Revised 02/2020

CADDO KIOWA TECHNOLOGY CENTER

Practical Nursing Program

Application

Practical Nursing Caddo Kiowa Technology

Center P.O. Box 190

1415 North 7th Fort Cobb, OK 73038

Main Phone: 405-643-5511 Practical Nursing: 405-643-3262 Fax: 405-643-3013

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CANDIDATE PREFERENCE POINT RECORD

Applicant Name Date Reviewed ____________Competitive (All required documentation has been received) Noncompetitive

Factor and Related Preference Points Possible/Awarded

1. Requirements: ______ Completed Application ______Birth Certificate ______Background check (Verified Credentials website pg5) ______Driver’s License ______Shot Record Current (Verified Credentials website pg5) ______Financial Aid

2. Education: (3 pts. max.) -High School Education -High school transcript (GPA 3.0+=1 pt.), OR

-GED (520 or above or 52 or above)/HiSET (54 or above) = 1 pts -Higher Education Technology Center Transcript (Health Related) (6 months or 525 hours of training = 0.5 pt.) OR College Credit (English, Math, or Science) (6 hours with 3.0=1 points) Specialized Education (Technology Center and/or College Official Transcript) -0.5 pts awarded for a B average or 80% or above in Anatomy & Physiology -0.5 pts awarded for a B average or 80% or above in Medical Terminology

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3. Work History (within the last 5 years) Verification Form (2 pts. Max.) All points awarded for verified employment only.

______0.5 pt. for 6 months ______1.5 pts for 6 mo of working in the medical field ______ 1 pt. for 1 year ______2 pts for 1 year of working in the medical field

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4. References: Positive References (3 pt. Max.) ______ reference #1 - exceeds standards or combination of meets/exceeds standards= 1point ______ reference #2 - all meets standards = .5 point ______ reference #3 - any reference does not meet standards = 0 point

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5. ATI TEAS Assessment Test (91% or above=1.5 pts., 78%-90%=1 pt., 59%-77%=0.5pts) ______Reading Ability _______Mathematics ______Science _______English or Language Usage ______Composite Total

7.5

6. INTEREST ASSESSMENT ______Health Science (1pt for high interest)

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7. Licensures/ Certifications (current license/certification) ______ CNA/ LTC (1 pt.) _______EMT/EMR (1pt.) _______CMA (1 pt.) ______CPR (1 pt.) _______Phlebotomy (1 pt.)

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8. Interview (0.5 pt. possible for each, 2.5 pt. Max) ______Punctuality ________Appropriate Dress ______ Communication Skills Written Essay (to be done at the time of the interview) ______Legible _________Grammar/Mechanics Interview Questions _______25-30 total interview question pts. = 2.5 pts. _______20-24 total interview question pts. = 2 pts. _______15-19 total interview question pts. = 1 pt.

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TOTAL Points Possible / Awarded

26.5

All required documents are highlighted

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ENTRANCE REQUIREMENTS Enrollment requires a two-step process:

1. Enroll at Caddo Kiowa Tech Center http://www.mycktc.com

2. Complete the attached Practical Nursing Application. Step 1- Practical Nursing Application Contents – Application should include:

Entrance requirements General information Practical nursing application Immunization requirements (Verified Credentials website pg5) Validation of recent work experience Three (3) reference request forms with three (3) envelopes (Must be mailed,

hand delivery will NOT be accepted) Copy of the Candidate Preference Point Record Background check (Verified Credentials website pg5)

*There is a nonrefundable fee of $91.40 for the background check and immunization verification. The instructions for this process are found on pg5 of this application. The applicant is responsible for completing and updating the information as needed.

If you are missing any part of this application, need additional copies, or have questions, please call the Practical Nursing 405-643-3262. *It is highly recommended that you visit with a Caddo Kiowa Tech Center counselor prior to scheduling your TEAS test. Step 2-- Assessment – There is a $70 nonrefundable testing fee for each attempt. Pre-entrance assessments are required for application to the Practical Nursing program: ATI TEAS test (Test of Academic Skills) and an Interest Assessment. Tests will not be given until proof of payment is presented. Payment can be made in the CKTC bookstore. Testing requires 4-5 hours (varies).

