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Kiamichi Technology Centers

SCHOOL OF PRACTICAL NURSING

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Kiamichi Technology Centers Practical Nursing Program isApproved by the Oklahoma Board of Nursing and

Accredited by the Oklahoma State Board of Career and Technology Education

KIAMICHI TECHNOLOGY CENTERSSchool of Practical Nursing

INSTRUCTIONS FOR PN APPLICATION FOR ADMISSIONBecause class sizes are limited the selection for entrance into the Practical Nursing Program is based upon a point system arrived at through the application process and seat availability. This process includes the following entrance requirements that must be met for consideration of an interview with the Admissions Committee:

STEP 1: The Kiamichi Technology Centers (KTC) Practical Nursing (PN) program is for ADULT STUDENTS ONLY. All applicants must be 18 years old by the first day of class. • Full-Time Programs begin July 8, 2020 Part-Time Programs begin August 11, 2020

STEP 2: Applicant must submit an official copy of their high school transcript, or a copy of their General Education Development (GED) scores. A copy of your diploma is NOT acceptable. If an applicant does not have a high school diploma or GED, the applicant must provide a copy of HiSET scores, or a transcript showing completion of secondary school education in a homeschool setting.

STEP 3: Applicants who received their high school education outside the United States must submit official documentation that their high school education and subsequent graduation is equivalent to that of a high school graduate in the United States. This may be accomplished by one of the following methods:

a) Take the GED exam and submit scores/documentation indicating high school equivalency. The applicant may contact KTC counselor for assistance with this process.

b) Request a review/evaluation of academic records from an official agency that specializes in validating academic credentials of person educated outside the United States. Applicant may contact the World Education Services at www.wes.org. Provide proof/documentation of such to KTC with the application packet. Such documentation must indicate that the applicant’s education meets high school graduate equivalency in the United States.

c) If the applicant has completed a minimum of 30 college hours from an accredited/approved higher education institution within the state of Oklahoma, the applicant may be eligible to petition the Oklahoma Department of Education to be awarded high school equivalency. For more information, the applicant may contact the Oklahoma Department of Education at 1(800)405-0355 or 1(405)521-3301.

It is the applicant’s responsibility to provide one of the above forms of documentation. The applicant is responsible for any cost that might be incurred.

STEP 4: Individuals applying for enrollment must comply with the request for Criminal History Records Search (CHRS/background check), which is a national search including a sex offender registry check. It is the applicant’s responsibility to purchase and complete the CHRS online at https://portal.castlebranch.com/KC82 and provide the CastleBranch Confirmation Number on the CHRS Form included in the KTC PN Application prior to submitting the PN Application for Admission. Results of this report will be sent to KTC PN Administration to be placed in the applicants file. Results will also be sent to the applicant.

The fee for the CHRS must be paid, by the applicant, online at https://portal.castlebranch.com/KC82. If an applicant fails to submit the CHRS and pay the fee by the deadline date, the Application is considered incomplete and the individual forfeits consideration for an interview with the Admissions Committee.

If an individual has a history of criminal charges/convictions, then a written statement describing the date, location, and circumstances of the incident(s), and the resulting action(s) taken by the court or agency must be provided with the PN Application. If the individual has more than one incident that is being reported, each case/charge filed must be described.

Potential applicants to KTCs PN Program with a criminal history of felony conviction(s), MUST obtain an initial determination of eligibility for licensure from the Oklahoma Board of Nursing (OBN) and submit a copy of the determination with the PN Application. To obtain an Initial Determination of Eligibility, the required form shall be obtained, completed and filed with the OBN. The OBN does charge a fee for the Initial Determination of Eligibility. The form can be accessed at http://nursing.ok.gov/initialdeterm.pdf.

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http://nursing.ok.gov/initialdeterm.pdf

https://portal.castlebranch.com/KC82


http://www.wes.org/

Upon acceptance into the PN Program “certified/official” copies of court documents for arrest records must be submitted to PN Administration to accompany your application to the State Board of Nursing at the time of graduation.

STEP 5: Applicants have two (2) pre-entrance exam options, the ACT (Residual or National) and the Next-Generation ACCUPLACER. Applicants may use one of these exams or a combination of scores from these exams.

a) Each Next-Generation ACCUPLACER Test cost $2.50 each.b) An applicant may retake any Next-Generation ACCUPLACER Test no more than one (1) time.c) Should an applicant decide to retake a Next-Generation ACCUPLACER Test, there must be a minimum of fourteen

(14) days between test dates.d) Next-Generation ACCUPLACER scores will be accepted up to two (2) years from the time of submission of nursing

application.e) Next-Generation ACCUPLACER scores may be accepted from other testing facilities/schools other than Kiamichi

Technology Centers.f) Contact a local KTC Campus to schedule a time for testing of the Next-Generation ACCUPLACER test(s):

a. Readingb. Arithmeticc. Quantitative Reasoning, Algebra & Statistics

g) Submit copies of ACT and/or Next-Generation ACCUPLACER scores with the KTC PN Application

STEP 6: All international applicants (regardless of U.S. Citizenship) for whom English is a second language (English Second Language – ESL) must present evidence of proficiency in the English language. A TOEFL test is required for admission in addition to taking the pre-entrance examination. These tests are used to assess placement. You may obtain information about the test by writing to: TOEFL, Box 899, Princeton, NJ 08541, U.S.A., or by accessing the TOEFL website, www.toefl.org. Submit a copy of your TOEFL results with your KTC PN Application.

