packets for 2020 will be accepted , 2020. PACKETS WILL NOT ...€¦ · packets for 2020 will be accepted November 2, 2020 through 4:00pm, Fri day, November 2 0, 2020 in the Shasta

SHASTA COLLEGE HEALTH SCIENCES AND UNIVERSITY PROGRAMS ASSOCIATE DEGREE NURSING (ADN) PROGRAM

2020 MULTICRITERIA SELECTION (MCS) APPLICATION PACKET

Multicriteria Selection (MCS) Application Packet Check-Off List

*OFFICIAL RECORDS are those which have been received from another educational institution in a sealed envelope and remain unopened. DO NOT OPEN. If an envelope has been opened (seal broken), prior to arriving at Shasta College, it cannot be accepted for the purpose of admission to the AssociateDegree Nursing Program.

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NAME: (Last) (First) (MI)

ID#: _

ADN MCS Program Application packets for 2020 will be accepted November 2, 2020 through 4:00pm, Friday, November 20, 2020 in the Shasta College Health Sciences Division Office. Mailed applications must be postmarked by November 20, 2020.

PACKETS WILL NOT BE ACCEPTED OUTSIDE OF THE APPLICATION PERIOD

COLLECT THE OFFICIAL DOCUMENTS REQUIRED AND SUBMIT WITH APPLICATION IN A SEALED ENVELOPE. Additional documents will not be accepted after submission of the application packet.

The following items are MANDATORY and must be included in the Multicriteria Selection Process Application packet. COMPLETED/ENCLOSED:

YES NO Valid E-mail Address must be included. (Lack of an email address may disqualify applicant.)

Shasta College Application – every applicant must have a new admissions application on file at the Office of Admissions & Records prior to turning in this packet. A new online admission application must be submitted no earlier than January 1, 2020. Do this step even if you have previously attended and/or applied to Shasta College. A link to the online application can be found on the shastacollege.edu website under Admissions – Apply for Admission, or by going directly to this webpage: www.shastacollege.edu/apply and clicking the link for “New Students”.

Shasta College 2020 Associate Degree Nursing Program MCS Application Packet Check-Off List (2 pages signed).

Shasta College 2020 Associate Degree Nursing Program MCS Application (3 pages signed).

OFFICIAL* Letter regarding prior attendance of nursing program (if applicable) – see page 2 of Application

OFFICIAL* High School Transcript showing the date of graduation, official transcript for completion of California High School Proficiency Examination (CHSPE), or official transcript of G.E.D test results. Official high school transcript, or official CHSPE, or official transcript of G.E.D test results are not necessary if applicant has a post-secondary degree and submits the official College Transcript showing the conferred degree. No copies of degrees, diplomas, certificates, or transcripts will be accepted (see footnote). OFFICIAL* Advanced Placement (AP) or CLEP test scores if using to satisfy graduation/prerequisite requirements or proficiency in languages other than English (if applicable). OFFICIAL* College Transcript from all colleges ever attended where work was attempted or classes were completed. If general education or prerequisite courses were not taken at Shasta College, please include course descriptions/syllabi from the other college(s) in your application packet. NOTE: It is not necessary to submit an official Shasta College transcript; a transcript of your Shasta College courses will be obtained from the Admissions & Records Office and made an official part of your application packet. NOTE: All other College and/or high school records that may already be on file with the Shasta College Admissions & Records Office cannot be used for this application packet. You must resubmit all college and/or high school records with each new application packet. If you were a previously qualified applicant, you may elect to use your previously submitted college

and/or high school records that are on file with the Shasta College Admissions & Records (A&R) Office. It is highly recommended that you contact the A&R office to confirm that all of your records are still on file as external records, such as transcripts from other schools, are purged over time. There may be a possibility that you may need to resubmit all or some of your college and/or high school records.

Mail or hand deliver to: Shasta College, Health Sciences Division Office, 1400 Market Street, Suite 8204, Redding, CA, 96001

http://www.shastacollege.edu/apply



Multicriteria Selection (MCS) Application Packet Check-Off List

*OFFICIAL RECORDS are those which have been received from another educational institution in a sealed envelope and remain unopened. DO NOT OPEN. If an envelope has been opened (seal broken), prior to arriving at Shasta College, it cannot be accepted for the purpose of admission to the AssociateDegree Nursing Program.

