advance placement – lpn/lvn application packet checklist

Advance Placement Applicant
ADVANCE PLACEMENT – LPN/LVN
APPLICATION PACKET CHECKLIST
Students must turn in a complete application packet in a plain manila envelope to a Nursing Program Advisor, Room 191-P, prior to the listed
application deadlines. Incomplete packets will not be accepted and each step below must be completed in order to be considered for the program. In
addition to the required material, an Admission, Progression, and Graduation Committee Interview will be scheduled.
COMPLETE PROGRAM APPLICATION PACKET SHOULD INCLUDE:
Completed and Signed Application
Signed ADN Student Practice Standards
Completed New Mexico Department of Health Caregivers Criminal History Screening Application returned with
payment receipt, three completed fingerprint cards, copy of driver’s license, and Authorization for Release of
Information. The $65 payment is made to the DACC Cashier. Receipt is turned into Nursing Program.
GPA Calculation with advising signature; Unofficial copies of all college transcripts.
Current copy of LPN license
All PN-ADN Mobility Exam summary pages
Complete a letter of intent
The Letter of Intent shall include a self-analysis of factors contributing to any course successes and/or
withdrawal/failure(s) and specific information about how the student will address these factors to ensure
successful course completion if admitted. If transferring from another institution, address factors
contributing to this decision. This letter shall be submitted to the Nursing Program Director for review by
the Admission, Progression and Graduation Committee. Letter due in office by April 15, 2011.
Distribute Recommendation Forms, DUE APRIL 26, 2011.
List persons who will be making recommendations
Employer: ______________________________
Contact: _____________________________
Nursing Institution: _______________________
Contact: _____________________________
Recommendation Forms are mailed by recommender to:
Dona Ana Community College, ATTN: Nursing Program
MSC-3DA, P.O. Box 30001, Las Cruces, NM 88003-8001
On outside of the sealed application packet, student must print name plus “Nursing Program Admission Packet,
AP-LPN/LVN FALL 2011 Cohort.”
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Advance Placement Applicant
PRIOR TO BEING ACCEPTED TO THE PROGRAM:
Complete a panel interview with the Admission, Progression, and Graduation Committee. A Nursing Program
Advisor will schedule the interview.
IF YOU ARE NOTIFIED OF ACCEPTANCE TO THE PROGRAM:
Submit on the day of semester nursing program orientation:
Completed Health Data / Physical Exam form– details provided with acceptance letter
Immunizations and Tests Required by State Law / Clinical Facilities form
Copy of current CPR card – American Heart Association only
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Advance Placement Applicant
Application for admission to Application for admission to:
ASSOCIATE DEGREE NURSING PROGRAM
Dona Ana Community College does not discriminate on the basis of race, color, creed, national origin, religion, age, gender, sexual
orientation, political affiliation, or physical disability.
ADVANCED PLACEMENT – LPN/LVN APPLICATION
FALL 2011
The New Mexico Department of Health Caregivers Criminal History Screen Application must be submitted with your ADN
Program application. Packet materials are available from a Nursing Program Advisor.
PLEASE PRINT OR TYPE
Completed applications are due no later than May 2, 2011.
Name in Full:
Home Address:
Last First Middle
Number & Street County City State Zip
_______
Home Phone: Alternate Phone: _____
Social Security No.: __ __ __ - __ __ - __ __ __ __
NMSU E-mail Address: _________________@nmsu.edu
Residency: State of Legal Residence: ______________
NMSU Banner Number: ______________________
Date of Birth: ______________________________
If a resident of NM, County of Legal Residence: __________________
LPN License #:_________________________ State: ___________ Expires: ________________
__________________________________ _________________________ _________________ _____________________
LPN Nursing School Attended Location (City, State) FROM (mo. & year) TO (mo. & year)
Reason for leaving:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please initial one of the following:
____________ YES, DACC may contact the above listed nursing program(s)
____________ NO, DACC may NOT contact the above listed nursing program(s)
Provide information concerning high school(s) attended or G.E.D.:
Name of School City & State Dates Attended
Provide information concerning all college, university, vocational schools and/or allied health schools attended. List all vocational
programs and certifications, including military, which relate to health care. Use additional pages if necessary. Academic regulations
require that students who have registered at other colleges or universities may not disregard their records at such institutions when
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Advance Placement Applicant
making application for admission to credit programs in this college. Students concealing attendance at another college or university
and not submitting a transcript from that college or university will be subject to suspension.
Name of Institution City & State Number of Credits Earned
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are you eligible to return to the last college or university attended YES NO
Have you been awarded one or more university degrees or vocational/technical certificates YES NO
Degree/Certificate Year Granting Institution
___________________________________________________________________________________________________________
______________________________________________________________________________
List other names used in previous enrollments at this or other institutions of higher education: _________________________________
Students must provide a COPY/UNOFFICIAL of transcripts for all course work as part of this application.
An OFFICIAL transcript for all course work must be provided to DACC Admission and Records.
I hereby certify that the information contained in this application is true and complete to the best of my knowledge, and I have
completed all the steps in the application process. I understand that any misrepresentation or falsification of information is cause for
denial of admission or expulsion from the College. I understand that the information contained in this application will be read by the
faculty and staff of DACC, as is appropriate.