TOEFL Scores required: 500 on paper-based test; 173 on computer-based test, or 61 on internet-based test

NOTE: The following exceptions apply to the English proficiency requirement:Students from Australia, New Zealand, the British Isles, and the English speaking provinces of Canada are exempt. Students from other countries where English is the primary language of instruction and the language spoken at home and by the indigenous population may petition for an exception.

Students who have earned a baccalaureate degree from a regionally accredited United States college or university and students who have earned a high school diploma from a United States high school with passing scores are exempt.

STEP 7: Submission of PN Application

a) Complete PN Application mailed to KTC, postmarked by the deadline along with accompanying documents.b) Official high school transcript; or a copy of GED Scores; or a copy of HiSet scores; or a transcript showing

completion of secondary education in a homeschool setting.c) Post-Secondary Educational Background or Certification(s) – Verification is required

a. Official Transcript(s) from any technology centers, colleges, or universities attendedb. Copies of any health-related certifications held (i.e., CNA, CMA)c. Copies of training completed (i.e., Phlebotomy, Registered Medical Assistant)

d) Three (3) appropriate references – Do NOT use family or friends as references.e) Criminal History

a. Purchase and complete the CHRS online at https://portal.castlebranch.com/KC82 and provide the CastleBranch Confirmation Number on the CHRS Form included in the KTC PN Application prior to submitting the PN Application for Admission.

b. Individuals with a history of criminal charges/convictions, must submit a written statement describing the date, location, and circumstances of the incident(s), and the resulting action(s) taken by the court or agency with the PN Application. If the individual has more than one incident that is being reported, each case/charge filed must be described.

c. Applicants with a criminal history of felony conviction(s), MUST obtain an initial determination of eligibility for licensure from the Oklahoma Board of Nursing (OBN) and submit a copy of the determination with the PN Application.

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http://www.toefl.org/

f) Pre-Entrance Test Scoresa. Copies of ACT (Residual or National) scores, and/orb. Copies of Next-Generation ACCUPLACER scores

g) International Applicants (regardless of U.S. Citizenship) – English Second Languagea. Copy of TOEFL scores

NOTE: Meeting the stated requirements does not guarantee admission to the KTC PN Program. Qualified applicants will be contacted for an interview. Selection for entrance in the PN Program is based upon a point system. Applicants are evaluated on a number of variables including: evidence of motivation, academic ability, personal understanding of and propensity for practical nursing, references, interview, and potential for continued constructive use of professional education. Following the interview process with the Admissions Committee, qualified applicants with the highest interview scores will be admitted into the program.

Dates for the KTC Practical Nursing Applicant Interviews Durant – May 15 & 18, 2020 (May 19, 2020 if needed) Hugo and Antlers (at Hugo Campus) – May 11-12, 2020 (May 13, 2020 if needed) Idabel – May 20 & 22, 2020 McAlester – May 27-28, 2020 Poteau – May 15 & 18, 2020 (May 19, 2020 if needed) Stigler – May 20, 2020 Talihina – May 22, 2020

KTC PN Administration reserves the right to close or extend the application period without advance notification.

KTC reserves the right to determine the number of applicants to interview at each campus based on the number of seats available and number of applications received.

KTC is not obligated to interview/admit applicants scoring below the pre-entrance minimum recommended scores. If more applicants are desired, KTC reserves the right to consider applicants scoring below the minimum criteria. If these applicants are admitted the school will establish preference determinations at that time. In this situation, certain additional admission conditions may apply.

KTC PN Program uses a self-manage application process in which it is the applicant’s responsibility to submit all transcripts and other required documents, by mail, to the KTC PN School of Nursing Office (P.O. Box 70, Antlers, OK 74523). Applicant is also responsible for submitting their CHRS online prior to submitting their PN Application. The PN Application must be postmarked, in one complete packet, along with all accompanying documents, by the application deadline. Please feel free to call the PN School of Nursing Office (580-298-5160) if you have any questions regarding the admissions process.

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

NOTE: KTC only keeps applications on file for the year in which the applicant applied. If you are not accepted for the school year which you applied for and want to be considered for the next class, you will need to reapply.

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KTC PRACTICAL NURSINGPRE-ADMISSION EXAMINATION

Applicants may use one of the following tests or a combination of scores from the tests when applying to Kiamichi Technology Centers Practical Nursing Program to be considered competitive. The two (2) testing options are the ACT (Residual or National) and the Next-Generation ACCUPLACER. The Pre-Admission Test Criteria and Interview Scoring Rubric is below.

If using ACT scores, the highest score from ANY test in the areas of Reading or Science Reasoning and Math will be accepted. Please refer to the table below for the minimum recommended ACT score.

If the ACT score in the Reading and Math are below the minimum required then the applicant will need to take the Next-Generation ACCUPLACER tests: Reading, Arithmetic, and Quantitative Reasoning, Algebra, and Statistics.

