The Virginia Board of Nursing requires a minimum of 500 ...



ASSOCIATE DEGREENURSING PROGRAMNURSING PROGRAMPOLICIESRevised Spring 2020Concept-Based CurriculumThomas Nelson Nursing Faculty and StaffDorothy Wentworth, MSN, RNCrystal Clark, MSN, RN-BC, CNEProgram Chair, Hampton CampusProgram Chair, Historic Triangle Campuswentworthd@tncc.educlarkc@tncc.edu Hampton III, Room 747-CHampton III, Room 747-E757-825-3844757-825-2813Kristin MayMitzi Williams maykr@tncc.eduwilliamsm@tncc.eduAdministrative AssistantAdministrative AssistantHampton III, Suite 747Hampton III, Suite 747757-825-2808757-825-2808Jenni Jones, MSN, RN-LRNSusan Stainback, MSN, RNjonesje@tncc.edustainbacks@tncc.edu Hampton III, Room 747-FHT Campus 313-JHT Campus 313- DHampton III, Room 747-D757-258-6642757-825-2762Karen Lynch, MSN, RN, CEN, CHSElynchk@tncc.edu HT Campus, Room 313-CHampton III, Room 747-F757-258-6647Sirena Sears, MSN, RNMarilou Wilder, MSN, RNsearss@tncc.eduwilderm@tncc.eduHampton III, Room 747-GHampton III, Room 747-HHT Campus 313-JHT Campus 313-J757-825-2922757-825-3691TABLE OF CONTENTSMission Statement …………………………………………………………………………………………………….4Philosophy ……………………………………………………………………………………………………………..4Program Outcomes …………………………………………………………………………………………………….4Student Learning Outcomes …………………………………………………………………………………………...4Admission Policy ……………………………………………………………………………………………………....7Promotion Policy ……………………………………………………………………………………………………....8Returning Student Policy ………………………………………………………………………………………………9Transfer Policy ……………………………………………………………………………………………...................10Graduation Policy ……………………………………………………………………………………………………...10Classroom Policy ……………………………………………………………………………………………………...11Academic Dishonesty Policy ………………………………………………………………………………………….Remediation Policy ……………………………………………………………………………………………………1313Clinical/Laboratory/Simulation Policy ………………………………………………………………………………...14Standards of Professional Behavior Policy ……………………………………………………………………………16Health Status Change Policy …………………………………………………………………………………………..Emergency Medical Treatment Policy ………………………………………………………………………………...1919HIPAA Policy ………………………………………………………………………………………………………….19Cell Phone Policy ……………………………………………………………………………………………………...20Social Medial Policy…………………………………………………………………………………………………...20ADA Requirements ……………………………………………………………………………………………………21Student Policy Agreement Form ………………………………………………………………………………………Business Partner Release of Information Form ……………………………………………………………………….. US Department of Education Statement for Nursing Programs……………………………………………………….232425Appendix A (NSNA Code of Conduct) ………………………………………………………………………………..26Appendix B (Notice to All Students) ………………………………………………………………………………….27Appendix C (Simulation Lab Latex Reponse Plan)……………………………………………………………………28Appendix D (Documentation of Student/Faculty Photo Videotape Release Form) …………………………………. 29Appendix E (Physical Form and Immunizations) ……………………………………………………………………..30Appendix F (Remediation Forms)……………………………………………………………………………………..Appendix G ( Assumption of COVID risk)……………………………………………………………………………. 3435Nursing program policies are reviewed annually and revised when needed as stated in the systematic evaluation plan.MISSION STATEMENT:The mission of the Virginia Community College System (VCCS) Nursing Programs is to provide affordable, community access to quality nursing education. The VCCS nursing programs prepare qualified students to provide safe, competent, entry-level nursing care in 21st century healthcare environments. Students are prepared to meet the ever-increasing complexity of the healthcare needs of the citizens of Virginia. Revised August 2018PHILOSOPHY:VCCS nursing faculty ascribe to the core competencies for nursing and nursing education. While firmly based in science and the arts, the essence of nursing is caring and compassionate patient centered care. Ethical standards, respect for individual dignity, and consideration of cultural context are implicit in the practice of patient centered care. The nurse advocates for patients and families in ways that promote self-determination, integrity, and ongoing growth as human beings. Nursing care is provided in collaboration with the patient, the family and members of the health care team. The nurse displays a spirit of inquiry by examining evidence to improve quality of care, promote safety and improve patient outcomes. Nursing judgment is integral to making competent decisions related to the provision of safe and effective nursing care. Information management essential to nursing care is communicated via a variety of technological and human means.Revised August 2018 NURSING PROGRAM OUTCOMES: The program outcomes reflect the Accreditation Commission for Education in Nursing 2017 Standards and Criteria. The licensure pass rate for Thomas Nelson Community College graduates on the NCLEX-RN for first time takers will be 100%.Eighty percent (80%) of students who are admitted into the Thomas Nelson Community College Nursing Program will complete the program within three years.Eighty percent (80%) of Thomas Nelson Community College nursing graduates seeking employment will be employed within one year after graduation.Revised August 2017STUDENT LEARNING OUTCOMES:Students who complete the Associate of Applied Science Degree with a major in Nursing will be expected to: Provide patient centered care promoting therapeutic relationships, caring behaviors, and self-determination across the lifespan for diverse populations. Practice safe nursing care that minimizes risk of harm across systems and client populations.Demonstrate nursing judgment through the use of clinical reasoning, the nursing process, and evidence-based practice in the provision of safe, quality care.Practice professional behaviors that encompass the legal/ethical