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									                                        CERTIFIED NURSING ASSISTANT PROGRAM
                                    APPLICATION AND REGISTRATION AUTHORIZATION
The applicant has read, understands, and acknowledges with their initial upon each line. TO REMOVE THE BLOCK FOR
REGISTRATION, you MUST take this signed sheet and show proof of eligibility for Reading 110 and/or English 501 as
indicated on START assessment or college transcript to the Health Sciences office on the Santa Maria campus M132 or FAX to
805-922-1403, Attn: Health Sciences. This can also be faxed from the Lompoc Campus. This must be completed and turned into
the Health Science office by 12/10/09 for beginning of Web Registration.

Initial each line:
 _____ SECTION A: DISQUALIFYING PENAL CODE SECTION (read before filling out initial application)

_____    SECTION B: GENERAL PROGRAM INFORMATION
             B1. Financial Aid                                                 B4. Dress Code
             B2. Absent/Tardy Policy                                           B5. Priority Nursing Student Registration
             B3. Financial Information/Estimated Expenses

_____    SECTION C: EXPLANATION OF MANDATED ITEMS AND DATES DUE
              C1. Physical Examination                         C7. Background Check
              C2. TB Skin Test                                 C8. Social Security Card
              C3. Acknowledgement/Consent Form-Substance Abuse C9. CPR Card
              C4. Potential Risk Form                          C10. CNA Initial Application
              C5. Student Acceptance Statements                C11. Live Scan Fingerprints
              C6. Substance Abuse Screening

_____    SECTION D: FORMS.
             D1. Substance Abuse Consent Form
             D2. Potential Risk Form                                            D4. Reference for Student Homework Assignments
             D3. Physical Examination Form (TB included)

_____    I have read this packet carefully and agree to comply with the standards and rules detailed within. I will complete mandated items and turn
         in copies of forms, money orders, etc. as detailed in. Student Acceptance Statements .

_____    I understand that there are state/federal mandated items and fees required for the CNA Program and that failure to follow procedures and
         meet deadline schedules may result in being dropped from the CNA Program. I understand that it is my responsibility to notify DHS within
         60 days of a change of address.

_____    I understand that by showing eligibility for Reading 110 and English 501 as indicated on START assessment. I have obtained a web reading
         score of 46 or higher on the START assessment or have provided college transcripts.

_____    I understand that I must have a valid “for employment” social security card in order to enter into the CNA program. This is a state
         requirement and is necessary for the Dept. of Health Services (DHS) to track certifications and those enrolled in training programs. It is also
         necessary to show the social security card when taking the required state board examination. This is not an Allan Hancock College
         requirement. Neither your federal tax ID #, nor student ID number can be used as a valid replacement for the social security number.
         (Note * on Initial Application, Section D, both the front and back pages, explaining social security number policy and state and federal
         regulations)

_____    I understand that the mandatory items packet must be turned into the Health Sciences Office between January 4th and January 20th if
         registered in the class. Failure to do so will result in being dropped from the program.

_____ If on the waitlist, I understand that I will be contacted between January 21st and January 29th depending upon seat availability. It is my
       responsibility to complete the packet within the timeframe specified upon notification.

 ______________________________________________                                      ________________________________________________
STUDENT'S SIGNATURE                                                                   DATE

 ______________________________________________                                      ________________________________________________
STUDENT'S NAME (PLEASE PRINT)                                                         STUDENT'S SOCIAL SECURITY # (mandatory)

 ______________________________________________                                      ________________________________________________
STUDENT’S CONTACT NUMBER                                                              STUDENT’S EMAIL ADDRESS

       You must turn in this top sheet into M-132 (Santa Maria campus) prior by December 10, 2009 to be unblocked for this class.
 The remainder of the packet must be turned into the Health Sciences Office (M-132) from January 4th – January 20th to retain your seat.
             REMEMBER TO REGISTER! REGISTRATION SCHEDULE AVAILABLE IN THE SCHEDULE BOOK.

                                                                  SPRING 2010
        For Office Use Only:          START Reading Score:                              OR        ENGLISH 101 COMPLETED _______
                               SECTION A
                            DISQUALIFYING
                                PENAL
                                CODES
STUDENT INSTRUCTIONS; ALL CNA/HHA applicants should review this list carefully.
Be aware that a person cannot receive the required criminal background clearance if they
have been convicted of any of these violations. If you are not cleared of a conviction, you
cannot become a Certified Nursing Assistant. If you have questions about the status of a
conviction, please call or contact:
                                        DEPARTMENT OF HEALTH SERVICES
                                     LICENSING AND CERTIFICATION PROGRAM
                                      PROFESSIONAL CERTIFICATION BRANCH
                                           1615 CAPITOL AVENUE, MS 33001
                                                   P.O. BOX 997416
                                             SACRAMENTO, CA 95899-7416
                                                 PHONE: 916-552-8881
                                         INTERNET ADDRESS: www.dhs.ca.gov

    PLEASE RETAIN THIS NUMBER FOR FUTURE REFERENCE. IT IS THE
   NUMBER THAT YOU WILL CONTACT SHOULD YOU HAVE ANY PROBLEMS
             WITH FUTURE CERTIFICATION OR RENEWAL.
**BACKGROUND CHECKS: The Joint Commission of Hospital Accreditation has required that any person having patient
contact be screened for criminal convictions, and the results must be available to the care facility (ACUTE CARE). The results of
Live Scan fingerprinting cannot go to the facility, making it necessary to perform a second screening through Corporate
Screening Services, Inc.

IMPORTANT: IT IS THE RESPONSIBILITY OF THE FACILITIES TO HOLD STUDENTS TO THE SAME STANDARDS AS AN
  EMPLOYEE WHO HAS PATIENT CONTACT. THE FACILITIES HAVE THE FINAL SAY AS TO WHETHER A STUDENT
  MAY PARTICIPATE IN PATIENT CARE. IT IS NOT THE DECISION OF ALLAN HANCOCK COLLEGE. IT MAY TAKE
  SEVERAL WEEKS TO COMPLETE THE BACKGROUND CHECK. YOU WILL BE DROPPED IF IT IS NOT COMPLETE
  WHEN THE LIST OF QUALIFIED STUDENTS IS SENT TO THE FACILITIES BEFORE PATIENT CARE TAKES PLACE.