If only one ACT score is below the minimum required, then the applicant will take the Next-Generation ACCUPLACER test(s) for that area ONLY.

Also, the applicant may take the Next-Generation ACCUPLACER test(s) in an attempt to raise their score and thereby, raise the points received for Reading or either of the Math Tests.

PRE-ENTRANCE TEST CRITERIA EVALUATION SCALEHigh School Grade Equivalencies

AreasOne of the following tests are required.

May combine test scores.8th – 9th

Grade10th

Grade11th

Grade12th

Grade

Reading Test (Minimum recommended 10th grade)

ACT – Reading orScience Reasoning

Accuplacer

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250-262

20

263-275

21 or greater

276 or greater

Points Awarded 2 4 6 8

Math Test ACT 17-18 19 20 21 or greater(Minimumrecommended Accuplacer8th – 9th grade) Arithmetic 225-249 250-262 263-275 276 or greater


Math Test ACT 17-18 19 20 21 or greater(Minimumrecommended Accuplacer8th – 9th grade) Algebra 225-249 250-262 263-275 276 or greater


Each Next-Generation ACCUPLACER Test costs $2.50/each.

An applicant may retake any Next-Generation ACCUPLACER Test no more than one (1) time.

Should an applicant decide to retest on a Next-Generation ACCUPLACER Test, there must be a minimum of fourteen (14) days between test dates.

Next-Generation ACCUPLACER Test scores may be accepted from other testing facilities/schools other than Kiamichi Technology Centers.

Next-Generation ACCUPLACER scores will be accepted up to two years from the time of submission of nursing application.

Applicant may still submit application with minimum or above Reading score and below minimum Arithmetic & Algebra pre-entrance scores as listed above for potential consideration.

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IMMUNIZATION GUIDELINESImmunization/Health Screening requirements are based on clinical institutions’ required documentation to attend clinical.

Additional immunizations/screenings may be required by clinical institutions.

EACH STUDENT MUST PROVIDE EVIDENCE OF IMMUNITY AGAINST THE FOLLOWING DISEASES:

IMMUNIZATION EVIDENCE OF IMMUNITY

Tuberculin PPDSkin Test

Evidence of a negative tuberculin PPD test received between June 1st of current year and the first day of class

or If evidence of a positive Tuberculin test, then:

Evidence of a follow-up negative Chest x-ray (within the past 3 years)

MMR(measles, mumps, rubella)

Documentation of immunity by either: Evidence of two (2) vaccines at least 4 weeks apart after the age of 12 months’ old

or Evidence of a positive blood test indicating immunity

HEPATITIS A (HAV)

& HEPATITIS B

(HBV)

Documentation of immunity by either: Evidence of injections: (3 for Hepatitis B and 2 for Hepatitis A) given over a 6-month period.

or Evidence of a positive blood test indicating immunity

or Completion of a waiver indicating the student’s unwillingness to undergo Hepatitis B vaccination.

VARICELLA(Chicken Pox)

Documentation of immunity by either: Evidence of two (2) varicella vaccines given at least 28 days apart.

or Evidence of a positive blood test indicating immunity.

Td, Tdap (tetanus, diphtheria,pertussis)

Documentation of immunity: One-time dose of Tdap and evidence of Td boosters every 10 years thereafter.

INFLUENZA(Flu Shot)

Documentation of immunity by either: Evidence of one (1) vaccine, Instructor will announce in the Fall when this immunization is due

or Documentation from healthcare provider that vaccination is contraindicated.

Students who suspect that they may be pregnant or who are pregnant must consult a physician regarding the advisability of immunization.

EVIDENCE OF IMMUNITY MUST BE COMPLETED AND ON FILE BY THE FIRST DAY OF CLASS FOR REGULAR STUDENTS OR BY THE FIRSTDAY OF CLINICAL ROTATION FOR ALTERNATES SELECTED TO FILL VACANT SEATS. Td/Tdap and PPD skin test must not expire before the end of that school year.

FOR PART-TIME STUDENTS (SECOND YEAR) ONLY – IN ADDITION TO THE ABOVE REQUIREMENTS, SECOND YEAR PT STUDENTS MUST ALSO PROVIDE EVIDENCE OF THEIR ‘SECOND’ PPD, BY THE FIRST DAY OF CLASS IN AUGUST OF THEIR SECOND SCHOOL YEAR, AND CURRENT CPR CERTIFICATION THAT WILL NOT EXPIRE BEFORE THE END OF THAT SCHOOL YEAR.