• ATI TEAS test is required. It is required that you allow at least two weeks between the two tests for remediation. The highest score on either test will be used on the scoring sheet.

• ATI TEAS assessment is used to assess an applicant’s overall preparedness for a health science program. The assessment contains items with an overall time limit of 209 minutes. This assessment contains 150 items divided among four content areas of reading, math, science and English and language usage. Also, a composite or total score will be given on the individual performance profile.

• ATI TEAS test results submitted to the PN department must have been taken within the last 2 years prior to the official date of the application deadline.

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• A maximum of 3 TEAS assessments can be taken at Caddo Kiowa Tech Center in a 2 year period.

• Interest Assessment. To take our pre-entrance tests, contact Student Services at 405-643-3240 for testing dates. There will be no refund of registration.

Persons wishing to test must arrive at 8:00am or 12:00pm and register with the Student Services. Please advise the Student Services staff that you are applying for the PN Program at the time of registration.

Step 3--Application – A completed application includes:

The practical nursing application Copies of all required immunizations (Verified Credentials website pg5) Copy of certified birth certificate Valid driver’s license A copy of high school transcript or GED certification/HiSET (no diploma copies) Copies of official transcripts. Verified employment record (within the past 5 years, with a minimum of 20

hours/week) No photo copy/original only Copies of ATI TEAS test and an Interest Assessment The three reference questionnaires are to be given to professional and

educational references only – no family or friends. A self-addressed envelope is provided for each questionnaire to be returned by mail to Caddo Kiowa Technology Center by the person completing the reference. Inform reference individual of the deadline date. References must be mailed in a sealed envelope and received prior to application deadline. Caddo Kiowa Technology Center employees are not eligible to give references.

Upon application to the Practical Nursing Program, a background check must be done through Background Screening Company, Verified Credentials (pg5). Applicants with a criminal history of felony conviction, please see page 9 of this application. Applicant results, once accepted into the program, will be given to the clinical facilities upon their request. Clinical facilities have the option to deny clinical placement to a student. If this occurs the faculty will attempt to find alternative placement for the student. If the faculty cannot find alternative placement, the student will be unable to complete the program. CKTC reserves the right to do repeat backgrounds as needed. A final background check is done prior to taking the National Council Licensure Examination (NCLEX) exam.

DEADLINES PN applications will be accepted for the calendar year entrance dates listed below. Month of Entrance Deadline for Application August 2020 Friday June 5th, 2020 January 2021 Friday October 2nd, 2020

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Caddo Kiowa Tech Center Practical Nursing Program Required Qualifications for Your Program

TIME SENSITIVE

DO NOT DELAY ATTENTION Students: We’ve partnered with Verified Credentials, Inc. to help you supply the required qualifications for your program. To get started, carefully follow the instruction below: How it Works:

IMPORTANT – Use the CODE below to get started:

Program: Code:

Background Check & Additional Requirements – Practical Nursing Program KKKJX-66498

GET STARTED NOW at: https://scholar.verifiedcredentials.com/mycktc

For Best Results - Use a laptop or desktop computer to complete this process.

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Frequently Asked Questions about the ATI TEAS test.

How will I be taking the test and what do I need to bring? This is a computerized exam. The test is proctored and is held at Caddo Kiowa Technology Center Student Service. No calculators are allowed. Scratch paper will be provided, and will be collected at the end of the test. You need to bring your driver’s license, passport, or state identification card, and a pen or pencil. What can I do to prepare for taking the ATI TEAS? The company that provides the exam (ATI) has a study manual and online practice exam that you may purchase if you wish. Make sure to purchase the ATI TEAS version. This can be purchased through www.atitesting .com. Is the test really four hours long? The ATI TEAS is slightly less than a four-hour test with four timed sections. Extra time is added to the total testing period for short breaks in between sections. You must take the entire test during the testing period. If you finish early, you may leave before the time has ended. When will I get my results? Results will be available within three to four business days from the testing date. You will be able to access the test results from the ATI website under “My Results”.

