Fillable Form 1: Nursing Program Information (Klamath Community College)

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1
Nursing Program Information
& Application Packet
Fall 2020
www.kl
amathcc.edu
It shall be the policy of the Klamath Community College District to affirm the rights of all individuals to equal education, activities,
facilities, and employment without regard to age, sex, disability, national origin, race, marital status, religion, or sexual
orientation in accordance with federal and state laws. Klamath Community College complies with Titles VI and VII of the Civil
Rights Act of 1964, Title IX of the Educational Amendments of 1972, and Section 504 of the Rehabilitation Act of 1973, and Title
II of the Americans with Disabilities Act of 1990, and any amendments thereto.
Inquiries or grievances concerning the application of these laws and regulations to the College may be directed to the Klamath
Community College’s Executive Director of Legal and Human Resources at 7390 South 6th St., Klamath Falls, OR 97603 or at
541-882-3521 or to the Director, Office of Civil Rights, U.S. Department of Education, Washington D.C. 20201
2
General Information
Thank you for your interest in Klamath Community College’s Nursing program. We offer an Associate of Science in
Nursing. Current enrollment is limited to eight students per year.
The application for admission opens January 6, 2020 and closes April 15, 2020. If accepted, you will begin nursing
classes Fall Term 2020. This packet has been prepared to help you understand the application and selection
process. Please read the entire packet carefully and refer to the College’s nursing webpage,
https://www.klamathcc.edu/Academics/Programs/Registered-Nursing, for additional information.
Associate Degree Nursing (ADN-RN program)
After successfully completing the two-year ADN program at Klamath Community College, you will receive an
Associate of Applied Science in Nursing and can take the licensing exam for registered nursing (RN). Students will
also qualify to enter most RN to Bachelor of Science in Nursing (RN-BSN) programs. Additonal prerequisites may be
required prior to acceptance in a RN-BSN program. Klamath Community College maintains an articulation agreement
with Linfield College. Linfield College offers an online RN-BSN degree.
Program Standards
As a student in the Nursing program, you are expected to meet minimum performance standards for nursing, which
include but are not limited to the following:
Ability to grasp scientific concepts, set up and answer basic math and algebra problems.
Critical thinking sufficient for clinical judgement.
Verbal and written communication sufficient to effectively interact with clients, peers, and others.
Ability to move from room to room, maneuver in small spaces, remain on feet for extended periods of time,
and support up to 50 pounds.
Gross and fine motor skills sufficient to provide safe and effective nursing care.
Hearing sufficient to monitor and assess clients, e.g., hear heart and breath sounds and use a telephone.
Visual acuity and color discrimination sufficient to read fine print, to observe and assess clients, e.g., identify
skin tones such as pale, ashen, gray, or bluish.
Tactile ability sufficient for physical assessment, e.g., palpate peripheral pulses.
3
Nursing Application Overview
Enrollment in the nursing program is limited.You must apply and be selected for admission. To be considered for
admission, you must meet the minimum requirements. If you do not meet the stated minimum requirements, your
application will be withdrawn from consideration.
Important 2020 Dates – subject to change
Application opens
January 6, 2020
Application closes 5pm
Wednesday, April 15, 2020
Notified (emailed) incomplete application
As evaluated
Phase 1 results emailed after 5pm
Friday, May 1, 2020
Phase 1 applicant inquiry/challenges
Saturday, May 2 – Thursday, May 7, 2020
Phase 1 inquiry/challenges closes Noon
Thursday, May 7, 2020
Phase 2 top 20 invited to essay by email after 5pm
May 15, 2020
Notified not in top 20 by email after 5pm
May 15, 2020
Phase 2 proctored essay/HSRT
Friday and Saturday, May 29-30, 2020
Phase 2 interviews
Thursday, Friday, Saturday, June 4,5,6, 2020
Notified (emailed) acceptance or alternate status
Friday June 19, 2020
Nursing student orientation #1
Friday, June 26, 2020
Program Information Session
Information sessions specific to the application process will be held at Klamath Community College in February and
March. Please plan to attend one or more of these sessions and reserve application-related questions for these
sessions. The dates for these sessions will be posted on the Nursing program webpage by January 15, 2020.