framework while incorporating self-reflection, leadership and a commitment to recognize the value of life-long learning. Manage client care through quality improvement processes, information technology, and fiscal responsibility to meet client needs and support organizational outcomes. Demonstrate principles of collaborative practice within the nursing and interdisciplinary teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Revised August 2018STUDENT LEARNING OUTCOMES WITH COMPETENCIES:Provide client centered care promoting therapeutic relationships, caring behaviors, and self-determination across the lifespan for diverse populations.Coordinate client centered care delivery with sensitivity and respect.Evaluate the effectiveness of teaching plans and outcomes and revise for achievement of desired outcomes.Promote client self-determination in making healthcare decisions as a level 4 student.Integrate therapeutic communication skills when interacting with clients and the client’s support network.Advocate independently for diverse individuals, families, and communities across the lifespan.Practice safe nursing care that minimizes risk of harm across systems and client populations.Evaluate human factors and safety principles.Participate in the analysis of errors and designing system improvements.Incorporate client safety initiatives into the plan of care.Practice safe client care as a level 4 student.Demonstrate nursing judgment through the use of clinical reasoning, the nursing process, and evidence-based practice in the provision of safe, quality care.Evaluate an individualized plan of care based on client values, clinical expertise and reliable evidence.Independently prioritize changes in client status and intervene appropriately.Apply the nursing process to guide care.Prioritize client care using evidence based practice independently.Evaluate existing practices and seek creative approaches to problem solving.Practice professional behaviors that encompass the legal/ethical framework while incorporating self-reflection, leadership and a commitment to recognize the value of life-long learning.Incorporate ethical behaviors and confidentiality in the practice of nursing.Assume responsibility and accountability for delivering safe client care.Deliver nursing care within the scope of nursing practice.Evaluate professional behaviors in interactions with clients, families and healthcare providers.Engage in reflective thinking for the purpose of improving nursing practice.Develop a plan for lifelong learning in the nursing profession.Manage client care through quality improvement processes, information technology, and fiscal responsibility to meet client needs and support organizational outcomes. Evaluate the common quality measures encountered in clinical practice.Evaluate use of technology and information management to promote quality.Evaluate fiscally responsible client care.Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of pare and contrast the effectiveness of the members of the interdisciplinary team to promote optimal client outcomes.Participate in the interdisciplinary plan of care to promote optimal client outcomes.Evaluate communication strategies that are inclusive of various communication and cultural differences.Evaluate management skills and principles of delegation when working with other members of the health care team.Reflects at a professional level on individual and team performance. Revised August 2018NURSING PROGRAM POLICIESStudents enrolled in the nursing program must adhere to the following program policies in addition to all general rules and regulations as stated in the Thomas Nelson Community College Catalog.I.ADMISSION POLICYThe Thomas Nelson Community College Nursing Department currently offers three admission options to qualified students. These include:Generic Program Hampton Campus: Admits up to 60 students annually in the fall semester (August)Generic Program Historic Triangle Campus: Admits up to 30 students annually in the spring semester (January)LPN to RN Articulation Program: admission varies depending upon available space. Students are admitted annually in the spring semester at the Hampton campusPre-Curricular GPA and TEAS scores will be considered when selecting students for admission. Steps to Admission and Essential Abilities are available at of Acceptance:In order to comply with clinical agency requirements, the Thomas Nelson Nursing Program mandates the following admission requirements:Pre-entrance medical examination with required laboratory tests and immunization records: If the medical exam indicates a finding which would prohibit a student from attending clinical, the student cannot successfully meet the course requirements and will not be able to continue in the nursing program. (See Appendix G) Validation of successful completion of the American Heart Association’s Healthcare Provider CPR course: Students are responsible for the cost of the CPR course.Criminal background check and drug testing: If the criminal background check or drug screen indicates a finding which prohibits a student from attending a clinical agency, the student cannot successfully meet the course requirements and will not be able to continue in the nursing program. Students are responsible for the cost of the background check and drug testing. In addition, clinical agencies may implement criminal background checks or random urine drug screenings. Nursing students, if selected by the agency, may be included in this testing. These policies are the procedures of the clinical agencies, not the college. Business Partner Student Release Form: Enrollment and participation in the Thomas Nelson Community College Nursing program requires that students provide proof of general and