Fill - Free fillable 1P4e AA NursingAdmissions 2019 LCCC Nursing Program Admission Information And Application Form (Laramie County Community College) PDF form

LARAMIE COUNTY COMMUNITY COLLEGE

NURSING PROGRAM

ADMISSION INFORMATION AND

APPLICATION FORM

for the class beginning January 2019

Application Deadline: September 1-15, 2018

The nursing curriculum at Laramie County

Community College is a leveled educational program

to facilitate career mobility. The first two semesters

provide a foundation for progression in the field of

nursing and prepare the student to enter the second

level of the nursing curriculum and/or take alternative

course work which will provide a PN certificate

and eligibility to take the qualifying examination

for Practical Nurse Licensure (NCLEX‑PN). Upon

completion of the third and fourth semesters of

nursing education, the graduate earns an Associate

Degree in Nursing (ADN) and may be recommended

to take the qualifying examination for Registered

Nurse Licensure (NCLEX‑RN).

Laramie County Community College is committed to

providing a safe and nondiscriminatory educational

and employment environment. The college does

not discriminate on the basis of race, color, national

origin, sex, disability, religion, age, veteran status,

political affiliation, sexual orientation or other status

protected by law. Sexual harassment, including

sexual violence, is a form of sex discrimination

prohibited by Title IX of the Education Amendments

of 1972. The college does not discriminate on the

basis of sex in its educational, extracurricular, athletic

or other programs or in the context of employment.

The College has a designated person to monitor

compliance and to answer any questions regarding

the college’s non‑discrimination policies. Please

contact: Title IX and ADA Coordinator, Suite 205,

Clay Pathfinder Building, 1400 E College Drive,

Cheyenne, WY 82007, 307.778.1217,

TitleIX_ADA@lccc.wy.edu.

The Nursing Program has been developed in

accordance with criteria established by the

Accreditation Commission for Education in Nursing,

Inc. (ACEN) with assistance from the Wyoming

State Board of Nursing (WSBN). The program has

received approval as a nursing education program by

the WSBN, 130 Hobbs Avenue, Suite B, Cheyenne,

WY 82002; 307.777.7601 and is accredited by the

ACEN, 3343 Peachtree Rd., NE, Suite 850, Atlanta,

Georgia 30326 404.975.5000.

ADMISSION CRITERIA

If you are an LPN – STOP!

Please fill out the Advanced Placement Application.

Laramie County Community College is an open

admissions institution and provides programs

beneficial to all students. College admission

requirements are found in the college catalog.

Admission to the Nursing Program is competitive and

students must be in satisfactory academic standing

with a minimum GPA of 2.5, of courses taken in the

nursing curriculum, in order to apply. Applicants must

complete the following steps:

Note:

Students who have failed more than one core

nursing course with a “C‑,” “D,” “F,” or “U”

are ineligible to apply.

Step 1. Submit an LCCC Admission Application to

the Admissions Office. It is the student’s

responsibility to request official transcripts

of high school and college courses to be

sent to the Student Records Office.

NOTE: Unofficial transcripts (student

copies of all institutions attended,

including LCCC) must be attached and

submitted with the Nursing Application.

Step 2.

Prerequisites:

A. COLS 1000 – Intro to College Success.

Verify satisfaction of completion of this

course as indicated by the Registrar.

(Some students may qualify for an

exemption from this course. See Page 39

of the catalog).

B. ENGL 1010 – English I: Composition.

You must verify satisfactory completion

with a minimum grade of “C”. An

incomplete or grade lower than “C” is

not acceptable.

C. MATH 1400 – College Algebra or higher.

You must verify satisfactory completion

with a minimum grade of “C”. An

incomplete or grade lower than “C” is

not acceptable. Statistics, Theory of

PRS 5324 5/18

Mathematics, or Clinical Calculations

will not fulfill this requirement. ACT

scores will not satisfy the math

requirement. A college math course

must be satisfactorily completed.

D. ZOO 2015 – Human Anatomy (or

A&P I). You must verify satisfactory

completion with a minimum grade

of “C”. An incomplete or grade lower

than “C” is not acceptable. If you take

Human Anatomy, you must complete

the sequence with Human Physiology.

