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Thank you for your interest in the North Carolina Piedmont (NCP) RIBN Collaborative. Students admitted to NCP RIBN must meet dual admission requirements set forth collaboratively by North Carolina A & T State University (A&T) and Davidson County Community College (DCCC). Please read this information thoroughly. Admission to NCP RIBN is competitive and reading these criteria thoroughly will help you understand the process. Please note that DCCC has a traditional two year, associate degree nursing education option. The traditional two year option has a separate admissions process from the NCP RIBN dual admission nursing option. If you wish to apply for the traditional option, you must complete the individual admissions process for the traditional option and meet the admissions criteria for that specific nursing option. Students involved in the NCP RIBN program are subject to the academic calendar for DCCC and NC A&T State University during dual enrollment in the program. THE APPLICATION PERIOD NC A & T and Davidson County Community College are collaborating on a dual admission process. NCP RIBN will begin accepting applications October 3, 2016 for the RIBN class that begins fall semester 2017. You must apply and meet all requirements by March 3, 2017. We want to ensure that you have the best possible chance of being selected by completing all processes and submitting all necessary application documents completely and correctly by the deadline. Should you have any questions regarding the application process for NCP RIBN, current high school students should email or call Anissa Wall, anissa_wall@davidsonccc.edu (336) 224-4522 while high school graduates should email or call Allen Hightower, allen_hightower@davidsonccc.edu (336)  249-8186, Ext. 6426.

North Carolina Piedmont Regionally Increasing Baccalaureate Nurses (NCP

RIBN) North Carolina A & T State University and Davidson County Community

College

Selective Admission Criteria, Fall 2017

Application Period: October 3, 2016 through March 3, 2017

 

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North Carolina Piedmont RIBN Check List

KEEP THIS PACKET AS YOUR CHECK LIST.

Items 1-7 must be completed prior to the Eligibility Review. Items 8-9 must be completed by Friday March 3, 2017 to be eligible for the selection process.

Date Completed

1. View RIBN Video and complete NCP RIBN Interest Form (online)

2. DCCC Application for Admission for those not currently enrolled at DCCC.

Select “NCP-RIBN-BSN 4Yr RN Degree w/NC A&T Univ” as your program of study on application.

3. Intent Form* for Fall 2017 NCP RIBN Program submitted for current selection cycle. *NCP RIBN Intent form is included with this packet.

4. Final high school transcript OR GED Score Report submitted. Current high school seniors must submit a transcript by the March 3 deadline AND follow up with a final transcript by July 3rd.

5. Official college transcripts from colleges attended. All transcripts are not required, only those in which you plan to transfer credit must be submitted. College transcripts must arrive in original sealed envelopes. Faxed, copied, and on-line college transcripts are not acceptable. If previously taken, Anatomy and Physiology I and II must be completed at the same institution.

6. Take SAT or ACT with minimum score achieved. Verify that DCCC and A&T have the documentation of my scores.

7. Eligibility Review – After completing items 1-6 above, you are responsible for completing an Eligibility Review between October 3, 2016 – March 3, 2017 by 12:00 pm ! Your DCCC Enrollment Officer is: Kendra Wilson,

kendra_wilson@davidsonccc.edu (336) 249-8186, Ext. 6420. ! During your review, items1-7 are reviewed for completion. ! Also, grades for any previously completed college-level support classes

are checked for a final grade of “C” or better for continued eligibility. Classes subject to grade review are: ENG 111& 112, BIO 165, and 166, PSY 150 & 241, HUM 115, and COM 231.

8. Completion of the TEAS® Test by January 27, 2017.

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*NOTE: Completion of all i tems above does not guarantee acceptance into the program.

Pre-Ranking Requirements for Dual Admission to

North Carolina Piedmont RIBN Collaborative NORTH CAROLINA RESIDENCY

Preference is given to North Carolina residents. If you are not a NC resident you will only be considered in the event that vacancies occur after June 1, 2017. Please be advised that this is not likely to occur. Applicants who (1) have lived outside NC during all of the 12 months immediately preceding the start of the fall semester 2017 or (2) are claimed as a dependent by a parent/guardian who is not a NC resident are generally not considered to be residents. In order to ensure that you meet the residency requirements and are eligible to apply, you must meet the criteria for legal residency in North Carolina set by the Davidson County Community College Admissions Office by March 3, 2017. NCP RIBN is not open to applicants who are not U.S. citizens unless the applicant is: (1) a permanent resident alien with an alien registration receipt card (“green card”) or (2) a nonimmigrant alien with an employment authorization card and a visa type which permits establishment of NC residency. Questions regarding this should be directed to Student Services at Davidson County Community College.