Point System
Acceptance into the Nursing program is determined by a weighted point system based on the eight categories listed
below.
Grade point average for prerequisite course work
Course work completed
Residency
Previous degrees
Evidence of volunteerism
Evidence of veteran and/or spouse service
Work experience
TEAS exam results
Heath sciences
Reasoning test
Foreign language fluency
Proctored essay
Nursing Program Admission Requirements
Nursing program enrollment is limited. Acceptance into the Nursing program is determined using a weighted point
system from a pool of qualified applicants. A student must meet the minimum requirements to be considered for
admission. If the minimum requirements have been met, the student’s application will be evaluated and awarded
points in a competitive process. The top ranking individuals will be offered admission to the program. Remaining
qualified candidates are placed on a ranked alternate list which expires when Fall Term commences. Program
information and application packets will be updated annually and can be obtained from the College website.
4
MINIMUM EVALUATION REQUIREMENTS – must be met by the published application deadline
A minimum of 25 prerequisite credits with a cumulative 3.0 GPA for all prerequisite coursework for
application. Student will be required to complete all 39 prerequisite credits before Fall Term 2020.
Completion of WR 121 English Composition (or have a bachelor’s or higher degree) completed with a grade
of “C” or above.
MTH111 College Algebra or MTH 243 Statistics completed with a grade of “C” or above.. The 2021
application will require completion within seven years.
Score of PROFICIENT on the TEAS exam. Exams will be offered on the Klamath Community College
campus in February and March. Watch for dates on the nursing program webpage. This exam can be taken
at any testing center.
Human Anatomy and Physiology I with lab (BI 231 & BI 231L), or the equivalent as determined by the
Klamath Community College Registrar’s Office completed with a grade of “C” or above. The 2021 application
will require completion within seven years.
o Some A&P courses are evaluated as two 5 credit courses. The point sheet will be marked as
meeting BI 231 and 233 with the understanding that BI 232 has been covered with a total of 10
credits earned.
o
4 credit semester A&P courses are typically evaluated as two 6 credit courses. The point sheet will
be marked as meeting BI 231 and BI 233 with the understanding that BI 232 has been covered with
a total of 12 credits earned.
Prerequisite/Required Preparatory Courses:
Course No
Credits
BI 231
3
BI 231L
1
BI 232
3
BI 232L
1
BI 233
3
BI 233L
1
BI 234
4
BI 234L
1
MTH 111 or MTH 243
4
HPE 225
4
PSY 235
3
WR 121
4
SPE 111
3
CAS 133
3
CAS 133L
1
5
Application Submission
There is ONE application deadline date to pay attention to: Wednesday, April 15, 2020, at 5 p.m.
All applications and transcripts from past coursework are due at the time of submitting the application. Applications
submitted after April 15, 2020, will not be accepted.
Application packets may be submitted beginning January 6, 2020, to Student Services, which is located in Founders
Hall at Klamath Community College, or mail to:
Klamath Community College
Student Services Welcome Center/Admissions
ATTN: Elizabeth Early/Nursing Admissions
7390 S. 6
th
St.
Klamath Falls, OR 97603
Please allow ample time for delivery. Applicants assume full responsibility for the method of delivery selected and any
resulting delays in delivery. Applications may not be transmitted by fax or e-mail. Any applicant requiring reasonable
accommodations for the application should call 541-882-3521.
If selected for the Nursing program, you must complete Human Anatomy & Physiology II and III (BI 232 and BI 233)
or the equivalent and all prerequisite courses as determined by the Klamath Community College Registrar’s Office
with a grade of “C” or above before the start of Fall Term 2020.