If you take A&P I, you must complete the

sequence with A&P II. Taking one course

from each sequence will not fulfill the

requirement.

Step 3.

Achieve a score on the TEAS test at or

above the National Mean for both the overall

score and the reading score (currently at

65.6 and 72.4 respectively) on the same

test. There is a $35 fee for this test.

Contact the LCCCC Testing Center for

details and scheduling at 307.778.1105 or

testcenter@lccc.wy.edu.

The test may be taken a maximum of two

times (in one‑year), with at least a three‑

week interval between the tests. The score is

acceptable for three years.

Step 4.

Complete the Nursing Program Application

and submit it between September 1-15.

When all applications have been verified

with enclosed transcripts (including

LCCC), placement scores, etc., letters

will be mailed out. Any forms postmarked

after September 15 will be ineligible for

consideration.

Step 5.

Begin the immunization process.

Note: It is not necessary to submit the

physical form with the application; however,

you may want to begin the immunization

process as soon as possible. The required

immunizations can take up to eight months

to complete. A physical form is provided for

you to take to your health care provider.

Hepatitis B Process: Verify the 3‑dose

series by receiving the first dose, then one

month later receive the second dose, and

then five months later receive the last dose.

You may choose to have a titer drawn

instead. If immunity is not indicated by the

titer, then you must have a booster or start

the 3‑dose series again depending on your

health care provider’s recommendation.

Rubella/Rubeola/Mumps Process: Verify

two doses of the MMR vaccine or have titers

drawn. If immunity is not indicated, by titers,

then you must either start the 2‑dose series

or have a booster and another MMR titer

drawn in six weeks.

Varicella Process: Verify two doses of the

varicella vaccine or have the titer drawn to

verify immunity. Having had the Chicken Pox

disease, does not mean you have immunity.

Note: If you have had two titers drawn for

these immunizations and you are still not

immune, then you are exempt from any

further attempts to become immune. Please

keep all copies of your immunizations for

your records.

PPD: In addition to the above‑listed titers, all

students are required to obtain a two‑step

TB (PPD) skin test and update it annually.

Other:

• A current TdAP booster (within 10 years)

• Basic Life Support for Health Care

Providers through the American Heart

Association valid through May 2020

• Annual Flu Shot

Any student found out of compliance with

these requirements will be sent home

from clinical and may be dismissed from

the program.

It is the student’s responsibility to furnish all the

required paperwork. Incomplete applications will

be ineligible for consideration.

Applications will be processed as quickly as possible.

Every applicant can expect to receive a letter by the

first week of November. Please do not contact us

prior to this date as it will delay the application review

process. Applicants may be placed on an alternate

list and selected on a space‑available basis. Students

not selected for admission into the Nursing Program

by the first day of class must initiate the admission

process the following semester before being

reconsidered for a future class. These students will

be considered along with all new applicants.

After acceptance into the Nursing Program, proof

of the following additional requirements must be

submitted to the Nursing Program as stipulated in

the acceptance letter.

Failure to submit required documentation may result in forfeiture of

your position in the Nursing Program and an alternate candidate will be notified.

Further Information and Assistance

Contact: Nursing Program

Laramie County Community College

1400 E. College Drive

Cheyenne, WY 82007

307.778.1267

lccc.wy.edu/programs/nursing

1. Acceptable report of the background check/

drug screen. Requirements will be explained in

the acceptance letter.

Note: Applicants who have been convicted of

a felony, treated for mental illness or substance

abuse should follow the instructions from the

Wyoming State Board of Nursing as found on our

website at lccc.wy.edu/programs/nursing,

select “Apply to the Program” and Background

check information (pdf). Our college will

provide education for those who meet our

program objectives and have an acceptable

criminal background check, but the Wyoming

State Board of Nursing must protect the

public and can deny licensure regardless

of our program’s or the hospital’s criminal

background check. Any student who cannot

pass the background check will not be

eligible to attend clinical, and therefore, will

be dismissed from the program.

2. A health insurance verification form. All

students admitted to the Nursing Program are

expected to be responsible for personal health

costs. Students are not covered by workers’

compensation because they are not employees

of our clinical sites.