HIGH SCHOOL COURSES REQUIRED

To be considered for admission, you must have earned a high school diploma or its equivalent and satisfy the following NC minimum course requirements:

• Four units of English • Two units of a language other than English • One unit of American History • Three units of mathematics (Algebra I, Algebra II, and Geometry). Other math such as

Statistics is encouraged but not required • One unit of a laboratory science (other than Chemistry) • One Unit of Chemistry (Required)

SAT OR ACT REQUIREMENT

You must submit your official SAT or ACT scores to the Student Success Advisor listed at the end of this criteria (scores must include the three components of critical reading, math and writing). Scores taken prior to March 2015 will not be allowed.

• North Carolina A & T State University will identify current acceptable SAT and ACT scores. Currently these are an ACT Composite score of 20 and an SAT score obtained prior to March, 2016 of 930. The benchmark SAT score obtained during and after March 2016 is 1010. If your scores are lower than the minimum requirement, you may elect to retake the SAT or ACT, as only the higher score will be used as a determination with your application.

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• Websites available for SAT/ACT Preparation: o http://sat.collegeboard.com/home o www.onlinecollegeprep.com o www.mymathtest.com o www.purplemath.com  

GRADE POINT AVERAGE

To be eligible to apply for admission to NCP RIBN directly from high school OR before completion of at least 20 hours of college credit, a student must have a weighted cumulative grade point average (GPA) of 3.0 on a 4.0 scale in high school courses.

Ranking Requirements for Acceptance to

North Carolina Piedmont RIBN Collaborative TEST OF ESSENTIAL ACADEMIC SKILLS (TEAS®) FOR NURSING STUDENTS

If you meet all of the dual admission requirements for NCP RIBN, you will be given written permission by the Student Success Advisor to schedule a time to take the ATI TEAS ® exam. You must schedule and take the TEAS ® exam by January 27, 2017 to be considered an applicant to NCP Collaborative RIBN for fall 2017 admission. The TEAS ® will be administered at the community college for fall 2017 admission. ATI TEAS Scores-- The Test of Essential Academic Skills, a computerized test of reading comprehension, English and language usage, science, and math will be used in the scoring and ranking process. The TEAS® is an assessment product of Academic Testing, Inc. (ATI). NCP RIBN uses applicant performances on the TEAS® as part of the ranking of applicants into the program. The student will be responsible for all costs associated with the TEAS® test and any costs associated with TEAS® study guides or TEAS® practice tests. In order to be competitive for the NCP RIBN program, students must take the ATI TEAS exam and score at or above the PROFICIENT level or a minimum of 62 points.

• Testing will be conducted by appointment beginning December 2016 and should be completed by the January 27, 2017 deadline.

• Multiple dates and times will be available for the TEAS Test, however, you may take the test at DCCC only once per NCP RIBN selection cycle. These scores must be less than 6 months old as of January 27. Your highest TEAS score will be used for ranking.

• Eligible applicants should complete their eligibility review for a TEAS testing slip and make TEAS appointments online at www.atitesting.com.

• Please note the test will be given on the Davidson and Davie campuses but appointments MUST be made online and students are not able to test until they have completed their eligibility review.

• The test is $66 and study materials are available for an additional cost through DCCC’s Bookstore and also available on the ATI website at: http://www.atitesting.com/ati_store/TEAS-products.aspx

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• TEAS workshops will be offered September 2016 – January 2017 in the Learning Commons on the Davidson campus – Additional information is available via the Learning Commons webpage under Workshops: https://davidsonccc.edu/lc  

• Completion of the TEAS test without also meeting all other eligibility requirements will not allow competition.

TEAS® Categories Description/Test Items/Time 170 total items

Reading paragraph comprehension, passage comprehension, and inferences/conclusions (53 items, 64 minutes)

Math whole numbers, metric conversion, fractions, decimals, algebraic equations, percentages, and ratio/proportion (36 items, 54 minutes)

Science

science reasoning, science knowledge, biology, chemistry, anatomy, physiology, basic physical principles, and general science (53 items, 63 minutes)

English and

Language Usage

Punctuation, grammar, sentence structure, contextual words, and spelling (28 items, 28 minutes)

DAY OF THE EXAM • You must arrive on time at the appropriate location. • Late arrivals will not be admitted. Photo ID is required for admission to the exam. Driver’s

license is preferred. • Use of calculators or other devices is not permitted. All personal items must be placed on

the floor. Proctors may require that you place personal items in a designated area in the exam room.

