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APPLICATION TO CLINICAL NURSING COURSES (SOWELA Technical Community College)

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Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
School of Nursing and Allied Health
Office: 337-421-6594 Fax: 337-491-2103
3820 Sen. J. Bennett Johnston Ave.
Lake Charles, LA 70615
APPLICATION TO CLINICAL NURSING COURSES
ASN PROGRAM
Student Responsibilities
Understand that any crimes whether expunged or dismissed must be reported to the Louisiana State Board
of Nursing and may result in the delay of approval to begin nursing clinical courses. Legal documents along
with a typed explanation of the incident must be provided to LSBN with the application to the Board.
Understand all policies and procedures for ASN admission. These are available online:
https://www.sowela.edu/programs/school-nursing-allied-health/nursing-rn/
ASN Student Handbook: https://www.sowela.edu/wp-content/uploads/SOWELA-ASN-Student-Handbook-
2019-2020.pdf .
The application process must be completed and students accepted into the program prior to beginning any
clinical nursing course. This application MUST be completed in full by the deadline or student will be
considered ineligible.
Decisions for acceptance will not be made until final grades are posted for the semester. This means the
middle of May in most circumstances.
CHECKLIST AND REQUIRED DOCUMENTATION:
KEEP PAGES IN ORDER
______ Apply to SOWELA Technical Community College (you must be a student at SOWELA and attending
classes before applying to the clinical courses).
Cumulative grade point average of 2.0 or higher.
Minimum grade of “C” in all required biology, mathematics, and nursing courses.
Students completing pre-requisite/co-requisite courses for the ASN program at SOWELA
or transferring from another institution can only have repeated 1 course in which a “W”, “D” or “F”
was earned. Credit for nursing courses from another institution will not be considered for transfer at
this time.
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
1
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Completion of pre-requisite general academic courses (at least the first semester as
shown on the curriculum). https://www.sowela.edu/programs/school-nursing-allied-health/nursing-
rn/nursing-rn-513801-associate-science/
Minimum grade point average of 2.8 in ALL non-nursing courses required for the degree
(All non-nursing courses shown in the ASN curriculum will be calculated into this GPA
if taken prior to application for admission).
Completion of the TEAS VI test with a score of 64%. This is a nationally ranked score and not
necessarily on a 100-point scale. Available dates to take the test are posted on the website by the
Testing Center https://www.sowela.edu/programs/school-nursing-allied-health/nursing-rn/nursing-
teas-dates/
If you have not taken the TEAS TEST at SOWELA; you must contact www.atitesting.com and have
results emailed to SOWELA ASN Program
Current CPR card (must be either American Heart Association Healthcare Provider or
Red Cross Professional Rescuer. Attach copy of card to application). Other certifications will NOT be
accepted.
Immunization record with current Tdap (must be current, within 10 years, include copy of
Immunization record).
______ Record of MMR- two (2) injections or Rubella and rubeola titers showing immunity. If you have not
had 2 vaccinations, you MUST get a titer drawn.
Proof of at least 1 meningococcal vaccination (or signed refusal, located in the application).
______ Proof of Hepatitis B (Hib) status (vaccinations [2 or 3 depending on vaccine type] or proof of immunity
(titer), include copy of Immunization record or titer). The vaccinations must have been given within the
correct time frame or you must have a titer drawn.
Proof of two (2) Varicella (VZV) vaccinations or varicella titer showing immunity. Even if you have had
the chicken pox; you must get a titer drawn if you do not have proof of 2 vaccinations.
Copy of negative PPD skin test or Chest X-ray result (must be within last year and
be the official copy from Healthcare provider). If you have not had a skin test in the past year, you
must have 2 PPD tests or QuantiFERON®-TB Gold blood test (QFT-G). This is a CDC Guideline
Signed Health Status Forms (health history and physical exam included in the
application must have been completed within last year).
______ Copy of health insurance card
2
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
______ Attach a passport photo with your name printed on the back of the photo to this
application.
______ Keep a copy of all documents for your records. (make copies prior to turning in application).
This nursing education program is Nationally Accredited by the
Accreditation Commission for Education in Nursing (ACEN).
