Southwest Virginia Community College (SWCC) Nursing Program
Student Statement of Criminal Background
(To be completed by student and uploaded to CastleBranch, no later than July 15. This form must be submitted
annually while continuously enrolled in the SWCC nursing program).
Academic Year: Empl ID:
Name:
Mailing Address:
Cell Phone: Home Phone:
VCCS Student Email:
Since the date of completion of your original background check for the SWCC Nursing
Program has any portion of your background check changed or have you received any
criminal convictions that are listed on the Virginia Barrier Crimes conviction list located at
https://www.dhp.virginia.gov/nursing/nursing_guidelines.htm, article 90-55 under the
heading, Licensure/Applicants.
Yes No
If your answer is yes, please contact the SWCC office at (276)964-7659 to schedule a meeting
with the Program Head of the SWCC Nursing Program.
By my signature below, I verify that the information provided on this form is a true and
accurate report of my criminal history.
Printed Name Signature
Date
rev. 3.27.2020