                                                                                                                                    2
                                                                         SECTION A
                                                 Disqualifying Penal Code Sections
 If they have been convicted of any of the penal codes listed, CNA/HHA applicants will be automatically denied certification or ICF/DD, DDH OR DDN
 applications will be denied employment.
 Section
 187              Murder
 192(a)           Manslaughter, Voluntary
 203              Mayhem
 205              Aggravated Mayhem
 206              Torture
 207              Kidnapping
 209              Kidnapping for ransom, reward, or extortion or robbery
 210              Extortion by posing as kidnapper
 210.5            False imprisonment
 211              Robbery (includes degrees in 212.5 (a) and (b))
 220              Assault with intent to commit mayhem, rape, sodomy, oral copulation
 222              Administering stupefying drugs to assist in commission of a felony.
 243.4            Sexual battery (includes degrees (a) - (d))
 245              Assault with deadly weapon, all inclusive
 261              Rape (includes degrees (a) - (c))
 262              Rape of spouse (includes degrees (a) - (e))
 264.1            Rape or penetration of genital or anal openings by foreign object
 265              Abduction for marriage or defilement
 266              Inveiglement or enticement of female under 18
 266(a)           Taking person without will or by misrepresentation for prostitution
 266(b)           Taking person by force
 266(c)           Sexual act by fear
 266(d)           Receiving money to place person in cohabitation
 266(e)           Placing a person for prostitution against will
 266(f)           Selling a person
 266(g)           Prostitution of wife by force
 266(h)           Pimping
 266(i)           Pandering
 266(j)           Placing child under 16 for lewd act
 266(k)           Felony enhancement for pimping/pandering
 267              Abduction of person under 18 for purposes of prostitution
 273(a)           Willful harm or injury to a child (includes degrees (a) - (c))
 273(d)           Corporal punishment/injury to a child (includes degrees (a) – (c))
 273.5            Willful infliction of corporal injury (includes (a) – (h))
 285              Incest
 286(c)           Sodomy with person under 14 years against will
 286 (d)          Voluntarily acting in concert with or aiding and abetting in act of sodomy against will
 286 (f)          Sodomy with unconscious victim
 286 (g)          Sodomy with victim with mental disorder or developmental or physical disability
 288              Lewd or lascivious acts with child under age of 14
 288a(c)          Oral copulation with person under 14 years against will
 288a(d)          Voluntarily acting in concert with or aiding and abetting
 288a(f)          Oral copulation with unconscious victim
 288a(g)          Oral copulation with victim with mental disorder or developmental or physical disability
 288.5            Continuous sexual abuse of a child (includes degree (a))
 289              Penetration of genital or anal openings by foreign object (includes degrees (a) – (j))
 289.5            Rape and sodomy (Includes degrees (a) and (b))
 368              Elder or dependent adult abuse; theft or embezzlement of property (includes (b) – (f))
 451              Arson (includes degrees (a) – (e))
 459              Burglary (includes degrees in 460 (a) and (b))
 470              Forgery (includes (a) – (e))
 475              Possession or receipt of forged bills, notes, trading stamps, lottery tickets or shares (includes degrees (a) – (c))
 484              Theft
 484b             Intent to commit theft by fraud
 484d-j           Theft of access card, forgery of access card, unlawful use of access card
 487              Grand theft (includes degrees (a) – (d))
 488              Petty theft
 496              Receiving stolen property (includes (a) – (c))
 503              Embezzlement
 518              Extortion
 666              Repeat convictions for petty theft, grand theft, burglary, carjacking, robbery and receipt of stolen property
Certification of applicants with convictions on this list MAY be reconsidered by ATCS only if misdemeanor actions have been dismissed by a court of law or a
Certificate of Rehabilitation has been obtained for felony convictions. Any other convictions, other than minor traffic violations, must also be reviewed by ATCS.
                                                                                                                                                ATCS 98-4 (4/02)
Note: A Background check and a LIVESCAN FINGERPRINTING are two different processes. Infractions, probations or pending court cases showing up on
backgrounds may result in non-admittance to or dismissal from the program. If you have been convicted of a penal code not listed and are unsure of eligibility please call
DHS Tech & Aide Division (916) 552-8881for clarification.
                                                                                                                                                                        3
          SECTION B
             PROGRAM

         INFORMATION

B1: FINANCIAL AID
B2: ABSENT/TARDY POLICY
B3: ESTIMATED EXPENSE/ITEMS NEEDED
B4: DRESS/GROOMING STANDARD
B5: PRIORITY REGISTRATION AS AN IDENTIFIED
    NURSING STUDENT




                                             4
                                                  SECTION B: PROGRAM INFORMATION

B1. FINANCIAL AID:
Assistance with registration fees, supplies, and childcare may be available. Contact the Financial Aid Office at (805) 922-6966 ext. 3216
(Santa Maria) 5249 (Lompoc) or the E.O.P.S. Office at ext. 3214 for more information. E.O.P.S. can refer students for funding which is
provided under the Department of Social Services. If calling from Lompoc or Santa Ynez areas, call toll free at: 800-338-8732, then the
extension number.

B2. ABSENT AND TARDY POLICY:
The first three weeks of CNA requires 100% attendance to meet state mandated curriculum required before patient contact may take
place. It is also mandatory to attend each facility orientation day (to meet state requirements that must be met by the facilities). One (1)
day absence is allowed after the first 3 weeks for the CNA portion. A makeup day is REQUIRED BY STATE MANDATE for the day
missed during CNA. If you are not present when roll is called, you are tardy. More than 30 minutes late is considered a full day’s
absence. Missing 30 minutes or more during ANY part of class is considered a full day’s absence. Three (3) tardies is considered a full
day’s absence. One (1) day absence is allowed for Acute Care Aide (last five weeks). No makeup day is required. Make sure you have
backup childcare and transportation. Do not make appointments during class time. There is no such thing as an excused absence. Not
meeting required State mandated hours is the number 1 reason for being dismissed from class.

