund. Step 4 References (pages 13-15)

� Deliver reference forms to individuals (at least two supervisor references required). Do not include relatives, family physicians (unless work related) or friends. These references will not be considered. *Three letters of reference must be in process when application is submitted. The references must be received to Admissions by September 24, 2021.

Step 5 � Register for the Family Care Safety Registry. This is to be completed online and paid with

debit/credit card. To complete the registration online go to http://health.mo.gov/safety/fcsr/. If you are already registered in the FCSR database, please notify the CTC office.

Step 6

� Complete a criminal background check. o Contact the CTC office at 417-359-7095 for more information. This must be paid online with

a debit/credit card. Background check must be in progress by September 24, 2021 with receipt proof.

Step 7 Informational Packet

� All applicants must receive an informational packet. Please pick this packet up in the CTC office if one was not given to you at the time your application was submitted.

*Carthage Technical Center Practical Nursing program reserves the right to change the application process as necessary. Applicants may be required to complete additional documentation for application.

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ACCEPTANCE INFORMATION: Acceptance into the Practical Nursing program is competitive. Applications will be reviewed and accepted by the Selection Committee without consideration of age, marital status, sex, national origin, race, color, creed, disability, financial status, and/or religion to the extent required by law. Applicants whose records are complete and indicate the greatest potential for achievement in the Practical Nursing program will be accepted. Please remember that the application process (application, references, transcripts, etc.) must be complete and in the Practical Nursing Office prior to the Selection Committee meeting to be considered for the next school year. The deadline for all applications and materials to be turned in is September 24, 2021. Early Acceptance Period Applicants that complete the application process and earn a TEAS score at or above 56 by June 17,2021 will be considered for early acceptance into the 2022 class. DRUG TESTING The final step in the acceptance process is a drug screening which is to be completed prior to the first day of the program. Information from this screening must be released to the school as part of the pre-entrance materials required of all students. An ongoing, random drug screening may be requested and given to any student at any time during the school year. Failure to participate or failure to pass a drug test will cause dismissal from the program based on the school’s policies regarding drug use and the rights of the student for appeal. IF ACCEPTED: Once the applicant is accepted by the Selection Committee, the Practical Nursing Coordinator will notify the applicant by mail of his or her eligibility to be a member of the program along with an acceptance form to be completed. If the applicant accepts a position in the program, the acceptance form is due by October 15, 2021 with a $100 Acceptance Fee. The following items are due on or before January 5, 2022:

� Physical Examination form—must be completed by your personal physician on form provided to you � Immunization Record – Reference immunization requirements under admission criteria � Have Financial Aid and/or Payment Plan in place with a signed Tuition Payment/ Enrollment Agreement � Proof of AHA BLS Healthcare Provider CPR Certification. Students will be expected to renew CPR certification if

certification expires prior to program completion in December of 2022.

Students selected for the program will be required to attend Orientation on Wednesday, January 5, 2022. Attendance is mandatory. OBLIGATION FOR PAYMENT Acceptance of Admission constitutes a financial contract between students and the school. Students are ultimately responsible for payment of amounts owed to the school, including instances where anticipated financial aid becomes unavailable. If students do not make payments of amounts owed to the school when they become due, the school has the right to cancel students’ registration; to withhold their grades, transcripts, diplomas, certificates, and to refuse admittance to final exams. FINANCIAL AID Any student receiving scholarships, facility pay, or any other outside funding will be required to file the FAFSA. AGENCY/FACILITY PAY If any agency or employer will be assisting a student with tuition and fees, a letter from that entity (on letterhead) stating the amount to be paid on the student’s behalf must be brought to the CTC office. The letter must be received by the date of the accepted applicant’s tuition payment meeting. ALTERNATE STATUS When the practical nursing class is filled, the remaining qualified applicants will be identified as ALTERNATES. Alternates will be ranked according to their selection tool. If a student seat becomes available the highest-ranking alternate will be called and asked if she or he would like to enter the class. LATE ADMISSION No student shall be admitted into the Practical Nursing program later than five days after the established entrance date of the program. *The number of students admitted to the program is established by the Missouri State Board of Nursing.

