WIXLIB

Pre-Admission Survey1. Full name:2. Mailing address:3. Your Phone Number:( ) -4. Where are you currently employed?5. Currently attending High SchoolHigh School Graduate/GEDInterested in Nursing as a CareerRelative/Close Friend is a Nurse6. Do you have any nursing or nursing assistant experience?NoYes Where?7. Where would you like to work after you have completed this CNA course?8. Have you ever attended another CNA program?NoYes Which one?9. I will email my instructor about any personal circumstances that need to be addressed (e.g. financialissues, vaccination concerns, scheduling consideration, etc.).10. Interesting fact about me:11. Emergency contact: Relationship:Emergency contact telephone: ( ) -

Consent Form for Drug and Alcohol TestingI understand that as a requirement to entering a health science program with an associated clinical component atDixie State University (DSU), I must submit to a urine drug test. The testing facility must provide results of the test tothe Program Chair for the department the student is attempting to enter. I understand that if the substance testresult is positive, the program chair will follow the guidelines listed in the College of Health Sciences (CHS) Drug andAlcohol Testing Procedure, which may include denial of entrance to the program.I authorize DSU to conduct all related alcohol and drug tests that are subject to the policy. I further authorize and givefull permission to have the University and/or its personnel to send the specimen or specimens so collected to alaboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratoryor other testing facility to release any and all documentation relating to such test to the University and/or to anygovernmental entity involved in a legal proceeding or investigation connected with the test.I also authorize the release of information concerning the results of such tests to designated University personnel, itsclinical partners, to any assistance program to which I may be referred, and to the appropriate licensing boards, ifapplicable.I will hold harmless DSU, its personnel and any testing laboratory the University might use, meaning that I will not sueor hold responsible such parties for any alleged harm to me that might result from such testing, including loss of rightto participating in the academic program, ineligibility to test for a certification exam, employment or any other kindof adverse action that might arise as a result of the drug or alcohol test, even if a DSU or laboratory representativemakes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmlessDSU, its personnel and any testing laboratory the University might use for any alleged harm to me that might resultfrom the release or use of information or documentation relating to the drug and/or alcohol test, as long as therelease or use of the information is within the scope of this policy and the procedures as explained in the paragraphabove.I understand refusal to complete the drug and/or alcohol testing process will prohibit me from entering the desiredprogram in the CHS at DSU as stated in the CHS Drug and Alcohol Testing Procedure.I consent to urine drug and/or alcohol testing for the purpose of admission to a program with a clinicalcomponent in the College of Health Sciences at Dixie State University. I understand that this consent formremains in effect during my enrollment in a CHS program with a clinical component at DSU.Print Name: DixieID:Student Signature: Date:

Student Awareness FormAfter you have read through the class syllabus concerning the policies and rules of thiscourse, the instructor will address any questions or concerns you may have.**If you are the parent of a minor child enrolled in this course and have any questions, pleasecall the course instructor.1. I have read and understand the clinical hours requirements of this course.2. I have read and understand the uniform code and agree to comply with it.3. I have no physical limitations that would impair my ability to lift and perform other physicalskills required of the profession.4. I understand that there is a last day that students are able to withdraw from this course withoutpaying a fee (around the 3rd week of school), but that I have until the deadline outlined in thesyllabus to complete all the required immunizations. I, as the student, am responsible forobtaining my refund (as applicable), or providing proof of all required vaccinations. I will not beeligible for clinical rotations if I don’t complete the required vaccinations by the deadline.5. I have read and understand the professionalism and confidentiality policies.6. I have read and understand the attendance and withdrawal policies.7. If I am a student under 18 years of age, my parent or legal guardian has signed the disclosureagreement related to the sensitive content of this course.I acknowledge that I have read and hereby agree to comply with the terms of the abovestatements.Student SignatureDate**If the student is under the age of 18 (or still in high school living with their parent/guardian),parent/guardian must sign below.Parent/Guardian SignatureDate