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The following items are MANDATORY and must be included in the Multicriteria Selection Process Application packet.

TEAS Test: An unofficial printed copy must be included in your application packet and an official copy must be sent electronically from ATI TEAS (www.atitesting.com) to Shasta College Health Sciences prior to the application filing period deadline. Completed TEAS Remediation Plan, signed off by appropriate Director/Dean (if applicable).

Clinical Requirements Check List Form (signed) and required immunization documentation.

The following items are OPTIONAL items for the Multicriteria Selection Process Application packet. COMPLETED/ENCLOSED:

YES N/A Proficiency or Advanced Level Coursework in Languages other than English Form and copy of Proficiency Certification or official* transcript from a U.S. regionally accredited, or equivalent, college or university, verifying successful completion of two (2) semesters of study in the same foreign language, successful completion of a level 2 or higher foreign language, or Official AP (score: 5) or CLEP (scaled score: 50 or higher) test scores (if applicable).

Licensed or State Certificated Worker Verification Form and a copy of your current License and/or state certificate that shows your license/certificate number, date of issue and expiration (if applicable).

Work or Volunteer Experience Form and letter from current and/or former employer/organization (if applicable).

Life Experience or Special Circumstance Form and documentation according to specific area requirements (if applicable).

Alternate Verification Form and a copy of your Alternate Acceptance Notification Email as program alternate for last selection period. (Only applicable if: applicant was an alternate for previous Multicriteria Selection Application Filing Period who was not enrolled into the ADN program and who completed all alternate requirements including participation in both online and in- person orientations).

Failure to follow any instructions or failure to include all required documents may result in disqualification of your Application.

Once an Application packet has been submitted, all materials become the property of Shasta College and cannot be returned to the student.

Applicant Signature: Date:



Multicriteria Selection (MCS) Application PLEASE PRINT IN INK APPLICATION DEADLINE: 4 P.M. Friday, November 20, 2020

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SHASTA COLLEGE ID NUMBER: EMAIL ADDRESS (REQUIRED FOR ALL APPLICANTS): BIRTHDATE:

NAME (Last, First, M.I.): TELEPHONE:

ALL OTHER NAMES UNDER WHICH YOU HAVE BEEN KNOWN: ALT. PHONE:

CURRENT ADDRESS:

Street City State Zip

NAME AND LOCATION OF HIGH SCHOOL LAST ATTENDED: __________________________________________________________________________________

HIGH SCHOOL GRADUATE: ( ) YES ( ) NO; EQUIVALENT: ( ) G.E.D. ( ) HIGH SCHOOL PROFICIENCY; COLLEGE: ( ) AA/AS ( ) BA/BS ( ) MASTERS/PhD

ARE YOU PROFICIENT IN SECONDARY LANGUAGE: ( ) YES ( ) NO If yes, Language:__________ documented by ( ) Proficiency Exam ( ) Advanced Coursework

ARE YOU CURRENTLY LICENSED/CERTIFIED IN A HEALTH FIELD (i.e. CNA, EMT, HHA, LVN? ( ) YES ( ) NO TYPE:______________ EXPIRES:_________________

DO YOU HAVE MORE THAN 2OO HOURS OF WORK/VOLUNTEER EXPERIENCE IN DIRECT PATIENT HEALTHCARE WITHIN THE LAST 3 YEARS? ( ) YES ( ) NO

DO YOU HAVE LIFE EXPERIENCE/SPECIAL CIRCUMSTANCES AS LISTED ON PG 8?: ( ) YES ( ) NO If yes, which area(s): ( ) 6A ( ) 6B ( ) 6C ( ) 6D ( ) 6E ( ) 6F ( ) 6G

ARE YOU A PREVIOUSLY QUALIFIED APPLICANT? ( ) YES ( ) NO If so, in what year(s) did you apply? _____________________________