B3. FINANCIAL INFORMATION/ESTIMATED EXPENSES FOR NURS 400 STUDENT (subject to change)
REGISTRATION FEES: $26.00 per unit ........................................................................................................... $312.00
STUDENT CENTER FEE: (12 units x $1.00 per unit) ........................................................................................ $12.00
HEALTH FEE ...................................................................................................................................................... $10.00
PARKING FEES .................................................................................................................................................. $20.00
UNIFORM: (See B4 #1 for instructions) .............................................................................................................. $60.00
SHOES: (See B4 #4 for instructions,) .................................................................................................................. $50.00
IDENTIFICATION NAME PIN: (See B4 #5 for instructions) ............................................................................ $10.00
WATCH: (NOT digital – MUST have a second hand)......................................................................................... $30.00
CPR CARD: (Costs vary) ........................................................................................................................$21.00 -$50.00
   ($21.00 for the textbook at AHC Bookstore for the EMS 306: CPR for Healthcare)
TB Test: (Costs vary) ..............................................................................................................................$15.00 - $50.00
   (FREE at Santa Maria Campus Health Services with current AHC student body card when school is in session)
HEPATITIS B VACCINE .................................................................................. Costs will vary depending on provider
PHYSICAL EXAMINATION: (Costs vary) ..........................................................................................$50.00 - $85.00
CORPORATE SCREENING SERVICES ......................................................................................... $48.00 credit card
DRUG SCREENING (Roblar Occupational Medicine Clinic) ............................................................................ $30.00
   Additional fee if sample needs further testing ............................................................................................... $25.00
REQUIRED TEXTBOOKS ............................................................................................................................... $110.00
   Nursing Assistant, Caldwell/Hegner, Text and Workbook, 10th Edition
                   Medical Dictionary (Bundled together at the Allan Hancock College Bookstore)
   DO NOT purchase a used book or workbook. Part of the course requirements is to complete workbook
   and text questions IN THE BOOK.
SUPPLIES: .................................................................................................................................................... Cost varies
      1.    Loose leaf Binder/Notebook
      2.    #2 Pencil/Black Pen, Highlighter pen
      3.    Small Pocket Note Pad
      4.    Small Pocket Dictionary
      5.    Scantrons for testing (100 questions, green) available in bookstore (25 total)
BANDAGE SCISSORS (RECOMMENDED) ..................................................................................................... $10.00
*CNA TESTING (NATAP) Due 5th week of CNA .... $90.00 cashier’s check or money order to “SBCC” ONLY
*You should be reimbursed for this fee if you go to work at a hospital or facility after successfully passing the
State Board Exam for CNA’s.



                                                                                                                                                                             5
B4. DRESS CODE
   Your appearance reflects the hospital and college standards and indicates to patients and co-workers your pride and
  interest in your profession. These standards are maintained by personal neatness and cleanliness, by wearing only the
                      authorized uniform and by avoiding the use of elaborate jewelry and cosmetics.
Uniforms may be purchased from any source. As a point of reference, Uniforms & More is aware of the CNA dress code
              standard and are located at 722 E Main Street, Suite 109, Santa Maria, CA 93454, 805.928.6513.
1. Uniform Shirt/Top – Solid Navy Blue: Scrub type top, with pockets, zip or snap front.
   The uniform shirt/top must fit freely over hips and be 2 to 4 inches below buttocks.
2. Pants – White: The pants must fit loosely over knees and thighs. Jeans or stretch pants are not allowed. The length
   must be long enough to cover the top of shoe at the heel when standing. Free from stains or wrinkles.
3. Sweater – White or Navy Blue: Button Up or Zip. The sweater is not required. If purchased, make sure it is machine
   washable. The sweater is not allowed when giving direct patient care.
4. Shoes/socks: White leather shoe. Closed toe and heel. No clogs. White socks. Neutral hose
5. Identification Name Pin: Purchase at Bob’s Rubber Stamp (110 N. Conception Ave; Santa Maria, CA 93454:
   805.925.8182): (allow 1 week for order to be completed).
   The identification name pin is mandatory and the following specifications are to be followed: (WHITE
   BACKGROUND WITH BLACK LETTERING) S.N.A stands for Student Nursing Assistant

            EXAMPLE:                        Allan Hancock College
                                                Alice D., S.N.A.


       It is also mandatory to purchase the student picture ID so that you may wear it in the acute care facilities.
                          You will not be allowed to take care of patients without a picture ID.

NOTE: THE NAME TAG IS AN ESSENTIAL PART OF YOUR UNIFORM. YOU ARE NOT CONSIDERED TO BE
  IN COMPLIANCE WITH THE DRESS CODE IF YOU DO NOT HAVE YOUR NAME TAG ON.

6. Watch: You MUST have a watch with a second hand (NOT digital).
7. Jewelry: You may wear an engagement or wedding ring on left hand only, and plain post earrings (only one earring per
    earlobe). Rings that are a hazard to patient care will be removed. No other visible piercing is allowed (tongue, nose,
    eyebrow, etc.). This may be offensive to the residents, patients, and we are complying with the rules of the facilities in
    which we are a guest.
8. Nails must be cut so as not to be seen from “palm” side of hand. They must be clean and filed. Clear nail polish only.
9. Hair must be clean, contained and neat. If it “touches your nose” you must wear it up. If the ponytail or braid “touches
    your nose” it must be worn up.
10. Makeup to be minimal, and in good taste for daytime wear.
11. No perfume.
12. Tattoos must be covered.