UNIFORM CODEYou will be expected to abide by the Dixie State University Nursing Department uniform codefor the CNA program and conform to all agency codes where Dixie State University CNAstudents attend.1. General Grooming1) Avoid using strong scented lotions, perfumes, or colognes.2) No chewing gum in the clinical setting.3) Offensive and/or distracting tattoos (students must cover tattoos while in clinical).4) No smoking during clinical shifts.5) Hair must be clean and neat. Long hair should be pulled back. NO extreme styles.6) Neatly trimmed male facial hair is acceptable. No extreme side burns or untrimmed beards.7) Wedding/engagement rings are allowed. (Rings with large settings are not advised.)8) Wrist watch with a second hand is allowed. Band should be as simple and conservative.9) Small earring posts may be worn in pierced ears only. Maximum of two posts per ear. Noloop earrings. NO other visible body jewelry or piercings.10) Fingernails must be clean and manicured. Natural color or clear polish must be kept ingood condition.2. Uniforms1) Mandatory Dixie State University CNA Program scrubs and badges are required at clinical.Students not wearing their identification badge will be asked to leave their clinicalassignment until they have their badges. There will be a 10 charge for replacement badges.2) Uniforms are to be clean and wrinkle-free. Uniform pant hems must not touch/drag onfloor.3) Approved uniform includes:(i) Program approved scrubs(a) slate gray tops; black bottoms(ii) White or black T-shirt may be worn underneath, if desired and must be tucked in. Nolace or patterns showing.(iii) Appropriate underclothing not visible through or around uniform. Must have a modestand non-revealing appearance.(iv) Shoes: Medical, professional footwear or athletic shoes.(a) Must be closed-toe4) CNA Program uniform are required for all labs.5) You are expected to behave professionally and dress in appropriate street clothes forclassroom and open lab practice.Dixie State University Nursing Department dress code will be in accordance with all clinicalfacilities.Printed Name: DixieID:Student Signature: Date:

Disclosure of Legal Convictions & ArrestsI understand that I have 48 hours to report any arrest, criminal conviction, orgovernmental sanction while enrolled in a Dixie State University College of HealthSciences (CHS) program to the appropriate department chair and the dean of CHS.I understand that I will be unable to participate in clinical activities until the issue is resolved.I further agree to, and hereby authorize, the release of my disclosure of a legalconviction and/or arrest to an appropriate representative of the clinical agency for thesole purpose of determining eligibility to participate in clinical activities within theagency.I understand that failure to report any arrests, convictions or governmental sanctionswithin 48 hours will result in my dismissal from the health science program.I do hereby swear or affirm that I have read and understand the requirements of thisprocedure. I will comply with the requirements of this procedure.Print Name: DixieID:Student Signature: Date:

Social media procedureI will refrain from posting insulting, disrespectful, or disparaging comments about any member ofthe Dixie State University campus community to social media sites. I will attempt to directly resolvea conflict, concern, or issue with a member of the DSU community. If I am unable to resolve aconflict, concern, or issue directly with the individual involved, I will utilize the resources availableto me including but not limited to the Dean of Health Sciences, Dean of Students, Health andWellness Center counselors, class representative, a trusted advisor or mentor.In exchange for the educational opportunities provided to me by the clinical rotations, I agree tocomply with all state, local, and federal requirements governing the privacy of medical information.Those privacy requirements have been explained to me, and I have had training in complying withthese requirements. I agree to uphold all HIPAA and other privacy requirements during my clinicalrotations.I understand that I am bound to comply with all privacy requirements when I am not at the clinicalrotation, including in my conversations with family, friends, and peers. I will be held accountablefor maintaining the privacy of any information I obtain, see, or am given during my clinicalrotations. In addition, to uphold the privacy of such information, I agree to not post or discuss anyclinical experience or information regarding my experience with the clinical agency, its staff, or itsclients/patients on any Internet social media (Facebook, Twitter, Linkedin, emails, MySpace, andany others not mentioned). I understand that administration periodically searches the Internet forbreaches in its privacy policies. I will be prohibited from returning to the clinical site if I violate anyprivacy requirement in any regard. Such violation may also result in a delay in completing mydegree requirements or in further disciplinary action against me by Dixie State University.Student Name (Printed):Student Signature:Date:

Honor codeMy signature below indicates that I have read the Integrity Statement and that I agree to the following:1. I commit myself to acting honestly, responsibly, and above all, with honor and integrity in allareas of the nursing program including classroom, lab, and clinical.2. I am accountable for all that i say and write.3. I am responsible for the academic integrity of my work.4. I pledge that I will not misrepresent my work nor give or receive unauthorized aid.5. I commit myself to behaving in a manner which demonstrates concern for the personal dignity,rights, and freedoms of all members of the Dixie State University community.6. Recognizing my responsibility to protect the integrity of the nursing profession, i will reportother students’ dishonest behavior to faculty or the dean of health sciences.7. I commit to uphold Dixie State University policies on student rights and responsibilities and thenursing program integrity statement.Student Name (Printed):Student Signature:Date:

State Certification FormTestMaster Universe (TMU)ut.tmuniverse.comLEGAL NAME:First NamePhone Number:Middle NameLast Name( ) -Dmail (used for TMU login):@dmail.dixie.eduClassroom Instructor:Semester Completed:SPRING / SUMMER / FALLI must complete the following:Classroom HoursYEAR:76 minimumClinical Hours24 minimumTotal Program Hours100 minimumPrinted Name DixieIDSignature