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ATI TEAS Scores Reading

Ability Mathematics Science English or

Language usage

Composite Total

91% or above

= 1.5 points

78% to 90%

=1 point

59% to 77% =0.5 points

0 to 58% =0 points

Total Reading points

Total Mathematics

points Total

Science points

Total English points

Total Composite

points

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All paperwork associated with the application including testing is due by 3:30 day of deadline. Only completed applications will be considered for admission. Return all forms to: Caddo Kiowa Technology Center Student Services P.O. Box 190 1415 North 7th

Fort Cobb, OK 73038 Step 4--Interview – Only applicants with completed applications will be considered for interview. Applicants will be notified by mail, email, or phone call of their interview time. An Interview is required for consideration for acceptance in to the program.

Step 5—Notification of Acceptance -- If selected into the program, applicant will be notified by mail, email, or phone call and given the start date for the LPN class.

READ THE FOLLOWING GENERAL INFORMATION PAGES LENGTH OF COURSE: The PN course is 1463 hours. Classes are held five (5) days per week, except for holiday periods listed on the school calendar and month of July. Students will attend on a full-time basis (30 Hours per week). TRANSPORTATION: Bus transportation will be available August through May within the district. Clinical sites are located in Caddo and surrounding counties. Clinical times will vary according to the locations. Travel to and from clinical sites is the responsibility of the student. Reliable transportation is necessary for all students. DAY CARE: Day care is available for students’ children during daytime hours at Caddo Kiowa Technology Center. There is limited space available, and prior arrangements must be made. For additional information, please call (405) 643-3247 or (405) 643-3248. LICENSURE: The Oklahoma Department of Career and Technology Education and the Oklahoma Board of Nursing have accredited the Caddo Kiowa Technology Center’s Licensed Practical Nursing Program. Graduates of the program are eligible to take the National Council Licensure Examination for Practical Nurses. ESTIMATED COSTS: Tuition - $3,657.50 Instructional Supply Cost $1,623.00 *Additional Books Total Program Cost $5,280.50 The costs listed above are approximate and subject to change. *Additional textbooks required will be purchased independently (See Licensed Practical Nursing Information sheet).

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BACKGROUND CHECKS: Potential applicants to Caddo Kiowa 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.

Readmission Policy -Students who chose to reapply to the program within the same school year as they exited will need to request specific documents in writing for their readmissions packet. *Documents that can be requested-birth certificate, High School Diploma/GED/HiSET, TEAS/Interest Assessment results -If one semester has lapsed, the student will be required to turn in all new documentation.

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PN Nursing Information Sheet

Foundations and Adult Health Textbook Nursing Textbook 8th Edition Authors: Cooper & Gosnell ISBN-13: 9780323484374 ISBN: 0323484379 Foundations and Adult Health Workbook Study Guide 8th Edition ISBN-10:0323524591 ISBN-13:9780323524599 Mosby’s Textbook for Nursing Assistants 9th Edition Author: Sorrentino ISBN-13: 9780323319744 Mosby’s Textbook for Nursing Assistants- Workbook 9th Edition ISBN-13: 9780323319768

*YOU are responsible for purchasing your own scrubs for clinical. Everyone is required to wear Cherokee brand pewter gray color scrubs. The style of the scrubs is up to the student. *On the first day of class you will be expected to make payment on the total program cost or have your financial aid in place in order to start the program.

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OKLAHOMA BOARD OF NURSING STATEMENT

The Caddo Kiowa Technology Center (CKTC) 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; 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 January 10, 2020)

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CADDO KIOWA TECHNOLOGY CENTER P.O. Box 190

1415 North 7th Fort Cobb, OK 73038

(405) 643-5511

PRACTICAL NURSING APPLICATION

Personal Information: (Please type or print legibly; all information is required)

Name: Date of Application: (Last) (First) (MI) Present Address: (Street Number) (City) (State) (Zip) Permanent Address: (Street Number) (City) (State) (Zip) Telephone Number (Home) (Work) If no telephone, message number Name Email address________________________________________________________________________________ Educational Background: You must have a high school diploma or GED Certificate to apply to the Practical Nursing Program. Please include an official copy of your high school transcript or your GED scores with your application. Name of High School Location Address of School (Street Number) (City) (State) (Zip) If GED Certification received, Cumulative GED Score Date Completed Universities or Colleges Attended: Attach official transcripts for courses to be considered for credit.