   NOTE: You are encouraged to wear your uniform on the first day of class. It is MANDATORY that you are in full
    uniform, including the name tag, by the second day of class. There will be a uniform/dress code check on that day.
     All other grooming and piercing policies will be enforced when class begins and WILL BE ENFORCED EVERY
                                      LECTURE/CLINICAL DAY AFTER THAT.

B5. PRIORITY NURSING STUDENT REGISTRATION:
To qualify as a “priority nursing student” contact the nursing counselor (x3293) to clarify eligibility
qualifications and fill out an SEP (Student Education Plan). This status will allow the student to register early and
have a better chance of getting the prerequisite classes required to enter the LVN/RN programs.




                                                                                                                            6
                   SECTION C
  EXPLANATION
      OF
 MANDATED ITEMS
 When are these items to be turned in?
   Registered Students: Between January 4th and January 20th.
   Waitlisted Students: If accepted, you will be given 1 week to complete all items,
   please have all appointments made, just in case. Please see instructions for wait list
   students below for more information.

 Instructions for Registered Students:
1. Make a copy of the entire application packet and put in a safe place.
2. Place all items (in order of the checklist) in an 11x14 envelope
3. Turn into the Health Sciences Office (M132 SM Campus) between January 4th and
   January 20th.
4. Fill out Goldenrod Application and turn into your instructor on the 1st day of class –
   Is will be given to you when you turn in your packet.

 Instructions for Wait List Students:
1. If the class is full, register and get on the waitlist.
2. Do everything in the packet except for Background, Drug Screening and Physical
   (Make an appointment) until you are contacted. If contacted after January 25th , you
   will have 1 week to complete the background, drug screening and Physical.
3. If accepted prior to school starting, turn completed packet into the Health Sciences
   Office (M132 SM Campus) by January 29th, 2010.
4. You are advised to come to the first day of class if you do not hear from us prior to
   school starting. If accepted on the first day of class, you will need to have all items
   completed and turned into the Health Sciences Office (M132 SM Campus) by
   February 5th, 2010.
                                                                                             7
     MANDATED ITEMS CHECKLIST: Instructions for each item on following pages.
NOTE TO STUDENT: PLACE ALL ITEMS, IN ORDER OF THE CHECKLIST, IN A LARGE YELLOW
ENVELOPE (11x14) WITH YOUR NAME IN THE TOP LEFT CORNER. (DO NOT FOLD ITEMS).

MY INITIALS VERIFIES THAT I HAVE COMPLETED AND MADE COPIES OF THE FOLLOWING
MANDATED ITEMS:

STEP 1 – ITEMS 1-10 ARE DUE BETWEEN JANUARY 4TH AND JANUARY 20TH.

________1. PHYSICAL EXAM: Original to AHC, make a copy for you.

_______ 2. TB SKIN TEST: Original (on Physical Exam Form or other form) to AHC, make a copy for you.

_______ 3. HEPATITIS B VACCINE: Provide documentation that the series has been completed or started to AHC.

________4. ACKNOWLEDGEMENT AND CONSENT FORM FOR SUBSTANCE ABUSE TESTING: Original to
        AHC, make a copy for you. (Compliance in drug testing will show up electronically to AHC administration).

________5. POTENTIAL RISK FORM: Original to AHC, make a copy for you.

_______ 6. SUBSTANCE ABUSE SCREENING AT ROBLAR: (Compliance in drug testing will show up electronically
         to AHC administration).

_______ 7. BACKGROUND CHECK – CORPORATE SCREENING: COPY of Electronic Receipt from screening
        service (print out on computer)

________8. SOCIAL SECURITY CARD (for employment): Make one copy for AHC. You must show the original
        when taking the state board examination (along with a picture ID).

________9. CPR CARD: Make a copy for AHC. (Remember, “Professional Rescuer” or “Healthcare Provider” must be on
        the CPR card to be valid)

________ 10. LIVE SCAN FINGERPRINT: You will need to show proper valid identification (Government issued
        Passport, Driver’s License or Government-issued Photo ID) at time of fingerprinting.

STEP 2 – ITEM 11 IS DUE ON THE 1ST DAY OF CLASS. You will receive this paperwork and instructions when
you turn in all of Step 1 into the Health Sciences Office (M 132, SM Campus).

_________11. CNA APPLICATION Original and 2 copies to AHC, make a copy for you. Include a letter of explanation
        if “yes” is marked on “convictions other than minor traffic violation.”


STEP 3 – ITEM 12 IS DUE THEORY DAY 12 (5TH WEEK OF CLASS):

________12. $90.00 CASHIER’S CHECK OR MONEY ORDER MADE OUT TO “SBCC” FOR STATE BOARD
        EXAM: Cashier’s check or money order and 1 copy to AHC, make a copy for you. (Make sure your name
        and Social Security Number are on check.)



                                                                                                               8
                         SECTION C: EXPLANATION OF MANDATED ITEMS

STEP 1 – ITEMS 1-11 ARE DUE BETWEEN JANUARY 4TH AND JANUARY 20TH
ITEM 1: PHYSICAL EXAMINATION (Forms Section) - To be completed and turned in between Jan. 4th and Jan. 20th.
Turn in original and make copy for yourself. The physical examination form must be completely filled out (leave no blank spaces).
As a CNA student, you may be required to assist the patient in walking, helping them to a wheelchair, lifting them into bed, and giving
personal care. If you are pregnant, request a written clearance from your physician or midwife permitting “unrestricted nursing
activities” and submit to your instructor by the end of the first trimester of pregnancy. NOTE: There can be absolutely no
restrictions, physical or mental, which would hinder your ability to function fully as a CNA student. You must have a note from
your physician stating you have no limitations. If there is any change in your physical/mental ability that occurs during the course of the
program (pregnancy, etc.), you may need to update your physical examination form. Pregnancy requires A LETTER from your
obstetrician stating that there are no restrictions for lifting.
ADVISE: The examination ($25.00 fee) is offered at the Health Services office during the Spring and Fall semesters with a current
AHC student Body ID card. If interested, please call Health Services at x3212 for an appointment.