3343 Peachtree Road NE, Suite 850
Atlanta, Georgia 30326
Phone: (404) 975-5000
Fax: (404) 975-5020
Email: info@acenursing.org
Web: www.acenursing.org
Sowela Technical Community College does not discriminate on the basis of race, color, national origin, gender,
disability, or age in its program and activities. The following person has been designated to handle inquires regarding
the non-discrimination policies:Title: Compliance OfficerAddress 3820 Sen. J. Bennett Johnston Avenue Telephone:
337-421-6565 or 800-256-0483 Email: complainceofficer@sowela.edu
3
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
___________________________________________________________________________________
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Attach
Picture
Here
School of Nursing and Allied Health
Application for Clinical Nursing Courses- ASN Program
_________First-time Applicant ________ Resubmission of Application
SS #: _____________________________ Student ID#___________________________
Student Name: ______________________________________________________________________
Last/Maiden Middle First
Permanent Mailing Address:
Street (P.O. Box, Apt. Number) City State/Zip code
Phone: (_______)______________________ ( _____)________________________
Home Cell
E-Mail Address: ________________________________________ Gender: M / F
DOB: _____________ Age: _________
Person to notify in an emergency: Relationship:
Address: City, State, Zip:
Cell number: Home number: Work number:
Ethnicity (required for Federal Reports by 1964 Civil Rights Act):
______White ______ Black _____Amer. Indian/Alaskan ______Asian/Pacific Islander
_____Hispanic ____ Other (please specify): ________________________________
Do you have any felonies or misdemeanors to report to LSBN? Yes No
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
4
______________________ _____________________ ___________________
______________________ _____________________ ___________________
_____________________________________________________________________________________________
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Please list below all courses and name of institution where you are enrolled this semester:
Spring 2019 courses:
Please list any other degrees held, year obtained, and name of college/university:
Degree earned Year obtained Name of college/university
Important Information:
1) Students who are accepted into the School of Nursing and Allied Health ASN program will be required to submit to
mandatory drug testing upon admission and random drug screens throughout the duration of clinical nursing courses.
2) The number of students accepted to the clinical nursing ASN Program will be dependent on resources. No waiting
list will be established and those students that are eligible but not accepted into the ASN nursing program must reapply
for admission.
3) Eligible students for admission to the clinical nursing ASN Program will be ranked based on nursing grade point
average (GPA), overall GPA and TEAS test results. Consideration will be given to students completing all pre-requisite
and co-requisite non-nursing courses at SOWELA Technical Community College.
4) I understand that this packet is for information purposes only and does not constitute a contract, expressed or
implied, between any applicant and SOWELA Technical Community College School of Nursing and Allied Health.
5) My signature below indicates that I have read and understand the criteria and requirements listed in this packet. I
declare that all the information I have submitted is complete and accurate.
Signature of Applicant: Date:
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
5
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
ASN CLINICAL APPLICATION FORM
STUDENT NAME: S
TUDENT ID#
Th
e SOWELA Technical Community College School of Nursing and Allied Health, in keeping with the rules and regulations
of the State Board of Nursing and health care agencies, requires all students to complete certain admission health
screening procedures. In addition, this form contains important information for students applying to the ASN Program.
HEALTH INSURANCE INFORMATION
A
LL SCHOOL OF NURSING STUDENTS must carry and be prepared to show evidence that you have current health
insurance. This is a requirement for the ENTIRE duration of your program. This health insurance must cover you
for any treatments related to blood borne pathogens, other potentially infectious materials, and any illness or
injury that could occur during class or clinical.
FORM INSTRUCTIONS
A
ll students are required to provide health history information and to have a health evaluation prior to admission to the
School of Nursing and Allied Health. Continuing students will be required to submit an annual immunization update for
PPD status and flu vaccination. If a significant change in health status occurs during a semester; the student must report
that change to the clinical faculty and follow the policy for Significant Change in Health Status found in the ASN Student
Handbook.