specific health status, immunization records, CPR certification, criminal background check, social security number, driver's license/photo identification card, academic records, urine/blood tests for drug screening and any other information that may be required by the college, clinical facility and/or field agency policy or legal mandate to establish students’ fitness to care for live patients in a clinical and/or field setting. Choosing to not provide permission for the release of this information will prohibit participation in Thomas Nelson Community College Health Professions Division, Nursing Department/Program as it will result in a ban from the clinical facilities where students are required to complete the clinical portions of training. Admission to and successful completion of the clinical training portions of Nursing courses are required for program enrollment and completion. Revised August 2018II.PROMOTION POLICYA.PROGRESSION: Satisfactory completion of nursing and general education courses will result in promotion. A grade of “C” or higher is required for satisfactory completion of all required nursing courses, all pre-requisite courses (BIO 141, ENG 111, PSY 230, and HLT 230) and all additional natural science courses (BIO 142, and BIO150). B.COURSE EVALUATION COMPONENTS: Nursing courses may include the following components: (1) theory, (2) drug dosage calculations, (3) clinical performance, (4) standardized assessments, and (5) simulations. These components are evaluated throughout the nursing program. The inclusion of these specific evaluative components vary based upon the individual NSG course objectives. Regardless of the number of evaluative components included in the course, all components must be successfully completed in order to pass the course.The nursing faculty puts much emphasis on the ability of the student to comprehend critical theory information related to the care and condition of patients under their care. The evaluation of the theory component of NSG courses consists of computer-based tests and/or other class assignments described in each course syllabus. A comprehensive final may be administered at the end of selected nursing courses. If a final examination is required for the course, it is mandatory that the student take the exam in order to successfully complete the course. A minimum cumulative grade of 80% must be attained for successful completion of the theory component.During the course, any student who has a failing test grade or course average is required to meet with the course instructor for intervention before taking the next scheduled test. This mandatory intervention is to be scheduled immediately upon receiving the test grade. Intervention will continue as long as the student’s course average grade is below “C”. The letter grade, based on scores achieved on evaluative tools and/or other graded class assignments as stated in each course syllabus, is determined by the following scale:92%100%A86%91.99%B80%85.99%C75%79.99%D (Failure)0%-74.99%F 2. The Nursing Faculty puts much emphasis on the ability of students to safely calculate and administer medications. On-going assessment of math skills is a component of the program. In selected courses, students are given 1 practice drug dosage test. Individual remediation will be based upon the results of the practice test. A 20 item drug dosage competency test will be administered prior to the withdrawal date for the course. A grade of 90% must be attained. Students who do not earn a score of 90% on the first attempt, will be given a second attempt. If the student does not score a 90% on the 2nd attempt, they will receive a grade of “W” for the course.3.The nursing faculty puts much emphasis on the ability of the student to perform safe clinical practice. The evaluation of the clinical component of the course consists of both formative and summative assessment of clinical competencies at midterm and at the end of the semester for selected courses. A written clinical evaluation tool will be used to evaluate clinical competencies.There are certain critical clinical competencies related to safe clinical practice identified within this evaluation tool that must be performed satisfactorily at all times. If these behaviors are not demonstrated, the student will receive a failing grade and will be immediately removed from the course. The grade will be determined by the nursing faculty depending upon the individual severity and circumstance of the behavior.The faculty reserves the right to permanently dismiss a student from the nursing program whose clinical or behavioral record indicates that it is inadvisable for him/her to continue in nursing. The dismissal may be immediate or may follow the development of a contract. Students must meet the conditions of the contract in order to continue in the program. When a student is dismissed because of these criteria, a course grade of “F” will be given. The student will be administratively withdrawn from other nursing courses in which they may be enrolled.C.COURSE WITHDRAWALS: A student will be limited to two enrollments in the same nursing course except under mitigating circumstances that must be documented and approved by the nursing program chair. Any student who withdraws from any nursing course will receive a letter regarding eligiblity to return. A request to return to the course must be submitted in writing to the Thomas Nelson nursing program head by the date stipulated in the eligibilty to return letter. An exit interview with the nursing program head is required.D.COURSE FAILURES: If a student fails either the theory, drug dosage calculations, or the clinical component of a required nursing course, the course must be repeated in order for the student to continue