ITEMS 2 & 3: REQUIRED LABORATORY TESTS (On physical examination form, Section D)
TB Skin Test: Located ON the “Physical Examination” form. Make copy for self and turn in original with the packet. The TB skin
test requires three days from the time it is administered to the time it can be read. This is offered at the Health Services office during
the Spring and Fall semesters with a current AHC student Body ID card. If interested, please call Health Services at x3212 for an
appointment.
      If the skin test is positive, you will need to follow up with a chest x-ray. The chest x-ray can only be done by the Public Health
     Dept. or a private physician. Allow at least 2 weeks before due date to get test done.

Hepatitis B Vaccine: Students must provide documentation of Hepatitis B Vaccination being completed or that the series has been
started. AHC Health Services does not offer this. You must go to a private doctor for this.

ITEM 4: ACKNOWLEDGEMENT AND CONSENT FORM FOR SUBSTANCE ABUSE TESTING:
      (Forms Section)
Read and sign as directed. Turn in original and make copy for yourself. This form is NOT turned in to Roblar Clinic.

ITEM 5: POTENTIAL RISK FORM: (Forms Section):
Read and sign as directed. Turn in original and make copy for yourself.

                                                                 NOTE:
It is a state/federal (not college) requirement that the mandated items be completed at the beginning of the program. A list of
qualified students, those who have completed all the mandated items, will be sent to the training facilities used by the Allan Hancock
College CNA Program. Your name cannot go on the list if you have not completed all the required items, and you will be dropped
from the CNA Program.

Word to the wise…“get the mandatory items done as soon as you receive this packet.” These items take time to complete. Allow time
for delays or cancelled appointments. Do not wait until the last minute. There most likely will be a student on the wait-list that will be
happy to take your spot!

ITEM 6: SUBSTANCE ABUSE SCREENING - To be completed and turned in between Jan. 4th and Jan. 20th.
 1.   Go to Roblar Occupational Medicine Clinic at 340 E. Betteravia, Suite “A”, Santa Maria, CA 93458. (805) 614-9000.
          (Open 8:00 am – 4:00 pm, Monday-Friday)
 2. Bring a list of any prescription or nonprescription meds you have taken in the past 30 days. You will need to complete a form listing
    these medications.
 3. You will need to show proper valid identification (Government issued Passport, Driver’s License or Government-issued Photo ID)
 4. You will need to pay the $30.00 (personal checks, cash or debit or credit cards) fee at the time of the test. If the sample must be
    sent out to another lab for further testing, an additional $25.00 charge will be due and payable.
 5. Turn in original and make copy for yourself.




                                                                                                                                         9
ITEM 7: BACKGROUND CHECK: To be completed and turned in between Jan. 4th and Jan. 20th.
          The Joint Commission of Hospital Accreditation has required that any person having patient contact be screened for criminal
convictions, and the results must be available to the care facility (ACUTE CARE). The results of Live Scan fingerprinting cannot go to
the facility, making it necessary to perform a second screening through Corporate Screening Services, Inc.
  IMPORTANT: IT IS THE RESPONSIBILITY OF THE FACILITIES TO HOLD STUDENTS TO THE SAME STANDARDS AS AN
  EMPLOYEE WHO HAS PATIENT CONTACT. THE FACILITIES HAVE THE FINAL SAY AS TO WHETHER A STUDENT MAY
   PARTICIPATE IN PATIENT CARE. IT IS NOT THE DECISION OF ALLAN HANCOCK COLLEGE. IT MAY TAKE SEVERAL
 WEEKS TO COMPLETE THE BACKGROUND CHECK. YOU WILL BE DROPPED IF IT IS NOT COMPLETE WHEN THE LIST OF
             QUALIFIED STUDENTS IS SENT TO THE FACILITIES BEFORE PATIENT CARE TAKES PLACE.

Note: A Background check and a LIVESCAN FINGERPRINTING are two different processes. Infractions, probations or pending court cases
showing up on backgrounds may result in non-admittance to or dismissal from the program. If you have been convicted of a penal code not
listed and are unsure of eligibility please call DHS Tech & Aide Division (916) 552-8881for clarification.

                               Background Check Instructions: (To be done ONLINE)
                           STUDENT BACKGROUND SCREENING REQUEST PROCEDURES
ONLINE Ordering Instructions:

1.   Check to make sure you have a printer that works.
2.   Log onto our website at www.VerifyStudents.com
3.   Click the ‘Start Here’ Button
4.   Enter the special promotional code provided to you by your school and then hit the ‘GO’ Button.
5.   Complete the online application section in its entirety.
6.   Have credit card (Visa/Mastercard/American Express/Discover) information ready in order to process payment.
7.   Click the ‘Submit’ Button at the end of the process and you’re done! You will be provided with an electronic receipt and
     confirmation code at the time of completion that you must print. Turn in original and make copy for yourself.
YOUR PROGRAM’S PROMOTIONAL CODE IS: AHCOL

ITEM 8: SOCIAL SECURITY CARD (for employment)
Turn in a copy. The state requires a valid social security number (for employment) to be on the CNA application. It is also mandatory
to show the card to the tester as well as a picture ID before you take the state board examination. Your picture student ID or a driver’s
license is acceptable. All state Dept. of Health Services records for the CNA program are maintained under the social security number.
If you falsify a number, you will not be able to receive your Certification for CNA, and you will need to take the CNA course over, and
re-test for the State Board examination. Note: If you have taken the state board exam and certification was blocked due to conviction,
you will not be allowed to repeat a CNA training program. (Patient contact is prohibited). Make sure that the name that you register at
the college under and the name are your social security card is the same.