WILL YOU BE SUBMITTING AN UPDATED TRANSCRIPT? ( ) YES ( ) NO, PLEASE USE MY PREVIOUSLY SUBMITTED TRANSCRIPT(S)

WERE YOU AN ALTERNATE CANDIDATE DURING THE LAST (MOST RECENT) MCS APPLICATION PERIOD & ATTENDED BOTH ORIENTATIONS? ( ) YES ( ) NO

ARE YOU A VETERAN? ( ) Y ( ) N If yes, did you receive medical training while in the service? (Explain type of training)__________________________________

LIST ALL COLLEGES AND UNIVERSITIES ATTENDED, INCLUDING SHASTA COLLEGE (Use an additional sheet if needed):

NAME OF COLLEGE LOCATION UNITS COMPLETED

(indicate Quarter or Semester) Dates Attended

FROM/TO DEGREE Q S Q S Q S

ACADEMIC HISTORY: OFFICIAL (sealed) high school & college transcripts of attempted/completed course work must be enclosed with the Application Packet. Note: High school transcript is not required if applicant has a post-secondary degree and is submitting an official transcript showing when the degree was conferred.

A. COMPLETED GENERAL ED. HUMANITIES COURSE (THREE SEMESTER UNITS FOR A.S. DEGREE) ( ) YES ( ) NO B. COMPLETED GENERAL ED. MULTICULTURAL REQUIREMENT (THREE SEMESTER UNITS FOR A.S DEGREE IF CATALOG RIGHTS 2008F FORWARD) ( ) YES ( ) NO C. COMPLETED MATH COMPETENCY FOR A.S DEGREE? (MATH 102, 110, OR HIGHER REQUIRED IF CATALOG RIGHTS 2009/2010 FORWARD) ( ) YES ( ) NO D. REQUIRED PRE-REQUISITE COURSES; PLEASE INDICATE BELOW WHICH YOU HAVE COMPLETED AND WHEN.

NO (complete all of pg. 1)

A.S. REQUIREMENTS (not included in pre-requisites) (units referenced are semester units)

NAME OF COURSE COLLEGE COMPLETED Semester &

Year GRADE

A. One three unit Humanities courseB. One three unit Multicultural course C. One three-unit Math course to meet A.S.

RequirementI have completed a higher level math course – pleaseuse grade from that course when calculating GPA

All courses listed in Sections A through D must be completed prior to applying to the Associate Degree Nursing Program. If courses were not taken at Shasta College, include course descriptions from college(s) attended.

If applicant has a B.A./B.S. or higher degree, applicant is exempt from A.S. requirements. Are you exempt? YES (go to item D)




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All courses listed in Sections A through D must be completed prior to applying to the Associate Degree Nursing Program. If courses were not taken at Shasta College, include course descriptions from college(s) attended.

D. PRE-REQUISITE COURSES(units referenced are semester units) NAME OF COURSE COLLEGE

COMPLETED Semester &

Year GRADE

Anatomy 1, with lab (4-5 units) Physiology 1, with lab (4-5 units) Microbiology 1, with lab (4-5 units) English 1A (3-4 units)

I have also completed English 1B or 1C – please use grade from that course when calculating GPA

Sociology 1 or Anthropology 2 (3 units) (SOC 2 accepted if completed Spring 2017 or prior.) Psychology 1A (3 units) (PSYC 14 accepted if completed Spring 2017 or prior.) Communication Studies 60 or 54 (3 units) (CMST 10 accepted if completed Spring 2014 or prior.)

Statement of Understanding and Signature Page to Follow on Page 3

NAME (Last, First, M.I.):________________________________________________________________SHASTA COLLEGE ID:_______________________________

EMAIL ADDRESS (REQUIRED FOR ALL APPLICANTS): _________________________________________________________________________________________________________________________________

If applicant has attended another nursing program, a letter from the nursing program director of the previous school, regarding applicant's standing in the program is required.