School Location Dates Attended Course of Study

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Caddo Kiowa Technology Center or Health-Related Courses Attended: Attach official transcripts for courses to be considered for credit.

School Beginning Date Ending Date Course of Study

Employment References: Begin with current or most recent employer, include any volunteer work (does not meet requirement for validation of recent work experience). Employer's Name: Address: City/State Zip Phone Number Dates Employed: From To Immediate Supervisor: Permission to Contact: Yes No Job Title and Duties: Reason for Leaving:

********************************************************************************** Employer's Name: Address: City/State Zip Phone Number Dates Employed: From To Immediate Supervisor: Permission to Contact: Yes No Job Title and Duties: Reason for Leaving:

********************************************************************************* Employer's Name: Address: City/State Zip Phone Number Dates Employed: From To Immediate Supervisor: Permission to Contact: Yes No Job Title and Duties: Reason for Leaving: _________________________________________________________ Notification of Nondiscrimination: This institution is an equal opportunity provider and employer. Caddo Kiowa Technology Center does not discriminate on the basis of race, color, national origin, sex, disability or age in its

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programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Assistant Superintendent, PO Box 190, Fort Cobb, OK 73038, 405-643-5511.

Immunization Requirements: The following immunizations/titers are required by the facilities used for clinical training and proof of these must be submitted. Your immunizations must be uploaded to the Verified Credentials website (pg5) for verification. 1. Tetanus Toxid (must be within last 10 years ........................................ Yes No (Enclose immunization record) 2. Have you included proof of chicken pox (varicella), or have you .. Yes No received the vaccination? 3. Rubella Titer or Rubella vaccine (must be since 1968) ..................... Yes No 4. Rubeola (measles) vaccine (series of 2) ................................................... Yes No 5. Current PPD ........................................................................................................ Yes No (Enclose immunization record) If PPD test is positive, a chest x-ray is required and should be included 6. Hepatitis B vaccine (series of 3) .................................................................. Yes No 7. Hepatitis A vaccine (series of 2) .................................................................. Yes No

I understand I may be subjected to a random drug screening. I agree to drug screening as it is requested in order to complete the clinical requirements of the program. STUDENT SIGNATURE: DATE: ______

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Caddo Kiowa Technology Center Student Services

P.O. Box 190 1415 North 7th

Fort Cobb, OK 73038

Professional Reference Request

Applicant Name ____________________________________ Date _________________________________________________ (Please Print) Release of Information: I give my permission to release information to Caddo Kiowa Technology Center concerning my qualifications for entrance into a health training program at Caddo Kiowa Technology Center, and I agree to hold blameless the person being requested to complete and return this form.

__________________________________________________________ (Signature of applicant)

Confidential Response Form Complete the following form based upon work association with the above applicant. Please complete all information requested below, or the reference will not be considered. Return reference form to the above address rather than to the applicant. The reference is confidential and will be kept secured. Please check the box that best describes the individual’s work performance for each of the dimensions or traits listed:

Dimension or Trait Exceeds Standard Meets Standard Below Standard

Judgment and Problem Resolution Tolerance for Stress Teamwork Communication Skills Attention to Detail and Organization Initiative Graciously Accepts Criticism and Suggestions Appropriate Appearance and Demeanor Attendance and Punctuality Comments:__________________________________________________________________________________________________________________________________________________________________________________________________ In what capacity do you know the applicant? _____________________________________________________________________________________________________ Individual Completing Reference (please print) Name __________________________________________ Date ______________________________________________ Company Name ________________________________________Phone___________________________________ Company Address_________________________________________________________________________________ By signing this reference I certify that I am in no way related to this applicant or work for Caddo Kiowa Tech Center. Signature__________________________________________________________________________________________

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Caddo Kiowa Technology Center Student Services

P.O. Box 190 1415 North 7th

Fort Cobb, OK 73038 Professional Reference Request

Applicant Name ____________________________________ Date _________________________________________________ (Please Print) Release of Information: I give my permission to release information to Caddo Kiowa Technology Center concerning my qualifications for entrance into a health training program at Caddo Kiowa Technology Center, and I agree to hold blameless the person being requested to complete and return this form.

