Davidson Campus: P.O. Box 1287, Lexington, NC Telephone: FAX:

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1 Davidson Campus: P.O. Box 1287, Lexington, NC Telephone: FAX: Davie Campus: 1205 Salisbury Road, Mocksville, NC Telephone: FAX: TO: FROM: SUBJECT: Persons Interested in the Nursing Assistant II Program Joey Goodman, Program Director Health and Public Safety Course Announcement DATE: February 22, 2017 Davidson County Community College will offer an NA II class in the Fall 2017 at the Davidson campus in Lexington. The class is scheduled for September 5 December 9, The course will be offered as a hybrid class, meaning part of the work is completed online with labs/skills completed at the campus. The online information will be assigned each week. Students will find the assignments on Moodle. Lab time is scheduled for Tuesday and Thursday evenings from 6:00 p.m.-9:00 p.m. Clinical will consist of 88 hours on Saturday and Sunday, 7 a.m.-3 p.m., with various locations. Successful completion of the course means students will be eligible to apply for listing as a Nurse Aide II with the North Carolina Nurse Aide II Registry. The registration fee will be $ (based on current rates). Other fees will include insurance: $9.25, technology fee: $5.00. Your textbook and lab kit will be available in the bookstore one week prior to class for approximately $180. To be eligible to register for this class, the following information must be submitted prior to receiving registration information. The enrollment for this class will be on a first come, first serve basis. There will be a maximum of 10 seats for this class. Information required for student to be eligible to enroll: Documentation of High School diploma /GED Proof of Nursing Assistant I training at state accredited program Current NC Nurse Aide I Registry listing copy Current CPR certification valid through the end of the class Acceptable college level reading test score or college credit for English Program Interest Form Students interested in this course should submit the Program Interest Form with the above information to office #112 in the Public Safety Building on the Davidson campus. Once we receive all of the above documentation you will be given the course ID number and will be eligible to register for the class. Please feel free to contact us if you have questions at , or via diane_hedgecock@davidsonccc.edu.

2 Immunizations: Required at least one week before the first day of class. Submit to Public Safety #112 2 MMRs or titers (Measles, Mumps, Rubella) Proof of 2 doses or positive serum titers for each disease Tetanus Booster (Tdap) A Tdap booster within the last 10 years Chicken Pox (Varicella) Proof of 2 doses or positive serum titer. History of the disease is not acceptable. Hepatitis B 3 doses over a 6-month period Proof of at least 2 of the 3 doses is required before class 2 TB skin tests completed within 1-3 weeks or Chest X-ray or Quantiferon Gold titer Seasonal Quadrivalent Flu for the class you will be taking Additional clinical site documentation that is required one week before the first day of class: Criminal Background Check and Urine Drug Screen Submit the attached authorization for Release of Information & Records to Investigative Associates & Consultants (IAC) via fax, or US mail. The fee varies depending on how many addresses are listed on your credit report. IAC will accept cash or check payment only. For further information or questions, please contact Investigative Associates & Consultants directly. Investigative Associates & Consultants 3796 Vest Mill Road Winston-Salem, NC info@iacinvestigations.com Students not completing requirements one week before class begins will not be allowed to continue in the class.

3 Nursing Assistant II (NAII) Program Interest Form Please complete this form and submit it to Health & Public Safety. Davidson County Community College, PO Box 1287, Lexington, NC Date Date of Birth: Print Your Name: Address City State Zip Home Phone No. Work Cell Address Date Packet Picked Up: How did you hear about this class? NOTE: An NAI skills competency test will be given at the first class. Failure to complete NAI skills proficiently may result in the inability to proceed in NA II. For College Use Only File Completion Date : Checklist of NAII items Required for Admission Interest Form. High School / GED / Adult High School Diploma Transcripts College credit for English or provide documentation of one of the following listed below: Accuplacer (57) NCDAP (136) Compass (63) ACT (22) SAT (500) Asset (34) Copy of current CPR certification good through end of course. Current NC Nurse Aide I Registry listing copy. Proof of Nursing Assistant I training

4 INVESTIGATIVE ASSOCIATES & CONSULTANTS, INC. (In association with Davidson Community College) AUTHORIZATION FOR RELEASE OF INFORMATION & RECORDS I,, understand that in consideration of my application for a clinical rotation at a healthcare facility associated with Davidson Community College, an investigation will be conducted. I authorize Investigative Associates & Consultants, Inc. to conduct such an investigation, which may include, but not be limited to, the gathering of information regarding verification of prior employment, education, references, consumer credit history, driving history, and any criminal history which may be in the files of any state, federal, or local criminal justice agencies. I understand that I have the right to request, in writing, a complete and accurate disclosure of the nature and scope of this investigation. I authorize Investigative Associates & Consultants to transmit a copy of my background investigation to other entities such as hospitals or clinical sites where I may participate in additional clinical rotations. I understand that the information requested below regarding sex, race, date of birth, and maiden name is for the sole purpose of gathering information accurately. Mo. Day Yr Last First (BIRTH) Middle Social Security # Date of Birth (Please print Full Name Do not use initials) Maiden, Previous Married, and all other Driver s license # State Sex Race Alias names used Daytime Telephone Number Address Present Address City/State Zip/County How long? List all other addresses used for the past 7 years - use additional page(s) if needed. Previous Address City/State Zip/County How long? Previous Address City/State Zip/County How long? Previous Address City/State Zip/County How long? If you have lived in the following states within the last seven years; Alabama, Arkansas, District of Columbia, Georgia, Idaho, Iowa, Massachusetts, Minnesota, New Hampshire, New Jersey, South Dakota, or Virginia, you will be asked to complete an additional form at the time of your interview. If you have lived in Delaware, Nevada, Ohio, South Dakota, West Virginia or Wyoming, you will need to obtain the appropriate fingerprint card(s) at the time of your interview. A telephone facsimile or photographic copy of this authorization shall be as valid as the original. PROGRAM - COURSE Applicant s Signature Date Investigative Associates & Consultants, Inc Vest Mill Road Winston-Salem, NC Telephone: (336) Telefax: (336) info@iacinvestigations.com