in the nursing program. If a student fails a nursing course during a semester in which they are enrolled in other nursing courses, the student will have the option to complete the other courses or to withdraw with mitigating circumstances. A request to repeat the course must be submitted in writing to the nursing program head. After any two nursing course failures, the student cannot continue in or be readmitted to the Thomas Nelson Nursing Program. An exit interview with the nursing program chair is required.E.CLASSROOM ATTENDANCE POLICY: In compliance with the College policy, any student with classroom absences accumulating to more than twenty percent of time will be subject to administrative withdrawal Revised Spring 2020III.RETURNING POLICYStudents re-entering the Thomas Nelson Community College Nursing Program must:plete the nursing program within three (3) years from the original date of admission into the nursing program.B.Have a cumulative GPA of 2.5. The cumulative GPA calculation will include all course completed at Thomas Nelson and grades from transfer courses included in the A.A.S. Degree in Nursing.plete a physical examination within one (1) year with required lab and immunizations (see admission requirements) This exam must be current (within 1 year prior to readmission).D.Provide documentation of current CPR (American Heart Association Healthcare Provider) certification that must remain current throughout the nursing program.E.Provide documentation of a valid PPD tuberculin skin test or chest xray that must remain current throughout the nursing program.plete an additional required background check and drug screen (within 1 year prior to readmission).G.Submit a request to repeat the course in writing to the nursing program chair by the date stipulated in the eligibilty to return letter.H. Successfully complete NUR 103, Clinical Reasoning in Nursing Practice. This course is required for any student who fails a nursing course or who has a failing course average at the time of withdrawal from a nursing course. Any student, who does not earn a grade of “C” or higher in NUR 103, is not eligible to re-enter the nursing program. NUR 103 is not part of the nursing curriculum; and therefore, may not be covered by financial aid.Revised August 2018IV.TRANSFER POLICYStudents requesting transfer MUST meet all Thomas Nelson nursing program admission criteria. Admission to transfer students is evaluated on an individual basis and is very limited.In addition, transfer students must have two letters of recommendation sent to the Thomas Nelson Community College Department of Nursing. One letter must be from the program chair of the previous nursing program and the other letter must be from the student’s last clinical instructor. Credit will be given to those nursing courses completed no longer than three years prior to transferring into the Thomas Nelson Nursing Program, at the discretion of the program chair.Reviewed August 2018V.GRADUATION POLICYTo be eligible for graduation with an Associate in Applied Science Degree from the College, the nursing student must:Have completed all graduation requirements listed in the catalog. The catalog to be used to determine graduation requirements is the one in effect at the time of the student's initial program placement in the curriculum from which the student is graduating or any subsequent catalog of the student's choice. Substitutions approved by the division dean may be necessary for any courses offered in the curriculum of choice that are subsequently discontinued from the college's offerings.Be recommended for graduation by the appropriate instructional authority in his or her curriculum.Have completed at least 67 credits applicable to an Associate in Applied Science Degree in Nursing, of which at least 25 percent of credit semester hours required for the degree must be acquired at the college.Have completed the general education requirements, listed in the college catalog, for an Associate in Applied Science Degree.Have earned a grade point average of at least 2.0 on all work attempted that is applicable toward graduation in his or her particular curriculum.Have filed an application for graduation in the Office of Enrollment Services by the required deadline.Have resolved all financial obligations to the college and returned all materials, including library books.Some academic programs may require students to take part in exit interviews, to complete surveys, to take license exams, to prepare portfolios, or to complete some other activity to demonstrate the acquisition of program and general education competencies. If the student is called upon to take part in such an activity, it becomes part of the institution's requirement for graduation in that program.The nursing program has the following requirements for graduation:The student must graduate within three years from the original date of admission into the nursing program.The student must participate in an NCLEX-RN review course at the students’ cost.Revised August 2018VI.CLASSROOM POLICYPapers and Projects When papers and/or projects, assignments and/or presentations are submitted to the instructor, the date received will be noted. Papers, assignments and presentations submitted to the instructor after the predetermined due date will be subject to a five (5) point deduction from the grade for each college day up to the value of the paper. This does not include weekends and holidays. The student is responsible for informing the instructor, prior to the due date, concerning reasons for being unable to meet the deadline.Examinations, Tests, and QuizzesOnce a required test has been completed, the grade is final, and no re-testing is allowed. If a student starts a test, the test must be completed