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Workforce and Community Development

Continuing Education & Customized Training

www.lsc.edu/ContinuingEducation

NURSING REFRESHER (RN/LPN)

Spring 2011 DESCRIPTION

This course is designed for nurses, with at least six months of professional experience in nursing, whose licenses have lapsed and wish to renew their registration. This is an online, independent study of nursing practice and theory combined with an on-site skills lab and clinical. You will review nursing procedures, skills, diagnostic tests, medications and documentation. Upon successful completion of the on-line component and skills refresher, a clinical experience in an acute or long-term care setting is required. The scope of practice for LPNs and RNs will be clearly defined.

PARTICIPANT REQUIREMENTS:

Contact the Minnesota Board of Nursing and receive a confirmation of status approval. o Individuals interested in participating in the course are required to contact the Board of Nursing directly to clarify whether this is an appropriate course for re-licensure or refresher. o Contact information for MN Board of Nursing: phone 612-617-2270 or 888-234-2690, fax 612617-2190, email [email protected] or web site www.nursingboard.state.mn.us Satisfactory background checks (Criminal Study and NET Study) Current physical exam (must be able to participate fully in patient care activities) Current immunizations including Mantoux Current CPR Certification

COURSE DETAILS:

Cost: $1,040 includes textbook Additional Cost: $50 (paid online by student) background check Instructor: Julie Drake, RN RN Refresher LPN Refresher

Course ID: #1173 Hours/CEU's: 150/15.0 CEU's 90 classroom, 20 skills lab, 40 clinicals Course ID: #1172 Hours/CEU's: 120/12.0 CEU's 60 classroom, 20 skills lab, 40 clinicals

DATES/TIMES:

MANDATORY Orientation: On-line coursework: Skills Lab in Room E2326: Clinicals: Tuesday, January 18, 2011 in Room E2402, 6:00 pm to 7:30 pm January 19, 2011 through May 12, 2011 Fridays May 13, May 20, and May 27 from 5:00 pm to 9:00 pm Saturdays May 14, May21, and May 28 from 10:00 am to 4:00 pm Arranged ­ approximately June 1 through June 24

Lake Superior College is an Equal Opportunity Employer and a member of the Minnesota State Colleges and Universities system. Individuals with disabilities may request reasonable accommodation or information from Georgia Robillard, (218) 733-7650 or (218) 722-6893 TTY.

2101 Trinity Road, Room E2060, Duluth, MN 55811 · Phone: (218) 733-5924 · Fax: (218) 733-5974

Workforce and Community Development

Continuing Education & Customized Training

www.lsc.edu/ContinuingEducation

NURSING REFRESHER (RN/LPN)

Spring 2011 Requirements Checklist Prior to December 31, 2010:

Register online. Full payment must accompany registration or your registration will be dropped. Complete the $50 online background check (www.myvci.com/lakesuperior)

To Registration

Prior to January 6, 2011:

Board of Nursing (BON) contact made, copy of their written response to LSC Background Check NET Form complete ­ Copy LSC Physical Exam Form complete ­ Copy to LSC Immunization Form (including Mantoux) ­ Copy to LSC Review New Student Log-in Instructions for Online Classes found at: https://www.lsc.edu/connect/index1.cfm Click on "Here's how" Click on "Student Login Instructions" Set up account to log-in Utilize LSC Online Skills Tutorial if necessary

On the Start Date,Tuesday, January 18, 2011:

Attend Orientation from 6:00 p.m. to 7:30 p.m. in room E2402

After Start Date:

Current CPR certification ­ Copy to LSC (by February 25, 2011) Clinical Permit (request from BON shortly before clinicals ­ instructor will discuss) Confirm clinical site with instructor; set up dates/times

Questions? Call or email Continuing Education, 733-5924, [email protected]

Lake Superior College NETStudy ­ Spring 2011

The following information is required by Minnesota Department of Human Services for Background Study Clearance. Your privacy rights are outlined in a separate notice entitled "Background Study Privacy Notice." Directions: Please print clearly. Items marked with an asterisk (*) are optional. All other information is REQUIRED. Circle Program enrolled in:

LPN Refresher

RN Refresher _______________________

Full middle name

HUC ___________________________

Full last name

Name: ___________________________

Full first name

Date of Birth: Gender:

______/_______/__19______ Male Female ______________________________ *

Minnesota Drivers License #: Race: *

Asian Pacific Islander African American Native American Caucasian Unknown/Other

Social Security #: _________-_______-______________ * Phone: ________________________________________________ * Address: _______________________________________________ _______________________________________________ State: ________________________ City: ____________________ Zip: ___________