5 IMMUNIZATION CHECKLIST Student Name: Date: Program: Every student must provide documentation of the following one week before the 1 st class to Public Safety #111 or #112: 2 MMRs (Measles, Mumps, Rubella) 2 dose series --documentation of two doses or positive titer for each showing immunity TDap (Tetanus) --latest TDap booster must be within 10 years of the class you will enroll in Chicken pox 2 dose series --documentation of two doses or titer showing immunity. History of the disease is not acceptable. Hepatitis B 3 dose series --documentation that the series has begun (2 doses) and a waiver; or --documentation of all three doses of the series 2-step TB skin test. **You must have (2) two injections and have them read to complete this requirement** within 12 months of the class you will enroll in. --Step One: Vaccine is injected under the skin and results to be read within hours. If result is positive: chest x-ray required. --Step Two: Repeat Step One in 1 to 3 weeks after the first test. If second test result is positive: chest x-ray required. current Quadrivalent Flu for the class you will enroll in Criminal Background Check AND 12-Panel Urine Drug Screen completed with Investigative Associates, Winston-Salem, NC Social Security Card and Photo ID Laminated SS cards will not be accepted 2/13/17

6 Nursing Assistant II (NAII) Applicant Certification of Understanding Please complete this form and submit it to the program coordinator following the orientation session. This form must be on file with the Health and Public Safety Office as part of your Program Interest packet. Name Date Address City State Zip Code Address Home Phone Work: Cell: Davidson County Community College has provided me with information regarding the immunization requirements for the NAII program including the background check and urine drug screen requirements. I understand that if I do not turn in all of the required immunization records, as well as complete the urine drug screen and criminal background check at least one week before the first day of class, I will be dropped from the class and will not be entitled to a full refund. Submission of background check and urine drug screen is required for clinical. Clinical sites may or may not allow you to complete clinical based on your criminal background and/or drug screen results. If any facility refuses to allow the student to participate in the clinical experience at that agency as a result of those findings, the student will not be able to progress in the program. Inability to progress will result in failure of the course and removal from the program. A full refund of tuition and fees is granted when the student officially withdraws from a class prior to the first class meeting or when the College cancels the class. A student who officially withdraws from a class prior to the ten percent date of the class will receive a 75% tuition refund, but fees will not be refunded. No refunds after ten percent date. Print Name Last 4 digits of Social Security # Signature Date

7 Nursing Assistant II CID September 5 December 9, 2017 Davidson Campus Modules listed indicate coursework to be completed online Classes are held in Briggs Technology, Room 223 unless listed otherwise; Clinical hours are 7a-3p, location TBD Wk Sunday Mon Tues Wed Thurs Saturday 1 (Module 1) 9/5 6p-9p VM 9/7 6p-9p VM 2 (Module 3 & Module 4) 9/12 6p-9p VM 9/14 6p-9p VM 3 (Module 9) 9/19 6p-9p VM 9/21 6p-9p VM 4 (Module 8) 9/26 6p-9p VM 9/28 6p-9p VM 5 (Module 8 cont.) 10/3 6p-9p VM 10/5 6p-9p VM 6 (Module 7 & Module 12) 10/10 6p-9p VM 10/12 6p-9p VM 10/14 Clinical 7 (Module 2 and Module 5) 10/15 Clinical 10/17 6p-9p VM 10/19 6p-9p VM 10/21 Clinical 8 (Module 6) 9 10/29 Clinical 10/24 6p-9p VM 10/26 6p-9p VM 10/28 Clinical (Module 10 & Module 11) 10/31 6p-9p VM 11/2 6p-9p VM 11/4 Clinical 10 11/5 Clinical 11/11 Clinical 11 11/12 Clinical 11/18 Clinical 12 11/19 Clinical 11/25 Thanksgiving Holiday 13 11/26 Thanksgiving Holiday 12/2 Clinical 14 12/3 Clinical 12/7 6p-9p VM Review 15 12/9 8a-5p (1 hour lunch) VM Competency Skills and Written Clinical sites: PRHR Pine Ridge Health & Rehab (formerly Britthaven); TMC Thomasville Medical Center; OF - Oak Forest Health & Rehab WFUBMC-LMC (Lexington Medical Center); DH (Davie Hospital- in Mocksville not the new hospital in Hilsdale) 88 total hours of clinical will be completed.