unless there are mitigating circumstances determined by the instructor. It is mandatory that students notify the instructor prior to an absence or tardiness when a test, examination, or quiz has been scheduled. Students must notify the instructor by e-mail or calling the instructor’s office phone number. If the instructor cannot be reached, the student must leave a voice mail message. If a message is not received by the instructor the student may receive a zero for the examination, test, or quiz. When a student has an excused absence on the day of a scheduled examination, quiz or test, the student is required to take the examination, quiz or test at a time that will be determined by the instructor. Test Review:Once all students have tested, if there is classroom time available, unit tests may be reviewed in class at the discretion of the instructor. Once all students have tested, individual test review may be arranged if the course instructor believes it will be beneficial to student success. No student can review a test unless they have a scheduled appointment with the course instructor of record.Scantron Answer Sheet:When scantron sheets are provided for multiple choice tests, only the answers marked on the scantron answer sheet will be graded. If more than one answer is marked, the item will be counted as wrong (unless otherwise specified in the testing directions).Testing Procedures:Thomas Nelson nursing faculty have a zero tolerance for violations of the College’s policy on scholastic dishonesty. If, during a testing situation, a student is observed exhibiting behaviors that could be interpreted as academic dishonesty then the following will occur:1.The student will be unable to continue testing2.The student will receive a "0" for the testAll personal belongings must be placed at the front of the classroom prior to every test. This includes book bags, purses, coats, hats, cell phones and/or other electronic equipment (including but not limited to smart watches, fitbits, pendants, etc). No eating or drinking is allowed during testing. If the instructor provides scrap paper for the test, all scrap paper must be returned to the instructor prior to exiting the test. Students who fail to comply with this policy may be placed under behavioral contract, may receive a grade of “0” for the test, or may be permanently dismissed from the program.Assessment Testing:The faculty has selected the HESI Testing and Remediation Program as an aspect of the nursing curriculum that is geared to prepare students for NCLEX-RN success.? Assessments will be administered throughout the program with a comprehensive assessment given during the final semester.?? When a student is enrolled in a course for which a HESI assessment is scheduled, the student must complete all assessments before a final grade will be issued for the course. As noted in the nursing program policies, “Regardless of the number of evaluative components included in the NSG course, all components must be successfully completed in order to pass the course.”? Students who fail to take HESI Assessments will receive a final course grade of “Incomplete” or “I” (if otherwise passing the course) until the outstanding assessments have been completed.? Students cannot progress to the subsequent semester until the requirements are satisfactorily completed and the “I” is replaced with a passing grade.Students are responsible for the cost of the assessment tests and submit an assessment test payment each semester of enrollment in the program. This payment also includes a three day, on-site NCLEX-RN review course scheduled at the end of the program. Failure to make the reqired payment will result in a course grade of “Incomplete” or “I” (if otherwise passing the course) until the outstanding assessments have been completed. Students cannot progress to the subsequent semester until the requirements are satisfactorily completed and the “I” is replaced with a passing grade.HESI Assessments include: 1st semester-Level 1 Exam (Versions 1 and 2)2nd semester- Level 2 Exam (Versions 1 and 2)3rd semester- Level 3 Exam (Versions 1 and 2)4th semester- Level 4 Exam (Versions 1 and 2) and Exit Exams (Versions 1 and 2)Revised August 2018VII.ACADEMIC DISHONESTYFaculty in the Nursing Department will not tolerate dishonesty in any form. Any student who engages in any form of academic dishonesty or deception, such as cheating or obtaining instructor resources from unauthorized sources, will be dismissed from the nursing program. Additionally, any discussions or replication of tests or specific test questions prior to, during, or after the test, without authorization of the instructor, will be considered a violation. As members of the academic community, it is the responsibility of all students to report those students suspected of violating the Honor Code Policy.ACADEMIC HONESTY: Officials of Thomas Nelson Community College certify successful completion of work for degrees, diplomas, and certificates when satisfied that the absolute integrity of the student has been maintained in the completion of such work. It is imperative that students maintain a high degree of individual honor in their scholastic endeavors. Scholastic dishonesty will not be condoned under any circumstances. Generally, scholastic dishonesty is interpreted as cheating on an examination or quiz, which includes giving or receiving information, copying, using unauthorized materials in tests, collaboration during examinations, substituting for another person or allowing substitutions during examination; plagiarism, submission of work other than one's own; and collusion with another person or persons in submitting work for credit unless such collaboration is approved in advance by the instructor. PLAGIARISM: Webster's Third International Dictionary defines plagiarism as follows: “Plagiarism--to steal and pass off, as one's own the ideas or words of another; to use without crediting the source; to present as new and original an idea or product derived from an existing source; to commit literary theft.” Nursing Program Honor Code:Faculty in the Nursing Department will not tolerate dishonesty in any form. Any student who engages in any form of academic dishonesty or deception, such as cheating or obtaining instructor resources from unauthorized sources, will be dismissed from the nursing program. Additionally, any discussions or replications of tests or specific test questions prior to, during, or after the test, without authorization of the instructor, will be considered a violation. As members of the academic community, it is the responsibility of all students to report those students suspected of violating the Honor Code Policy.Scope of the Honor CodeThe Honor Code and Honor Pledge embody the trust that is placed in TNCC students and the reciprocal responsibility students have to behave ethically in their academic pursuits. Students are responsible for adhering to the Code of Student Conduct, which can be found at: ? ?Code of Student Conduct violations will not be tolerated. Violations include but are not limited to cheating on tests & assignments and plagiarism. Please see the School of Nursing Student Handbook for further information.Some Examples of Violations:Team collaboration on a projects and testing. Unless specifically authorized by your instructor, you are expected to do your own work unaided by anyone else. Use of commercial or other students as sources for "readymade papers". Your work must clearly be of your own effort. Don't believe that by changing a few words you can disguise the source. You can't. If you use someone else's work you will be found out. The differences in tone, style, and comprehensiveness of the writing will be readily apparent to the faculty. Failing to cite reference materials used within your paper or work. This includes not only printed material, but materials taken in part, or in whole, from Internet sources. Use of "crib sheets" etc. during an examination. Although some instructors allow the use of reference materials during examinations, such use is clearly defined. If you have not been authorized use of reference material, or you exceed the defined scope of use, you are guilty of cheating. Revised Spring 2020 VIII. REMEDIATION POLICYFollowing HESI Exams, students are required to remediate and the remediation requirements are dependent on each individual student’s level of risk for success in the program and on NCLEX. Students with lower scores require more intense remediation. There are certain nursing courses that may require students to complete a Remediation Plan. Students receive their Exam reports and correlating online remediation after completion of the exam. Based upon their standardized test report, students can develop their personal plan for remediation. Students will list specific activities they will complete in order to understand their missed concepts/content. Students will complete the Remediation Plan, gain faculty approval for the plan, and then notify faculty when the remediation is complete. Revised August 2018IX.CLINICAL/LABORATORY/SIMULATION POLICYOne or more clinical experiences per week are assigned each semester for nursing courses with a clinical component. Days of the week and clinical hours vary and some days, evenings, and weekend clinicals may be required. Additionally, lab and/or simulation hours may be included as part of the clinical experience. Attendance Requirements:The Virginia Board of Nursing requires a minimum of 500 clinical hours be completed in all registered nursing education programs. These must be direct client care hours supervised by qualified faculty. If 500 clinical hours are not completed, the student is ineligible to complete the NCLEX-RN exam. See VBON Regulation 18VAC90-27100.18VAC90-27-100. Curriculum for direct client care.A nursing education program preparing a student for licensure as a registered nurse shall provide a minimum of 500 hours of direct client care supervised by qualified faculty. Direct client care hours shall include experiences and settings as set forth in 18VAC90-27-90 B 1. Students who are unable to report to the assigned clinical agency or the oncampus clinical lab/simulation are required to report by telephone to the hospital unit where the assigned patient is located or the nursing office, 825-2808, one hour before the start of assigned clinical/lab/simulation experience. It is the student's responsibility to obtain the name of the person taking the message. Students who fail to comply with this policy, “No Call, No Show”, will be placed under behavioral contract for the first offense. If a second offense occurs, the student will may be permanently dismissed from the nursing program.If a student is tardy more for clinical/lab/simulation days, the student will need to meet with the instructor and complete a conference form related to professional behaviors. If a student is tardy for clinical more than three (3) days, this will count as a clinical absence. Arrangements to make up missed clinical time must be arranged and documented with the clincal instructor.3. Absences should be reserved for emergency situations and illness. Under no circumstance should students attend clinical rotations when ill with an infectious or potentially infectious illness as this would compromise the well-being of the patients and staff. However, the clinical hours missed will be eligible for make-up if the student follows the policies related to calling out of clinical noted in the nursing program