Student Name
(please print)__________________________________
Student ID Number ______________
Please check the appropriate boxes:
I certify that I have viewed and understand the online
presentation of information for the
_________________________ program at Caldwell
Community College & Technical Institute.
I still have questions that were not answered in the
presentation. I will contact Student Services or the
Program Director for assistance.
I understand that in order to complete the Information
Session admission requirement that I must submit this
form to Student Services immediately. The date that this
form is received by CCC&TI will be used to meet this
requirement in my admission folder.
I have made a copy of this confirmation for my personal
click to sign
click to edit
return to the Health Sciences Admissions Office**
Clinical Eligibility & Licensure/Certification/Registry Eligibility for Health Sciences Students
Clinical: Clinical education is a vital component in the training of health sciences students. The college maintains a
formal clinical affiliation agreement with each facility where students are sent for clinical instruction. These affiliation
agreements specify requirements similar to those required of facility employees and may include health and
immunization requirements, personal health insurance, mandatory HIPAA and OSHA training, criminal background
checks and drug screens.
Not all facilities impose the same requirements, and these requirements may change with little or no notice. After
admission to the health science program students are required to submit to a criminal background check and urine drug
screen through or the school’s designee. Any dispute concerning unsatisfactory background findings
or drug screen will be between the student and the party providing the service. Background checks and drug screens are
to be completed on or before the date set by the student’s individual program.
Any of the following positive findings may cause a student to be ineligible for clinical:
Felony conviction (class A-E)
Class A1 misdemeanor conviction (examples: assault inflicting serious injury with a deadly weapon, assault on a
female, assault on a child under 12 years of age, assault on a state officer or employee, assault by pointing a
gun, violation of a valid protective order)
Class 1 misdemeanor conviction ( examples: breaking or entering buildings, larceny of property, unauthorized
use of a motor vehicle, worthless checks for $2,000 or less from a closed account, willful and wanton injury to
real property, communicating threats, possession of drug paraphernalia, misrepresentation to obtain
employment security benefits [worth $400 or less])
Listing on the national sex offender list
Listing by the Office of Inspector General (OIG) disbarring individual from participation in health care programs
Students who show any of the above findings will have a flag on their background screen and may be ineligible for
participation in clinicals subject to approval by each individual assigned facility.
Many of the facilities scrutinize the student background checks themselves and may impose stricter standards. If a
facility deems that a student must be excluded from their site, the student will be unable to progress in the program. If
you have any questions about this policy please contact your program director or the department chair for Health
Licensure/Certification/Registry Eligibility: When considering whether to admit an individual into a specific program of
study, the College shall take into account that federal law prohibits states from granting professional licenses to
undocumented immigrants. Furthermore, graduation from a CCC&TI health science program alone does not guarantee
that the student has met all eligibility requirements for licensure, certification, or registry required in order to practice in
the related medical field. Prospective students should contact the appropriate agency prior to enrollment if they have
any questions concerning their eligibility for credentialing examinations and legal ability to practice.
I have read and understand the policy for required criminal background checks as it relates to my eligibility for
progression within all health science programs at CCC&TI. I also have read and understand that graduation from CCC&TI
does not automatically guarantee my eligibility to sit for any required licensure, certification, or registry exams.
Student: Date of Birth or last 4 of SSN:
Signed Date
Student ID # revised 08/28/19
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