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CARTHAGE TECHNICAL CENTER -NORTH CAMPUS

PRACTICAL NURSING APPLICATION FOR ADMISSION Application Deadline: September 24, 2021 Early Acceptance Deadline: June 17, 2021

Check box if reapplying ⎕

First Name M.I. Last Name Maiden Name All Previous Alias’s Street Address City State Zip Code

Ethnic Origin: � American Indian or Alaska Native Social Security Number - - ______ � Asian � Black or African American Male � � Native Hawaiian or Other Pacific Islander Female � � White � Hispanic or Latino

Date of Birth _______________ Home Phone ___ _ Cell Phone___________________ E-Mail Address _______________________________

Is English your second language? YES NO Are you a citizen of the US? YES NO

EMPLOYMENT HISTORY (current or most recent employment)

1. Employer: ___________________________ __________________________________________________

Address: ____________________________________

Phone: ( ) - _ Date Employed: ___________ _ Date of Termination__________________

Reason for leaving (Optional)________________________________________________________________

2. I I have not been employed outside the home.

ALTERNATE CONTACT: Please list below one individual, such as a spouse, parent or guardian, we may contact for follow-up purposes or in case of any emergency.

Name / Relationship Address Phone Number

Date Received: ________ Received By: __________

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Have you ever previously attended Carthage Technical Center? YES NO If yes, what program(s)? Have you ever been convicted as an adult offender of any crime? YES NO If yes, please explain: ___________________________________________________________________________ _____________________________________________________________________________________________

Is your name on the Department of Health and Senior Services Employee Disqualification List? YES NO DRUG SCREENING As part of the final steps in the selection process the Practical Nursing applicants will be required to submit to a drug screening. Further information will be given to applicants when necessary. HOW DID YOU HEAR ABOUT CARTHAGE TECHNICAL CENTER PRACTICAL NURSING PROGRAM? Please check all that apply: Past Graduate Newspaper High School Counselor Career Fair or Presentation Radio

Magazine Billboard ________ Friend If so, who? ______________ Other ________________________

If accepted as a student, I give the Carthage Technical Center permission to release a copy of my school records to inquiries such as employment for educational purposes, according to the Family Educational Rights and Privacy Act of 1974. I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information. I certify that the information provided on this application is correct to the best of my knowledge and that I am at least 17 years of age. Falsification of any part of this application may be grounds for dismissal from the Carthage Technical Center Practical Nursing program. I authorize the Carthage Technical Center and its affiliates to contact me using automatic dialing equipment via telephone, email, prerecorded message, and physical mailing address. I certify that I have read and understand the Application Packet in its entirety. _____________ _ Signature Date

Statement of Non-Discrimination The Carthage R-9 School District does not discriminate in its programs, services, activities, facilities, or employment with regards to race, color, national origin, ancestry, religion, sex, disability, age, genetic

information, or any other characteristic protected by law. If you feel as though you have been discriminated against in any manner, please contact the district's 504 Coordinator, Director of Special Services, or

Compliance Officer/Title IX Coordinator, Director of Human Resources. They can be reached at 417-359-7000 or 709 W. Centennial Ave., Carthage, MO, 64836.

Notice of Confidentiality The Carthage Technical Center is required by law to collect social security numbers (SSN) from its students for the

administration of certain programs. We are also required by law to maintain certain documents in accordance with Missouri’s records retention policies. We do not collect or share personal information for any purpose other than to

respond to you and the governmental agencies requiring us to report such information. Non U.S. Citizens

Pursuant to 8 U.S.C.A. §1621, the Board of Nursing is prohibited from granting professional licensure to a non-eligible, non-citizen of the United States. An individual who is a qualified alien, a nonimmigrant or an alien paroled into the US as

documented by the US may be eligible for licensure. However, individuals who may have permission from the US to be here for a specific duration or purpose may not be eligible for professional licensure pursuant to federal law.

