CNA Packet
General Information
- Availability for the CNA class is limited due to the State of Iowa regulations.
- Filling out an application does not guarantee that you will be enrolled in the next starting class.
- Deadline to return completed paperwork to us is ONE Month prior to the class start date. This allows us time to process your background check and to make any adjustments to the class roster.
- You will not be enrolled in the CNA class until the CNA Coordinator has contacted you by phone or email or both.
- PLEASE be certain to provide accurate Phone and E-Mail Information.
- You can pay your tuition bill by going to the Self Service tab on Hawknet. If you do not see a tuition bill, you are NOT enrolled for the class.
- Unless you have funding, Financial Aide, PACE or Voc Rehab, YOU are Responsible for the Full amount of the CNA class.
- This must be paid in FULL before classes begin.
NOTE: Print this packet single-sided so forms will print individually.
Nurse Aide Certificate Registration Packet & Check Off
Please use the following steps to ensure your packet is complete.
- Using a Laptop or Desktop Computer, Apply for Admission to Southeastern Community
College
- Go to the Apply Now webpage and start your SCC Admission Application
- Program information can be found on our website at: Nurse Aide Certificate
- Fill out the Course & Contact Information page. Please select which CNA class you wish to attend.
- Complete the Iowa Division of Criminal Investigation Criminal History Record Check Request Form
- Read the Background Check Policy
- Complete the Background Check and Release Form
- Review the Iowa Core Performance Standards for Health Care Career Programs page
- Sign the Iowa Core Performance Standards Acknowledgement Form
- Complete a 2-Step Tuberculosis (TB) Skin Test (Need Copy)
- You must have TWO TB tests within 12 months
- If you have a Positive TB, a chest x-ray must be submitted
- A QuantiFERON Gold blood test is accepted
- A Flu Vaccine is required between October 1st and May 1st. (Need Copy)
- COVID-19 Vaccine or an approved exemption is required to complete the Clinical component (Need Copy)
High School Age Applicants: Contact High School Counselor
- Responsible for the $190 CNA Testing fee—Skills and Written tests
- May be responsible for the $25 Background Check Fee
Complete and Return these forms with the $25 Background Check Fee
- Course and Contact Information Form
- State of Iowa Criminal History Record Check Request Form
- Background Check and Release Form
- Iowa Core Performance Standards Acknowledgement Form
Additional forms to be submitted when complete:
- Tuberculosis (TB) Skin Test Form
- Record of Influenza Vaccination Form
For Questions, please contact the Nurse Aide Coordinator at (319) 208-5278
Background Check Policy
The education of Health Professions students at Southeastern Community College requires collaboration between the college and clinical affiliates. The education of Health Professions students cannot be complete without a quality clinical education component. The college shares an obligation with the clinical affiliates to protect the affiliate's patients to the extent reasonably possible.
In establishing clinical affiliation agreements, healthcare educational programs are contractually obligated to comply with the requirements set forth by the clinical affiliates. Students enrolled in Health Professions programs must conform to the rules, policies and procedures of the clinical affiliate in order to participate in clinical learning experiences. Therefore, all students enrolled in a Southeastern Community College Health Professions program will be required to complete a criminal background check. An independent third-party vendor will be used to complete all Southeastern Community College background checks. The cost of these background checks has been added to your student fees when you enrolled in the program.
Students will be notified of the requirement for the background check prior to admission and upon admission to a Health Professions program. The background check may include, but is not limited to searches, histories, and verification as listed below:
- Positive Identification
- Maiden/AKA Name Search
- Social Security Number Trace which is verification that the number provided by the individual was issued by the Social Security Administration and is not listed in the files of the deceased. The SNN trace is also used to locate additional names and addresses.
- Residency History
- National Criminal Database Searches which include a compilation of historical data, collected from multiple sources in multiple states by background check companies.
- Child and Dependent Adult Abuse/Registries-Single Contact License and Background (SING)
- Office of Inspector General (OIG) search
Background checks which would render a student ineligible to obtain clinical learning experiences include, but are not limited to, certain convictions or criminal charges which could jeopardize the health and safety of patients and sanctions or debarment. Felony or repeated misdemeanor activity within the past seven (7) years and Office of the Inspector General violations will normally prohibit the obtainment of clinical learning experiences with clinical affiliate(s). Positive findings on background checks can have licensure implications upon graduation from a health program. Criminal offenses which occur during the nursing program shall consider due process which provides that an individual is innocent until proven guilty up until which time he/she pled or is found guilty and is then subject to review by regulating authorities.