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ATOKA

School of Practical Nursing

PRACTICAL NURSING PROGRAM APPLICATION(2020 PN Program Application)

Applicants are selected in accordance with nondiscriminatory practices. We use a self-managed application process in which it is the applicant’s responsibility to mail application, transcripts and other required documents to:

Kiamichi Technology Centers, School of Practical Nursing, P.O. Box 70, Antlers, OK 74523

Check which KTC Campus you are applying for ANTLERS DURANT HUGO IDABEL McALSTER POTEAU STIGLER TALIHINA

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. Complete the form by printing legibly in black ink.USE FULL LEGAL NAME (NO INITIALS)First Name Middle Name (no initials) Last Name

Street Address or P.O. Box City State Zip Code

Primary Phone Alternate Phone County (NOT COUNTRY) Email Address

CITIZENSHIP STATUSEffective November 1, 2007, applicants for licensure/certification by examination or endorsement, for reinstatement, and for renewal must provide verification of citizenship or qualified alien status as a requirement for licensure. HB 1804, The Oklahoma Taxpayer and Citizen Protection Act of 2007, requires all state agencies to cooperate with federal immigration authorities in the enforcement of federal immigration laws. Questions about your immigration status should be directed to the Bureau of Citizenship and Immigration Services (BCIS) at 1-800-375-5283.

Please check the appropriate box below to indicate your citizenship status.

I am a U.S. CitizenI am U.S. nationalI am a legal permanent resident alienI am a qualified alien

NURSING PROGRAM ATTENDANCEHave you applied to the KTC PN Program previously?

Yes NoIf yes, what year(s)? If yes, which campus?

VOLUNTARY INFORMATIONPROVIDING THE FOLLOWING INFORMATION IS STRICTLY VOLUNTARY. You will not be subject to adverse action or treatment if you choose not to provide this information. If you choose not to provide this information, please indicate “Decline” on each question.Gender: Male Female Decline to Identify

Ethnicity: African American/Black (Non-Hispanic) American Indian or Alaska Native Asian Hispanic or Latino of Any Race Native Hawaiian or Other Pacific Islander White (Non-Hispanic) Some Other Race/Ethnicity Two or More From this List Decline to Identify

EDUCATIONAL BACKGROUND: List all educational schools attended with degrees, diplomas or certificates received. Include a high school transcript, copy of GED scores, or a copy of HiSet scores with this application.

Name of High School/Home School City & State Graduation Date (mm/yyyy)

If you did not graduate, what is the highest grade you completed? Date of GED Test (mm/dd/yyyy) GED Score

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Date of HiSet (mm/dd/yyyy) HiSet Score

URSING PROGRAM ATTENDED

EDUCATIONAL BACKGROUND – CONTINUED POST-SECONDARY EDUCATION: List formal education beyond high school and include transcripts with this application.

Name of Institution City & State Attended From (mm/yyyy)To (mm/yyyy)

Major List diploma, Cert/Degree,# of Credits, GPA

HEALTH RELATED CERTIFICATIONS HELD Mail copies of certifications with this application.

Name of Certification Certification Earned From Date of Certification(mm/dd/yyyy)

Expiration Date ofCertification (mm/dd/yyyy)

EMPLOYMENT HISTORY: List work experience beginning with the most recent.Employer’s Name & Supervisor Position Held City & State Date From

(mm/dd/yyyy)Date To (mm/dd/yyyy)

Reason for Leaving

MILITARY SERVICEDate Entered(mm/dd/yyyy)

Branch of Service Rank at Discharge Date of Discharge orSeparation (mm/dd/yyyy)

Type of Discharge or Separation

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Major Duties

Service Schools Attended

ORGANIZATIONAL MEMBERSHIP, AWARDS, HONORSList participation in high school/college organizations and/or offices held in organizations. List awards received. List any extracurricular and scholastic honor received. ALL MUST BE WITHIN THE LAST TWO (2) YEARS WITH DATES LISTED.

COMMUNITY SERVICE, VOLUNTEER WORK, ADDITIONAL DATAList any information regarding community service or volunteer work you are or have been involved with that you feel may be helpful to us in considering your application. Use space to also give any other information you desire concerning work experience, qualifications, accomplishments, etc. ALL MUST BE WITHIN THE LAST TWO (2) YEARS WITH DATES LISTED.

t 2 years MUST LIST DATESNURSING PROGRAMS APPROVED BY THE OKLAHOMA BOARD OF NURSING

The Kiamichi Technology Centers (KTC) Practical Nursing Program (PN Program) is approved by the Oklahoma Board of Nursing (OBN). Graduates of this state- approved program are eligible to apply to write the National Council Licensure Examination (NCLEX) for practical nurses. Applicants for Oklahoma licensure must meet all state and federal requirements to hold an Oklahoma license to practice nursing. In addition to completing a state-approved nursing education program that meets educational requirements and successfully passing the licensure examination, requirements include submission of an application for licensure, a criminal history records search, and evidence of citizenship or qualified alien status [59 O.S. §§567.5 & 567.6]. To be granted a license, an applicant must have the legal right to be in the United States (United States Code Chapter 8, Section 1621). In addition, Oklahoma law only allows a license to be issued to U.S. citizens, U.S. nationals, and legal permanent resident aliens. Other qualified aliens may be issued a temporary license that is valid until the expiration of their visa status, or if there is no expiration date, for one year. Applicants who are qualified aliens must present to the Board office, in person, valid documentary evidence of:

1. A valid, unexpired immigrant or nonimmigrant visa status for admission into the United States;

2. A pending or approved application for asylum in the United States;

3. Admission into the United States in refugee status;

4. A pending or approved application for temporary protected status in the United States;

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5. Approved deferred action status; or