*NOTE: Letters from program director of previous nursing schools must be OFFICIAL; Official letters are those which have been received onletterhead from another institution in a sealed envelope and remain unopened. DO NOT OPEN. Once an envelope is opened (seal broken), itcannot be accepted by Shasta College for the purpose of admission to the Associate Degree Nursing Program

( ) NO, I have not attended another nursing program

( ) YES, I have attended (an)other nursing program(s) and have included a letter from the nursing program director(s)

If yes, name of nursing school(s)________________________________________________________________

___________________________________________________________________________________________

STATEMENT OF UNDERSTANDING: By reading the Shasta College Associate Degree Nursing Program Enrollment Procedure and Eligibility Requirements at www.shastacollege.edu/HSUP , I hereby acknowledge that failure to follow Multicriteria Selection procedures or omission of required materials will result in disqualification of my Multicriteria Selection packet.

_______________________________________________________________________ _______________________________ Signature of Applicant Date

http://www.shastacollege.edu/HSUP




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NAME (Last, First, M.I.):________________________________________________________SHASTA COLLEGE ID:_______________________________________

EMAIL ADDRESS (REQUIRED FOR ALL APPLICANTS):_________________________________________________________________________________________________________________________________

STATEMENT OF UNDERSTANDING:

I. I acknowledge reading the Shasta College Associate Degree Nursing Program Multicriteria Selection Process athttp://www.shastacollege.edu/Academic%20Affairs/HSUP/REGN/Pages/Multicriteria%20Selection%20Process.aspx , and hereby understand that failure to follow application procedures, and/or omission of required materials will result in disqualification of my ADN Multicriteria Selection Application.

II. I understand that this is an application to Shasta College’s Associate Degree Nursing Program through the 2020 Multicriteria Selection Process. I further understand that I need to enclose all pages (one (1) through three (3)) of this application in the application packet for submission during the 2020 filing period.

III. I understand that a complete application packet requires additional items as outlined on the Multicriteria Selection Check List. These items need to be enclosed in the application packet with this application. I further understand if any required criterion is not met or if documentation for a required criterion is omitted, my application may be disqualified.

IV. I understand that if any optional criterion is not met, or if documentation for an optional criterion is omitted, its respective points may NOT be awarded.

V. I understand that failure to provide a sealed and unopened letter regarding my standing in any prior nursing programs in which I have participated may cause my application to be disqualified.

VI. I understand that any question answered “No” in items A through C (Graduation Requirements) or D (Pre-Requisite Courses) on the application means that I have NOT met a necessary criterion for eligibility into the Associate Degree Nursing Program and my application may be disqualified.

VII. I certify that I have a 62% or higher score for all individual areas (Reading, Math, Science, and English and Language Usage) of the TEAS exam in addition to a total (Composite) score of 62% or higher. I understand that if any score on my TEAS exam is below 62%, I have NOT met a necessary criterion for eligibility to Shasta College’s Associate Degree Nursing Program through the Multicriteria Selection Process and my application may be disqualified. EXCEPTION: I certify that I have successfully completed all remediation requirements which may include, but is not limited to, having to retake the TEAS exam and have included a copy of my completed remediation plan, signed off by the appropriate Director/Dean, with this application.

VIII. I understand that the TEAS exam may be repeated a maximum of one (1) time; if acceptable scores are not attained after the second attempt, I am ineligible to apply to Shasta College’s Associate Degree Nursing Program through the Multicriteria Selection Process indefinitely.

IX. I certify that I have NOT received unsatisfactory scores for the TEAS exam more than once (1).

X. I understand that all non-time-sensitive clinical requirements (Tdap, Varicella, MMR, HepB) are required and proof of immunization or proof of immunity in lieu of immunization must be enclosed in the applicant packet for submission during the 2020 filing period. I further understand that if I am found to be non-immune to any of the clinical requirements, or if proof of vaccination is omitted and immunity has not been proven, my application may be disqualified.

XI. I understand per California Code of Regulations, 16 CCR § 1105, science courses: Anatomy, Physiology, Chemistry, Biochemistry, and Microbiology, must typically have included an in-person laboratory component. Online labs are will be accepted at this time.

XII. By signing below I certify that, for each science course aforementioned and stated on page 1, I have participated in a lab component, either online or in-person.