Other first names you have used: _________________________________ _________________________________ Other last names you have used: _________________________________ _________________________________ _________________________________

Return completed form with registration to: Lake Superior College, Attn: G. Faith, 2101 Trinity Road, Duluth, MN 55811

Health Occupation Programs ­ Spring 2011 History and Physical Examination Form

(To Be Completed by the Student)

Program: (Check One) o Associate Degree Nursing o Medical Assistant o Phlebotomy o Radiologic Technology o Health Unit Coordinator o o o o Dental Hygiene Medical Lab Technician Practical Nursing Respiratory Care Practitioner o o o o Massage Therapy Nursing Assistant Physical Therapist Assistant Surgical Technology

Student Name: ______________________ ______________________ ____________________ ____________________ Last First Middle Maiden Address: ________________________________________________ ___________________ _________ _____________ Street City State Zip Code Phone: ______________________ Home ______________________ Work ______________________ Cell DOB: _____/_____/______ MM DD YYYY

Emergency Contact: __________________________________ ________________________ _______________________ Name Relationship Phone __________________________________ Street ________________________ ______ City State ______________ Zip Code

Check the appropriate answer to each of the following:

Yes No Rheumatic Fever _____ _____ Heart Disease Emotional Disorder/Disability _____ _____ Back Injury Color Blind _____ _____ Hemophilia Diabetes _____ _____ Asthma Allergies to Latex** _____ _____ Epilepsy/Seizures** **If yes, please see Health Services** Please specify all allergies: ___________________________________________________________________ Yes _____ _____ _____ _____ _____ No _____ _____ _____ _____ _____

Please read carefully and sign:

I understand that there are conditions for which accommodations may be appropriate under the Americans with Disabilities Act and that the Health Occupation Programs will make all reasonable accommodations required by law for otherwise qualified individuals. To receive accommodations, I must contact the Office for Students with Disabilities. I understand that any health care costs incurred during the period of time I am a student in the Health Occupation Programs will be my responsibility. I hereby grant Lake Superior College permission to share information contained in the Health Examination and Immunity Requirement forms with those clinical institutions with whom I affiliate in my student role, should the clinical institution request or require it. I understand that failure to sign this form or to provide the information requested in the Health Examination and Immunity Requirement forms could mean that a clinical site may refuse me placement at their facility. The Health Occupational Programs do not guarantee an alternative facility placement. I also understand that if no alternative facility placement is available, I may be terminated from the Health Occupational Programs.

__________________________________________________

Student's Signature

__________/_____/__________

Month Day Year

Health Occupation Programs H&P Updated 11/23/2010 GF Page 1 of 4

To be Completed by the Physician or their Designee:

Spring 2011

EXAMINER: the individual presenting this form is admitted to the Lake Superior College Health Occupation Programs. You are asked to make careful examination of the individual and their history to determine if the individual is in sufficiently good health to undertake a program in health occupations.

Student Name: ______________________ ______________________ ____________________ ____________________ Last First Middle Maiden Blood pressure: ______/______ Vision: Is the student's visual ability sufficient for observation, assessment, and performance of safe patient care such as reading of mercury and digital thermometers, sphygmomanometers, fine print on drug vials and literature, demarcations on insulin, tuberculin and other syringes, computer terminals and medical records, etc.

Check appropriate response: _____ Comment(s): Hearing: Is the student's auditory ability sufficient to hear normal conversation and/or assess health needs such as telephone conversations, auscultation of blood pressures, apical pulse, lung and bowel sounds using a stethoscope, hear and locate source of equipment warning signals when in or outside patient rooms, etc. Yes, without correction _____ Yes, with correction _____ No

Check appropriate response: _____ _____ Yes, without use of hearing aid(s) or adaptive equipment Yes, with adaptive equipment (e.g., amplified stethoscope) _____ Yes, with hearing aide(s) [_____ left / _____ right] _____ No

Comment(s): Ambulation: Is the student's ambulatory capability sufficient to maintain a center of gravity when met with an opposing force as in lifting, supporting, and/or transferring a client. Can the student tolerate long periods of sitting and/or standing?