Please print unless otherwise indicated. ALL Date Fields required by this Form must be legible and completed with
Month, Day and Year Values. Failure to comply with these requests will prevent your registration for the upcoming Term
and prevent your participation in Clinical Rotations
DISABILITY INFORMATION
If you have a health problem that may require individualized disability support services, it is your responsibility to
contact:
Office of Student Services
3820 Senator J. Bennett Johnston Ave
Lake Charles, LA 70616
337.421.6969
800.256.2443
6
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
PART 1: STUDENT INFORMATION
S
TUDENT LEVEL (Circle one) Clinical semester 1 2 3 4 Other
Full Name:
Address:
(Street) (City State Zip)
Date of Birth
Mo
/
Day
/
YYYY
Gender (Circle one) Male Female
HEALTH INSURANCE
I verify that I carry, and will carry for the entire duration of my program, health insurance that will cover payment of
treatment and follow-up procedures related to blood borne pathogens, other potentially infectious materials, and any
illness or injury that could occur during class or clinical. Attach a copy of your health insurance card or policy.
_
(Student signature) (Date)
PART 2: IMMUNIZATION/VACCINATION HISTORY
Attach Immunization Records to the Application
T
ETANUS/ACELLULAR PERTUSSUS (Tdap)
***STUDENT MUST HAVE HAD A BOOSTER TO INCLUDE PERTUSSUS WITHIN THE LAST 10 YEARS***
HEPATITIS B
Must have the 2 or 3-vaccination series or titer showing immunity
***If Non-immune, please give current booster. The date of booster must be within 6 months
VARICELLA
Must have 2 doses of vaccine or titer showing immunity
***If Non-immune, please give current booster date within 6 months
MMR – MUMPS RUBELLA RUBEOLA (MEASLES)
Must have 2 doses of vaccine or titer showing immunity
***If Non-immune, please give current booster date within 6 months
MENINGOCOCCAL
Must have 1 dose of vaccine or a signed refusal form
Check here when you are attaching a signed refusal form if immunization is contraindicated or refusing (Form
at end of application).
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
7
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
TUBERCULOSIS SCREENING
***If you do not have a documented negative Mantoux PPD test within the past year; you must have the 2 Step PPD
test. The second PPD Test must be administered 1 week to 3 weeks after the first PPD Test. These tests cannot be
completed during a single visit with a healthcare provider. *** Or one QuantiFERON®-TB Gold blood test (QFT-G)
Must have signed form from Provider
Chest X-Ray (required if PPD is positive) X-Ray Date: _/ / Normal Abnormal (Circle one)
MO DAY YYYY
***If abnormal, you must have clearance from a healthcare provider stating you are free from contagion.
Please attach documentation of medical clearance.
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
8
Physical Requirements:
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
PART 4: HEALTH HISTORY AND PHYSICAL EXAMINATION
Students should complete this page prior to visiting the healthcare provider.
PAST MEDICAL HISTORY
Chronic health problems:
Surgical procedures/dates:
Hospitalizations:
Allergies/reactions:
Do you have a latex allergy or sensitivity? Yes No
If yes, it is the student’s responsibility to notify each assigned clinical instructor of this condition and to provide proof of
medical management prior to the start of each clinical setting. Please refer to the Latex Allergy Policy in the SoNAH
Student Handbook.
List Current Medications (include over-the-counter medications):
VERIFICATION OF PERFORMANCE DUTIES
Purpose:
Sowela Technical Community College nursing students are expected to be able to perform duties associated with those
of a registered nurse, which means able to perform their clinical care responsibilities in a safe, appropriate, and effective
manner free from the adverse effects of physical, mental, emotional, and personal problems.
Nursing is a physically demanding profession. Clinical experiences may be up to twelve hours in duration in a hospital,
health care, or community setting and students may be on their feet for extended periods of time. Clinical experiences
may also be required on weekends and unusual hours of the day (e.g. until 11 p.m.). Nursing students are required to lift
and transport patients and use equipment which may require some degree of physical strength. Considerable manual
dexterity is also required for many nursing skills and activities.