XIII. I understand that if I am selected as an Invitee or as an alternate, the Health Sciences Division shall determine when my entry into the program will begin, whether it shall be in the spring or the fall semester. I further understand that program entry dates are non-negotiable, meaning I will NOT have a choice as to which semester I will be required to begin.

XIV. I understand that deferment is not an option for the Shasta College Associate Degree Nursing Program Multicriteria Selection Applicants.

XV. I understand that if I am unable to participate in the program during the semester for which I am selected and invited into, I will be disqualified and my position will be offered to the next alternate awaiting an opening in the program.

XVI. I understand that if I am disqualified during this application filing period but am still interested and eligible to participate in the Shasta College Associate Degree Nursing Program, I will need to re-apply during a future application filing period and complete all Multicriteria Selection Process steps, including, but not limited to, obtaining all required official documents such as, but not limited to, official transcripts, work experience letters, proof of immunity or vaccination, etc., the same as students who are applying for their first time.

XVII. I certify that the statements I have made on this application are true and complete. I understand that any misrepresentation or omission of data may result in program ineligibility or dismissal from the program.

_______________________________________________________________________ _______________________________ Signature of Applicant Date

http://www.shastacollege.edu/Academic%20Affairs/HSUP/REGN/Pages/Multicriteria%20Selection%20Process.aspx


MULTICRITERIA SELECTION (MCS) APPLICATION PACKET

Proficiency or Advanced Level Coursework in Languages other than English Verification Form

In order to receive credit for proficiency or advanced level coursework in languages other than English, applicants must submit additional documentation with this verification form.

In order to ensure the applicant’s proficiency or advanced level coursework in languages other than English can be appropriately evaluated, please provide complete information and include the required documentation as noted below.

I understand and acknowledge that, in addition to this form, additional documentation, as disclosed above in section titled Additional Required Documentation, is required to obtain credit for proficiency or advanced coursework in languages other than English and that I have enclosed such documentation, along with this form, in my application packet.

Student Signature: _______________________________________________________________________Date:___________

Additional Required Documentation In order to receive credit for proficiency or advanced level coursework in languages other than English you will need to obtain and submit the following respective required documentation:

For Proficiency in Languages other than English: Copy of proficiency certification indicating applicant is fluent in all aspects of language (reading, writing, listening and speaking) from college/university professor on college/university letterhead; or certification of proficiency from an accredited foreign language proficiency test center such as the American Council on the Teaching of Foreign Languages (ACTFL).

For Advanced Level Coursework in languages other than English: Official transcript from a U.S. regionally accredited college or university, or equivalent, verifying successful completion of two (2) semesters study in the same foreign language or successful completion of one level 2 or higher foreign language; or an Advanced Placement (AP) Transcript showing a Foreign Language with a score of 5; or an Official College Level Examination Program (CLEP) transcript showing completion of a Level II foreign language course with a scaled score of 50 or higher.

Proficiency or Advanced Level Coursework in Language other than English

Applicant must be fluent in all aspects of language (reading, writing, and speaking) to qualify.

Proficiency in languages other than English:Language: _______________________________________________________________

Proficiency Certification: ___________________________________________________

Certifying Organization: ____________________________________________________

Advanced level coursework in languages other than English:

Language: _______________________________________________________________

School: _________________________________________________________________

Term: _____________ Course: ______________________________Grade: ___________

School: __________________________________________________________________

Term: _____________ Course: ______________________________ Grade: __________



Licensed or State Certificated Worker Verification Form

In order to receive the licensed or state certificated worker credit, applicants must complete and submit this form along with a copy of their current state license, and, or certificate with the following: license/certificate number, date of issue and expiration.

In order to ensure the applicant’s state licensed, and, or certificated worker credit can be appropriately evaluated, please provide complete information and include the required documentation as noted below.