3. Nursing Drug Screening and Background

Policies/Signature Pages

4. Proof of all immunization requirements outlined

in Step 5.

5. Applicants must be able to perform the

Essential Functions of a Nurse. See the

attached list of physical expectations.

CURRICULUM PLAN OF THE LCCC NURSING PROGRAM

PREREQUISITES Credit Hours Clock Hours

COLS 1000 – Intro to College Success .......................... 3 hrs 45 hrs

ENGL 1010 – English I: Composition ........................... 3 hrs 45 hrs

MATH 1400 – College Algebra (or higher) ........................ 3 hrs 45 hrs

ZOO 2015 – Human Anatomy (or A&P I) ....................... 4 hrs 75 hrs

_______ _______

13 hrs 210 hrs

Passing score for the Kaplan Nurse Entrance Exam

Accumulative GPA of 2.5 for courses taken in the nursing curriculum.

Semester Course Number Title Credit Hours Clock Hours

1st

NURS 1100 Professional Nursing Care in Health Promotion 5 hrs 75 hrs

NURS 1115 Professional Nursing Care in Health Promotion Clinical 5 hrs 225 hrs

ZOO 2025 Human Physiology (or A&P II) 4 hrs 75 hrs

Total Hours 14 hrs 375 hrs

2nd

NURS 1200 Professional Nursing Care of Pt w/Chronic Illness 5 hrs 75 hrs

NURS 1215 Professional Nursing Care of Pt w/Chronic Illness Clinical 5 hrs 225 hrs

PSYC 1000 General Psychology 3 hrs 45 hrs

MICR 2240 Medical Microbiology 4 hrs 75 hrs

Total Hours 17 hrs 420 hrs

The above courses must be successfully completed to progress to the second year.

NRST 1980 PN Exploration 2 hrs 30 hrs

Optional course to become eligible to take NCLEX-PN Exam

Public Speaking must be completed in order to earn the certificate in nursing.

Semester Course Number Title Credit Hours Clock Hours

3rd

NURS 2300 Professional Nursing Care of Pt w/Acute Illness 5 hrs 75 hrs

NURS 2315 Professional Nursing Care of Pt w/Acute Illness Clinical 5 hrs 225 hrs

CO/M 2010 Public Speaking 3 hrs 45 hrs

Total Hours 13 hrs 345 hrs

4th

NURS 2400 Professional Nursing Care of Pt w/Complex Illness 5 hrs 75 hrs

NURS 2415 Professional Nursing Care of Pt w/Complex Illness Clinical 5 hrs 225 hrs

+POLS 1000 American & WY Government OR

+HIST 1211 US History to 1865 OR

+HIST 1221 US History from 1865 OR

+HIST 1251 Wyoming History OR

+ECON 1200 Economics, Law, and Govt 3 hrs 45 hrs

Total Hours 13 hrs 345 hrs

TOTAL CREDITS for ADN Curriculum 70 hrs 1695 hrs

TOTAL CREDITS if Optional PN Exploration course is Completed 72 hrs 1725 hrs

+ If any of these courses have been accepted for transfer at LCCC from an out‑of‑state institution,

a one‑credit hour course of Wyoming Constitution (POLS 1100) is required. Refer to your degree

requirements in the college catalog for more specific guidelines.

The above credit hours use a 50‑minute hour. One credit of theory class = 15 clock hours;

one credit of lab = 30 clock hours and one credit of clinical = 45 clock hours.

Note: All courses must be completed prior to or during the semester it is listed. Students may not progress to

the next semester without having satisfactorily completed all courses listed in the current semester.

PROGRESSION IN THE NURSING PROGRAM

To progress semester to semester in the Nursing Program, the student must:

1. Maintain a minimum grade of “C” in every required general education and nursing course

for each semester. A student may request faculty appeal for consideration if less than a “C”

is earned.

2. Take nursing courses in sequence.

3. Take general education courses within or prior to the semester in which they are found, as

outlined in the curriculum.