6. A pending application for adjustment of status to legal permanent resident status or conditional resident status.

The Oklahoma Board of Nursing has the authority to deny a license, recognition or certificate; issue a license, recognition or certificate with conditions and/or an administrative penalty; or to issue and otherwise discipline a license, recognition or certificate to an individual with a history of criminal background, disciplinary action on any professional or occupational license or certification, or judicial declaration of mental incompetence [59 O.S. §567.8]. These cases are considered on an individual basis at the time application for licensure is made, with the exception of felony convictions. Potential applicants to state-approved education programs, with a criminal history, may obtain an initial determination of eligibility for licensure or certification from the Oklahoma Board of Nursing for a fee. The initial determination of eligibility for licensure petition can be accessed at http://nursing.ok.gov/initialdeterm.pdf. (updated November 12, 2019)

REFERENCES: DO NOT USE FAMILY MEMBERS OR FRIENDS DO NOT USE FAMILY MEMBERS OR FRIENDSReferences are an important part of the selection process and should be from past or present employers, counselors, supervisors, or teachers. Reference forms must be mailed by KTC not by the applicant. KTC will not mail reference forms to an incomplete address. It is your responsibility to complete this section accurately. It is also your responsibility to ensure that the address information is correct. Reference forms will be mailed one time only by KTC staff. KTC is not responsible for lost or stolen mail.REFERENCE #1 – Name of Reference Business/Company Relationship to Applicant

Mailing Address City, State & Zip Code

REFERENCE #2 – Name of Reference Business/Company Relationship to Applicant


REFERENCE #3 – Name of Reference Business/Company Relationship to Applicant


NCES:

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CH

KTC use onlyTotal Points Achieved:

APPLICANT QUESTIONNAIRE1. Give four (4) specific reasons why you want to enter a nursing education program.

A.

B.

C.

D.

2. What do you consider your strongest qualification for nursing?

3. What motivated you to decide to come to school at this time?

4. Upon completion of the nursing program, what are your career goals?

5. How did you become aware of the KTC Practical Nursing Program? Please check all that apply.

NEWSPAPER KTC WEB PAGE

RADIO KTC BROCHURE

INSTRUCTOR FACEBOOK

FRIEND/FAMILY MEMBER TWITTER

CURRENT KTC STUDENT

CHOCTAW NATION CAREER DEVELOPMENT OTHER (PLEASE DESCRIBE)

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STATEMENT OF HEALTH BY APPLICANTTO THE APPLICANT: Health/Hospitalization Insurance is the applicant’s individual responsibility. It is not required but highly recommended. KTC and clinical facilities are not responsible for student’s personal injury. The student is not covered by sick benefits provided to employees of KTC or clinical facilities.

Professional Liability Insurance is insurance that protects the student & KTC in the event of a patient accident/injury. Professional Liability Insurance is required and will be included in the tuition.

The information provided below, by applicant, will help to ascertain that the student’s health status is suitable for activities in the role of a Student Practical Nurse in all aspects of theory and clinical practice. A physical examination may be required for further screening of any condition that might be detrimental in the role as a Student Practical Nurse or in patient care.

Applicant’s Name (print legibly): Date:

PLEASE ANSWER THE FOLLOWING QUESTIONS CONCERNING YOUR PERSONAL HEALTH HISTORY:1. Personal or family history of hepatitis and/or tuberculosis: (Answer N/A if not applicable)

2. Surgeries and approximate dates: (Answer N/A if not applicable)

3. Major injuries and approximate dates: (Answer N/A if not applicable)

4. Fractures or other orthopedic problems: (Answer N/A if not applicable)

5. Describe any limitations to lifting: (Answer N/A if not applicable)

6. Allergies (contact or respiratory): (Answer N/A if not applicable)

7. Sight, hearing, speech impediments: (Answer N/A if not applicable)

8. Do you wear glasses, contact lenses, hearing aids, or artificial body parts – If yes please explain: (Answer N/A if not applicable)

9. List ALL medications you take routinely: (Answer N/A if not applicable)

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STATEMENT OF HEALTH BY APPLICANT – continued10. Do you have any limitations that you feel might influence your ability to function in the role of Student Practical

Nurse in any aspect of theory or clinical practice? If yes, please explain. (Answer N/A if not applicable)

11. Do you have any condition, medical or otherwise, that would prevent you from participating in hospitaldepartmental rotations (i.e. lab, x-ray, special procedures, etc.)? If yes, please explain. (Answer N/A if not applicable)

I, the undersigned, an applicant for the Practical Nursing Program at Kiamichi Technology Centers, hereby state that to the best of my knowledge I am in good physical and emotional health and do not have any illness, infirmity, disease or deformity, except as indicated herein. I certify that this information is true and correct to the best of my knowledge. I realize that deliberate falsification of this information may result in my not being admitted to this program or being dismissed if I am admitted. I further agree that I will be willing to have a more complete physical examination/evaluation/testing if so requested by Kiamichi Technology Centers School of Practical Nursing. I have attached any information that I would consider pertinent to my present health status.

