FALL 2016

Revised 6/09/2016

Certified Nursing Assistant Program Eligibility

To become a Certified Nurse Aide you must: To help you apply I have included a checklist to guide you through the process.

Meet with advisor Brandi Kerley to submit application for KRC: Certified Nursing Assistant. (Email complete application to bekerley@kpc.alaska.edu and call to schedule appointment 907.262.0353)

Submit your Background Check information, as well as your debit/credit card payment for processing.

Take a placement test to demonstrate necessary English and Math proficiency.

Register and pay for the 6-credit course.

Mail your fingerprint card packet to the State.

Obtain proof of immunizations prior to start of class (may include blood test if you do not have your immunization records).

Submit State exam application: Requires completion of an approved CNA course of 60 hours or more of classroom and lab instruction and 80 hours or more of clinical experience.

NOTE:

You could be eligible to take the CNA course, but not the state exam for licensing. Be sure to read the application thoroughly and answer all questions.

High School Graduation or GED equivalency is not required for state licensing but may be required for employment!

The HCA A105- 6 credit course is typically structured:

Class and Lab 8/29-12/17 M-F 9am-3pm

Clinicals 8/29-12/17 M-F 6am-3pm

MANAGING COSTS

Financial assistance may be available to help you manage the costs of the course. Ask your

advisor to help you determine which programs you may be eligible for.

Department of Labor Job Services, Alaska Job Center 907-335-3010

Department of Vocational Rehabilitation, 907-283-3133 or 1-800-

478-3136 KPC payment plan for tuition and fees. Ask about the EZ

payment plan and other options at the KPC Financial Aid office.

See the Estimated Cost breakdown on the following page.

FALL 2016

Revised 6/09/2016

Estimated Costs: Payable to Kenai Peninsula College prior to start of

course:

Tuition & Fees*** $1329.00

Accuplacer** $18.00

Books (approx. costs) $52.00

CPR/First Aid Manual & Card* $20.00

Scrubs (approx. costs) $36.90

Total $1455.90

Payable to Certified Finger printers (Majority Arm or

VIP)

Fingerprints (3 sets) $25.00

Photo for State Exam* $15

Notary Service* $5

Payable to State of Alaska

Background check $74.75

State of Alaska Certification Exam $279.00

Estimated GRAND TOTAL $1854.65

***Approximate estimates and subject to change

**May not be needed if previously tested or taken college level Math and English

*As needed

NOTE: Costs for immunizations/lab tests may vary and are not included in the above

estimates.

FALL 2016

Revised 6/09/2016

Background Check Requirements Your Certified Nurse Assistant course includes classroom and clinical training. The clinical

portion of the course requires a completed, approved application with the State of Alaska

Background Check Program (BCP). The deadline for submitting the application and other

paperwork to KPC is at least six weeks prior to the start of the class.

Students who are not cleared by the background check will not be allowed to register for the

class. Questions about licensing requirements or background barriers should be addressed

prior to registering for HCA A105. Inquiries should be made to the Alaska Board of Nursing at

(907) 269-8161. Further information is available online at

http://commerce.alaska.gov/dnn/cbpl/ProfessionalLicensing/NurseAideRegistry.aspx

Not all offenses bar an individual from participating in clinicals or licensure. Crimes that are

considered barriers are listed on the State of Alaska Barrier Crime Matrix found at

http://dhss.alaska.gov/dhcs/Documents/publicnotice/PDF/145.pdf.

Students must complete two background checks. The first background check is for clearance to participate in the clinical portion of the course.

If you have a current background check in place, speak with Developmental Advisor, Brandi

Kerley as you may be eligible for reduced fees for the background check.

State of Alaska Nurse Aide Exam for licensing.

The second background check is conducted by the AK Board of Nursing as part of the licensing

process, when applying to take the state exam.

You will be required to answer questions relating to professional conduct and personal history pursuant to AS 08.68.334.

A second set of fingerprint cards will be required.

Students ineligible for licensing due to a criminal background or history of substance

abuse will not receive a refund on KPC tuition. A criminal conviction or history of

substance abuse problems does not automatically keep a person from being licensed,

but will make the application process longer.

Getting your background check You must bring your complete CNA application packet for initial processing to the Advisor,

Brandi Kerley at least 6 weeks before the course starts. You will not be allowed to register for

the course until your Background check is complete.

1. Make an appointment with Developmental Advisor, Brandi Kerley: bekerley@kpc.alaska.edu, call 907.262.0353

2. Bring completed Packet to the appointment with: a. Debit or Credit card, for making an online payment to the State of AK BCP

FALL 2016

Revised 6/09/2016

b. Obtain fingerprints (2 sets) from VIP Alaska or Majority Arms c. Mail one set of fingerprints to:

State of Alaska: Dept. of Health & Social Services Division of Public Health Background Check Unit 4601 Business Park Blvd, Bldg. K Anchorage, AK 99503 Fax: (907) 269-3488

d. Keep second set of fingerprints for Licensing certification.