You may review this document on the Missouri State Board of Nursing website at http://pr.mo.gov/boards/nursing/CITIZENSHIP-LAWFUL-PRESENCE.pdf.

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DRUG SCREENING AND CRIMINAL BACKGROUND CHECK CONSENT FORM

I, the undersigned, hereby authorize laboratory testing of my blood, urine, and/or breath for the presence of drugs, alcohol, and controlled substances. I give consent for the release of test results to the Practical Nursing Coordinator for appropriate review and action as described in the rules and policies of the school and program.

I understand that this testing is not part of any medical treatment, treatment for illness, or therapy. I agree to hold harmless and release from all liability all physicians, employees and agents who work to perform the testing or the disclosure of results from and against any claims, actions, or losses that arise as a result of the testing or disclosure of test results.

I acknowledge that this signed Drug Screening Consent Form is a requirement for consideration for acceptance into the Practical Nursing program. If I qualify and am accepted into the program contingent on a negative drug screen, I realize that a positive result will compromise my acceptance into the program. I will not hold anyone responsible but myself if my acceptance is denied because of this testing.

I also consent to a Criminal Background Check and being screened on the Employee Disqualification List prior to acceptance into the Practical Nursing program.

Students that are accepted through false or incorrect information on this background form will be terminated from the educational program. Any individual who has been convicted of a felony may be ineligible for completing clinical experiences and therefore unable to complete the requirements for this program. The Carthage Technical Center reserves the right to not admit anyone that has finding(s), a pattern of unlawful behavior, or whose background check comes back unsatisfactory. In order to be considered for the program I understand that a background check and drug screening is required for acceptance and I request and authorize the Carthage Technical Center to obtain background and drug screening reports as they deem necessary.

Print your name________________________________________________________________________

Signature of Applicant_____________________________________Date__________________________

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CONFIDENTIAL RELEASE WAIVER LETTERS OF REFERENCE

Personal references are given assurance of confidentiality. For this reason, we are requesting the following waiver agreement be signed. This is necessary in order to comply with federal law PL93-380, regarding confidential letters and statements of recommendations submitted by the references on your behalf. I, , hereby waive my right to see the personal/professional letters of reference from people I have listed as references on my application for admission to Carthage Technical Center. I do give permission for the selection committee to have full access to this confidential information during the admission process. Signature_______________________________________ Date______________________

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SUPERVISORY LETTER OF REFERENCE APPLICANT: _______________________________________ The above named applicant has applied for admission to the Carthage Technical Center Practical Nursing program. Please complete this form and return it as soon as possible. The applicant has signed a waiver of confidentiality. All information supplied will be kept confidential. Please give us your candid opinion of the person’s suitability for the duties of the Practical Nursing program. RELATIONSHIP TO APPLICANT:__________________________________ How long have you known the applicant? 0-5 yrs. 6-10 yrs. 11-20 yrs. Lifetime Has he/she been under your supervision? YES NO On a scale of one to five, with (5) being the highest, and (1) being the lowest possible rating, please rate the applicant named above.

Place a check mark in the space provided below to best describe the applicant.

Please state briefly what you believe to be his/her greatest strengths: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please state briefly what you believe to be his/her greatest challenges: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you recommend this applicant for our program? YES NO PLEASE COMPLETE THIS INFORMATION BELOW: NAME:_________________________________ SIGNATURE:___________________________ DATE:____________ TITLE:_____________________________________________ INSTITUTION:_______________________________________ ADDRESS:___________________________________________________________ PHONE:____________________________ Please return the completed form to Carthage Technical Center Practical Nursing program in care of Kaitlin Riner at 609 S. River Street, Carthage, MO 64836 or fax it to (417)359-7419. Do not send it with the applicant. References must be received by September 24, 2021.