I understand that my health status must be such that I can perform the duties associated with theory and clinical practice required of a Student Practical Nurse. I understand that I must adhere to the health requirements of the clinical facilities. I understand that the following minimum physical and mental requirements are reflective of industry standards:

Requires corrected hearing and vision within functional ranges. Requires frequent standing/walking, usually conducted over linoleum or hard-surface floors, for up to 12 hours a day. Work is moderately heavy with frequent lifting and carrying of objects weighing 30 to 50 pounds, and pushing and pulling 100 to

150 pounds. Requires bending, stooping, kneeling, pushing and pulling, reaching and occasionally climbing and/or balancing. Expected to use proper body mechanics at all times. Mental demands include analytical skills, including initiative, independent judgment, languages ability, memory of numerous

methods for handling multiple situations, and reasoning ability to interpret a variety of multi-disciplinary tasks.

Applicant Signature: Date:

EQUAL OPPORTUNITY / NON-DISCRIMINATION STATEMENT: Kiamichi Technology Center does not discriminate on the basis of race, color, sex, pregnancy, gender expression or identity, national origin, religion, disability, veteran status, sexual orientation, age, or genetic information with respect to its programs or any aspect of its operations. (October 2018)

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HISTORY OF CRIMINAL CHARGE, DISCIPLINARY ACTION, OR MENTAL INCOMPETENCEand IMPORTANT INFORMATION from the OKLAHOMA BOARD OF NURSING

OKLAHOMA APPLICANTS: Potential applicants to Kiamichi Technology Centers School of Practical Nursing with a criminal history of felony conviction(s), MUST obtain an initial determination of eligibility for licensure from the Oklahoma Board of Nursing and SUBMIT a copy of the determination with this application. To obtain an Initial Determination of Eligibility, the required form shall be obtained, completed and filed with the Oklahoma Board of Nursing. The Oklahoma Board of Nursing does charge a fee for the Initial Determination of Eligibility. The form can be accessed at http://nursing.ok.gov/initialdeterm.pdf.

The Oklahoma Board of Nursing has the authority to deny a license, recognition or certificate; issue a license, recognition or certificate with conditions and/or an administrative penalty; or to issue and otherwise discipline a license, recognition or certificate to an individual with a history of criminal background, disciplinary action on any professional or occupational license or certification, or judicial declaration of mental incompetence [59 O.S. §567.8]. These cases are considered on an individual basis at the time application for licensure is made, with the exception of felony convictions.

THE FOLLOWING INFORM ATION IS REQUIRED BY THE OKLAHOMA BOARD OF NURSING FOR ALL APPLICANTS SEEKING ADMISSION INTO THE NURSING PROFESSION.

1. Have you ever been summoned, arrested, taken into custody, indicted, convicted or tried for, or charged with, or pleaded guilty to, the violation of any law or ordinance or the commission of any misdemeanor or felony, or been requested to appear before any prosecuting attorney, or investigative agency, in any matter? (Please note that charges including, but not limited to DUI or DWI are not considered minor traffic violations and must be reported.)

Yes No

2. Have you ever had disciplinary action taken against any health-care related license, certificate, or recognition; any professional or occupational license, recognition, or certificate; and/or any application for a nursing or professional or occupational license, recognition, or certificate in any state, territory or country?

Yes No

3. Is there currently any investigation of your health-care related license, recognition, or certificate; and/or any professional or occupational license, recognition, or certificate; and/or any application for a nursing and/or professional or occupational license, recognition, or certificate in any state, territory or country?

Yes No

4. Have you ever been judicially declared mentally incompetent in any state, territory, or country?

Yes No

If any answer to questions #1 through #4 is “YES”Please provide with this application a written statement describing the date, location, and circumstances of the incident(s), and the resulting action(s) taken by the court or agency. If you have more than one incident you are reporting, you must describe every case/charge that has been filed.

Once admitted into the KTC PN program, certified copies of court records or board orders must be obtained from the Court or Agency in the jurisdiction in which the offense occurred.

CRIMINAL HISTORY STATEMENT OF UNDERSTANDING I understand a national criminal history records search (CHRS/background check), including a sex offender search, must be completed at,

https://portal.castlebranch.com/KC82 prior to submitting my PN Application. The cost of which is my responsibility. I understand that the results of my background check will be sent to KTC Practical Nursing Administrative Office to be placed with my PN Application. A copy of said results

will also be sent to me. I understand my CHRS/background check will be shared with any clinical facilities, upon their request, that may be utilized during my education. I understand that KTC complies with the Oklahoma Board of Nursing relative to felony convictions and application for licensure. (Refer to “Criminal History” section

above.) Based upon a history of arrest and/or convictions, students may be unable to perform clinical practice at certain facilities. If the student is unable to perform clinical rotation, there is a possibility that the student may be dismissed for inability to complete the clinical course.

I understand a second fingerprint background check will be required before graduation and will be submitted to the Board of Nursing with my application to take the licensure exam.

I understand that if I am an Oklahoma applicant with a history of felony conviction(s), I MUST submit a copy of the Oklahoma Board of Nursing Initial Determination of Eligibility for Licensure or Certification with this application.