6
Evaluating Nursing Applications
There are two phases to the application:
Phase I - assessment of points
Phase II - protored essay - interview – HSRT exam
Phase 1 - Admissions Point System - applicants will be assessed using 60 points in the following:
Cumulative Grade Point Average. Maximum points: 25
The points you receive for your cumulative GPA will be based on all Nursing program prerequisite courses completed by
the application deadline with a “C” or above. Applicants must have completed at least 25 Nursing prerequisite credits to
meet minimum qualifications. Only the Nursing program prerequisite courses will be calculated in the GPA for assignment
of points in the admission process. Points will be assigned as follows:
3.80 - 4.00 = 25 points
3.50 - 3.79 = 23 points
3.20 - 3.49 = 20 points
3.15 - 3.19 = 17 points
3.00 - 3.14 = 15 points
Select courses. Maximum points: 3
You will receive points for completing the course below with a grade of “C” or better
MTH 243 or 244 (Statistics)
Anatomy and physiology grades. Maximum points: 6 points
You will receive points for receiving an A or B in anatomy and physiology as listed on your transcript(s):
BI 231 (4 credits): A = 2 points
B = 1 point
BI 232 (4 credits): A = 2 points
B = 1 point
BI 233 (4 credits): A = 2 points
B = 1 point
.
Test of Essential Academic Skills (TEAS test). Maximum points: 0-5
As part of the selection process for acceptance into the Nursing program at Klamath Community College, all applicants are
required to take a TEAS exam. The exam must be taken within the last six months (since August 15, 2019). Dates, times,
and places for testing on the Klamath Community College campus will be made available on the Nursing webpage at
https://www.klamathcc.edu/Academics/Programs/Registered-Nursing by November 15, 2020. Students may take the TEAS
test in any proctored location and are required to “share” results with Klamath Community College. A score “Below
Proficient” will disqualify the applicant; a score of “Proficient” with a cumulative score < 75 will receive 0 points; a
cumulative adjusted score of >75 will receive 3 points; a score of “Advanced” will receive 4 points; and a score of
“Exemplary” will receive 5 points.
7
Earned degrees. Maximum points: 1-2
Applicants will receive 1 point with an earned associate degree from a regionally accredited college or university. This must
be documented in an official sealed transcript from the college or university.
Applicants will receive a maximum of 2 points with an earned bachelor’s degree or higher from a regionally accredited
college or university. This must be documented in an official sealed transcript from the college or university.
Residency. Maximum points: 3-6
You will receive points for one residency. Submit your official transcript as proof of residency.
Minimum of 24 graded credits from Klamath Community College completed between 2010 and 2019 will receive 6 points.
OR
Applicants who graduated from a Klamath County high school in 2017, 2018, or 2019 will receive 3 points.
Applicants who graduated from a Lake County high school in 2017, 2018, or 2019 will receive 3 points.
Volunteerism. Maximum points: 0-3
Applicants may receive up to 3 points for volunteering in any organization/circumstance where the applicant was supervised
(directly or indirectly) under the following conditions:
a. Volunteer experience must have been completed in the last five years.
b. Student can not use hours performed as a graduation or course requirement.
c. Volunteer experience may not be court ordered.
d. Paid experince is not considered “volunteer experience.”
e. A relative cannot serve as a supervisor, verify hours or provide the reference letter.
f. Points will be awarded as follows:
i. < 48 hours = 0 points
ii. 48 – 71 hours = 1 point
iii. 72 – 95 hours = 2 points
iv. > 96 hours = 3 points
Active military/spouse, retired military or veteran status. Maximum points: 3
Applicants will be awarded 3 points for proof of active military/spouse status, retired military status or veteran status with proof
of honorable discharge. Current active/retired military ID or documentation of honorable discharge documentation must be
attached to the application. Retired military or veteran spouses will not qualify for points
.
