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Student ID:Name:Date of Birth:Physical Address:City, State, Zip:Mailing Address (if different than Physical):City, State, Zip:Home Phone:Cell Phone:E-mail:HIGHEST EDUCATION LEVEL ACHIEVED:Less than a H.S. DiplomaH.S. Diploma Some College Technical DiplomaAssociates Degree Bachelors Degree Masters Degree Doctorate Degree G.E.D.Social Security Number:Gender :MaleFemaleRACE - Please check all that apply: (The following information is optional.)Black/African AmericanAmerican Indian or Alaska NativeNative Hawaiian/Other Pacific ic,LatinoCourse Title/Date:Cost:Course Title/Date:Cost:Course Title/Date:Cost:CashDiscoverCARD Holder’s Name:CC#:VISAMasterCARDCheck #Exp Date:I CONSENT(DL#, 2 phone #’S and address required)CID Code:I DO NOT CONSENTto receiving non-emergency Automated Calls from Southern Tech at the telephone number(s) I provided to the District within thisform. By signing below, I agree to the terms above:Student’s Signature:Date:Payment is required at the time of enrollment. Must be at least 18 years old to enroll in most courses. You may be asked to provideproof of residency and/or“tax letter”at time of enrollment.For information on billing,invoicing, enrolling or refunds, please call 580-224-8201 or visit www.sotech.eduSouthern Tech does not discriminate on the basis of race, color, national origin, gender, age, religion, disability, or veteran status.CAMPUS LOCATIONS:ARD- ARDMORE CAMPUS LCEC- LOVE COUNTY EXTENSION CENTER MCEC- MURRAY EXTENSION CENTER WEC- WESTERN EXTENSION CENTER31

Nurse Refresher CourseName:FirstMILastHome Address:City:State:Home/Cell Phone:Zip:Bus. Phone:Email:Name of Technology CenterPlease check one:Educated as LPN OREducated as RN Please check one:I plan to take the theory, skills lab, and clinical components of the course. ORI plan to take the theory portion only. Reason for taking the course (Please check one): I am currently licensed in Oklahoma, and just want to refresh my nursing knowledge. To be eligible for the NCLEX examination For reinstatement of my Oklahoma nursing license (I have previously been licensed in Oklahoma.) For endorsement of my nursing license (I am currently or have been previously licensed in another state orcountry.) Board ordered

Acceptable Use of Information Systems atThe University of Oklahoma Health Sciences CenterGeneral PrinciplesAccess to computer systems and networks owned, operated, or provided by the University is predicated oncompliance with certain responsibilities and obligations and is granted subject to University policies and local, state and federal laws. Byusing University information systems or computing resources, you agree to abide by and comply with the applicable policies, procedures andlaws. Acceptable use must be ethical, reflect academic honesty, and show responsible use in the consumption of shared resources.Acceptable use also demonstrates respect for intellectual property, ownership of data, system security mechanisms, and freedom fromintimidation and harassment. Information created or stored on University computer resources, networks and systems may be subject to theOklahoma Open Records Act.In making acceptable use of information resources you MUST: Comply with all University policies, procedures, and local, state, and federal laws Use resources only for authorized administrative, academic, research or clinical purposes; or other University business Protect your user-ID and system from unauthorized use. (you are responsible for all activities on your user-ID or that originatefrom your system); Access only information that is your own, that is publicly available, or to which you have been given authorized access; Comply with all copyright laws, licensing terms, patent laws, trademarks, trade secrets and all contractual terms Be responsible in your use of shared resources (refrain from monopolizing systems, overloading networks, degrading services, orwasting computer time, connect time, disk space, printer paper, manuals, or other resources.)In making acceptable use of information resources you MUST NOT: Use another person's system, files, or data without express authorization Use another individual's user id or password Use computer programs to decode passwords or access control information; Attempt to circumvent or subvert system or network security; Engage in any activity that might be harmful to systems or to any information stored thereon, such as creating or propagatingviruses, disrupting services, damaging files, or making unauthorized modifications to or sharing of university data; Use university systems for commercial, private, personal, or political purposes, such as using electronic mail to circulateadvertising for products or for political candidates; Harass or intimidate another person including, but not limited to, broadcasting unapproved, unsolicited messages, repeatedlysending unwanted or threatening mail, or using someone else's name or user-id Waste computing resources or network resources including, but not limited to, intentionally placing a program in an endless loop,printing excessive amounts of paper, or sending chain letters or unapproved, unsolicited mass mailings Attempt to gain access to information or services to which he/she has no legitimate access rights Engage in any other activity that does not comply with the general principles presented above, university policies and procedures,or applicable law;Enforcement The University considers any violation of acceptable use principles or guidelines to be a serious offense and reserves the rightto copy, monitor and/or examine any files or information residing on University systems, networks, or computing resources allegedly relatedto unacceptable use, and to protect its systems and networks from events or behaviors that threaten or degrade operations. Violators aresubject to disciplinary action including, but not limited to, penalties outlined in the Student Code, Staff Handbook, or Faculty Handbook.Offenders also may be prosecuted under laws including, but not limited to, the Communications Act of 1934 (amended), Family EducationalRights and Privacy Act of 1974, Computer Fraud and Abuse Act of 1986, Computer Virus Eradication Act of 1989, Interstate Transportationof Stolen Property, Digital Millennium Copyright Act, Health Insurance Portability and Accountability Act, Electronic Communications PrivacyAct, Oklahoma Open Records Act, and state conflicts of interest laws.Individuals using computer systems owned by the University do so subject to applicable laws and University policies. The user assumes allrisk of loss of materials or data or damage thereto. The University disclaims any responsibility and/or warranties for information and materialsresiding on non-University systems or available over publicly accessible networks. Such materials do not necessarily reflect the attitudes,opinions or values of the University, its faculty, staff or students. These guidelines should not be construed as a limit on any individual's rightunder the Constitution of the United States or the laws of Oklahoma.Instructions:Please print your name and your college in the box below, sign and date this policy agreement (page 1), and return withthe rest of your paperwork or bring to orientation.I have read and understand the above policy and agree to abide by this policy in my use of OUHSC computer resources.Resident:Last NameUser’s Signature:Form SEC01 (NurCE)First NameMiddle InitialDepartment: NursingDate:Policy Approved by the Senior Vice President and Provost, January 19, 2000 - Revised 8/21/03