4. Maintain acceptable background checks/drug screens.

Estimated Program Expenses

See LCCC catalog for general school expenses. Additional estimated expenses for the Nursing

Program are:

Physical Exam, Immunizations, Titers (Varies with number and types of

immunizations necessary)

Background check and drug test ............................$ 159

Books .................................................$ 1,750

Required clinical course fee for the Nursing Program .............$ 500 per semester

Scissors, watch, stethoscope ...............................$ 75

Pin (at graduation time) ...................................$ 30

Licensure Exam Fees

NCLEX‑RN .........................................$ 200

WSBN Application Fees ................................$ 190

The student is expected to provide transportation to class and to assigned clinical experiences.

Student Services: See LCCC catalog for information.

STUDENT COMMITMENT

Due to the demands of the full‑time Nursing

Program, student employment and other college

elective courses should be approached with caution.

This personal decision should be based on individual

performance in the classroom, clinical areas and

personal health. It is the desire of the nursing faculty

that students be successful in this program and that

essential learning not be compromised. Students will

not be excused from class or clinical assignments

for personal work schedules or elective classes.

Alternative funding may be found by contacting the

Financial Aid Office (307.778.1215).

Clinical experiences in hospitals, clinics and other

facilities may be scheduled as early as 6 a.m. or as

late as midnight, including weekends. Clinical sites

are held in a variety of communities and students

may need to commute. The student is required

to participate in the clinical experience as it is

scheduled. Childcare arrangements, work schedules

and transportation are the responsibility of the

student.

Classroom attendance is expected and accountability

for knowledge and assignments is the student’s

responsibility. Skills labs are required to prove

competency and are part of the required clinical

experience. Failure to comply with attendance or

assignments could result in dismissal from the

program.

NURSING APPLICATION CHECKLIST

Before submitting your application, make sure you have

included the following:

1. Submitted an application for admission to the

College and OFFICIAL Transcripts to the Student

Records Office.

2. Submitted the Nursing Application to Nursing

Program.

3. Attached Entrance Exam score.

4. Attached a copy of all transcripts of all colleges

attended including LCCC.

5. Signed and included “Statement of Understanding

Concerning Licensure.”

If any of these items are missing, the application may

be considered incomplete and will not be considered for

acceptance.

LCCC NURSING PROGRAM APPLICATION

Due between September 1-15, 2018 for the class beginning January 2019

Print or type — All items MUST be completed for your application to be considered.

First Name:

___________________________ Middle Initial:______ Last Name: __________________________

Address: ________________________________________________ Primary Phone: ______________________

City, State, ZIP: ___________________________________________ Secondary Phone: ____________________

Last four digits of SS#: ______________ LCCC Student ID #: ________________________________________

Personal Email: _______________________________________________________________________________

Step 1: I submitted an LCCC Admission Application and requested official transcripts from other schools

(if applicable) to be sent to the Student Records Office. Unofficial transcripts from all institutions

(including LCCC) are attached to this application.

Institutions attended: __________________________________________________________________

__________________________________________________________________

Step 2: A. COLS 1000 – College Success: You must verify satisfaction of COLS 1000 according

to Admissions.

B. ENGL 1010 – English I: Composition: I completed ENGL 1010.

C. MATH 1400 – College Algebra: I completed MATH 1400 or higher.

D. ZOO 2015 – Human Anatomy: I have completed Human Anatomy or A&P I.

Step 3:

I have taken the TEAS test within the last 3 years and attached the score.

Date test was taken____________ Overall Score_____________ Reading Score_____________

Step 4: Submit the Nursing Program Application to the nursing office.

Step 5: Start the immunization process.

Other: I am currently taking the following college courses:

COURSE # COURSE NAME INSTITUTION CREDITS

The courses listed below are all of the general education requirements for graduation from the

Nursing Program. If a grade for a course cannot be determined on the actual institution’s transcript, no

points will be given and the course will need to be successfully completed.

Please complete the table below using the following point system. No points are given for COLS 1000.

Grade of: A = 12 points B = 8 points C = 5 points

COURSE COURSE # COURSE NAME INSTITUTION SEMESTER GRADE POINTS

COLS 1000:

Intro to College Success

ENGL 1010: Freshman English

Composition I

MATH 1400: College Algebra

ZOO 2015:

Human Anatomy or A&P I

ZOO 2025:

Human Physiology or A&P II

PSYC: 1000:

General Psychology

MICR 2240:

Medical Microbiology

CO/M 2010: Public Speaking

US & Wyoming Government or

History Requirements*

*If a history or government class is accepted as a transfer course from an out-of-state institution,

a one-hour course, POLS 1100 – Wyoming Constitution is required.