ADVISE: Most Social Security Cards will only list your name and Social Security Number, unless you have restrictions. If you have
restrictions, you will need to have “for employment” printed on your social security card

ITEM 9: CPR CARD
Turn in a copy. The CPR card that is required is Healthcare Provider(American Heart Association) OR Professional Rescuer
(American Red Cross) OR EMS 306: CPR FOR HEALTHCARE. Make sure that the CPR card includes: Adult (1 man and 2 man),
Child, and Infant. NOTE: If you register for CPR through Allan Hancock College and do not attend, you need to go to Admissions &
Records to withdraw from the class or the instructor will give you an F grade and you will be blocked if you try to re-register for any
other class. Students are strongly encouraged to enroll as soon as possible as classes fill quickly.

If taking the EMS 306 course, you MUST purchase and REVIEW the textbook for the CPR class prior to class date to insure
success. You CANNOT receive a CPR card and will not be admitted to class without the text. It is available at the campus bookstore.
For registration information see Credit Class Schedule under Emergency Medical Services. Register and get on the wait list if the class
is full. It is advised to go to the class and see if the instructor can make room for you. You cannot have patient contact (by law) until you
have your CPR certification.

Note: Classes are usually held as a one-time 8 hour class or two four hour classes. Majority of the EMS 306 offerings are held prior to school
starting to accommodate programs like nursing. Please take advantage of these classes and sign up



                                                                                                                                           10
ITEM 10: LIVE SCAN FINGERPRINTS – This will be done during class.
It is mandatory for all CNA and HHA applicants to be fingerprinted when enrolling in training program (Senate Bill 945 CH.
558). Read over attached list of convictions (Section A, Disqualifying Penal Codes) which constitute automatic denial/revocation.
If you have a prior conviction, Allan Hancock College cannot guarantee that you will be cleared and eligible to receive your CNA
certification. For further information about getting your conviction cleared, contact Department of Health Services: 1-916-327-2445.

      ONLY LIVE SCAN FINGERPRINTS DONE SPECIFICALLY FOR THIS CLASS WILL BE
    ACCEPTED. FINGERPRINTS DONE FOR ANOTHER AGENCY OR PURPOSE WILL NOT BE
                   ACCEPTED BY DEPT. OF HEALTH SERVICES (DHS).

REQUIRED: PROPER VALID IDENTIFICATION (Government issued Passport, Driver’s License or
Government-issued Photo ID)

All students who are enrolled in the Certified Nurses Assistant (CNA) Program must get their fingerprints done
during the third week of classes by Silvia’s Fingerprinting. It is the student’s responsibility to show up on time
prepared.

Students will be required to pay $65.00 and WILL NOT be reimbursed ($55.00, subject to change) if:
   1. Fingerprinting does not take place with the class.
   2. Fingerprinting is done through any agency other than Silvia’s Fingerprinting.


NOTE: Other law enforcement agencies may be available for Live Scan, but you will not be reimbursed. For
   example, Lompoc Police Department (805-736-2341), SMPD (805-928-3781, press 5, then press 293),
   SBCPD (805-934-6150) Cal Poly University Police Dept. performs the procedure Mon-Fri 9am-7pm.
   Number: 805-756-6663 or tminetti@calpoly.edu.

STEP 2 – ITEM 11 IS DUE ON THE 1ST DAY OF CLASSES.
You will receive this paperwork and instructions when you turn in all of Step 1 into the Health Sciences Office (M
132, SM Campus).

ITEM 11: CNA INITIAL APPLICATION (goldenrod form HS283 B, Section D)
Original and 2 copies to AHC, make a copy for you. Mark “yes” under convictions for ANY conviction you have other than a
minor traffic violation (even petty theft, DUI, etc.). Mark “yes” even if the conviction occurred when you were a minor. Include a letter
of explanation with your CNA and/or Home Health Aide initial application form. The convictions that are listed in Section C in your
admission packet are those convictions that may negate any possibility of you becoming a CNA. Do not take chances. If in doubt,
contact the Department of Health Services in Sacramento at (916) 327-2445. All students need to be LIVE SCAN fingerprinted and a
background check is done on all students. If you complete the course and the background check shows that you have a conviction, you
may be delayed or blocked from ever becoming a CNA. NOTE: Allan Hancock College cannot guarantee that you will
become a CNA, even if you successfully complete the course and pass the State Board, if you have a
conviction that bars you from becoming certified or if you use an invalid social security number.

Your “California Training Program ID Number” depends on if you signed up for the Santa Maria Campus or the Lompoc Campus.
Santa Maria Students: “California Training Program ID Number” is S0008, your “Beginning date of Training is 02/02/10”
Lompoc Students: “California Training Program ID Number” is S0359, your “Beginning date of Training is 02/01/10”

Remember to sign and date as “Signature of Applicant”.

Do not fill out “Equivalent Training or Reciprocity from Another State” or “Processing Fees Returned”.




                                                                                                                                      11
       SECTION D

            FORMS
Page 13: Substance Abuse Consent Form
Page 14: Potential Risk Form
Page 15-17: Physical Examination Form (TB included)
Page 18: Reference for Student Homework Assignments




                                                      12
                           ALLAN HANCOCK COLLEGE
          ACKNOWLEDGMENT AND CONSENT FORM FOR SUBSTANCE ABUSE TESTING
                         Make copy for self and turn in original..

I, (print name) __________________________________________, acknowledge that I have received and read
the Central Coast Consortium for Nursing Position Statement – Background Checks/Drug Screen. I
understand that the clinical agencies that provide sites for training in the health science programs require this
testing prior to students having contact with patients. I understand that a positive test result may subject me
to dismissal from the nursing program. I also understand that failure to cooperate with testing or refusal to
provide a test specimen, will result in inability to attend clinical courses and therefore unable to meet program
requirements. This will result in dismissal from the program.

My signature below indicates that:

1)     I consent to drug testing as required by clinical agencies.

2)     I authorize the testing laboratory to disclose the results of any such tests to the Director of the Nursing
Programs or to such other persons designated by the Director of the Nursing Programs to receive confidential
information including the clinical agencies requiring the test.