Consistently Excellent

Very Good

Average Below Average

Needs Improvement

PERSONAL QUALITIES 5 4 3 2 1

Disposition

Honesty

Communication Skills Interpersonal Relations Conflict Management Organization and Planning Problem-solving Self- Motivation Dependability - Commitment to Task

Responsibility Punctuality Attendance For Office Use Only

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SUPERVISORY LETTER OF REFERENCE

APPLICANT: _______________________________________ The above named applicant has applied for admission to the Carthage Technical Center Practical Nursing program. Please complete this form and return it as soon as possible. The applicant has signed a waiver of confidentiality. All information supplied will be kept confidential. Please give us your candid opinion of the person’s suitability for the duties of the Practical Nursing program. RELATIONSHIP TO APPLICANT:__________________________________ How long have you known the applicant? 0-5 yrs. 6-10 yrs. 11-20 yrs. Lifetime Has he/she been under your supervision? YES NO On a scale of one to five, with (5) being the highest, and (1) being the lowest possible rating, please rate the applicant named above.

Place a check mark in the space provided below to best describe the applicant.

Please state briefly what you believe to be his/her greatest strengths: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please state briefly what you believe to be his/her greatest challenges: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you recommend this applicant for our program? YES NO PLEASE COMPLETE THIS INFORMATION BELOW: NAME:_________________________________ SIGNATURE:___________________________ DATE:____________ TITLE:_____________________________________________ INSTITUTION:_______________________________________ ADDRESS:___________________________________________________________ PHONE:____________________________ Please return the completed form to Carthage Technical Center Practical Nursing program in care of Kaitlin Riner at 609 S. River Street, Carthage, MO 64836 or fax it to (417)359-7419. Do not send it with the applicant. References must be received by September 24, 2021.

Consistently Excellent

Very Good

Average Below Average

Needs Improvement

PERSONAL QUALITIES 5 4 3 2 1

Disposition

Honesty

Communication Skills Interpersonal Relations Conflict Management Organization and Planning Problem-solving Self- Motivation Dependability - Commitment to Task

Responsibility Punctuality Attendance For Office Use Only

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LETTER OF REFERENCE APPLICANT: _______________________________________ The above named applicant has applied for admission to the Carthage Technical Center Practical Nursing program. Please complete this form and return it as soon as possible. The applicant has signed a waiver of confidentiality. All information supplied will be kept confidential. Please give us your candid opinion of the person’s suitability for the duties of the Practical Nursing program. RELATIONSHIP TO APPLICANT:__________________________________ How long have you known the applicant? 0-5 yrs. 6-10 yrs. 11-20 yrs. Lifetime Has he/she been under your supervision? YES NO On a scale of one to five, with (5) being the highest, and (1) being the lowest possible rating, please rate the applicant named above.

Place a check mark in the space provided below to best describe the applicant.

Please state briefly what you believe to be his/her greatest strengths: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please state briefly what you believe to be his/her greatest challenges: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you recommend this applicant for our program? YES NO PLEASE COMPLETE THIS INFORMATION BELOW: NAME:_________________________________ SIGNATURE:___________________________ DATE:____________ TITLE:_____________________________________________ INSTITUTION:_______________________________________ ADDRESS:___________________________________________________________ PHONE:____________________________ Please return the completed form to Carthage Technical Center Practical Nursing program in care of Kaitlin Riner at 609 S. River Street, Carthage, MO 64836 or fax it to (417)359-7419. Do not send it with the applicant. References must be received by September 24, 2021.

Consistently Excellent

Very Good

Average Below Average

Needs Improvement

PERSONAL QUALITIES 5 4 3 2 1

Disposition

Honesty

Communication Skills Interpersonal Relations Conflict Management Organization and Planning Problem-solving Self- Motivation Dependability - Commitment to Task

Responsibility Punctuality Attendance For Office Use Only