• You will need your username and password to log in on the website in order to start your exam.

After you take the ATI TEAS ® exam, you must make sure the Enrollment Officer has your scores so that they can be included with your application packet by March 3, 2017.

• Applicants with disabilities should contact the Disability Services Counselor at DCCC at least three weeks prior to testing to receive special accommodations for the TEAS ® exam.

RANKING AND NOTIFICATION OF ACCEPTANCE/ALTERNATE STATUS

Admission to the program is highly competitive. After meeting all general and NCP RIBN program admission requirements for NC A & T University and Davidson County Community College, all NCP RIBN applicants will be ranked numerically based on the following criteria:

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The maximum number of points possible in the ranking process is 16.

0-10 points TEAS score (Students must score a 62 to be ranked)

2-4 points

! BIO 165 or BIO 166 earns 2 to 4 points, as determined by the final grade. Points will be given for either BIO165 or BIO 166 with the highest grade if both are completed by deadline. A=4, B=3, C=2

! Current high school seniors with a completed HS lab science (above general biology) and chemistry earns 2 to 4 points, as determined by the average final grade. A=4, B=3

1 point ! College Math (Math 115 or higher with a grade of C or better). ! High School students can take MAT 171 through Career and College Promise

1 point ! ACA 090 completed at DCCC with a grade of SC or higher ! Enrolled in NAS Career and College Promise Pathway

Once all applicants have been ranked:

! If applicants have identical total admission points, the following component scores will be used to further delineate candidates, in this order:

1. TEAS Composite Score 4. BIO/HS Science Points 2. TEAS Reading Score 5. ACA or NAS Point 3. TEAS Math Score

! Acceptance and alternate letters will be mailed on April 14, 2017. ! Applicants with the highest overall scores will be offered program acceptance and

remaining students will be placed on an alternate list in ranked order. Alternates will be called by that order should space become available up until the first day of class for Fall, 2017.

! Applicants who remain on the alternate list will not be carried over to a waiting list for the following year and must renew the intent process for consideration the following year.

Accepted NCP RIBN Student Follow-Up:

! Newly admitted NCP RIBN students must return a Confirmation Form to the Selective Admissions Officer to accept or decline the DCCC program seat by May 1, 2017.

! Newly admitted NCP RIBN students must attend the NCP RIBN student success seminar held the summer prior to the August start date of fall classes. This date is provided in the acceptance packet.

! Failure to meet these follow-up requirements will result in ACCEPTANCE BEING REVOKED.

SUMMARY OF IMPORTANT DATES AND DEADLINES

Fall 2017 NCP RIBN Selective Admission Criteria and Intent Form Available:

October 3, 2016 through March 3, 2017 Completion of all preparatory courses January 2017

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Application, transcripts, SAT or ACT, Eligibility Review and TEAS Score March 3, 2017

TEAS Testing appointments (various days and times) November– January, 2017 Acceptance/Alternate Letters mailed on or by April 14, 2017

ADDITIONAL NCP RIBN REQUIREMENTS- 2nd Year Once enrolled, failure to meet these requirements will result in the student being suspended

from the NCP RIBN Program NURSE AIDE: NAI REQUIREMENT

All NCP RIBN nursing students must, by July 13, 2018 (prior to starting NUR 111 in the 2nd year):

1. Provide documentation of successful completion of a Division of Health Service Regulation (DHSR) state approved Nurse Aide I Program which includes theory, lab, and clinical components*. (A copy of a college transcript or a notarized course completion certificate will be acceptable documentation). *Challenging the Nurse Aide I examination will not meet this requirement*, AND

2. Hold a documented, current, unrestricted listing as a Nurse Aide I (NAI, CNA) from the North Carolina Nurse Aide Registry https://www.ncnar.org/index1.jsp and the Division of Health Service Regulation. (A copy of current listing on the NC DHSR Nurse Aide Registry Website will be acceptable documentation).