Points on the application for the Klamath Community College Nursing program can be awarded to the following individuals:
• Active-duty members of the Army, Air Force, Navy, Marine Corps, and Coast Guard and their spouses
• Active members of the Army National Guard, Air National Guard, Army Reserve, Air Force Reserve, Navy Reserve,
Marine Corps Reserve, and Coast Guard Reserve and their spouses
• Retired members of the Army, Air Force, Navy, Marine Corps and Coast Guard
• Retired members of the Army National Guard, Air National Guard, Army Reserve, Air Force Reserve, Navy Reserve,
Marine Corps Reserve, and Coast Guard Reserve
• Veterans discharged honorably from any military or Department of Defense service
8
Work experience in healthcare field. Maximum points: 2 - 4
Applicants will be awarded 4 points for the following: at least 500 hours of work experience caring for human patients with
current unencumbered certification as an Oregon certified nursing assistant, or Oregon licensure or national certification as a
licensed practical nurse, respiratory therapist, emergency medical technician, paramedic, medical assistant (national
certification required), or service as an Armed Services medic or corpsman in the past four years, or,applicants will be awarded
2 points for an Oregon certified nursing assistant, national certification as a medical assistant, Oregon state licensed practical
nurse or state/national certification of emergency medical technician, paramedic, or respiratory therapist with less than 500
hours or work experience.
Applicants with work experience > 500 practice hours gained in other areas of healthcare may submit their evidence of
experience along with an explanation as to why they believe their experience should be considered for points. If allowed,
experience in roles other than those listed above will receive a maximum of 2 points.
Copy of active Oregon state certificate/license or national certification must be provided with application to receive points.
Foreign language fluency. Maximum points: 3
Applicants may receive 3 points for foreign language fluency, including American Sign Language (speaking and listening) as
determined by an official high school transcript from a school located in a foreign country or school for the deaf for use of
American Sign Language. An official transcript/certificate identifying “Advanced” (any subcategory) language proficiency as
defined by the American Council on the Teaching of Foreign Languages (ACTFL) 2012 Proficiency Guidelines, or ASLPI Level
4 for American sign language is also acceptable. The OPI, OPIc and LPT assessments are acceptable language proficiency
exams administered by Language Testing International. Applicants must demonstrate both fluency in speaking and listening.
This will require two assessments: the OPI or OPIc AND the LPT assessment. See https://www.languagetesting.com/ for
language proficiency exam availability and https://www.actfl.org/publications/guidelines-and-manuals/actfl-proficiency-
guidelines-2012 for criteria indicating “Advanced” language proficiency as defined by the ACTFL 2012 Proficiency Guidelines.
For information about ordering a language proficieny assessment through Language Testing International follow this link:
https://www.useloom.com/share/345bc9f2c19345b2b5a485593935dc6f
There are fees associated with the above process set by and due to Language Testing International or other company used to
determine level of fluency.
Students are required to provide to Klamath Community College a proficiency certificate or high school diploma to documenting
language proficiency. Applicants must demonstrate both fluency in speaking and listening.
Applicants unable to validate fluency by above measures due to unavailability of proficieny exams for specific foreign languages
are encouraged to contact the nursing program adminstrator. Alternate measures for determining fluency are approved on a
case by case basis per program policy.
Phase 2 – Proctored Essay, Panel Interview and HSRT exam – applicants will be assessed using 50
points in the following:
Essay – Maximum 30 points: The top 20 applicants as determined in Phase 1 will be invited to participate in a proctored
essay. Up to 30 points may be awarded for a proctored essay based various attribute/experience criteria. The essay questions
will not be based on any specific prerequisites or other courses, but will address general attributes such as integrity, diversity,
9
communication, transferable skills (e.g. leadership, critical thinking, teamwork), motivational fitness, and resilience.
Interview – Maximum 20 points: The top 20 applicants as determined in Phase 1 will be invited to participate in a panel
interview. Up to 20 points may be awarded based on cumulative scores submitted by the interview panel using a rubric for
appearance and responses.
HSRT – Maximum 10 points: The top 20 applicants as determined in Phase 1 will be invited to participate in a proctored
administration of the Health Sciences Reasoning Test (HSRT), an assessment of critical thinking by Insight Assessment.
Additional information regarding the HSRT can be found by following this link:
https://www.insightassessment.com/Resources/Teaching-Training-and-Learning-Tools/node_1487
.