Documentation of criminal background checks is maintained in secured files and destroyed upon graduation of the Health Professions program.
The background information of any student with a discrepancy will be reviewed by the Nursing Program Clinical Coordinator and the student and submitted to the Department of Inspections and Appeals (DIA) for review. A representative from the assigned clinical experience or field internship site may also be consulted to ascertain the appropriateness of allowing the student to participate in clinical or field experience.
Students who are unable to resolve a positive criminal background check will be dismissed from the health care program. The student will be advised as to their eligibility for program re-entry and the mechanisms for reapplication to the program.
One background check is required during continuous enrollment in a program. In the event a student leaves the program, a new background check will be required prior to re-entry.
(Sign form located at end of handbook)
Iowa Core Performance Standards
Iowa Community colleges have developed the following Core Performance Standards for all applicants to Health Care Career Programs. These standards are based upon required abilities that are compatible with effective performance in health care careers. Applicants unable to meet the Core Performance Standards are responsible for discussing the possibility of reasonable accommodations with the designated institutional office. Before final admission into a health career program, applicants are responsible for providing medical and other documentation related to any disability and the appropriate accommodations needed to meet the Core Performance Standards. These materials must be submitted in accordance with the institution’s ADA Policy.
| CAPABILITY | STANDARD | SOME EXAMPLES OF NECESSARY ACTIVITIES (NOT ALL INCLUSIVE) |
| Cognitive-Perception | The ability to gather and interpret data and events, to think clearly and rationally, and to respond appropriately in routine and stressful situations. |
|
| Critical Thinking | Utilize critical thinking to analyze the problem and devise effective plans to address the problem. |
|
| Interpersonal | Have interpersonal and collaborative abilities to interact appropriately with members of the healthcare team as well as individuals, families and groups. Demonstrate the ability to avoid barriers to positive interaction in relation to cultural and/or diversity differences. |
|
| Communication | Utilize communication strategies in English to communicate health information accurately and with legal and regulatory guidelines, upholding the strictest standards of confidentiality. |
|
| Technology Literacy | Demonstrate the ability to perform a variety of technological skills that are essential for providing safe patient care. |
|
| Mobility | Ambulatory capability to sufficiently maintain a center of gravity when met with an opposing force as in lifting, supporting, and/or transferring a patient/client. |
|
| Motor Skills | Gross and fine motor abilities to provide safe and effective care and documentation |
|
| Hearing | Auditory ability to monitor and assess, or document health needs |
|
| Visual | Visual ability sufficient for observations and assessment necessary in patient/client care, accurate color discrimination |
|
| Tactile | Tactile ability sufficient for physical assessment, inclusive of size, shape, temperature and texture |
|
| Activity Tolerance | The ability to tolerate lengthy periods of physical activity |
|
| Environmental | Ability to tolerate environmental stressors |
|
Source: https://educate.iowa.gov/media/2431/download?inline
Revised 2018
(Sign form located at end of handbook)
Course & Contact Information Form
Please indicate your class location, start date, and time: (Select one from each section)
| Locations | Time | Start Date |
| Ο - West Burlington Campus | Ο - Days | Ο - January |
| Ο - West Burlington Hybrid | Ο - Evenings | Ο - March |
| Ο - Keokuk Campus | Ο - Hybrid | Ο - May |
| Ο - Mt. Pleasant Center | Ο - June | |
| Ο - High School Class (see below) | Ο - August | |
| Ο - October |
Please provide contact information to notify you of enrollment into the nurse aide course. Ensure you write clearly and provide an email address that is checked regularly:
__________________________________________________
Printed Student Name
_________________________________________________
Email Address
_____________________
Phone Number
If you are a high school student, please complete this information as well:
__________________________________________________
Name of High School
The course I plan to take will be at:
Ο - My High School
Ο - West Burlington Campus
Ο - Keokuk Campus
Ο - Mt. Pleasant Center
Please deliver this and all other required forms with the $25 (made out to SCC) non-refundable fee to:
Nurse Aide and Health Continuing Education Coordinator
Southeastern Community College
1500 West Agency Road, Health Professions Bldg. (office HP 104C)
West Burlington, Iowa 52655
Phone: (319) 208-5278 or (866) 722-4692
FAX: (319) 208-5005
Background Check and Release Form
I have received and carefully read the Background Check and Release Policy and fully understand its contents. I understand that the healthcare program to which I am admitted requires a background check to comply with clinical affiliate contracts and state regulatory requirements. By signing this document, I am indicating that I have read and understand Southeastern Community College's policy and procedure for background checks. I voluntarily and freely agree to the requirement to submit to a Background Check and to provide a negative Background Check prior to participation in clinical learning experiences. Any charges the Department of Human Services do not evaluate will result in denial of enrollment in the program. These are inclusive of juvenile charges, pending charges, ft charges with an outstanding disposition or warrant. I further understand that my official enrollment in the health care program is conditioned upon satisfaction of the requirement of the Background Check with the vendor designated by the college.