I understand that if I answer “yes” to any question from #1 through #4 above, I must submit a statement (with this application) describing the date, location, and circumstances of the incident(s), and the resulting action(s) taken by the court or agency.

I hereby certify that all statements in this Application for Admission are true and correct to the best of my knowledge. I understand if I am admitted to the program, false statements on this “History of Criminal Charge, Disciplinary Action, or Mental Incompetence” form and/or PN

Application for Admission shall be considered sufficient and appropriate cause for dismissal.Printed Name of Applicant Applicant Signature Date

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APPLICANT’S STATEMENT OF UNDERSTANDINGPlease read each of the statements listed below and sign at the bottom of this page to acknowledge your understanding of the following. Your application is incomplete without this acknowledgement.

I understand that any false or misleading information or statements in, or in connection with, my application shall be considered sufficient and appropriate cause for denial to or dismissal from the Kiamichi Technology Centers Practical Nursing Program, hereinafter referred to as the KTC PN Program.

I understand a national criminal history records search (CHRS/background check), including a sex offender search, must be completed prior to submitting my PN Application. I further understand that proof of completion of the CHRS will be documented in the application as appropriate by providing the CastleBranch Order Confirmation Number. The cost this background check is my responsibility.

I understand that the results of my CHRS/background check will be shared with any clinical facilities, upon their request, that may be utilized during me education.

I understand that KTC complies with the Oklahoma Board of Nursing relative to felony convictions and application for licensure. Based upon a history of arrest and/or convictions, students may be unable to perform clinical practice at certain facilities. (If the student is unable to perform clinical rotation, there is a possibility that the student may be dismissed for inability to complete the clinical course.)

I understand that if I am arrested and charged/convicted with a misdemeanor and/or a felony while enrolled in the PN Program, I must report this immediately, the PN Administrative Office and that I must also submit official court documents regarding the arrest to them. I understand that conviction of a felony is cause for immediate dismissal from the PN Program.

I understand that CPR Certification is a prerequisite. Prior to the first day of class, I must obtain BLS Provider or Healthcare Provider CPR Certification from the American Heart Association. It is my responsibility to obtain this certification and I must be certified for the entire length of the program. I further understand that online CPR courses will NOT be accepted.

I declare and affirm that the statements made in this application, including accompanying documents, are true, complete and correct. I understand that any false or misleading information in, or in connection with, my application, including my background check, shall be considered sufficient and appropriate cause for denial to or dismissal from the KTC PN Program.

Printed Name of Applicant Applicant Signature Date

EQUAL OPPORTUNITY / NON-DISCRIMINATION STATEMENT: Kiamichi Technology Center does not discriminate on the basis of race, color, sex, pregnancy, gender expression or identity, national origin, religion, disability, veteran status, sexual orientation, age, or genetic information with respect to its programs or any aspect of its operations. (October 2018)

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T H I S S E C T I O N T O B E C O M P L E T E D A N D S I G N E D B Y A P P L I C A N T .APPLICANT NAME (PRINT LEGIBLY):

FIRST MIDDLE MAIDEN LAST

DATE:

RELEASE OF INFORMATION: I give my permission to release information to Kiamichi Technology Centers concerning my qualifications for entrance into the PN Program.

APPLICANT SIGNATURE:

(References should be from past or present employers, counselors, and teachers. DO NOT use relatives or friends.)

T H I S S E C T I O N T O B E C O M P L E T E D A N D S I G N E D B Y A P P L I C A N T ’ S R E F E R E N C E .

CONFIDENTIAL PERSONAL REFERENCE REPORT1. My acquaintance with the above mentioned applicant has been as: EMPLOYER

CO-WORKER TEACHER/COUNSELOR OTHER (please list)

2. How long have you known the applicant?

3. Rating of applicant: (check one column below for each descriptive term).Outstanding Above Average Average Below Average Unknown

Common Sense/Judgment

Concern for Others

Cooperation

Family Relations

Health

Initiative

Intellectual Endowment

Sense of Responsibility

4. What qualities or characteristics does the applicant have that you believe would contribute to his/her success as a practical nurse?

5. What qualities or characteristics does the applicant have that you believe would interfere with his/her success as a practical nurse?

Signature of Reference Title or Position Phone

Printed Name of Reference Company /Business Name Address

Please Return This Form To:

attach KTC campus return label here

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DATE:










Concern for Others

Cooperation

Family Relations

Health

Initiative









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DATE:










Concern for Others

Cooperation

Family Relations

Health

Initiative









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CHRS

CRIMINAL HISTORY RECORDS SEARCH

(background check)

All applicants must complete a Criminal History Records Search (CHRS/background check) online at https://portal.castlebranch.com/KC82 prior to submitting your PN Application to KTC.

Payment for this background check is the responsibility of the applicant. Results of the background check will automatically be sent to KTC Administration to be placed

with your application. Results will also be available to the applicant on the Castle Branch website.

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KIAMICHI TECHNOLOGY CENTERSSchool of Practical Nursingk t c . e d u

WHAT I NEED TO KNOW All Applicants must complete the required background check online at http://portal.castlebranch.com/KC82 prior to submitting the PN Application to KTC. The

results of the background check will automatically be sent to KTC Practical Nursing Administration and will be placed with applicant’sPN Application. Applicant will also have access to the results on the CastleBranch website.

