Fillable Petition Scorecard: Associate Degree Nursing (ADN) (Blackhawk Technical College)

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Petition Scorecard: Associate Degree Nursing (ADN) (Blackhawk Technical College)

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6004 S County Rd G • PO Box 5009 • Janesville, WI 53547-5009
(608) 758-6900 • info@blackhawk.edu • blackhawk.edu
Last Revised: 12/3/2019 1
Petition Scorecard: Associate Degree Nursing (ADN)
Petitioning deadlines may be found on the Nursing Petition Information page at Blackhawk.edu.
Only students who have completed the application process and meet all program-ready requirements are eligible to
petition. Petition forms, unofficial BTC transcripts, shadow/work experience forms, and residency information must be
submitted/received no later than 4:00 p.m. on the last petition day.
Deliver as follows:
In-person at the Health Sciences Reception Desk (Room 2304 or Room 1200) at Central Campus
Mailed (and received by deadline) via U.S. mail to:
Blackhawk Technical College, Health Sciences, 6004 S County Road G, Janesville, WI 53547-5009
Faxed to (608) 743-4578
Students will be notified by U.S. mail within two months of the petition deadline regarding the status of their petition.
Letters will be sent to the address on record in the college computer system.
Student Name
BTC Student ID Number
Full-Time Admission
Part-Time Admission*
* Part-time admission is only available during the February petition period.
Please read and initial the following statements:
_____ I have verified that Blackhawk Technical College (BTC) has my current mailing address on file.
_____ In the case of a tie, the “Date of Pre-Clinical Admission” as a date-stamped by BTC Admissions will be the
deciding factor.
_____ If I am selected and choose not to begin the core clinical courses, I must petition again.
_____ If I am selected as an “alternate” I may be contacted as late as one month prior to the start of the core courses. If I
choose not to begin the core clinical courses, I must petition again.
_____ I understand a background check and possible drug screen will be conducted and the results may prevent my
placement at a clinical site and interfere with my ability to complete the program.
_____ I understand that program requirements for future petition periods may have different selection criteria and I must
meet those new requirements if I am not selected in this current petition period or thereafter.
_____ I understand that a petition meeting must be attended every year that I petition. Failure to attend a petition
meeting every year before petitioning will result in my application being considered incomplete and void.
_____ I understand that while I may take the required, program-specific test (i.e. TEAS-Nursing) as many times as I
choose, the most recent test result will be used in determining points for petitioning.
_____ I understand that I must attach a copy of the TEAS test score transcript (or ATI transcript validation for Nursing)
_____ I understand that I must attach an unofficial BTC transcript. Students can print unofficial transcripts through
MyBTC at mybtc.blackhawk.edu. Any relevant transfer coursework must be documented on the BTC transcript at
the time of submission to be considered valid. Failure to provide BTC transcripts will result in an invalid petition.
_____ I understand that an incomplete petition will be considered invalid.
_____ I understand if I choose a full-time or part-time track and want to switch, I will need to follow the process outlined
in the BTC Nursing Handbook.
Student Signature: ________________________________________________ Date: _________________________
6004 S County Rd G • PO Box 5009 • Janesville, WI 53547-5009
(608) 758-6900 • info@blackhawk.edu • blackhawk.edu
Last Revised: 12/3/2019 2
Read, complete all sections, and submit all required documents. Failure to do so will result in an invalid petition.
Student Name
BTC Student ID Number
Date of Nursing Petition Meeting Attended
I. College Coursework Total Points: ______/160 points
Check the column that represents the grade achieved and indicate where the course was completed. Blackhawk’s Credit for
Prior Learning process must be complete in order for courses taken at other institutions to be considered for petitioning.
Required Pre-Requisite Courses – these courses must be completed in order to petition
Course
A-/B+
= 8pts
B =
5pts
B-/C+
= 3pts
C =
0pts
Taken
at BTC
If taken elsewhere,
list school name:
Awarded
Points
Chemistry *
English Comp/ Written Communication
General A&P *
Additional points are awarded for the following general education courses, if complete at the time of petitioning.
These courses are needed for graduation, but are not required for petitioning.
Microbiology *
Advanced A&P *
Intro to Sociology
Intro to Psychology
Developmental Psychology
Speech
Optional Nursing Prep Courses
Nursing Math *
Pharmacology Prep
Total Points for College Coursework: __________/160
*Points are doubled for science and math courses.
II. Work Experience Total Points: ______/20 points
I have worked in the following position(s) within the previous five years. Include a completed Verification of Occupational
Experience form. Only the final candidates will be audited. For Type of Position, “no customer/patient interaction” is awarded 0pts,
“customer care/service” is awarded 5pts, and “direct patient care” is awarded 10pts. For Time in Position, “up to one year” is
awarded 0pts, “one to five years” is awarded 5pts, and “five years or more” is awarded 10pts.
Type of Position
Points
Time in Position
Points
Total Points for Work Experience: __________/20
For clinical placement, have you ever worked in a long-term care facility or at an acute care facility?
If so, explain (no points are awarded for this): ___________________________________________________________________
________________________________________________________________________________________________________
Have you been enrolled in the BTC ADN program in the past? Yes No
Have you previously petitioned and your employment information has not changed since then? Yes No
III. Program Admission Testing (TEAS-Nursing) Total Points: ______/100 points
The following points are awarded: 0-59% = 0pts, 60-64% = 20pts, 65-69% = 40pts, 70-74% = 60pts, 75-79% = 80pts, 80-100% =
100pts
IV. BTC District Resident Total Points: ______/10 points
If you are a resident of the Blackhawk District (i.e. live in Rock or Green Counties in Wisconsin), you will receive 10pts. If not,
please indicate 0pts. District residence is verified by BTC by the address on file and is not required for petitioning.
6004 S County Rd G • PO Box 5009 • Janesville, WI 53547-5009
(608) 758-6900 • info@blackhawk.edu • blackhawk.edu
Last Revised: 12/3/2019 3
FOR OFFICE USE ONLY (Final Ranking Process)
Petition Meeting Attended: Yes No
1. College Coursework
/160 points
4. Residency Points
/10 points
2. Work Experience
/20 points
TOTAL POINTS: /290
3. Program Admission Testing
/100 points
ASSOCIATE DEGREE NURSING PROGRAM
MINIMUM REQUIREMENTS TO PETITION
In order to petition for a spot in the core ADN courses, students must complete the following requirements.
Please initial each requirement (1-6) below:
Course Requirements:
_____ 1. Chemistry – One year of high school chemistry with lab OR one semester of college chemistry with lab with a
grade of C or better. Acceptable BTC courses include:
Chemistry Prep (856-787) OR
General Chemistry (806-134) OR
General, Organic, & Biochemistry (806-199)
_____ 2. Written Communication (801-195) OR English Comp 1 (801-136) with a grade of C or better
_____ 3. General Anatomy & Physiology (806-177) with a grade of C or better
Additional Requirements:
_____ 4. Test of Essential Academic Skills (TEAS) – provide transcript
ATI Test Score
Points
0-59%
0
60-64%
20
65-69%
40
70-74%
60
75-79%
80
80-100%
100
Total TEAS Test Points: __________/100
_____ 5. Basic Nursing Assistant completed. The Basic Nursing Assistant course must be completed within five years
of petitioning to the Nursing program. Consideration will be given for those who are, or have been, employed as a
Nurse Assistant.
_____ 6. Mandatory Information Meeting – Meeting must be within one calendar year of petition date.
Please provide date of attendance: ____________________
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Petition Scorecard: Associate Degree Nursing (ADN) (Blackhawk Technical College)

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Completed 27 July 2020

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