Passed all general education courses required for the Nursing Program on the rst attempt = 20 pts.

Only one or two failing grades in any general education or nursing course = 10 pts.

More than two failing grades in any general education or nursing course(s) = 0 pts.

(Note: A “C-,” “D,” “F,” or “U” is considered a failing grade.

Any failing grade in a general education course prior to 10 yrs. will be disregarded.)

Wyoming Resident = 4 pts

The following courses are prerequisite courses for the BSN program at UW.

Grade of: A = 12 points B = 8 points C = 5 points

COURSE COURSE # COURSE NAME INSTITUTION SEMESTER GRADE POINTS

BIOL 1010: Biology I

(BSN Requirement)

HOEC 1140: Nutrition

(BSN Requirement)

Human Culture Elective

(BSN Requirement)

CHEM 1000: Introductory

Chemistry (BSN Requirement)

STAT 2050 or 2070: Statistics

(BSN Requirement)

Total Possible Points: 180 Total Applicant Points __________

Detach and submit completed application form, copies of transcripts (including LCCC), exam scores, and

Statement of Understanding Concerning Licensure to:

Nursing Program

Laramie County Community College

1400 E. College Drive

Cheyenne, WY 82007

NOTE: You cannot register for any nursing class until

you are notified of official acceptance or have

written permission from the Program Director.

STATEMENT OF UNDERSTANDING CONCERNING LICENSURE

The following questions are asked on the State of Wyoming application for licensure as an LPN/RN;

therefore, it is for your information and written answers are not required.

1. Has any disciplinary action been taken or is pending (i.e. open investigation) against you from

a LICENSING AUTHORITY?

2. Have you ever been investigated or charged with ABUSE, NEGLECT OR MISAPPROPRIATION

OF PROPERTY?

3. Has your application for examination or licensure ever been DENIED BY A LICENSING

AUTHORITY?

4. Do you have a physical or mental disability which renders you unable to perform nursing

services or duties with reasonable skill and safety and which may endanger the health and

safety of persons under your care?

5. Are you now or have you in the past five (5) years been addicted to any controlled substance,

a regular user of any controlled substance with or without a prescription, or habitually

intemperate in the use of intoxicating liquor?

6. Have you been terminated or permitted to resign in lieu of termination from a nursing or other

health care position because of your use of alcohol or use of any controlled substance, habit‑

forming drug, prescription medication, or drugs having similar effects?

7. Have you ever been arrested, convicted, pled guilty to, pled nolo contendere to, received

a deferment, or have charges pending against you for any crime including felonies,

misdemeanors, municipal ordinances, and/or any military code of justice violations, including

driving under the influence of any intoxicating substance? Do not include non‑moving traffic

violations or moving violations which did not involve alcohol or substance impairment.

If you answer ‘yes’ to any of the above, refer to www.lccc.wy.edu/programs/nursing, select “Apply to the

Program” and Background check information (pdf). LCCC will provide education for those who meet our

program requirements and have an acceptable background check/drug screens, but the Wyoming State

Board of Nursing’s role is to protect the public and it can deny licensure regardless of our program’s

background check/drug screens.

Clinical agencies may require drug screening, abuse clearances and/or criminal background checks prior

to allowing students into a clinical setting. Students are advised that the inability to gain clinical educational

experiences can result in the inability to meet program objectives and outcomes. The circumstances may

prevent progression through the program and ultimately result in dismissal from the program.

I have read and understand the above statement regarding nursing licensure in Wyoming.

