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BASIC C.N.ARegistration Process Check SheetDATE COMPLETEDComplete an online DMACC application and select one of the following:(1) “Nurse Aide” as your major if you only plan on taking C.N.A classes OR(2) “Nursing (RN) – AAS” as your major if you are taking C.N.A as a pre-requisite and plan to goon to DMACC’s Nursing pplyonlinefull.aspxBe sure to notify DMACC immediately if your name, address, or phone number changes after you apply.PLEASE READ THESE INSTRUCTIONS CAREFULLY: The registration process for C.N.A requires you to register in person.The forms listed below, must be filled out completely prior to registration.Completed forms may be submitted on (or after) the “Registration begins” date that is listed for theBasic C.N.A section you are wanting. Dates can be found on the Basic C.N.A schedule on the DMACCwebsite (see link below). Registration forms will be accepted basic on seat availability.A photo ID is also required for registration, be sure to bring this with you.All forms must be submitted at the campus where you plan to attend Basic C.N.A.All paperwork, schedules and additional information can be found ANDARDS(2 pages)INSTRUCTIONSFORM READY( )PAGE 1: Read and determine if you can perform all the activities listed.PAGE 2: Sign the signature page stating that you can perform the duties listed on the form.(Also known as “Iowa Core Performance for Health Care Career Programs”)PAGE 1: Read Directions.3.4.CRIMINALABUSE/BACKGROUNDCHECK FORM(3 pages)HEALTH ANDPUBLICSERVICESDEPARTMENTRECORD OF TBTESTINGPAGE 2: “Notice & Release of Criminal Record/Child and Adult Abuse Registry Checks”You may fill out your name, social security number, address and phone number. Do notwrite below the “phone number” line. Do NOT sign this form; it must be signed in front ofour staff.PAGE 3: “State of Iowa Criminal History Record Check Request Form”You may complete the gray section. Note: if you have had more than one last name inyour lifetime, you must fill out a form for EVERY last name you have had (ex: maiden,married, adopted, etc.) Note: You MUST have TWO TB tests administered and read by a physician. Thephysician must sign this form. There must be a minimum of 7 days between the date the first TB test is administeredand when the second TB test is administered. If you have a positive test, you will need to have and submit a report from a chest xray. See form for details. Quantiferon Gold or T-spot TB blood tests are also acceptable, if your provider offersthem. A copy of blood test lab results are required.10/31/19

FLU VACCINEFORM5.I ITake this form with you to the location where you get your flu shot and have the provider fillit out, documenting that you received your shot.--Required when taking classes fromOctober through May only.C.N.A FREQUENTLY ASKED QUESTIONS (FAQ’s):1. How do I get my Nurse Aide Certification so I can work as a C.N.A?After completing the Basic C.N.A course successfully, you will have the opportunity to take the Nurse Aide written(NRAO858) and skills (NRA0859) tests for placement on Direct Care Worker Registry, which is your Nurse AideCertification.2. Where can I find more information about the C.N.A program?The DMACC Nurse Aide website has extensive information about the program and should answer most, if not all,questions you may have. Please consult the website ges/welcome.aspx3. Where do I go to register on each campus and who is the contact person?Ankeny Campus: Desha Nielsen, Building 24, room 308, 515-964-6849, Hours: 8am-12pm Monday-Friday,7:30am-12pm on “Registration begins” dateBoone and Ames Campus: Wendie Fagen, Boone Campus, Building 1, room 120, 515-433-5027Carroll Campus: Val Enenbach, Building 1, room 125, 712-792-8331Newton Campus: Kathy Sylvester, Building 1, 641-791-1724Capitol Center: Kate Chandler-Ernst, Building 1, room 101 G, 515-248-7255(NOTE: On “Registration Begins” date from 7-9 am, registration will be at the DMACC Capitol Center,1300 Des Moines St. Des Moines-Room 215. After 9 am on that day and all other days, forms will beaccepted at the main Urban Campus, 1100 7th St., Des Moines-Building 1, room 101 H.)West Campus: Charlene Hartman, Building 1, room 110W, 515-633-24114. Do I really need to get TWO TB tests or is one ok?Yes, you DO need to get two TB tests. This is a requirement for the State of Iowa not a DMACC requirement.Additional FAQ’s can be found on the DMACC Nurse Aide Pages/faq.aspx10/31/19

