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Southern University at Shreveport School of Nursing 610 (Southern University at Shreveport)

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Southern University at Shreveport
School of Nursing
610 Texas Street, Suite 500-D
Shreveport, Louisiana 71101
(318) 670-9641
Certified Nursing Assistant
Application
Name: _________________________________ SS#_________________ DOB: _______
Last First M
Address:________________________________ Ph# (Home) __________________
Street (Cell) ____________________
_________________________________ Enrollment____________________
City State Zip Semester/Year (Month)
Yes No
1. Have you ever been charged with or convicted of a crime? ___ ___
2. Have you ever had a license that was revoked, suspended
or restricted? ___ ___
3. Do you have a high school diploma or GED? ___ ___
4. If no, are you currently working toward a diploma or GED ___ ___
5. Do you currently hold a health care license? ___ ___
List licenses held_________
_________ ___ ___
6. Have you completed any courses at Southern University
at Shreveport? ___ ___
7. Do you hold any degrees? ___ ___
List degrees ______________
______________
___________________________________ ____________________________
Student Signature Date Submitted
___________________________________ _____________________________
Nursing Representative Signature Date Received
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Instructions for Criminal Background Check
Revised 08/2019
• Students must bring a money order in the amount of $42.50 (made payable to Data Quest
Research) to the CNA office.
• Complete the online application through Data Quest Research & Investigative Services.
*CNA faculty will assist students with this process.*
• Complete and sign the criminal background authorization form. Please write legibly.
• After completion of the application & authorization forms, students must bring the
$42.50 money order to the address below:
Data Quest Research & Investigative Services
2800 Youree Drive
Shreveport, LA 71104
• A minimum of 48 hours is required to process the background check.
• Once the background information is received, the student will be contacted by the CNA
faculty to notify of acceptance in the program.
• Based on the results of the criminal background check, a student may be required to
submit fingerprint cards for further investigation. The cost of the fingerprint cards will be
the responsibility of the student.
• The program cannot accept a trainee into the program without a completed criminal
background check.
Southern University at Shreveport
School of Nursing
Certified Nursing Assistant Program
Senate Bill 204: Criminal History Checks of Licensed Personnel
Offenses Which Bar Employment
Tiffany Varner, MSN, RN
Director, School of Nursing
Persons pleading guilty, nolo contendere, or convicted of any of the following offenses
MAY NOT be admitted to the Certified Nursing Assistant Program.
1. Solicitation for murder 36. Cruelty to the infirm
2. First degree murder 37. Exploitation of the infirm
3. Second degree murder 38. Sexual battery of the infirm
4. Manslaughter 39. Extortion
5. First degree feticide 40. Aggravated kidnapping of a child
6. Second degree feticide 41. Felony carnal knowledge of a juvenile
7. Criminal assistance to suicide 42. Molestation of a juvenile
8. Aggravated battery 43. Cruelty to juveniles
9. Second degree battery
10. Aggravated second degree battery
11. Simple battery of the infirm
12. Aggravated assault
13. Assault by drive-by shooting
14. Aggravated assault with a firearm
15. Mingling harmful substances
16. Aggravated rape
17. Forcible rape
18. Simple rape
19. Sexual battery
20. Second degree sexual battery
21. Oral sexual battery
22. Intentional exposure to AIDS Virus
23. Aggravated kidnapping
24. Second degree kidnapping
25. Human trafficking
26. Aggravated arson
27. Aggravated burglary
28. Simple burglary of a pharmacy
29. Armed robber
30. First degree robbery
31. Second degree robbery
32. Theft of assets of an aged person or disabled person
33. Distribution or possession with intent to distribute any schedule I through V controlled
dangerous substance.
34. Crime against nature
35. Aggravated crime against nature
Course Payment
Course tuition is $510.00. This does not include the cost of books or uniforms. The approximate
cost of these items are $120.00. Payment for the CNA course is due prior to the first day of class.
Students needing assistance with fee payment have the option of setting up a deferment plan
through the Office of Finance and Administration. A five-day “grace period” will be allowed to
students who need time to make payment arrangements. Students who have not paid course fees
(or made arrangements to pay) will not be allowed to progress in the course and will be given the
opportunity to return at the next course offering.
Payments may be made at the Cashier’s window located in the Administration building at
3050 Martin Luther King, Jr. Drive, Shreveport, LA 71107.
Prometric testing
As of July 1, 2018, The Louisiana Department of Health has partnered with a national testing
company, Prometric, to begin providing nurse aide certification testing throughout the state. The
cost of this exam and skills check-off is $125 and must be paid at the end of the course (prior to
testing). This fee is not included in tuition and is not regulated by the University. A full discussion
of the process to become certified will take place during orientation.
If you have any questions, please contact the School of Nursing at 318-670-9556 or 318-670-9641.
Certified Nursing Assistant Application Checklist
___ CNA Application
____ Background Check
Follow the instruction sheet attached.
____ Admissions
Students with a high school diploma or its equivalency must apply for admission to the
University either via website at www.susla.edu or in person in the Office of Admissions
located at 3050 Martin Luther King, Jr. Drive, Shreveport, LA 71107
If you are currently working toward a high school equivalency, please check with the
CNA faculty regarding dual enrollment in the course. If you would like to pursue a high
school equivalency, you may obtain information from the Intake Office on the first floor
of the Metro Center building.
____ TB Skin Test
In order to participate in clinical experiences, students must show proof of a negative TB
skin test (or negative chest x-ray if skin test is positive). TB skin tests may be done at
your doctor’s office or any other medical facility.
Revised 8/2019
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Completed 17 September 2020

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