Signature________________________________________________________ Date________________________

PRS 5324 11/15

Essential Functions of a Nurse

• Lift 10‑25 lbs Frequently

• Lift 26‑50 lbs Occasionally

• Carry 10‑25 lbs Occasionally

• Push/Pull up to 50 lbs Occasionally

• Squat/Kneel Occasionally

• Wrist Pronation/Supination Constantly

• Wrist Flexion/Extension Constantly

• Sit Occasionally

• Stand/Walk Constantly

• Crawl Infrequently

• Back Flexion Constantly

• Back Extension Occasionally

• Back Rotation Constantly

• Neck Flexion Constantly

• Neck Extension Occasionally

• Neck Rotation Frequently

• Reaching Above Shoulder Frequently

• Use of Fingers and Hands Constantly

• Repeated Bending and Reaching Frequently

• Ability for Rapid Mental & Muscular Coordination Simultaneously Constantly

• Near Vision Required

• Hearing (aid permitted)

LCCC Nursing Program Technical Standards

Please read the following information as you will be required to abide by its content. All

nursing students admitted to Laramie County Community College Nursing Program must

be able to meet these standards with or without accommodation(s).

• Observation/Sensory-motor: Students must be able to observe demonstrations and

learn from experiences in the basic sciences, including but not limited to, anatomy,

physiology and microbiology laboratory situations. Students must be able to observe

and learn from experiences in the clinical nursing laboratory such as the following

examples: accurately read gradients/calibrations on a syringe; measure medications

accurately; accurately recognize color changes on chemical reaction strips; assess

heart, breath, abdominal sounds; assess normal and abnormal color changes in the

skin; observe pupil changes; and observe digital or waveform readings.

• Communication: Communications include not only speech but also reading, writing

and computer usage, including handheld digital access. Students must be able to

communicate accurately and effectively with patients, caregivers, physicians, other

health professionals, clinical facility staff, faculty and staff, peers, and the community in

general in order to elicit information, describe changes in mood, activity and posture,

and perceive nonverbal communications.

• Psychomotor: Students should have sufficient motor function to elicit information

from patients by palpation, auscultation, percussion, and other diagnostic maneuvers.

Students should be physically able to collect specimens and perform basic tests (such

as glucose finger stick, urine dipstick). Students should be able to execute motor

movements reasonably required to provide general care and emergency treatment

to patients. Example of emergency treatment reasonably required of nurses are

cardiopulmonary resuscitation (CPR), administration of intravenous (IV) medication,

application of pressure to stop bleeding, and assist in moving and lifting patients using

proper body mechanics. Such actions require coordination of both gross and fine

muscular movements, equilibrium and using tactile and visual senses.

• Intellectual-Conceptual, Integrative, and Quantitative: Students must be able

to comprehend and interpret documents written in English. Students should have

cognitive abilities including measurements, calculation, reasoning, analysis, and

synthesis. Critical thinking is the ability to synthesize knowledge and integrate the

relevant aspects of a client’s history, physical exam findings and diagnostic studies.

Problem solving, the critical skill demanded of nurses, requires all of these intellectual

abilities. In addition, the student should be able to comprehend three dimensional

relationships and to understand the spatial relationships of structures in order to

understand normal and abnormal anatomy and physiology.

• Behavioral and Social Attributes: Students must possess the emotional health

required to utilize their intellectual abilities fully, exercise good judgment, complete

all responsibilities attendant to the nursing diagnosis and care of patients promptly,

and the development of mature, sensitive and effective relationships with patients

and their families. Students must be able to tolerate physically taxing workloads

and to function effectively under stress. They must be able to adapt to changing

environments, to display flexibility, and to learn to function in the face of uncertainties

inherent in the clinical problems of many patients. Compassion, integrity, concern for

others, interpersonal communication skills, interest and motivation are all personal

qualities that should be assessed during the education process. As a component of

nursing education, a student must demonstrate ethical behavior including adherence

to the professional nursing code and the LCCC and LCCC Nursing Program students

conduct codes.

These standards were adapted from the University of Kansas School of Nursing Technical

Standards for Admission.

The physical form does not need to be

submitted with the application.

We will request this to be submitted

after acceptance to the nursing program.

Medical Release

Any student undergoing surgery, pregnancy, or an acute or chronic process,

or who is on any medication that could affect clinical performance, must

submit a written medical release from a health care provider to the clinical

instructor to be placed in the student le to attend clinical.