3)     If the drug test is positive, I understand that further screening will be done at additional expense, for
which I will be responsible.

4)     In the event my drug test result is positive, I understand that I will forfeit my     seat in the      current
nursing class and that I will be allowed to reapply for the next year’s class.

5)     I acknowledge that this policy is a condition required by acute care           agencies. I understand that if I
do not wish to be subject to the testing policy, I may resign my seat in the class.

6)     I hereby release and agree to hold harmless Allan Hancock College and agents from all action, claim,
demand, damages, or costs arising from such testing, in connection with, but not limited to the testing procedure,
analysis, the accuracy of the analysis, and the disclosure of the results.

My signature indicates that I have read and understood this consent and release, and that I have signed it
voluntarily in consideration of enrollment in the Nursing Program at Allan Hancock College.


_______________________________________________                       ___________________________________
Signature of Student                                                  Date




                                                                                                                   13
                                ALLAN HANCOCK COLLEGE
                     ACKNOWLEDGEMENT AND ASSUMPTION OF POTENTIAL RISK

STUDENT INSTRUCTIONS: Make a copy for self and turn in original.

______________________________________ wishes to participate in the Allan Hancock Joint Community College
District sponsored activity/activities of   NURS 400: CNA/Acute Care Aide.

I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to
individuals who participate. I understand and acknowledge that some of the injuries/illnesses, which may result from
participating in these activities, include, but are not limited to the following:

1. sprains/strains       3. unconsciousness       5. paralysis             7. death
2. fractured bones       4. head/back injuries    6. loss of eyesight      8. communicable diseases

I understand and acknowledge that participation in this/these activity/activities is completely voluntary and as such is not
required by the District.

I understand and acknowledge that in order to participate in this/these activity/activities,
I agree to assume liability and responsibility for any and all potential risks that may be associated with participation in such
activity/activities.

I understand, acknowledge, and agree that the District, its employees, officers, agent, or volunteers, shall not be liable for
any injury/illness suffered by me, which is incidental to and/or associated with preparing for and/or participating in this
activity/activities.

Unless otherwise advised, I understand that I am responsible for my own transportation to and from the activity/activities
the college assumes no liability for loss or injury resulting from my transportation, and any person driving a personal
vehicle is not an agent of the District. Although the college may assist in coordinating the transportation, any assistance
and/or recommendations provided may not be mandatory.

If the college is providing transportation but I do not use the transportation, I am responsible to make my own transportation
arrangements and the college assumes no responsibility or liability of any kind.

I have no known medical condition that may pose a health and/or safety risk to others or me by participating in the
activity/activities.

I acknowledge that I have carefully read this ACKNOWLEDGEMENT AND ASSUMPTION OF POTENTIAL RISK
form and that I understand and agree to its terms.

________________________________________________________                   ___________________________________
Student Signature                                                          Date

________________________________________________________                   ___________________________________
Parent’s Signature (if minor)                                              Date


A signed ACKNOWLEDGMENT AND ASSUMPTION OF POTENTIAL RISK form must be on file with the District
before a student will be allowed to participate in the above extra-curricular activity/activities.

Revised: 8/16/00




                                                                                                                             14
                               ALLAN HANCOCK COLLEGE
                 HEALTH SCIENCES PROGRAMS, CERTIFIED NURSING ASSISTANT

INSTRUCTIONS TO THE STUDENT: READ THE FOLLOWING, COPY FORM FOR YOURSELF AND
TURN IN ORIGINAL.

A complete physical examination as listed on this form is required for admission to the Health Sciences
Programs. Complete the student's section then take the medical report form to your physician for your physical
examination. When the form is completed, please be sure the form is returned to the instructor on the 2nd of class.

TO THE PHYSICIAN:

This student will not be accepted into the Allan Hancock College Health Sciences Programs until a physical
examination has been completed and a TB skin test or Chest X-ray has been done and the Hepatitis B Vaccine
Series has been verified, and administered (if necessary). Please leave these areas blank if they are not done in
your office.

A      Tuberculin skin test required prior to entering the program. Positive PPD requires a standard negative chest
       film with medical consultation. Standard chest x-ray is recommended if there is any history of previous
       chest disease.

B.     Students must provide proof of Hepatitis B Vaccine (for all healthcare workers) or provide documentation
       that the series has been started.

ALTHOUGH NOT REQUIRED, Santa Barbara County Health Department recommends the following
immunizations:

C.     Diphtheria, Pertussis, and Tetanus Toxoid (DPT) Booster. Recommended dose of Tetanus toxoid (Adult)
       intramuscularly every ten years.

D.     Measles, Mumps, Rubella (MMR)

E.     Poliomyelitis Vaccine. Complete series and booster one year after the initial series. (Vaccine should not be
       received if part or complete series were once received during lifetime.)

F.     Varicella (chicken pox)


Immunizations C-F will be required for those planning on entering into the LVN or RN programs.

                     Santa Maria                                                Lompoc
            Santa Maria Public Health Clinic                            Lompoc Public Health Clinic
      2115 Centerpointe Parkway; Santa Maria, CA                           3001 North R Street
                    (805) 346-8410                                           (805) 737-6400

           Wednesdays: 1:30 p.m. – 6:00 p.m.                  Tuesdays: 1:00-4:00 p.m. By Appointment Only
     Fridays: 9:30 a.m. – 11:30 a.m. & 1:30-4:30 p.m.

                                       Call ahead for further information.