Applicant is responsible for the cost to CastleBranch for their background check.

WHICH PACKAGE SHOULD I SELECT?PACKAGE OPTION:BACKGROUND CHECKWITHOUT LICENSE VERIFICATION

PACKAGE OPTION:BACKGROUND CHECKINCLUDING LICENSE VERIFICATION

$49.00 If you HAVE NEVER possessed a professional or occupational license/certificate (health care related, i.e., CNA, CMA) select this package.

$49.00PLUS$6.00 for each license verification

If you now have or have ever possessed a (health care related) professional or occupational license/certificate (even if it is expired), you are required to select this package. You are required to list all of your license(s)/certificate(s) for verification. Your background check will increase by $6.00 for each license verification. This additional cost is because of the current requirement by our clinical facilities that any license/certificate be verified and checked for disciplinary action and/or investigation.

CastleBranch has created a portal for your Kiamichi Technology Center background check. Go to http://portal.castlebranch.com/KC82 for instructions,payment options and contact information. More information included on previous page.

CRIMINAL CHARGES, ARREST RECORDS, DISCIPLINARY ACTION, MENTAL INCOMPETENCEPlease note that if you have an arrest record you are required to submit a letter/statement of explanation regarding any arrest(s) with your KTC PN Application for Admission. Further, if you have a felony conviction you are required to submit a copy of the Oklahoma Board of Nursing Initial Determination of Eligibility for Licensure with your KTC PN Application for Admission. If you fail to submit the required documentation for any arrest record, criminal charges, etc. with your application, your application will be considered incomplete and you forfeit consideration for an interview with the Admissions Committee. You are required to report all arrests and/or charges that have been brought against you. If you are found to have been dishonest you may be dismissed from the KTC PN Program.

WHICH KTC CAMPUS SHOULD I SELECT?Make your “first choice” selection from the KTC Practical Nursing Programs accepting students in 2020. These programs are located at:

Full-Time option programs attend 5 days per week; 11 months to complete

Durant: Full-Time option Hugo: Full-Time option Idabel: Full-Time option McAlester: Full-Time option Poteau: Full-Time option

Antlers: Part-Time option Durant: Part-Time option Stigler: Part-Time option Talihina: Part-Time option

Part-Time option programs attend 3 days per week; take 18 months to complete.

My signature below acknowledges that prior to submitting this PN Application to KTC, I have purchased and completed my Criminal History Records Search (CHRS/background check), including a sex offender search, online at: http://portal.castlebranch.com/KC82. I understand the results of such CHRS Report will automatically be sent to KTC Practical Nursing Administration to be placed with my PN Application. A copy will be available to me at Castle Branch.

My signature below authorizes Kiamichi Technology Center (KTC) to receive the results of my Criminal History Records Search (background check), including a sex offender search, on myself and release any results to the following persons or entities:

Kiamichi Technology Center School of Practical Nursing, PO Box 70, Antlers, OK 74523, phone 580-298-5160 Any clinical facilities that may be utilized during my education.

I also understand that KTC complies with the Oklahoma Board of Nursing relative to felony convictions and application for licensure. Based upon a history of arrest and/or convictions, students may be unable to perform clinical at certain facilities.

Based upon a history of arrest and/or conviction, students may be unable to perform clinical practice at certain facilities. If the student is unable to perform clinical rotation, there is a possibility that the student may be dismissed for inability to complete the clinical course.

Individuals applying for enrollment in the Kiamichi Technology Centers School of Practical Nursing must comply with the request for Criminal History Records Search, which is a national search including a sex offender registry check.

Potential applicants to Kiamichi Technology Centers School of Practical Nursing with a criminal history of felony conviction(s), MUST obtain an initial determination of eligibility for licensure from the Oklahoma Board of Nursing and SUBMIT a copy of the determination with this application. To obtain an Initial Determination of Eligibility, the required form shall be obtained, completed and filed with the Oklahoma Board of Nursing. The Oklahoma Board of Nursing does charge a fee for the Initial Determination of Eligibility. The form can be accessed at http://nursing.ok.gov/initialdeterm.pdf.

The Oklahoma Board of Nursing has the authority to deny a license, recognition or certificate; issue a license, recognition or certificate with conditions and/or an administrative penalty; or to issue and otherwise discipline a license, recognition or certificate to an individual with a history of criminal background, disciplinary action on any professional or occupational license or certification, or judicial declaration of mental incompetence [59 O.S. §567.8]. These cases are considered on an individual basis at the time application for licensure is made, with the exception of felony convictions.

Applicant Signature: Date:

NAME MUST BE PRINTED LEGIBLY (USE LEGAL NAME) CastleBranch Order Confirmation Number

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CRIMINAL HISTORY RECORDS SEARCH( C H R S / B A C K G R O U N D C H E C K )


http://portal.castlebranch.com/KC82.%20

http://portal.castlebranch.com/KC82

http://portal.castlebranch.com/KC82

FIRST MIDDLE LAST Required Prior to Submission of Application

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