Students must be able to hear equipment alarms from a distance and distinguish subtle changes in breath sounds, heart
sounds, and other assessment data. Patients are often observed from a distance and heart monitors must be accurately
read from at least the end of a patient’s bed, approximately six (6) feet away. Students must also be able to accurately
read small print on the barrel of a syringe. Students may be exposed to cleaning materials, as well as biological (i.e.,
blood, mucous), infectious/communicable diseases, and chemically hazardous materials in the clinical setting.
Emergency situations frequently occur that require immediate response and action by the student, including situations
involving agitated patients who may be physically or verbally combative. Considerable reaching, stooping, bending,
kneeling and crouching are also required. Students must have the ability to judge distance and space relationships, see
peripherally, and, distinguish and identify different colors.
Students with physical health conditions must be considered to be under control and able to function safely in a clinical
setting.
9
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Psychological Requirements:
Nursing students must be emotionally stable in order to provide safe care to patients. Students on medication for
psychological/psychiatric conditions must be considered to be on a stabilized dose in order to function safely in a clinical
setting.
The following are examples of the everyday demands of clinical nursing courses.
Lifting
40-50 lbs
Frequently
Carrying
20 lbs
Occasionally
Pushing
< 200 lbs
Frequently
Pulling
45-50 lbs
Frequently
Pushing with Assist
> 200 lbs
Frequently
Climbing
Occasionally
Stooping
Frequently
Balancing and Kneeling
Occasionally
Acuity, Near and Far
Frequently
Depth Perception
Frequently
Color Vision
Frequently
Field of Vision
Frequently
Ordinary Conversation
Constantly
Other Sounds
Frequently
Reading
Frequently
Reasoning and Problem Solving
Constantly
Organization
Constantly
Math
Frequently
Language
Constantly
Detailed Work
Constantly
Multiple Concurrent Tasks and Interruptions
Constantly
Stress
Constantly
Confidentiality
Constantly
Training classes
Frequently
Exposure to radiation and chemicals
Occasionally
Exposure to blood/body fluids, infectious agents, and airborne pathogens
Frequently
Exposure to needle/syringes and waste handling
Frequently
10
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Description of Terms:
Occasionally (activity or condition exists up to 1/3 of the time)
Frequently (activity or condition exists from 1/3 to 2/3 of the time)
Constantly (activity or condition exists 2/3 or more of the time)
I have read and understand the above physical and mental requirements for clinical nursing courses. I am able to
withstand the physical or mental exertions related to the requirements of the SOWELA Technical Community College
Nursing Program.
Student Signature Date
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
11
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
PHYSICAL EXAMINATION FORM: HEALTHCARE PROVIDER FORM
ASN CLINICAL APPLICATION
Ht: Wt: Temp:
B/P: HR: Resp:
General appearance:
SYSTEM
NORMAL
ABNORMAL
COMMENTS
HEENT
LUNGS
CARDIOVASCULAR
MUSCULOSKELETAL
NEUROLOGICAL
DERMATOLOGICAL
VERIFICATION OF PERFORMANCE DUTIES
Purpose:
SOWELA Technical Community College nursing students are expected to be able to perform duties associated with those
of a registered nurse, which means able to perform their clinical care responsibilities in a safe, appropriate, and effective
manner free from the adverse effects of physical, mental, emotional, and personal problems.
Physical Requirements:
Nursing is a physically demanding profession. Clinical experiences may be up to twelve hours in duration in a hospital,
health care, or community setting and students may be on their feet for extended periods of time. Clinical experiences
may also be required on weekends and unusual hours of the day (e.g. until 11 p.m.). Nursing students are required to lift
and transport patients and use equipment which may require some degree of physical strength. Considerable manual
dexterity is also required for many nursing skills and activities.
Students must be able to hear equipment alarms from a distance and distinguish subtle changes in breath sounds, heart
sounds, and other assessment data. Patients are often observed from a distance and heart monitors must be accurately
12
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
____________________________________________ _______________________________
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
read from at least the end of a patient’s bed, approximately six (6) feet away. Students must also be able to accurately
read small print on the barrel of a syringe. Students may be exposed to cleaning materials, as well as biological (i.e.,
blood, mucous), infectious/communicable diseases, and chemically hazardous materials in the clinical setting.