License/Certificate Type

Licensed Healthcare Worker (examples: Licensed Vocational Nurse, Psych Tech, Radio Tech, Paramedic)

Certificated Healthcare Worker (Certified Nurse Aide, Home Health Aide, EMT, Medical Assistant)

This verifies that I,______________________________ , hold a current and valid: License and/or State Certificate. (Name of Applicant)

License Number: ______________________________ Date of Issue: __________________ Expiration: _________________ Certificate Number: ____________________________ Date of Issue: __________________ Expiration: _________________

I understand and acknowledge that, in addition to this form, a copy of my current and valid license and/or certificate as disclosed above in section titled Additional Documentation, is required to obtain credit for the licensed and/or state certificated healthcare worker criteria and that I have enclosed such documentation, along with this form, in my application packet. Student Signature: _______________________________________________________________________Date:___________

Additional Documentation In order to receive credit for holding a state license, and/or certificate as a healthcare worker, in addition to submitting the Shasta College Licensed or State Certificated Worker Verification Form, you will need to provide copies of the following, as applicable:

For licensed healthcare worker credit:

Copy of your current license with your license number, date of issue, and expiration.

For state certificated healthcare worker credit:

Copy of your current state certificate with your certificate number, date of issue, and expiration.



Work or Volunteer Experience Verification Form

In order to receive work and/or volunteer experience credit, applicants must submit additional documentation of work/volunteer experience along with this form. In order to use work/volunteer experience hours accumulated from more than one employer/organization, a separate form must be submitted for each employer/organization.

In order to ensure the applicant’s work experience can be appropriately evaluated, please provide complete information and include the required documentation as noted below.

This verifies that I,_________________________ , was an employee or volunteer at (Name of Applicant) (Please circle experience) (Name of firm, agency, etc.)

________________________________________________________________ ________________________________ (Address of firm, agency, etc.) (Phone number)

From to for a total of hours. (Date) (Date)

Name of Supervisor: ____________________________________________________________________________________

I understand and acknowledge that, in addition to this form, additional documentation, as disclosed above in section titled Additional Documentation, from my current, and, or former employer/organization is required to obtain credit for my work and, or, volunteer experience and that I have enclosed such documentation, along with this form, in my application packet.


Work or Volunteer Experience Type • Employee: Healthcare experience (>200 hours, with direct human care/contact, within the last 3 years)

• Volunteer: Healthcare experience (>200 hours, with direct human care/contact, within the last 3 years)

Requirement: Accumulated Employee/Volunteer Healthcare experience > 200 hours, with direct human contact, within the last 3 years; or, accumulated Employee Healthcare experience >200 hours, with non-direct human care/contact, within the last 3 years

Additional Documentation In order to receive credit towards work/volunteer experience, in addition to submitting the Shasta College form, you will need to obtain a formal letter from each of your current, and, or former employer(s)/organization(s) meeting the requirements below:

For Work Experience with Direct Human Care/Contact: The letter must be on organization letterhead with an original signature and include the applicant’s name (must match name on application), start date and end date (if applicable), employment status, (full-time/part-time), number of hours worked per week (or total hours worked from/to date), job title, department (if applicable), and examples of duties including patient interaction.

For Work Experience with Non-Direct Human Care/Contact: The letter must be on organization letterhead with an original signature and include the applicant’s name (must match name on application), start date and end date (if applicable), employment status, (full-time/part-time), number of hours worked per week (or total hours worked from/to date), job title, department (if applicable), and examples of duties.

For Volunteer Experience with Direct Human Care/Contact: The letter must be on organization letterhead with an original signature and include the applicant’s name (must match name on application), start date and end date (if applicable), total number of hours volunteered, and examples of duties including patient interaction.

Employee: Healthcare experience (>200 hours, with non-direct human care/contact, within the last 3 years) [i.e. Clerical positions such as medical scribe, patient registration, and reception.]

•



Life Experience or Special Circumstance Verification Form

In order to receive life experience or special circumstance credit, applicants must submit additional documentation with this verification form.

In order to ensure the applicant’s life experience(s) or special circumstance(s) can be appropriately evaluated, please provide complete information and include the required documentation as noted below.

I understand and acknowledge that, in addition to this form, additional documentation, as disclosed above in section titled Additional Required Documentation, is required to obtain credit for life experience or Special Circumstance and that I have enclosed such documentation, along with this form, in my application packet.