Iowa Core Performance Standards for Health Care Career Programs 2Iowa Community Colleges have developed the following Core Performance Standards for all applicants to Health Care Career Programs. These standardsare based upon required abilities that are compatible with effective performance in healthcare careers. Applicants unable to meet the Core PerformanceStandards are responsible for discussing the possibility of reasonable accommodations with the designated institutional office. Before final admission intoa health career program, applicants are responsible for providing medical and other documentation related to any disability and the appropriateaccommodations needed to meet the Core Performance Standards. These materials must be submitted in accordance with the institution’s ADA policy.CapabilityCognitive-PerceptionStandardThe ability to perceive events realistically,to think clearly and rationally and to functionappropriately in routine and stressful situations.Some Examples of Necessary Activities (Not All-Inclusive) Identify changes in patient/client health status Handle multiple priorities in stressful situationsCritical ThinkingCritical thinking ability sufficient forsound judgment. Identify cause-effect relationships in clinical situations Develop plans of careInterpersonalInterpersonal abilities sufficient to interactappropriately with individuals, families andgroups from a variety of social, emotional,cultural and intellectual backgrounds. Establish rapport with patients/clients and colleagues Demonstrate high degree of patience Manage a variety of patient/client expressions(anger, fear, hostility) in a calm mannerCommunicationCommunication abilities in English sufficientfor appropriate interaction with others inverbal and written form. Read, understand, write and speak English competently Explain treatment procedures Initiate health teaching Document patient/client responses Validate responses/messages with othersMobilityAmbulatory capability to sufficiently maintaina center of gravity when met with an opposingforce as in lifting, supporting and/ortransferring a patient/client. The ability to propel wheelchairs, stretchers, etc.,alone or with assistance as availableMotor SkillsGross and fine motor abilities sufficient toprovide safe and effective care anddocumentation. Position patients/clients Reach, manipulate and operate equipment,instruments and supplies Electronic documentation/keyboarding Lift, carry, push and pull Perform CPRHearingAuditory ability sufficient to monitor andassess, or document health needs. Hears monitor alarms, emergency signals,auscultatory sounds, cries for help Hears telephone interactions/dictationVisualVisual ability sufficient for observation andassessment necessary in patient/client care,accurate color discrimination. Observes patient/client responses Discriminates color changes Accurately reads measurement onpatient/client-related equipmentTactileTactile ability sufficient for physical assessment,inclusive of size, shape, temperature and texture. Performs palpation Performs functions of physical examinationand/or those related to therapeuticintervention, e.g., insertion of a catheterActivity ToleranceThe ability to tolerate lengthy periods ofphysical activity. Move quickly and/or continuously Tolerate long periods of standing and/or sittingEnvironmentalAbility to tolerate environmental stressors. Adapt to rotating shifts Work with chemicals and detergents Tolerate exposure to fumes and odors Work in areas that are close and crowded Work in areas of potential physical violence10/31/19

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2DMACC Nursing Assistant Program – HSC 172Name: DMACC ID: CRN:Core Performance Standards:Program continuation requires each student to perform every essential function of the student role. If thestudent, with reasonable accommodation, is unable to perform any essential function in a safe and successfulmanner, he/she will be required to withdraw from the program.I have reviewed the attached Iowa Core Performance Standards for Health Career Programs.Signature: Date:10/31/19

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3Des Moines Area Community CollegeCriminal/Abuse Background ChecksDMACC will complete Criminal/Abuse background checks on each student. Criminal convictions or documented historyof abuse may prevent students from participating in clinical education experience. Students unable to participate inclinical education will be unable to complete the course requirements. The Department of Inspections and Appeals(DIA) regulations can be found on their website, http://dia.iowa.gov/Criminal/Abuse background checks are processed at DMACC. At the time of Registration, required signatures will bewitnessed by a DMACC employee. Incomplete forms and forms or copies from outside sources will not be accepted. Ifthe student has used more than one last name (e.g., maiden, married), they must complete one State of Iowa “CriminalHistory Record Check Request Form” for each last name used. Students will be required to provide a photo ID.DMACCDES MOINES AREACOMMUNITY COLLEGE10/31/19

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CampusDES MOINES AREA COMMUNITY COLLEGE 3Notice & Release of Criminal Record/Child and Adult Abuse Registry ChecksI, the undersigned student in the Nursing Assistant program at Des Moines Area Community College (DMACC),understand that participation in a clinical experience is part of the Nursing Assistant program, and that this includesworking at an affiliating agency. I further understand that the affiliating agencies have the right to establishrequirements for participation in clinical experience and that the requirements may include submission to criminalrecord/child and adult abuse registry checks, based upon all current and former last names and aliases. Results ofthe criminal record/child and adult abuse registry checks will be released to the Department of Human Services(DHS) who will determine if the crime or founded abuse warrants prohibition from clinical education experience.In accordance with DMACC’s contract with affiliating agencies, results of the criminal record/child and adult abuseregistry checks will be released to contracted agencies only upon request.I understand and agree that if I am prohibited from participation in a clinical experience by DHS, or by an affiliatingagency or if I refuse to submit to the registry checks that are required in order to participate in a clinical experience,I may be unable to complete my program of study. I hereby release DMACC, its employees, and all affiliatingagencies from any liability with regard to my participation in a clinical experience and decisions made concerningmy participation in a clinical experience.Further, I give DCI (Department of Criminal Investigation) and DHS permission to release information to Des MoinesArea Community College, which may be requested as a result of the criminal/child and adult abuse check.Please PrintName:Social Security Number:Address:City:State:Zip:Phone Number:Signature:Date:Witness:Date:DMACCDES MOINES AREACOMMUNITY COLLEGE7/2006, 3/201010/31/19

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