policies. When calling to request an excuse from clinical, an explanation must be given regarding the reason for the absence. The make-up will be scheduled at the discretion of the faculty, and students will be informed of the make-up clinical arrangements. Habitual absenteeism or an unexcused absence will deem a student ineligible to make-up clinical hours. Failure to complete the clinical hours required for a particular course will result in the receipt of an “I” (incomplete grade) or an “F” (failure). Please note that all incomplete grades must be resolved prior to progressing to a subsequent semester and incomplete grades must be resolved the following semester, otherwise they revert to an “F.” If a student receives an incomplete grade in a nursing course, the required work or clinical hours must be completed by the end of the next semester (or the time frame specified by the instructor); otherwise, it will revert to the earned grade. Please note that all incomplete grades must be resolved prior to progressing to a subsequent semester. In compliance with the College policy, any student with absences from clinical/lab/simulation accumulating to more than twenty percent of time will be subject to administrative withdrawal. Simulation Experiences: The Thomas Nelson Nursing Program has developed a Simulation Integration Plan to enhance clinical learning and to aid in meeting the Virginia Board of Nursing clinical hour requirements. Students MUST attend the simulation experiences to meet the objective for clinical hours and to also provide patient-care experiences not otherwise available in actual clinical settings. Simulation offers avenues to assess clinical judgment and critical thinking without jeopardizing patient safety. In addition to simulation promoting active learning and participation, a simulation experience allows students to critically analyze their own actions (or failure to act), reflect on their own skill sets and clinical reasoning, and critique the clinical decisions of others. (VBON, Guidance Document, 3/19, 2013.)Written Clinical Assignments:If written clinical assignments are not submitted on the specified due date, the student will receive an unsatisfactory grade for those assignments. Arrangements with the instructor must be made if adherence to the above cannot be fulfilled.Students whose written clinical assignments do not meet the passing criteria as outlined in the grading rubric are to confer with the instructor for recommendations and additional assistance immediately after the grade is received. All clinical assignments are described in each course syllabus.Clinical Conduct and Dress CodeThe following regulations are related to the student's clinical, simulation, and/or laboratory experiences and must be followed at all times:1.The student must adhere to the Thomas Nelson Nursing Program standards of conduct at all times. 2.Professional and ethical conduct must be displayed at all times as defined by the National Student Nurses’ Association, Inc., Code of Academic and Clinical Conduct (see Appendix A). Any breech of code will be documented in the student’s permanent record and appropriate action will be taken.The student must adhere to the following dress code:Uniforms must be purchased at the designated uniform company. Only approved Thomas Nelson nursing uniforms can be worn while participating in clinicals (on or off campus).(1)Uniforms must be the correct size and the appropriate length. (2)Standard white regulation hose or white socks (worn above the ankle) and white shoes with closed heels and toes (no clogs or crocs). Shoes should be white professional shoes, leather or vinyl material, clean and polished, no stripes, designs or exposed color interiors other than white.(3)A solid white long sleeve cotton shirt may be worn under the scrub top (no v-necks).b.The Thomas Nelson approved white lab coat may be worn over the nursing uniform while giving direct patient care. No sweaters, sweat shirts or hoodies can be worn over the nursing uniform while in lab, simulation, or clinical.c.Required equipment includes: watch with sweep second hand, scissors, stethoscope, hemostat, name tag, pen light, and pocket sized note pad, and black pen. d.Jewelry(1)One pair of small studs is allowed for pierced ears worn on lobes only. No visible body piercing jewelry including tongue piercings or ear gauges can be worn.(2)No other visible jewelry except for wedding bands (which must be smooth and without settings) and watches.e.Hair must be worn off the collar while in uniform (includes males and females).f.Nails should be clean and well groomed and at a length that is not visible above the finger tips. No nail polish or artificial nails are allowed.g.No tattoos can be visibleh.Hair color must be a naturally occuring hair color.Beards and/or mustaches must be neatly trimmed.4.Eating, drinking, and chewing gum are not allowed on the clinical unit.Smoking, vaping, e-cigarettes, or the use of any tobacco products will not be allowed at any time before, during, or after the clinical experience or while on the premises of the health care or the on-campus lab facilities, including the parking lots.Personal appearance and hygiene must adhere to professional standards. Students must be clean, odor free of perfumes, body scents or other scents, including cigarette smoke.Students may be dismissed from the clinical area if they are not in compliance with the clinical dress code. The student will be counseled and documentation related to professionalism will be completed and placed in the students’ file. It will be the students responsibilit to make up the missed clinical hours. A pattern of noncompliance with dress code will lead to dismissal from the program.Clinical Health Requirements:It