A copy of this signed and dated document will constitute my consent for release of the original results of my Background Check to the college. I direct that the vendor hereby release the results to the college. A copy of this signed and dated document will constitute my consent for the college to release the results of my background check to the clinical affiliate(s).
__________________________________________________
Printed Student Name
__________________________________________________
Email
______________________________
Phone Number
____________________
Student ID (if known)
__________________________________________________
Student Signature
____________________
Date
Iowa Core Performance Standards Acknowledgement Form
Program continuation requires each student to perform every essential function of the student role. If the student, with reasonable accommodation, is unable to perform any essential function in a safe and successful manner, he/she will be required to withdraw from the program.
I have reviewed the attached Iowa Core Performance Standards for all applicants to Health Care Career Programs.
__________________________________________________
Printed Student Name
__________________________________________________
Email
______________________________
Phone Number
____________________
Student ID (if known)
__________________________________________________
Student Signature
____________________
Date
Tuberculosis (TB) Skin Test Form
Payment Received for: One | Two Tests (circle choice)
Student/Patient Name: __________________________________________________
Testing Location: _______________________________________________________
| Test #1 | Test #2 |
|
Date Placed: ____________________
Site: Left | Right (circle choice)
Lot #: ____________________
Exp. Date: ____________________
Administered by: ______________________________ |
Date Placed: ____________________
Site: Left | Right (circle choice)
Lot #: ____________________
Exp. Date: ____________________
Administered by: ______________________________ |
|
Date #1 Read: ____________________
Induration (mm): ____________________
PPD (Mantoux) Results: Negative | Positive (circle choice)
Read by: ______________________________ |
Date #1 Read: ____________________
Induration (mm): ____________________
PPD (Mantoux) Results: Negative | Positive (circle choice)
Read by: ______________________________ |
* In order for this document to be valid, all sections of this form must be completed.
Record of Influenza Vaccination Form
Annual Influenza Vaccination is required of Nursing Assistant Students and Faculty who have clinical contact October through May of the following year.
SECTION A
Students: Complete the information below and return completed documentation to your Campus Intake Personnel.
Faculty: Return completed documentation to the Program Coordinator.
PLEASE PRINT
Last Name: ________________________________________ First Name: ____________________ Middle Initial: _____
Date of Birth: ____________________ Student/Employee ID: ____________________
Program: ______________________________ Campus: ____________________
(CNA: HSC-168)
Students and faculty must have this record completed during flu season, October through May of the following year.
SECTION B
This section must be completed and signed by the person administering the flu vaccination.
Select one:
[ ] This vaccine is contraindicated for this person at this time due to:
__________________________________________________________________________________________
Reason(s) for contraindication
____________________________________________________________ ____________________
Signature and Title
Date
[ ] This verifies that an Influenza Vaccination was given to the person named above on:
__________________________________________________
Administered by (print name)
____________________________________________________________ ____________________
Signature and Title of Vaccine Administrator Date Administered
____________________________________________________________ ____________________
Street Address
Phone Number
____________________________________________________________
City/State/Zip