Life Experience or Special Circumstance Type

• 6A - Disabilities (Same meaning used in Section 2626 of the Unemployment Insurance Code)

Additional Required Documentation In order to receive credit for life experience(s) or special circumstance(s), you will need to obtain and submit the following respective required documentation:

6A: Documented disability from College Learning Disability Program or Partners in Access to College Education (PACE)

6B: Proof of eligibility or receipt of financial aid for the current year under a program that may include, but not limited to, a fee waiver from California’s Promise Grant, the Cal Grant Program, the Federal Pell Grant Program or CalWORKS.

6C: Attach and sign a letter which supports and explains your situation or circumstances

6D: Paycheck stub during period of time enrolled in prerequisite courses or letter from employer (must be on organization Letterhead and signed) verifying employment was at least part-time while completing prerequisite courses

6E: Documented proof of current participation in Extended Opportunity Programs and Services (EOPS)

6F: Documentation or letter from United States Citizenship & Immigration Services (USCIS)

6G: Copy of DD-214. Service in active military, naval, or air service, and discharge under conditions other than dishonorable. Active service includes full-time duty in the National Guard. An eligible spouse would include the widow/er of a veteran that otherwise meets this criterion.

• 6D - Need to Work (Need to work means student is working at least part-time while completing academic work that is prerequisite for the Nursing Program

• 6E - Disadvantaged Social or Educational Environment

• 6F - Refugee Status

• 6B - Low Family Income

• 6G – Veteran Status/Veteran’s spouse

• 6C - First Generation to Attend College



Alternate Verification Form

In order to receive credit for being an Alternate, applicants must complete and submit this form, provide a copy of their Alternate Acceptance Notification email, and have completed all Alternate requirements including, but not limited to, participation in both online and in-person orientations.

In order to ensure the applicant’s work experience can be appropriately evaluated, please provide complete information and include the required documentation as noted below.

ADN Alternate Requirements

Received and accepted alternate invitation from last Multicriteria Selection period

Has not previously enrolled in the ADN program

Completed all alternate requirements: including, but not limited to, participation and completion of both online and in-person orientations

This verifies that I,___________________________________ , received and accepted the ADN alternate invitation for the last Multicriteria Selection Application Filing Period, was not enrolled into the ADN program and completed all alternate requirements including, but not limited to, participation in both online and in-person orientations.

Furthermore, I understand and acknowledge that, in addition to this form, all requirements as disclosed above in section titled ADN Alternate Requirements must be satisfied, and additional documentation, as disclosed above in section titled Additional Required Documentation, are required to obtain credit as an Alternate and that I have completed all such requirements and have enclosed required documentation, along with this form, in my application packet.


Additional Required Documentation A list of candidates eligible for points as an alternate from the last Multicriteria Selection Application Filing Period will be submitted to the Admissions and Records office by the Health Sciences Office, however, in order to receive credit for being an Alternate in the last Multicriteria Selection period, you will need to:

Print and submit a copy of your Alternate Acceptance Notification email

Health Sciences & University Programs

Associate Degree Nursing MCS Application Process Clinical Requirements Check List

Last Reviewed & Revised 9/9/2019 Page 1 of 3

Name ____________________________________________________________________

Date: ______________________________ Shasta College ID #___________________ Directions: Complete all the sections below and include this form in your MCS application packet along with a copy of your official immunization documentation. Students who cannot complete or provide documentation of immunization requirements are ineligible for application to the Associate Degree Nursing (ADN) program. If an ineligible packet is received, the MCS application will be disqualified.

DOCUMENTATION REQUIREMENTS TDaP Documentation Requirements: 1. Official immunization documentation showing a one-time dose of TDaP (includes Pertussis) as an adult, and a