The University of Oklahoma Health Sciences CenterInformation TechnologyNursing Continuing Education Computer Account Request* Please Print Legibly *Student’s Name:LASTFIRSTSSN (last 4 digits):MIDDLE INITIALDepartment: NURSINGPersonal Email Address:Access Privileges: Each resident account holder will be granted access to the following:Electronic MailInternet Access* A c c oun t S pon s o r On l y *As an account sponsor, I (1) agree to assume limited responsibility for the use of this user account as outlined inthe attached OUHSC Information Technology Computer Account Policy and (2) state that this user accountis necessary for an official university activity/endeavor or to conduct university business.Sponsor’s Name:Patrice BrownSponsor’s Signature:Form SEC01 (NurCE)Title:Sr. Administrative AssistantDate:Policy Approved by the Senior Vice President and Provost, January 19, 2000 - Revised 8/21/03

Southern TechNurse Refresher Statement of UnderstandingNurse Refresher Program Student Guidelines (Rules and Policies)I, , have received and understand the rules and polices’ ofSouthern Tech and the University of Oklahoma as stated in the guidelines provided to me (student).ProgramI understand that I am enrolled in a Nurse Refresher Program that meets the requirements of theOklahoma Board of Nursing (OBN).I understand that my 2000.00 tuition includes 6 months of access to the online program. If I amunable to complete the online program as agreed upon in my orientation I will be chargedadditional fees in order to complete the program.I understand I must make an average of 75% or better in the online (Component 1) portion of theprogram. I also understand I must make a minimum of a 90% on the dosagecalculation/medication administration exam to pass the course.I understand that I must possess basic computer skills in order to complete the online coursethrough OU (component 1and 3).I understand that attending 70 hours of theory (online), 10 skill lab hours (at Southern Tech) anda minimum of 40 hours of online simulation clinical is what is required of me to pass the course.I understand that I must attend 100% of the class in order to complete my required hours.I understand that any violation of HIPPA, including the use of social media, or other privacyviolations will be grounds for immediate dismissal from the program.I understand that if I jeopardize a resident’s safety, breech confidentiality, violate HIPPA,mistreat, neglect, abuses or misappropriates a residents/clinical property the student will beimmediate grounds for dismissal from the program.I understand that the use or possession of drugs, weapons, alcohol or the use of tobacco(including smokeless) products on campus or clinical site is grounds for dismissal from theprogram.I understand that I may be exposed to many hazards associated with laboratory practice andclinical rotations, including but not limited to, needle sticks, inhalation of microorganisms, andcontacted with bodily fluids. I understand that it is my responsibility to follow universalprecautions for infection control and maintain safe practices.I understand that LPNs must show proof of completion of an IV Therapy Course. LPNs who arenot currently certified in IV therapy or who did not obtain IV therapy training in their practicalnursing curriculum must complete an IV Therapy Course (offered through the participatingtechnology centers) prior to enrollment in the Nurse Refresher lab and clinical courses.Nurse Refresher Packet1/2021

Criminal HistoryI understand state law requires all nursing facilities to secure an Oklahoma State Bureau ofInvestigation criminal arrest report prior to permanently employing a Practical Nurse orRegistered Nurse. If the results of the criminal arrest check reveal that an applicant foremployment at a facility has been convicted of certain offenses, the facility shall not hire theperson. ALL STUDENTS MUST PASS A BACKGROUND CHECK AND DRUG TEST PRIORTO CLINICALSOther expenses for students requiring additional clinical experience: Current CPR Card: American Heart Association Only; No Red Cross or Online Certificationwill be accepted; if CPR is not taken prior to the clinical rotation student will not be allowed toattend clinical and will be dropped from the courseImmunizationso Tetanus Vaccine (within the last 10 years)o MMR Series (2 vaccines) or Positive MMR Titero Negative TB Skin Tests (within the last 12 month)o Varicella Series (2 vaccines) (chicken pox) Vaccine or Positive Titero Hepatitis B Series (3 vaccines) or (2-2/dose vaccine) or Waivero Annual Flu VaccineCopy of Driver’s License or Valid Government Photo IDDrug ScreenBackground CheckScrub Set(s) (Clean and solid color only)Clean tennis/nursing type shoesStethoscopePen with black inkSmall notepadI, , understand that signing this statement of understanding meansthat I verify that I received, read, and agree to the terms of the Nurse Refresher Guidelines. I understand and agreeto uphold the rules and statements above.Print Name of ApplicantSignature of ApplicantDateNurse Refresher Packet1/2021

The Nurse Refresher Program costs 2000.00; this is non-refundable. The following items are included in the price of the class: online class, skills sessions (10 hours), 40 hours of online simulated clinicals, and skills session supplies. For those the OBN directs to the online only course (didactic portion), the cost is 600 for 6 months .