__________________________________________________________ (Signature of applicant)

Confidential Response Form Complete the following form based upon work association with the above applicant. Please complete all information requested below, or the reference will not be considered. Return reference form to the above address rather than to the applicant. The reference is confidential and will be kept secured. Please check the box that best describes the individual’s work performance for each of the dimensions or traits listed:

Dimension or Trait Exceeds Standard Meets Standard Below Standard

Judgment and Problem Resolution Tolerance for Stress Teamwork Communication Skills Attention to Detail and Organization Initiative Graciously Accepts Criticism and Suggestions Appropriate Appearance and Demeanor Attendance and Punctuality Comments:__________________________________________________________________________________________________________________________________________________________________________________________________ In what capacity do you know the applicant? _____________________________________________________________________________________________________ Individual Completing Reference (please print) Name __________________________________________ Date ______________________________________________ Company Name ________________________________________Phone___________________________________ Company Address_________________________________________________________________________________ By signing this reference I certify that I am in no way related to this applicant or work for Caddo Kiowa Tech Center. Signature__________________________________________________________________________________________

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Caddo Kiowa Technology Center Student Services

P.O. Box 190 1415 North 7th

Fort Cobb, OK 73038 Professional Reference Request

Applicant Name ____________________________________ Date _________________________________________________ (Please Print) Release of Information: I give my permission to release information to Caddo Kiowa Technology Center concerning my qualifications for entrance into a health training program at Caddo Kiowa Technology Center, and I agree to hold blameless the person being requested to complete and return this form.

__________________________________________________________ (Signature of applicant)

Confidential Response Form Complete the following form based upon work association with the above applicant. Please complete all information requested below, or the reference will not be considered. Return reference form to the above address rather than to the applicant. The reference is confidential and will be kept secured. Please check the box that best describes the individual’s work performance for each of the dimensions or traits listed:

Dimension or Trait Exceeds Standard Meets Standard Below Standard

Judgment and Problem Resolution Tolerance for Stress Teamwork Communication Skills Attention to Detail and Organization Initiative Graciously Accepts Criticism and Suggestions Appropriate Appearance and Demeanor Attendance and Punctuality Comments:__________________________________________________________________________________________________________________________________________________________________________________________________ In what capacity do you know the applicant? _____________________________________________________________________________________________________ Individual Completing Reference (please print) Name __________________________________________ Date ______________________________________________ Company Name ________________________________________Phone___________________________________ Company Address_________________________________________________________________________________ By signing this reference I certify that I am in no way related to this applicant or work for Caddo Kiowa Tech Center. Signature__________________________________________________________________________________________

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Validation of Paid Work Experience

Applicant Directions: Please sign the “Release of Information” section of this form and request that your employer complete the “Validation of Paid Work Experience” portion. Use separate sheets for each employer. You may make an additional copy of this sheet if necessary; however, submit original document only.

I have no work history at this time

_________________________________________________________________________________________________ Applicant Signature Date

Release of Information

I give my permission for my present/previous employer to release information concerning my employment background. _________________________________________________________________________________________________ Applicant Signature Date

Validation of Paid Work Experience

Employed from: _______________________to_______________________ Average Hours Worked________________________________ per week _____________________________________________________________ Employee Job Title _____________________________________________________________ Employer/Supervisor Signature & Title _____________________________________________________________ Agency Name & Phone Number Please return completed form to: Caddo Kiowa Technology Center Student Services P O Box 190 1415 North 7th Fort Cobb, OK 73038