LCCC NURSING PROGRAM PHYSICAL FORM

TO BE SUBMITTED AFTER ACCEPTANCE

TO BE COMPLETED BY APPLICANT

Name of Applicant

_____________________________________________________________________________

(Print Name)

Date of Birth _____________________________________________

Childhood diseases ____________________________________________________________________________

Hospitalizations (why and when) _________________________________________________________________

_____________________________________________________________________________________________

Have you ever had:

Yes No

a) Heart problems ..................................

b) Rheumatic fever ..................................

c) Epilepsy or seizures ...............................

d) Tuberculosis .....................................

e) Hepatitis ........................................

f) Difficult breathing past moderate exertion ..............

g) Asthma .........................................

h) High Blood Pressure ...............................

i) Fainting Spells ...................................

j) Allergy to drugs, foods, etc. .........................

k) Diabetes ........................................

l) Hearing problems .................................

m) Back problems that prevent lifting more than 40 pounds ...

n) Arthritis .........................................

o) Vision problems (Other than corrected by lenses) .........

Do you have any limitations that require accommodations to be successful in the program?

_____________________________________________________________________________________________

Are you currently receiving any medical treatment or taking any medications? Yes No

If so, please describe treatment and list medications

________________________________________________

Have you ever been treated for any psychological issues? Yes No If yes, when _______________

_____________________________________________________________________________________________

How would you describe your general state of health?

_______________________________________________

I have revealed my medical history truthfully and wholly. I authorize my medical provider to give information to

the LCCC Nursing Department regarding my ability to participate in clinical rotations.

________________________________________________________

____________________________________

Applicant's Signature Date

Once both pages are completed, please submit this form to: Nursing Program

Laramie County Community College

1400 E. College Drive

Cheyenne, WY 82007

1 of 2

HEALTH CARE PROVIDER TO COMPLETE THIS SIDE Student Name____________________________

Please check Yes if the applicant’s past or present medical history indicated any of the below. Explain if “Yes.”

Yes No

Chronic Illness ____________________________________________________________________

Physical disability __________________________________________________________________

Acute Illness ______________________________________________________________________

Recurring Physical or Mental health concerns __________________________________________

Visual Impairment _________________________________________________________________

Hearing Loss _____________________________________________________________________

Neck, Shoulder, Back Problems ______________________________________________________

Significant medical history of applicant ____________________________________________________________

_____________________________________________________________________________________________

REQUIRED IMMUNIZATIONS

1. 2‑Step PPD (Mantoux) (within one year) Date_______ Reaction________ Date________ Reaction________

Chest x‑ray if PPD is positive: Date___________________ Results ______________________________

2. Diphtheria‑Tetanus Toxoid (TdaP) (within 10 years) Date__________________

3. Flu Vaccine (October‑March) Date__________________

4. MMR – All students admitted to the nursing program are required to verify two doses of the MMR vaccine

or have a positive titer drawn to show immunity. Having had the disease does not constitute immunity.

Rubella Titre – Date__________________ Immune Yes No

Rubeola Titre – Date__________________ Immune Yes No

Mumps Titre – Date__________________ Immune Yes No

MMR Titre – Date__________________ Immune Yes No

OR 2 doses MMR vaccine – Date__________________ Date__________________

5. Varicella Titre – Date__________________ Immune Yes No

OR 2 doses Varicella vaccine – Date__________________ Date__________________

Note: Having had the disease does not constitute immunity.

6. Hepatitis B: Submit proof from health care provider that student is in the process of receiving vaccine.

Dates: (1)________________ (2)________________ (3)________________ Completed__________________

Hepatitis B Titer – Date_____________ Immune Yes No Date_____________

7. Color Vision: Distinguishes all colors Yes No If not, what colors are involved? _____________

(Color Vision Testing can be done in LCCC’s nursing office.)

8. Applicant can perform essential functions of a nurse. Yes No

RECOMMENDATION: From the preceding exam, do you believe

_____________________________________

is capable to undertake all the demands placed on a health care provider?

(Name)

Remarks _____________________________________________________________________________________

_____________________________________________________________________________________________

__________________________________________

Health Care Provider’s Signature

PRINT Health Care Provider’s Name ______________________________________________________________

Address ______________________________________________________________________________________

Phone___________________________________________________ Date________________________________

PRS 5324 11/16

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