I acknowledge my responsibility for understanding and complying with the following information:
1. Withholding or falsifying the requested information, documentation of academic dishonesty, or failure to provide the required
documents will make me ineligible for admission to the Nursing Program
2. Filing this form does not guarantee acceptance into the nursing program.
3. This application is only valid for consideration for the FALL 2011 Cohort Associate Degree Nursing classes.
4. Admission acceptance for placement beyond the second semester of nursing classes will require additional placement testing.
The cost of such testing is the responsibility of the applicant.
5. Admittance to the ADN Nursing Program is provisional until a criminal background check is completed and I am cleared for full
admittance. The New Mexico Department of Health requires a criminal background clearance through their Department. The
cost, which may change, is $65 and is non-refundable. Examples of some of the disqualifying convictions are: homicide,
trafficking in controlled substances, kidnapping, false imprisonment, aggravated assault, or aggravated battery, rape, criminal
sexual penetration; criminal sexual contact, incest, indecent exposure, or other related felony sexual offenses. Crimes
involving child abuse or neglect, crimes involving robbery, larceny, extortion, burglary, fraud, forgery, embezzlement, credit
card fraud, or receiving stolen property; or an attempt, solicitation, or conspiracy involving any of the felonies in this
subsection.
6. Admission to the program does not guarantee program completion and/or licensure as a Registered Nurse after program
completion.
I acknowledge my responsibility for understanding the following information about submission of my application:
1. The deadline for submission of my application is May 2, 2011 before 4:30 pm to a Nursing Program Advisor.
2. All required information must be submitted at the same time in a plain manila envelope.
3. On outside of the sealed application packet, I must print my name plus “Nursing Program AP – LPN/LVN FALL 2011
Cohort.”
4. I must obtain a receipt from a Nursing Program Advisor when submitting my application packet. If there are questions, this
receipt will provide proof that my application packet was submitted by the deadline date and time.
Signature of Applicant
Date
Questions concerning the program or the application process can be addressed by a Nursing Program Advisor at (575) 527-7630.
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Advance Placement Applicant
Associate Degree Nursing Program
Student Practice Standards
Minimum abilities expected include but are not limited to:
The following technical standards and essential functions outline reasonable expectations of a student in the ADN Program for the
performance of common nursing functions. The ADN student must be able to apply the knowledge and skills necessary to function in a
variety of classroom, lab and/or clinical situations while providing the essential competencies of the ADN program.
The student must be able to meet the following requirements to apply for admission and continuation in the program:
Categories of Essential
Functions Definition Example of Technical Standard
Observation
Ability to participate actively in all
demonstrations, laboratory exercise, and
clinical experiences in the professional
program component and to assess and
comprehend the condition of all clients
assigned to him/her for examination,
diagnosis, and treatment. Such observation
and information usually requires functional use
of visual, auditory, and somatic sensations.
Visually discriminating incremental readings on
syringes, sphygmomanometers and other
various medical equipment
Visually discriminating between different
colored objects
Discriminating between auditory stimuli
Perform a comprehensive assessment on
patients
Communication
Ability to communicate effectively in English
using verbal, non-verbal and written formats
with faculty, other students, clients, families
and all members of the healthcare team.
Ability to read English and interpret without
assistance.
Patient teaching
End of shift reports
Documentation in legal records/ charts
Medication records
Transcribe doctors orders from chart, interpret,
and implement
Testing within the ADN program without
assistance to read
Collaborates with members of healthcare team
Motor
Sufficient motor ability to execute the
movement and skills required for safe and
effective care and emergency treatment.
Standing for long periods of time (8-10 hrs/day)
Lifting up to 50 lbs.
Performing one person and two person
transfers
Turning, log rolling and ambulating another
person
Manipulating equipment
Performing patient care procedures with finger
and manual dexterity (i.e., starting IVs,
phlebotomy, dressing changes, catheterization)
Intellectual
Ability to collect, interpret and integrate
information and make decisions.
Ability to read and interpret the English
language without assistance.
Transcribe orders from chart, interpret the
orders and intervene
Display critical thinking abilities in planning
patient care – analyze data, formulate nursing
diagnosis, and prioritize care
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Advance Placement Applicant
Categories of Essential
Functions Definition Example of Technical Standard
Behavioral and Social
Attributes
Possess the emotional health and
stability required for full utilization of
the student’s intellectual abilities, the
exercise of good judgment, the
prompt completion of all academic
and patient care responsibilities and
the development of mature, sensitive,
and effective relationships with clients
and other members of the health care
team.
Possess the ability to tolerate taxing
workloads, function effectively under
stress, adapt to changing
environments, display flexibility, and
learn to function in the face of
uncertainties inherent in clinical
settings with patients.
Possess compassion, integrity,
concern for others, and motivation.
Possess the ability to demonstrate
professional behaviors and a strong
work ethic.
Utilize intellectual abilities
Exercise good judgment and complete tasks
within required time limits
Demonstrate the emotional health required for
full utilization of intellectual abilities and
exercise of good judgment
Show integrity, concern for others,
interpersonal skills, interest and motivation
In general, successful applicants possess qualities such as:
Interest and aptitude for math and science
A strong motivation to learn
Well-developed study skills
Good problem-solving and decision-making skills
An ability to work with people with diverse backgrounds
Applicant Signature
Date
Updated 2/1/11