3. The advisor will verify all documents are present, input your BCP application into the

State electronic database It is your responsibility to mail the completed packet to the address listed above.

We understand that this process is unfamiliar, please call Brandi Kerley at 262-0353 if

you have questions!

A6. What records are checked by the BCP before a provisional clearance is issued? Before issuing a provisional clearance to an individual wishing to become a direct care service

provider, the BCP conducts an exhaustive background check. This background check includes

records from both Alaska and those states the individual has lived in for the past 10 years.

Records searched are:

Alaska Public Safety Information Network (APSIN) - APSIN serves as a central repository for Alaska criminal justice information. This information is also known as an “Interested Persons Report.”

Alaska Court System/Court View and Name Index – Provides civil and criminal case information and is used to assist in determination of disposition for cases in APSIN.

Juvenile Offender Management Information System (JOMIS) – JOMIS is the primary repository for juvenile offense history records for the State of Alaska, division of Juvenile Justice.

Centralized Registry (employee misconduct registry) – Includes those persons which have been investigated by a state investigator for abuse, neglect and/or exploitation, found guilty of abuse, neglect, and/or exploitation, and due process has been provided. Alaska and other states (birth and residence) as applicable.

Certified Nurse’s Aide (CNA) Registry – professional registry listing those individuals certified to perform duties as a CNA. In some states, this registry also serves an abuse registry. Alaska and other states (birth and residence) as applicable.

National Sex Offender Registry (NSOR) – The NSOR provides centralized access to registries from all 50 states, Guam, Puerto Rico and the District of Columbia.

Office of Inspector General (OIG) – A database which provides information relating to parties excluded from participation in the Medicare, Medicaid and all Federal health care programs.

And any other records/registries the Department deems are applicable.

FALL 2016

Revised 6/09/2016

STUDENT HEALTHCARE CHECKLIST

Please use this checklist to track your progress as you work to comply with these requirements. Keep all records of previous immunizations, TB skin testing and lab tests for immunities, together in a safe place. These documents will be needed as you seek employment in the health care field.

The following items are mandatory by federal and state regulations.

1. TB screening – QFT (quantiferon) TB Gold Test 2. Proof of immunity (lab test/titers) for:

Rubella

Rubeola (measles)

Mumps

Varicella zoster (chicken pox)

Hepatitis B 3. Immunizations (at any local provider)

Rubella

Rubeola (measles) or official documentation of 2 doses of MMR vaccine is acceptable. Only doses of vaccine with written documentation of date and location of receipt will be accepted as valid proof. Self-reported doses or parental report of vaccination is not considered adequate documentation.

Hepatitis B. If you don’t have documented evidence of a complete hepB vaccine series, or if you don’t have an up-to-date blood test that shows you are immune to Hepatitis B (i.e., no serologic evidence of immunity or other prior vaccination) then you should:

Get the 3-dose series (dose #1 now, #2 in a month, #3 approximately 5 months after #2)

Get anti-HBs serologic tested 1-2 months after dose #3

If unable to take a vaccine for a medical reason (e.g., allergy, previous reaction) you must provide a signed medical release from your health care provider listing the medical reason for exclusion from immunization.

4. Optional but recommended:

Mumps

Varicella zoster (chicken pox)

Hepatitis A

Flu Shot

FALL 2016

Revised 6/09/2016

Department of Health & Social

Services Background Check Program

RELEASE OF INFORMATION AUTHORIZATION FOR BACKGROUND CHECK

I, , authorize and consent to any person provided a copy or

facsimile of this Release of Information Authorization for Background Check by an authorized representative

of the Department of Health & Social Services, to disclose any information regarding me in relation to civil

court information, criminal justice, juvenile justice, protective service and licensing records. I understand

any person providing information or records in accordance with this authorization is released from any and

all claims or liability for compliance. I understand that this information may otherwise be confidential and

that I am waiving that confidentiality and any claim I may have with regard to release of these records. I

understand information obtained through this Release of Information Authorization for Background Check

will be held in confidence in accordance with DHSS guidelines.

I, , authorize and consent to the department

marking my name in the Alaska Public Safety Information Network (APSIN) under 7 AAC 10.915(e).

This form must be signed; if the individual is 16-17 years of age, a parent signature must also be included.

Applicant Printed Name Date

Applicant Signature Applicant SSN

Parent Printed Name (If applicable) Parent Signature

KPC: Kenai River Campus Certified Nursing Assistant Application

PERSONAL INFORMATION

LAST NAME:

FIRST NAME:

SOCIAL SECURITY NUMBER:

PHONE NUMBER:

EMAIL ADDRESS:

DRIVERS LICENSE # and STATE OF ISSUE:

ALIAS: Stage, Maiden, Married, Adopted, Tribal/Indigenous

Yes No

Aliases: list previous names

Date of Birth:

Place of Birth: include country

CITIZEN of U.S.? Yes No

GENDER Female Male

HAIRCOLOR:

HEIGHT:

WEIGHT:

EYECOLOR:

ETHNICITY:

Addresses

List your previous addresses for the past 10 years, beginning with the most recent.