CRIMINAL BACKGROUND CHECK AND DRUG SCREENING:

For the fall of 2018, all students will be required to complete a criminal background check and drug screening prior to attending clinical in clinical agencies by July 13, 2018. These screenings will be conducted at the student’s expense by a professional and independent vendor and include nation-wide criminal record and sexual predator checks. A 12-panel urine drug screen must be obtained from a DCCC-approved lab. Failure to achieve acceptable standards for these screenings will result in the denial of clinical privileges. Successful completion of clinical is required for program completion. Students will receive additional information about submitting these requirements. If any facility refuses to allow the student to participate in the clinical experience at that agency as a result of those findings, the student will not be able to progress in the program. Inability to progress will result in failure of the course and removal from the program. Additional details can be obtained on the website: http://davidsonccc.edu/conditionally-accepted-nursing-clinical-training-requirements. Applicants should be aware that as of January 1, 2002, the North Carolina State Board of Nursing requires criminal background checks including fingerprints for all applicants for initial licensure and may deny licensure to individuals convicted of a misdemeanor or felony. The NC Board of Nursing does not become involved in reviewing the applicant’s conviction record until such time as application is made to take the national examination. The question asked on this application is whether or not the applicant has ever been convicted of a misdemeanor/felony. If the response is yes, a certified copy of the criminal record and a detailed written explanation must be submitted.

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Review of the record is made by the Board staff in accordance with guidelines established by the Board. The applicant may take the licensure exam as scheduled; however, the license may or may not be issued upon passing the exam.

HEALTH EVALUATION FOR ACCEPTED NCP RIBN STUDENTS:

Applicants should be aware that admission to the NCP RIBN Program is dependent upon physical and emotional health, compatible with the ability to provide safe patient care. To document evidence of satisfactory health, accepted ADN students may access a copy of the Student Health Forms, available on the website: (http://davidsonccc.edu/conditionally-accepted-nursing-clinical-training-requirements). A physical examination performed no more than one year prior to the prospective date of entry into the program is required. Proof of current immunizations is also required. The cost to obtain the physical examination and required vaccinations is the responsibility of the student and should be completed July 13, 2018. An applicant with problems in physical or emotional health must provide evidence that appropriate treatment and/or counseling has taken place and that the problem has been alleviated. Persons with physical or emotional problems, which have not responded to treatment within a reasonable time, may be denied admission to the program. All health forms must be completed and returned to the Allied Health Clinical Coordinator no later than July 13, 2018. If these forms are not received or are received incomplete by that date, admission into the second year of NCP RIBN Program will be revoked. Detailed information about the due dates for health records will be provided to accepted applicants. All documents that you submit with your application for NCP RIBN must be true, correct and complete. Falsification of documentation may result in denial of admission or dismissal after admission. Admission criteria are subject to change from year to year.

DISABILITIES All members of the NCP RIBN will abide by the disability policies for Davidson County Community College.

TRAVEL NCP RIBN students will be required to complete clinical rotations which may require them to travel more than one hour from campus.

CPR Students accepted into the NCP RIBN nursing option will be required to obtain CPR certification for Health Care Providers from the American Heart Association by July 13, 2018 (prior to Year 2 in the curriculum). This CPR for the healthcare provider/professional rescuer course must include hands on skill demonstration of one and two rescuer adult, child and infant CPR and use of an AED. This certification must be kept current through the 4th year of the NCP RIBN program.

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READMISSION POLICY The following readmission policy applies to students who receive an unsuccessful grade in any required course in the NCP RIBN Program, or who voluntarily withdraw from the program. Successful grades are defined as “A,” “B,” or “C.”

1. If you receive an unsuccessful grade in the competitive NCP RIBN program, you may not proceed to any subsequent course which has the course in question as a prerequisite. You must repeat the course in question before proceeding to the next higher course in the program. You must take all required support courses prior to or during the semester specified on the course sequence sheet/degree plan draft, so you are not permitted to postpone a course on the sequence sheet/degree plan draft. You must abide by the readmission policy of the Associate Degree Nursing Program once nursing courses in the ADN Program have been started.

2. Most NCP RIBN courses are offered only once annually. 3. Since a new class of students is admitted to the program annually and because of the

competitive nature of the program in question, it will be necessary for students who have received an unsuccessful grade in a course during their first semester to reapply for readmission to the NCP RIBN program for the following fall.

4. It is possible for students to remain in the DCCC ADN Program and not continue their participation in the NCP RIBN option.