subsequent TD booster if TDaP is over 10 years old. Varicella, MMR, and Hep B Documentation Requirements: Immunity to Varicella, Measles (Rubeola), Mumps, Rubella, and Hepatitis B must be documented by serum quantitative titers (with numerical values). Titers offer the most objective documentation and protection for the student and institution. Titers can be obtained at a clinical laboratory through a written order by a primary care provider. TITER RESULTS All Titers must show patient name/information, lab/doctor’s information, date of collection, name of test, the numerical values used in interpreting the results, and the results. Titer results don’t expire. POSITIVE: If the results are immune and/or reactive, no further titer labs are needed. NEGATIVE/EQUIVOCAL/NON-REACTIVE: If titer results indicate lack of immunity, are non-reactive, or are equivocal, to any of these diseases, the applicant must consult with their primary care provider about receiving the applicable, required booster and/or series to obtain immunity. After receive any required boosters/series, an applicant must obtain a new titer showing immunity and submit proof of the titer. No other documentation of the boosters/doses are required. NOTE: Quantitative titers have a numerical value. Qualitative titers simply indicate “immune vs. non-immune” (with no numerical value). Qualitative titers will not be accepted and will result in disqualification of application. Applicants need IgG titers. DO NOT get labs for IgM titers. Applicants must obtain proof of the Hepatitis B Surface AB (antibody), NOT the AG (antigen) titer.




Name ____________________________________________________________________

Date: ______________________________ Shasta College ID #___________________

THIS FORM IS A REPORTING DOCUMENT FOR SHASTA COLLEGE HEALTH SCIENCES – NOT INTENDED TO BE

AN OFFICIAL RECORD. ALL OFFICIAL TITER RESULTS MUST BE ATTACHED. This form is to be filled out by the applicant, not the healthcare provider.

Tetanus, Diphtheria, Pertussis (TDaP): Must submit proof of

A. One time dose of TDaP (includes pertussis) as an adult, and a subsequent TD booster, if TDaP is over 10 years old.

OR Date ___________________

B. Subsequent Td booster every 10 years following one-time TDaP Date ___________________

Varicella: Must submit proof of a quantitative IgG titer

Titer Date: _________________________________ Numerical Value: _____________________

Measles (Rubeola), Mumps, Rubella (MMR): Must submit proof of quantitative IgG titer

Titer Date(s): __________________________________ ______________________________________________

Numerical Values Measles (Rubeola): ________________

Mumps: ___________

Rubella: _____________

Hepatitis B – see page 3 if non-reactive or equivocal

Hepatitis B: Must submit proof of titer (Hep B AB [antibody], NOT Hep B AG [antigen])

Titer Date:_______________________________ Numerical Value: _______________________




Hepatitis B continued

Applicant Statement: I hereby certify that all materials presented and all statements made are true and correct. I authorize investigation of all records submitted and am prepared to provide original documentation when requested. I understand that any misrepresentation of material facts may be cause for immediate disqualification. Furthermore, I understand and acknowledge that, in addition to this form, additional documentation showing proof of immunity or immunization, as disclosed above in section titled Documentation, on page 1, is required and failure to meet requirements or omission of required documentation will result in disqualification of my MCS application packet.

Signature of Applicant: ______________________________________ Date: _____________________

For Health Sciences Division Use Only: Date Received:

Immunization official documentation verified by:

Notes:

If numerical value for titer falls in the “grayzone”/borderline or non-reactive/negative range, you will need to: 1) Receive at least one (1) booster of the vaccine. Discuss with your healthcare provider if your titer results

indicate that you may need multiple booster or to repeat the entire series. PLEASE START THIS IMMEDIATELY.

2) Obtain a new titer for Hepatitis B (AB) [antibody], NOT Hep B AG [antigen] at least 4 weeks after the final booster/dose and submit the results showing positive/immune.

1st Booster/Dose: __________________________

(if applicable)

2nd Booster/Dose: __________________________ Date of repeat titer: _________________

3rd Booster/Dose: ___________________________

Note: If three dose vaccine series is needed, the CDC standard recommendations are for the series to be given at 0, 1, and 6 months. CDC minimum requirements allow for the series to be given at 0, 1, and 4 months.

For applicants deemed “non-converters” by their primary healthcare provider, provide proof of ALL Hep B vaccination & titer records as well as a letter from the provider confirming non-converter status.

Documents

packets for 2020 will be accepted , 2020. PACKETS WILL NOT ...€¦ · packets for 2020 will be accepted November 2, 2020 through 4:00pm, Fri day, November 2 0, 2020 in the Shasta