Up to 10 points may be awarded for the applicant’s overall HSRT score. The HSRT score describes overall strength in using
reasoning to form reflective judgments about what to believe or what to do. Nursing students and RNs must be able to
demonstrate sustained, focused, and integrated application of core reasoning skills including analysis, interpretation, inference,
evaluation, explanation, induction and deduction. The point spread for the HSRT scores will not be published and applicants will
not see their scores.
Tie breakers: In the event that two or more applicants’ scores cluster at the same point,
Klamath Community College will use
tie breakers in the following order:
a. HSRT scores, then
b. No evidence of having repeated any of the prerequisite BIO courses (unless required due to time limit), then
c. Overall prerequisite GPA
2020 Nursing Application – Submit this Page
Phase 1 Assessment of Points:
Please score yourself with this sample point sheet
You must have completed 25 Nursing program prerequisite credits to meet minimum qualifications.
Courses must meet grade criteria (“C” or higher; “C-” or lower not accepted) and
appear on a transcript by date of application.
There is a maximum of 39 credits for Phase 1
* Some A&P courses are evaluated as two 5 credit courses and in the point sheet will
be marked as meeting BI 231 and 233.
** Semester A&P courses are typically evaluated as two 6 credit courses and in the
point sheet will be marked as meeting BI 231 and 233
Points:
3crs of C or C+ = 6, 3crs of B = 9, 3crs of A = 12
4crs of C or C+ = 8, 4crs of B = 12, 4crs of A = 16
5crs of C or C+ = 10, 5crs of B = 15, 5crs of A = 20
GPA:
C = 2, B = 3, A = 4
Do not calculate – or + grades
CCC Course Number
Courses listed below must meet criteria as defined in the Application Information.
Phase 1
Required Courses
College Name, Course #, Course
Name, Term/Year
As it appears on transcripts (e.g. PCC FN
225 Nutrition, Fall 2015)
Max
Quarter
Credits
Grade
Points
Credits
x
points=
Total
BIO 231
(3 Credits)
BI 231 (Required to Apply)
BIO 231L
(1 credit)
(Required to apply)
BIO 232
(3 credits)
BIO 232L
(1 credit)
BIO 233
(3 Credits)
BIO 233L
(1 credit)
CS 133 (
3 credits)
(max 4 credits w/ CS 133L)
CS 133L
(1 credit
)
BIO 234
(4 credits)
(max 5 credits w/BIO 234L)
BIO 234L ( 1 credit)
WR 121 (3/4 Credits) BA/BS gives 4
credits using Approved Electives
(required to apply) (max 4 credits)
MTH 111 or 243 (4/5 Credits)
(required to apply) (max 5 cr 111 & 4 cr
243)
HPE 225 (max 3 credits)
PSY 235 (max 3 credits)
SPE 111 (max 3 credits)
Total Credits & Quality Points & GPA:
2020 Nursing Application – Submit this Page
GPA:
3.80 - 4.00 = 25 points
3.50 - 3.79 = 23 points
3.20 - 3.49 = 20 points
3.15 - 3.19 = 17 points
3.00 - 3.14 = 15 points
Possible
Points
Allowed
15-25
Points
Designations
Select Course:
You will receive points for the course below if you have earned a grade of “C” or
better prior to the application deadline.
INFO
INFO
Math 243 or 244 (Statistics)
3
Anatomy and physiology grades
You will receive points for receiving an A or B in anatomy and physiology as listed on your
transcript:
BI 231 (4 credits): A = 2 points
B = 1 point
BI 232 (4 credits): A = 2 points
B = 1 point
BI 233 (4 credits): A = 2 points
B = 1 point
0-6
TEAS Test
A score “Below Proficient” will disqualify the applicant.
“Proficient” with a cumulative score < 75 will receive 0 points.
>75 will receive 3 points.
“Advanced” will receive 4 points.
“Exemplary” will receive 5 points.