5. All records, except a Davidson County Community College transcript, are destroyed if the student has not attended in the past five years. If you are not selected for the NCP Collaborative RIBN class beginning fall semester 2017, and wish to apply for the fall 2018 class, you must re-apply and re-compete. This means that all required paperwork must be re-submitted.

Technical and Professional Standards

Applicants for NCP RIBN at Davidson County Community College must demonstrate the ability to meet certain technical and professional standards critical to the successful completion of the program. These standards include skills and abilities defined by Davidson County Community College. Purpose: In addition to DCCC requirements and course objectives, there are technical standards that encompass communication, motor skills, sensory and cognitive ability and professional conduct that are essential for the competent study and practice of nursing. The foundations for the Technical Standards for Nursing Students in the NCP RIBN Program are:

! The faculty has authority for the course as described in the Faculty Handbook. ! The instructor is to be treated with respect and has the right and authority to direct the class

in whatever manner he/she determines will best facilitate the student’s learning based upon the instructor’s education and experience.

! Mutual respect is an essential component to effective education. It is important that all positions of a discussion are treated with equal respect and courtesy.

! The instructor’s obligation is to design a learning opportunity and present it effectively. ! It is the student’s responsibility to attend all components of the course and take

responsibility for his/her performance in the course.

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These Technical Standards are to be used as a guide:

! For admission, retention and graduation policies ! For comprehensive evaluation of subjectively and objectively measured skills, behaviors

and attributes ! To articulate a set of standards for students and faculty to refer to for identification,

reflection upon and correction of unsatisfactory behavior ! To assist students to reflect on, understand and accept accountability for the overt and subtle

aspects of their behavior and how it impacts the learning environment, clients, colleagues, and the academic and health care environments.

! To assess the reasonableness of requests for special accommodations that would allow the student to practice the nursing profession following the standards of nursing practice without fundamentally altering the program of study

The Technical Standards are referenced in the following manner:

! Letter of Intent ! Information Session ! Clinical Progress Report ! Course Syllabus ! ADN Student Handbook ! DCCC General Catalog and Student Handbook

These Technical Standards include but are not limited to the following:

1. Cognitive a. Ability to measure, calculate, reason, analyze, integrate and synthesize information.

i. Example: Apply information, evaluate the meaning of data and engage in critical thinking in the classroom and clinical setting.

ii. Example: Apply broad class concepts to unique client situations. iii. Example: Concentrate to correctly perform dosage calculations and analyze

information to make clinical decisions in the often distracting and noisy, clinical setting.

iv. Example: Make correct judgments on seeking consultation or supervision in a timely manner.

v. Example: Respond appropriately to constructive feedback. 2. Communication

a. Appropriate interpersonal interaction with other students, faculty, staff, patients, family and other professionals.

i. Example: Establish and maintain a professional relationship with patients and colleagues.

ii. Example: Demonstrate appropriate impulse control and professional level of maturity

b. Effective communication with others, both verbally and in writing. i. Example: Explain treatments and interventions, document nursing actions,

record patient responses to treatment in a professional manner. ii. Example: Convey information in a clear, professional and timely manner.

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iii. Example: Listen and respond to others in an accepting and respectful manner. 3. Motor Skills

a. Sufficient motor function to execute movements required to provide general care and treatment to patients in all health care settings.

i. Example: Participate, within reasonable limits, to safely assist a patient in moving; for example, from a bed to a chair or from a chair to a commode.

ii. Example: Manipulate equipment to perform treatments including preparation and administration of injections, catheter insertion.

b. Sufficient physical endurance to participate fully in the clinical and academic settings at an appropriate level.

i. Example: Participate completely in classroom activities. ii. Example: Participate fully in required activities in clinical setting including

extended periods of standing, lifting equipment and walking briskly as is reflective of the general practice of nursing.