                                                                                                                15
                                HEALTH SCIENCES PROGRAMS
                               CERTIFIED NURSING ASSISTANT
                          REPORT OF GENERAL MEDICAL EXAMINATION

TO BE FILLED IN BY STUDENT: (MAKE COPY FOR YOURSELF AND TURN IN ORIGINAL)

LAST NAME: _____________________ FIRST NAME: __________________ MIDDLE: __________
ADDRESS: ________________________ CITY/STATE: ______________________                        ZIP: __________
PHONE #: (      ) ___________________ MESSAGE PHONE #: (                     ) ____________________________
SOCIAL SECURITY #: ________________________                           MALE             FEMALE
EMERGENCY CONTACT PERSON                                                PHONE #: (     )   _______________

TO BE FILLED IN BY EXAMINING PHYSICIAN:

HEIGHT: _____________ WEIGHT: _____________         BLOOD PRESSURE: _____________________________________
EYES - Right: ______________ Left: ______________   MOUTH: ______________________________________________
EARS - Right: ______________ Left: ______________   THROAT: ______________________________________________
NOSE: _________________________________________     LYMPH NODES: ________________________________________
TEETH: _______________________________________      BREASTS: _____________________________________________
THYROID: _____________________________________      HERNIA: ______________________________________________
LUNGS - Right: _____________ Left: ______________   ABDOMEN: ____________________________________________
HEART: _______________________________________      BACK: ________________________________________________

                                    REQUIRED LABORATORY TESTS

TB TEST Available at Santa Maria AHC Health Services – FREE – to students with an AHC I.D. card. Not open
during the summer.
TUBERCULIN TEST (T.B. Test) - The reading date MUST BE filled in and the results checked. Attach a
copy of results: (TB tine not accepted.)

DATE GIVEN: ____________________________              DATE READ: ________________________________

NEGATIVE: __________________ *POSITIVE: ______________ DEGREE: ______________________
*If positive, a chest x-ray must be taken AND copy of chest x-ray report (with date) attached.

PRINT NAME OF EXAMINER _____________________________________________________________

SIGNATURE OF EXAMINER
READING THE TEST: ___________________________                  DATE: ________________________________


REQUIRED IMMUNIZATIONS (Immunization must be verified by physician, copy of immunization records,
or lab titers. If titer does not confirm immune status, student must be immunized.)

HEPATITIS B VACCINE: 1ST:                  ______ 2ND:           _______________ 3RD:
Students must show proof of Hepatitis B Vaccination or provide documentation that the series has been started.



                          DO NOT LEAVE ANY BLANK SPACES
                                                 (Please turn over)
                                                    Page 1 of 2
                                                                                                                 16
CURRENT COMPLAINTS OR DISABILITIES PERTINENT TO ALLAN HANCOCK COLLEGE
HEALTH SCIENCES PROGRAMS:

________________________________________________________________________________________


SIGNIFICANT MEDICAL HISTORY (Major illnesses, accidents, deformities, or operations):

_________________________________________________________________________________________________________

INSTRUCTIONS: MAKE COPY FOR YOURSELF AND TURN IN ORIGINAL ON 2nd DAY CLASS.
The Health Sciences programs require the student to have patient contact. Students must be able to lift, ambulate, and
interact with people that have chronic and acute disorders. There can be absolutely no restrictions for lifting or
transferring patients.

This person  does / does not qualify physically to enter the Allan Hancock College Health Sciences programs.

 This person  does / does not have any mental/physical conditions that would create a hazard to himself/herself,
fellow employees, patients, or others. An obstetrician must include a letter stating that the student has no restrictions if the
student is pregnant or becomes pregnant during the program.


                                          VERY IMPORTANT!
Your signature verifies that the student has no physical or mental health condition that would
create a hazard to himself/herself, fellow employees, patients, or others.


EXAMINER’S SIGNATURE: _______________________________________ DATE:

PRINT EXAMINER’S NAME AND PROFESSIONAL INITIALS (M.D., P.A., N.P.):

___________________________________________________________________________________

EXAMINER’S ADDRESS:
___________________________________________________________________________________
___________________________________________________________________________________

TELEPHONE: (           ) _________________ MESSAGE PHONE: (                      ) ________________________



PLEASE NOTE: A release from an obstetrician is required if the student is pregnant or gets pregnant during the
program. There can be no restrictions for a pregnant student. The release must be on office letterhead and states
that the student may perform “unrestricted nursing activities.”




                                                          Page 2 of 2




                                                                                                                             17
          REFERENCE FOR STUDENT HOMEWORK ASSIGNMENTS

         NOTE TO STUDENT:
             THE FIRST 3 WEEKS OF CNA IS ESPECIALLY RIGOROUS AND COVERS THE MANDATED
              CURRICULUM REQUIRED BY THE STATE DEPT. OF HEALTH SERVICES TO BE COVERED
              BEFORE RESIDENT CONTACT CAN TAKE PLACE. IT IS STRONGLY RECOMMENDED THAT
              YOU BEGIN.
             READING THE TEXT
             COMPLETING THE “REVIEWS” AT THE BACK OF EACH UNIT
             COMPLETE THE CORRELATING WORKBOOK ASSIGNMENTS
             VOCABULARY: WRITE WORD (FROM BEGINNING OF EACH UNIT) WITH THE
              DEFINITION. Example…Nosocomial: Hospital Acquired Infection.
             ASSIGNMENTS TO BE READ AND COMPLETED AS FOLLOWS:

Following is the class schedule:

                THEORY DAY            UNITS COVERED
             THEORY DAY-1          SYLLABUS/ ORIENTATION/ Units 1, 2

             THEORY DAY-2          Units 3, 4, 12 & 13

             THEORY DAY-3          Units 15, 16 & 17

             THEORY DAY-4          Units 7, 8, 9, 10 & 11

             THEORY DAY-5          Units 26, 48 & 27

             THEORY DAY-6          Units 23 & 24

             THEORY DAY-7          Units 14, 18, 19, 20 & 52

             THEORY DAY-8          Units 25 & 21

             THEORY DAY-9          Skills Review

             THEORY DAY-10         Units 33 & 5 (as covered)

             THEORY DAY-11         Units 5, 6, 22 & 38

             THEORY DAY-12         Units 39 & 32

             THEORY DAY-13         Units 40 & 41

             THEORY DAY-14         Units 42 & 45

             THEORY DAY-15         Units 43 & 44

             THEORY DAY-16         Unit 46/CNA final




                                                                                        18

								
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