0-5
College Degree
Associate degree or
Bachelor’s degree or higher
1 or
2
Residency
24 graded credits earned at
Klamath Community College 2009-2019
OR
2017, 2018, 2019 Klamath or Lake County high school graduate
6
or
3
Volunteerism
48-71 hrs. = 1
72-95 hrs. = 2
≥ 96 hrs. = 3
1 or
2 or
3
Military status
Active duty/spouse status or
Retired military or
Veteran with honorable discharge
3
Work experience as CNA, LPN, EMT, Paramedic, RT, MA or armed forces
medic/corpsman with > 500 hours of practice = 4 points;
CNA, LPN, EMT, Paramedic, RT, MA or armed forces medic/corpsman with <
2 or
4
2020 Nursing Application – Submit this Page
500 hours practice or other approved work experience = 2 points
Foreign Language (or ASL) Fluency
Foreign Language (ASL) proficiency determined by exam or HS transcript
3
Total Phase I score:
XXXXXXXX
XXXXXXXX
XXXXXXXX
2020 Nursing Application – Submit this Page
Declaration of Residency
Please do not submit residency documentation with your application if one of the following criteria does not apply to you.
I have earned a minimum of 24 graded credits from Klamath Community College between 2010 and 2019. I
am submitting a Klamath Community College transcript as documentation. I understand I will receive 6
points.
OR
I graduated from a Klamath or Lake County high school in 2017, 2018, or 2019. I am submitting an official
high school transcript showing that I graduated. I understand that as a Klamath or Lake County high school
graduate I will receive 3 points.
A maximum of 6 points will be awarded. Choose one of the above options.
I understand that falsification of any of the above information will jeopardize my application and/or admission to the
Nursing program. I certify that all of the above information is complete and true.
Sign and date.
Print name: _____________________________________________________________________
Signature: _______________________________________________ Date: _______________________
Address: _____________________________________________________________________________
2020 Nursing Application – Submit this Page
Volunteer Verification Form
Students may receive up to 3 points for volunteering in any organization/circumstance where the student was
supervised (directly or indirectly), excluding court ordered or other disqualifying experience.
Please do not submit volunteer verification documentation with your application
if you have not performed at least 48 hours of volunteer service in the last 5 years.
Note to applicant: Be sure to fill in necessary information in the top section before sending this form to the
supervisor/organization where the volunteer hours were performed. Volunteer hours must be verified using this form
and include a letter of reference from your supervisor/designee. You may duplicate this form as needed. You
must include a reference letter from each organization filling out a verification form. Be sure the form is complete.
Incomplete forms or missing reference letters cannot be given consideration in the point assignment process.
Dear Human Resources/Supervisor,
I am in the process of applying to the Nursing Program offered by Klamath Community College. The points process
requests verification of volunteer hours and a reference letter. Volunteer hours must be within the last five years.
I, ________________________________ (program applicant’s name) authorize the college to contact the individuals
listed on this form to verify the information provided.
Program Applicant’s Signature: _____________________________ Date: _______________
----------------The portion below is to be completed by Supervisor/Human Resources-----------------
Verification of volunteer hours:
A. Dates of Service: _____________________________ Total Hours: ________________
mm/dd/yy – mm/dd/yy
B. Supervised by: __________________________________________________________
Name, Title
C. Organization: ___________________________________________________________
D. Supervisor contact number: ________________________________________________
E. Supervisor signature: _____________________________________ Date: ___________
PLEASE ATTACH A LETTER OF REFERENCE FOR THE APPLICANT
2020 Nursing Application – Submit this Page
2020 Nursing Program Application
Checklist and Agreement
(for Fall 2020 entry)
_______________________ _____________________________ __________________________
Applicant Name Social Security Number Date of Birth
_____________________________________________________________________________________
Secure Email Address (Official notifications will occur by email. It is the applicant’s responsibility to
provide a secure email address and ensure the College and Nursing program assistant
are notified of any changes in email address.)
Applicant: You must complete and submit the following checklist as part of your application. Please
initial each statement below, indicating that you have read, understand, and agree to the application
requirements for the Klamath Community College Nursing program.
___1. I have attached sealed official college transcripts from ALL previous attended, regionally accredited,
colleges or universities, including coursework completed through Winter Term 2020 for prerequisite and
earned degree purposes. (Klamath Community College transcripts do not need to be official).