4. Professional Conduct a. Function effectively and adapt to circumstances including highly stressful or rapidly

changing situations. i. Example: Examine and change his or her behavior when it interferes with

professional relationships or the academic or health care environments. ii. Example: Maintain mature, sensitive and effective relationships with patients,

colleagues, faculty, staff and other professionals. iii. Example: Demonstrate emotional stability to participate fully in the clinical

and academic setting at an appropriate level. b. Incorporate professional standards of practice into all activities.

i. Example: Engage in patient care delivery in all settings and be able to deliver care to all patient populations including but not limited to children, adolescents, adults, developmentally disabled persons, medically compromised patients and vulnerable adults.

ii. Example: Work effectively with a team in an academic or health care setting. iii. Example: Refrain from using improper grammar, profane or inappropriate

communications. c. Demonstrate integrity and accountability in clinical and academic setting.

i. Example: Complete all assignments in a timely manner while adhering to the DCCC code of ethics.

ii. Example: Respond appropriately to constructive feedback. iii. Example: Take all nursing tests and final examinations as scheduled.

d. Present self in a professional manner in clinical and academic settings. i. Example: Attend clinical following uniform policy, including appropriate

hygiene with no detectable scents or odors. ii. Example: Wear appropriate clothing that is not distracting or offensive when

in the learning environment. e. Utilize computers correctly, effectively and professionally to acquire information and

to communicate with others. i. Example: Use moodle to collect course information.

ii. Example: Utilize clinical computers to deliver safe patient care.

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iii. Example: Utilize the internet to collect current information from appropriated sources to provide evidence-based nursing care.

iv. Example: Communicate via e-mail in a professional and ethical manner. 5. Sensory

a. Hearing sufficient to assess health needs. i. Example: Hear an alarm, accurately assess breath sounds, and hear a cry for

help. b. Vision sufficient for assessment necessary to deliver nursing care.

i. Example: Observe a patient accurately, at a distance and close at hand. c. Accurately interpret non-verbal communications.

STUDENT SUCCESS ADVOCATES FOR THE

NORTH CAROLINA PIEDMONT RIBN COLLABORATIVE

Current High School Students Contact Anissa Wall anissa_wall@davidsonccc.edu (336)224-4522 High School Graduates Contact DCCC Student Success Enrollment Advocate / Selective Admissions Officer Allen Hightower (336) 249-8186, Ext. 6426 allen_hightower@davidsonccc.edu Office Location: Davidson Campus – Mendenhall Enrollment Center Office 104 NC A & T State University Success Advocate R.I.B.N – Student Success Advisor/Recruiter: Alex Smith (336) 285-3594 ajsmith10@ncat.edu

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                                                                                                                                                                                                                                                                                                                                                 Revised  08/16  dlp  

NCP RIBN Intent Form Deadline March 3, 2017

PRINTED Name: __________________________________________ Birth Date: ___________________

DCCC Student ID # ________________ DCCC E-Mail Address:_____________________________________

Address ___________________________________ City_____________________ State _____ Zip_________ Primary Phone # ____________________________ Cell Phone # ___________________________________

Please mark your answer for each question.

If YES: Do you have a high school science above general biology with a lab? Are you a high school senior this year? NO YES If YES: Do you have a unit of high school chemistry?

Have you completed a DCCC application? NO YES

Have you completed a NC A&T State University application? NO YES

Have you sent your official high school transcripts NO YES

Have you completed BIO 165 or BIO 166 at DCCC? NO YES If YES: FINAL BIO 165 grade ______

FINAL BIO 166 grade ______ Have you transferred BIO 165 and BIO166? NO YES If YES: FINAL BIO 165 grade ______

FINAL BIO 166 grade ______ Have you successfully completed or are currently enrolled in the NAS Career and College Promise pathway at DCCC?

NO YES If YES, when?

Have you completed ACA 090 at DCCC? NO YES If YES: What is your FINAL ACA grade?

Have you completed College Level Math? NO YES If Yes: What is your final math grade?

Have you been admitted to the DCCC ADN Program in the past? NO YES If YES, when?

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______ I have sent my official high school transcripts. ______ I have sent my official college transcripts. ______ I have taken the SAT or ACT and have verified that DCCC and A&T have the

documentation of my scores. _____ I have read the NCP RIBN packet and technical standards and understand it is my responsibility to contact the DCCC Success Advocate to follow up or obtain further information if I have any questions. ______ I am responsible for submitting and completing the steps outlined in this packet and doing so by a reasonable time for review (see specific deadlines throughout the packet). _____ After completing all required items, I am responsible for completing an eligibility review with the Success Advocate to review my eligibility.

___________________________________________________ ____________________ Signature Date

Success Advocate Office Use Only: Eligibility: ____YES; ____ NO Reason_________________________________ ACA or NAS_________; BIO ________ (or HS Sci. / Chem. _________); MATH __________

Review Date: ____________________