Emergency situations frequently occur that require immediate response and action by the student, including situations
involving agitated patients who may be physically or verbally combative. Considerable reaching, stooping, bending,
kneeling and crouching are also required. Students must have the ability to judge distance and space relationships, see
peripherally, and, distinguish and identify different colors.
Students with physical health conditions must be considered to be under control and able to function safely in a clinical
setting.
Psychological Requirements:
Nursing students must be emotionally stable in order to provide safe care to patients. Students on medication for
psychological/psychiatric conditions must be considered to be on a stabilized dose in order to function safely in a clinical
setting.
The student meets the physical and mental demands described above and listed below.
Provider:
In your opinion, is there any reason why the student could not withstand the physical or mental exertions related to the
requirements of the SOWELA Technical Community College Nursing program?
YES NO If YES, please explain:
I find the above-named individual able to perform the applicable duties of a student registered nurse and free from
communicable disease: YES NO
____________________________________________ ______________________
Print Name of Healthcare Provider Date
Signature of Health Care Provider Address stamp (including phone #)
13
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
The following are examples of the everyday demands of clinical nursing courses.
Lifting
40-50 lbs
Frequently
Carrying
20 lbs
Occasionally
Pushing
< 200 lbs
Frequently
Pulling
45-50 lbs
Frequently
Pushing with Assist
> 200 lbs
Frequently
Climbing
Occasionally
Stooping
Frequently
Balancing and Kneeling
Occasionally
Acuity, Near and Far
Frequently
Depth Perception
Frequently
Color Vision
Frequently
Field of Vision
Frequently
Ordinary Conversation
Constantly
Other Sounds
Frequently
Reading
Frequently
Reasoning and Problem Solving
Constantly
Organization
Constantly
Math
Frequently
Language
Constantly
Detailed Work
Constantly
Multiple Concurrent Tasks and Interruptions
Constantly
Stress
Constantly
Confidentiality
Constantly
Training classes
Frequently
Exposure to radiation and chemicals
Occasionally
Exposure to blood/body fluids, infectious agents, and airborne pathogens
Frequently
Exposure to needle/syringes and waste handling
Frequently
Description of Terms:
Occasionally (activity or condition exists up to 1/3 of the time)
Frequently (activity or condition exists from 1/3 to 2/3 of the time)
Constantly (activity or condition exists 2/3 or more of the time)
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
14
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
Save a life. Learn CPR.
In need of your CPR card? Look no further!
SOWELA will be offering CPR training taught by BLS providers. Please visit the website below
for available dates. The cost of the course is $65 with payment due at registration. For more
information, contact SOWELA’s Workforce Solutions at (337) 421-6560.
https://registration.xenegrade.com/sowela/searchResults.cfm?couID=280
Physicals and PPDS’s:
1. You may visit your personal healthcare provider and have them fill out the history and physical form in
the application packet. They may also provide PPD’s, immunizations and flu shots.
2. Many of the local Urgent Care facilities are able to physicals, PPD’s and immunizations without an
appointment. Call agency prior to visiting to make sure they are able to complete requirements
needed for admission.
3. The Calcasieu Community Clinic located in Hardtner Hall on the McNeese State University Campus
offers physicals to students that meet their criteria. The clinic is open on Thursday’s only and new
patients need to arrive between 4:00pm-5:30pm. The student MUST contact Kayla Rigney at 478-8650
to make appointment.
4. If you have had a positive PPD or are allergic to the PPD components, refer to the ASN student
handbook under the Tuberculosis policy for the steps that need to be taken.
15
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
TEAS VI TESTING
Please visit the SOWELA website: https://www.sowela.edu/programs/school-nursing-allied-health/nursing-rn/nursing-
teas-dates/ for spring 2020 TEAS dates.
TEAS VI test instructions
1. You will need to sign up for the TEAS VI exam online at www.atitesting.com. The TESTING CENTER will offer
several test dates and there are limited seats at each test time. We cannot add more seats at the test times so
do not wait until last minute to sign up.