___2. I understand that a minimum of 25 prerequisites must be completed with a “C” or better (with a minimum
cumulative GPA of 3.00) by the time of application, including BI 231 Anatomy & Physiology I with lab, WR
121 and MTH 111 or 243, in order to be eligible to apply.
___3. I have completed my TEAS Test at ____________________ on__________________ date.
___4. I have provided a secure email address on my application and give my permission for Klamath Community
College to contact me through this email address. I understand that a receipt verifying my application
packet was submitted to Klamath Community College will be emailed to me and that I will also receive
notification of my degree audit (transcript evaluation) results by email once it has been completed.
___5. I understand that I will be sent an email and a copy of my Phase 1 results and initial status after points have
been awarded, and that the letter will state the time frame in which I may contact the College with
questions about my points.
___6. I understand that if my points qualify me for Phase 2 I will be notified, and will schedule a proctored essay,
interview, and HSRT exam to continue my application.
___7. I understand that each applicant will be notified by email of his or her status regarding acceptance by June
19, 2020. I also understand that I am not to call the Nursing program or Student Services regarding
acceptance status unless directed to do so.
___8. I understand that if I have a financial hold on my Klamath Community College account, my application will
be disqualified unless the financial hold is removed before 5 p.m., April 15, 2020.
___9. I have completed and filled out the residency form and documentation, if applicable.
___10. I have included an official transcript showing language proficiency, if applicable.
2020 Nursing Application – Submit this Page
___11. I have included volunteer verification form(s) and corresponding reference letter(s), if applicable.
___12. I have included documentation indicating active duty military/spouse, retired military or veteran with
honorable discharge status, if applicable.
___13. I have included current/active unencumbered state or national certification/license as CNA, LPN, EMT,
MA, RT, paramedic, armed forces medic/corpsman, or other approved work experience, if applicable.
Practice hours can be verified at the following:
Location(s), phone number(s), and practice hours:
(Practice hours will be verified to receive full points)
___14. I understand that reading and following directions is critical to success in any nursing program. Incomplete
applications will result in disqualification and that disqualified applicants will only receive notice of such
after the application deadline has passed.
___15. I have read and I understand the program information and admission criteria (including requirement for
negative urine drug screen and criminal background check in order to be admitted) for the Nursing
program at Klamath Community College. I understand that I will be asked to consent to a urine drug
screen for any signs of impairment while in the clinical setting and will be dismissed from the program if
the screen is positive for any substances. Program information, including selection points, prerequisites,
and information sessions can be found at: https://www.klamathcc.edu/Academics/Programs/Registered-
Nursing
___16. I understand that if accepted I will be required by a specified deadline to order a criminal background
check with the Klamath Community College Nursing Department’s contracted agency, which performs
criminal background checks and must self-disclose all past arrests, charges, and/or convictions and/or
disciplinary action taken by a Board of Nursing, even if the disclosures are outside a five or 10 year
window, and must disclose any warrant, arrest, citation, charge or conviction if such occurs after
acceptance.
___17. I understand that a history of certain crimes might result in my being denied admission to the program and
have reviewed the criminal background check information available on the Nursing webpage.
___18. I understand that the Oregon State Board of Nursing (OSBN) has limits on eligibility, as defined in OAR
851-031-0006 (2) (a) (b) for licensure. Ultimately, a license can be denied to students with a criminal
offense and those with a major physical or mental condition that could affect their ability to practice
nursing safely. https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=259280
___19. I understand that it is my responsibility to meet all program and application criteria. Klamath Community
College staff are available to answer application related questions, but will not check my application for
completeness prior to submission.
2020 Nursing Application – Submit this Page
___20. I verify that all statements on this application are complete and true and I understand that falsification of
any information may lead to disqualification or dismissal from the program.
___________________________________________________________ ___________________
Applicant Signature Date
If the applicant is less than 18 years old, a parent must also sign ___________________________
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Form 1: Nursing Program Information (Klamath Community College)

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Completed 26 July 2020

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