Check appropriate response: _____ Comment(s): Weight Bearing/Lifting: Is the student sufficiently able to bear or lift weight to accomplish common health occupation functions such as moving and lifting patients in bed, wheelchair or cart, assist with transfer and walking of patients who may require substantial support and moving of heavy equipment (e.g., hospital beds, meal carts), any of which may involve moving or supporting equal or greater weight than the student themselves (25 pounds frequently, 50 pounds less often). Check appropriate response: _____ Yes _____ No Yes _____ No

If the student is unable to perform the listed weight bearing/lifting activities, please state below: 1. Why (nature of the problem) 2. If any restriction(s) in bearing and/or lifting of weight and/or bending exist and state the specific restriction(s) 3. If the restriction(s) is/are permanent or temporary (give date of anticipated removal of restriction(s), if temporary) Comment(s):

Health Occupation Programs H&P Updated 11/23/2010 GF Page 2 of 4

Spring 2011

Immune Status: Health Occupation students are assigned in clinical areas where exposure to infection and communicable disease is common. Is the student's immune response or status sufficient to allow assignment in all clinical areas and to all patients (assuming use of protective measures ordered by the facility)? Check appropriate response: _____ _____ Yes No

If the student's immune response or status is not sufficient to allow assignment in all clinical areas and to all patients (assuming use of protective measures ordered by the facility), please state below: 1. 2. The condition(s) and/or treatment which make the student vulnerable to infection If there is a: a. permanent problem b. temporary problem. If so, state date when student may be exposed to pathogens commonly found in a hospital setting. c. episodic problem. If so, describe the student's current status.

Comment(s): Examiner: I certify that this individual's immunizations are current and he/she does not have any health problems which would jeopardize either the student's welfare or patient's welfare and does not have any limitations which would restrict them from performing the customary duties of a health occupation student/employee.

_____________________________________________________________________ (Signature of Examiner) (Credential)

Date _______________________________

____________________________________________________________________________________________________________ (Name of Examiner ­ Printed) (Credential ­ Printed) ____________________________________________________________________________________________________________ (Clinic Name and Address) (Clinic Phone Number)

DO NOT SIGN BELOW UNLESS ONE (1) YEAR AFTER YOUR PHYSICAL One-Year Update

__________ There have not been any changes in my health status in the past twelve (12) months. ______________________________________________ Student's Signature __________________________ Date

or

__________ There have been changes in my health status in the past twelve (12) months. Please provide recent exam/report from physician.

**Student must inform program of any changes in health status as they occur**

Health Occupation Programs H&P Updated 11/23/2010 GF Page 3 of 4

Spring 2011

The immunizations required are standards set by the Minnesota Department of Health & Human Services Centers for Disease Control and Prevention

This form MUST be filled out completely, using dates, even if immunization records are attached.

Required Immunizations

Measles (Rubeloa) Report 2 doses after age 12 months or Titre date & results *2 Doses are required* Mumps Report 2 doses after age 12 months or Titre date & results *2 Dose are required* Rubella (German Measles) Report 1-2 doses after age 12 months or Titre date & results *Only 1 dose is required* Hepatitis B Report 3 doses or Titre date & results or Signed Waiver Varicella (Chicken Pox) Self Report of Disease History or Report 2 Doses or Titre date & results Tetanus/Diptheria (Td) Report most current dose *Must be within 10 years* Pertussis (Whooping Cough) (Tdap) *Only 1 dose is required* Mantoux (Tuberculosis)

Dates Immunizations Received OR

Dose 1 Date Dose 2 Date

Antibody Titre

Date ____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

Results Date ____ / ____ / ____

MM DD YYYY

Dose 1 Date

Dose 2 Date

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

Results Date ____ / ____ / ____

MM DD YYYY

Dose 1 Date

Dose 2 Date

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

Results Dose 3 Date

MM

Dose 1 Date

Dose 2 Date

Date ____ / ____ / ____

DD YYYY

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

Results Date ____ / ____ / ____

MM DD YYYY

Self Report of Disease (Circle) Yes / No If yes, stop here If no, continue with vaccine doses Dose Date

Dose 1 Date

Dose 2 Date

____ / ____ / ____

MM DD YYYY

____ / ____ / ____

MM DD YYYY

Results

Dose Date

*Required Annually*

Please attach official documentation from the agency where test was completed to this form. A Chest X-Ray & documentation is required if your Mantoux results are positive. Mantoux tests can also be given and read at LSC Health Services for a minimal fee.

If student is pregnant and vaccinations are needed to meet immunity requirements, they MUST be received after delivery. If pregnant, please indicate due date: ___________________

______________________________________________ Signature of Health Care Provider* Date

_________________________________ Organization

*Health care provider is defined as a doctor's office, school, military, prior employer or other official source of vaccine information

*Signature not required if official immunization records are attached.

Health Occupation Programs H&P Updated 11/23/2010 GF Page 4 of 4

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