2. The exam has 170 multiple choice questions and is 3 ½ hours long so plan accordingly. The exam will
automatically cut off at the 3 ½ hour mark. If you are approved through the office of student support services to
receive extra time for the TEAS VI test you must notify us at the time you sign up for the exam. Failure to do this
will result in you taking the test during the scheduled time frame without the extra time concession.
3. There are fees that change for the proctored exam and must be paid at the time of enrolling.
4. You will need to create an account with ATI prior to test day. You will not be allowed to test without a username
and password.
a. Go to www.atitesting.com
. (Download free Silverlight software, if necessary).
b. Click “Create an account” and keep track of your username and password.
c. My Username _____________________ My Password _____________________
5. You will only be allowed to take the TEAS VI test two times total and only one time a semester. You will not be
allowed to retake the TEAS VI test in order to improve your score. In order to be considered eligible for the
program you must pass the TEAS VI test with a score of 64%.
6. Arrive on time for the test to the TESTING CENTER IN THE SYCAMORE BUILDING.
7. Bring a picture ID with you day of test to show the test proctor.
8. Bring two pencils with you. You will be given paper upon entry to test.
9. Do not bring a calculator, the test has a pull up calculator.
10. We recommend purchasing the TEAS VI study guide. Go to ATItesting.com click on the online store in the upper
right corner then click on the TEAS products, they have several options of products, under shop for: on left side
of screen. You can also copy and paste the following link into your browser to go directly to the site.
https://www.atitesting.com/ati_store/product.aspx?zpid=1175
11. If you are not able to purchase study products through ATI then you can also utilize a free test prep resource
offered through the SOWELA Technical Community College library. Go to www.sowela.edu click on library under
quick links on lower right side of page. On library page go to databases, middle of page, then scroll down until
you see learning express library and click on it. You will have to create an account to log in. Click on new
featured resources, middle of page and this may take several seconds to load. On the left side of that page you
will see prep for entrance exams, click on prepare for nursing school entrance tests. You will then see a list of 12
different 50 question practice tests in biology, chemistry, general science, math, reading and verbal availability.
We do not guarantee that by using either this site or any of the ATI study guides will ensure that you pass the
TEAS VI test.
16
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
SCHOOL OF NURSING AND ALLIED HEALTH
Why get vaccinated?
Meningococcal disease is a serious illness caused by a type of bacteria called Neisseria meningitidis. It can lead to
meningitis (infection of the lining of the brain and spinal cord) and bacteremia or septicemia (infections of the blood).
Meningococcal disease often strikes without warning – even people who are otherwise healthy.
Meningococcal disease can spread from person to person through close contact (coughing or kissing) or lengthy
contact, especially among people living in the same household.
There are at least 12 types of Neisseria meningitidis, called "serogroups." Serogroups A, B, C, W, and Y cause most
meningococcal disease.
Anyone can get meningococcal disease but certain people are at increased risk, including:
• Infants less than one year old
• Adolescents and young adults 16 through 23 years old
• People with certain medical conditions that affect the immune system
• Microbiologists who routinely work with isolates of N. meningitidis
• People at risk because of an outbreak in their community
Even when it is treated, meningococcal disease kills 10 to 15 infected people out of 100. And of those who survive,
about 10 to 20 out of every 100 will suffer disabilities such as hearing loss, brain damage, amputations, nervous
system problems, or severe scars from skin grafts.
Serogroup B meningococcal (MenB) vaccine can help prevent meningococcal disease caused by serogroup B. Other
meningococcal vaccines are recommended to help protect against serogroups A, C, W, and Y.
Obtained from: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening-serogroup.html
17
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
Applications Due - Nursing office by 3:00PM on April 9, 2020 NAME:
WAIVER FORM FOR MENINGOCOCCAL VACCINATION
My signature below indicates that I have elected NOT to receive the meningococcal immunization at this time. I
understand that I may be at risk for acquiring meningitis by refusing this vaccine. I accept the responsibility of this risk by
refusing the meningococcal vaccine.
Student Signature Date
18
ASN Faculty 11-2016; 4-2017; 9-2017; 5-17-18
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