Current STREET ADDRESS:

CITY, STATE:

ZIP CODE:

DATES AT THIS ADDRESS: *mm/yyyy - mm/yyyy

Does your mailing address differ from your physical address?

YES NO

Current MAILING ADDRESS:

CITY, STATE, ZIP CODE:

CITY:

STATE:

COUNTRY:

DATE AT THIS ADDRESS: *mm/yyyy- mm/yyyy

CITY:

STATE:

COUNTRY:

DATE AT THIS ADDRESS: *mm/yyyy -mm/yyyy

CITY:

STATE:

COUNTRY:

DATE AT THIS ADDRESS: *mm/yyyy mm/yyyy

Education

List your Education starting with most recent

NAME OF SCHOOL:

CITY, STATE:

DATES ATTENDED: mm/yyyy-mm/yyyy

GRADUATED:

NAME OF SCHOOL:

CITY, STATE:

DATES ATTENDED: mm/yyyy-mm/yyyy

GRADUATED:

NAME OF SCHOOL:

CITY, STATE:

DATES ATTENDED: mm/yyyy-mm/yyyy

GRADUATED:

Application Questions

WHY DO YOU WISH TO BECOME A CNA?

DESCRIBE ANY PREVIOUS HEALTHCARE EXPERIENCE YOU MAY HAVE: specify type and number of years

Are you presently taking health care courses toward a degree?

YES NO

Are you planning to take other courses during the duration of the CNA course:

YES NO

Do you have any problems with walking or standing for prolonged periods of time, including stooping and sitting?

YES NO

If yes, please explain

Are you currently BLS-CPR Certified: YESNO

What Date did you receive certification:

Barrier Crimes

Has a certificate ever been denied, revoked, suspended, on probation, or disciplined in any jurisdiction?

YES NO

Have you been in Treatment for mental illness in the last five years?

YES NO

Have you had any problems related to habitual use of drugs or alcohol within the last five years?

YES NO

Do you have any physical disability which may impair or interfere with your ability to practice as a nurse aide?

YES NO

Have you ever been convicted of any criminal offense other than minor traffic violations?

YES NO

I understand that marking yes to any of the above may disqualify me from the State Licensing Exam and it is my responsibility to contact the Alaska State Department of Health to determine eligibility. Refunds will not be issued from KPC for failure to do so.

YES NO

MEMORANDUM OF UNDERSTANDING

I am expected to purchase the required textbook/workbooks prior to the start of classes. I am expected to complete all reading and assignments.

I am expected to supply a copy of my American Heart Association BLS or First Aide Certification (If I have one) to my instructor. I understand that the BLS/First Aide Certification required must include 2-person, infant, child and adult resuscitation techniques.

Attendance requirements and absentee policies are strictly adhered to. A student cannot miss more than 12 total hours of class time, including time missed due to tardiness. Absolutely NO clinical time may be missed.

I will be expected to complete all written quizzes and the final tests.

I am expected to maintain a minimum average grade of "C": on all graded assignments.

I am expected to be able to move or lift 50lbs or 25% of my body weight, whichever is less, and be able to lift over my head.

I am expected to assume responsibility for my own learning with guidance from the instructor.

I am expected to wear clean, comfortable and appropriate clothing to class.

I am expected to wear Scrubs in class labs and other clinical training sites.

I understand the use of drugs or alcohol is unacceptable while caring for an individual and will disqualify me from the program.

I understand it is my responsibility to verify with the Alaska State Board of Nursing, whether I am eligible to apply for certification through the State of Alaska as a nursing assistant; and to become certified I must personally submit state test, application and certification fees.

I understand that being convicted of a crime does not prevent me from registering for the class, but may prevent me from attending the clinical portion of the course; and could therefore prevent me from completing the required clinical hours according to State certification standards.

I understand that no refund will be given for students who have taken the course but are ineligible for state licensing or examination, or are unable to complete the class due to criminal history.

I understand that I must drop this course before the published drop deadline in order to receive a 100% refund. After the deadline, there will be no refund.

The campus assumes no responsibility for illnesses and/or injuries experienced by students in conjunction with their CNA clinical experience; students who are injured while completing clinical assignments are responsible for all associated medical costs. It is strongly recommended that students maintain personal medical insurance. Students may purchase student insurance through UA's Student Health Service. Students are not covered by workers compensation through the University or medical facilities.

I have read the attached CNA Eligibility criteria and application requirements.

YES NO

I fully understand that I am responsible to follow the provisions and conditions set forth during the course.

YES NO

ALL INFORMATION CONTAINED IN THIS APPLICATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. Please print this form then sign and date on the line below.

Signature