is the responsibility of the student to ensure that all immunizations (including PPD and CPR certification) remain current while enrolled in the nursing program. Failure to do so will prohibit a student from attending clinicals and successfully meeting the course requirements.Revised Spring 2020X.STANDARDS OF PROFESSIONAL BEHAVIOR POLICYAccording to the National Students Nurses’ Association Code of Academic and Clinical conduct:Students of nursing have a responsibility to society in learning the academic theory and clinical skills needed to provide nursing care. The clinical setting presents unique challenges and responsibilities while caring for human beings in a variety of health care environments. The Code of Academic and Clinical Conduct is based on an understanding that to practice nursing as a student is an agreement to uphold the trust with which society has placed on us. The statement of the Code provide guidance for the nursing student in the personal development of an ethical foundation and need not be limited strictly to the academic or clinical environment but can assist in the holistic development of the person.Standards of Professional BehaviorNursing students are expected to demonstrate professionalism, responsibility, and accountability at all times and in all settings. The Nursing Program believes that this goal will be attained if each student’s actions adhere to the Standards of Professional Behavior. Failure to adhere to any one of the Standards outlined below may result in: An “unsatisfactory” for the experienceDocumentation of the occurrence on the Student Progress Conference RecordThe development of a behavioral contractImmediate dismissal from the nursing program. While the Standard of Professional Behavior is important in all areas of the health care learning environment, it is especially relevant to the clinical setting where safety, teamwork, and collaboration are paramount. Safe clinical practice always includes, but is not limited to, the following behaviors:Practice within the boundaries of the nursing student role and within the scope of practice of the registered professional ply with institutional policies and procedures for implementing nursing care.Prepare for clinical learning assignments according to course requirements and as determined by the specific clinical setting.Demonstrate the application of previously learned skills and principles in providing nursing care.Demonstrate the progression of skills, competence, and critical thinking.Promptly report significant patient information in a clear, accurate, and complete oral or written manner to the appropriate person(s).Effective interpersonal interactions with patients, peers, instructors, and health care team members.Maintain a professional image in dress and behavior.Examples of unprofessional behavior include but are not limited to:Ineffective interpersonal interactionsPoor communicationWeak verbal and written communication skillsFailure to articulate learning needs (i.e., does not ask questions or ask for assistance)Inappropriate nonverbal communication (i.e. rolled eyes, facial expressions, and other body language responses)Difficulty developing relationshipsInappropriate interactions with patients, peers, instructors, and other health care professionalsIneffective interactions with instructors and other health care professionalsPatient, staff, peer, and/or facility complaint about the student as substantiated by the instructorKnowledge and skill incompetenceLimited cognitive abilityKnowledge deficit—failure to relate classroom concepts to clinical situationsLack of critical thinking or failure to progress in critical thinkingPoor insight into appropriate interventions and rationale for interventionsPoor problem solvingLack of insight into personal strengths and weaknessesWeak skill demonstrationInconsistent assessment skillsFails to perform basic care/skills at a satisfactory levelLack of organizational and/or time management skills, or a failure to progress Patient needs not met, as substantiated by the clinical instructorMedication errorsViolation of the 6 rights of medication administrationUnprofessional imageInappropriate attitudesDisrespect to patients, families, staff, peers, and/or instructorAngerDefensivenessOverconfidence or low confidenceApathy—unenthusiastic about nursingUnreceptive to feedback or blames clinical instructor for own performance issuesInappropriate behaviorUncontrolled anxiety/nervousnessLack of preparationTardinessAvoidance of patients or clinical instructorNoncompliance with facility procedures and protocolsViolation of dress codeViolation of Nursing Program Honor CodeViolation of HIPPA policies and proceduresBreach of confidentialityLack of accountabilityNot reporting important informationCrossing professional boundariesDishonestyCarelessness and/or risk-taking behaviors, i.e. under the influence of drugs and/or alcohol upon arrival to educational settingPerforming outside the scope of practice of a nursing studentInadequate sleep before clinicalPhysical abuse to patient, families, staff, peers, and/or clinical instructorRefusal to care for the assigned patient(s)Providing an unsafe environment for patients, families, or staffDisciplinary ProceduresUpon acceptance into the nursing program, students will receive a copy of the Standards of Professional Behavior Policy. The policy will be reviewed at the beginning of each semester. Students will sign an Agreement form to adhere to the standards. The student will retain a copy of the Agreement and one copy will be kept in the student’s file indicating their consent.Violation(s) of the policy will be evaluated on an individual basis. Failure to abide by the policy can result in disciplinary action, which may include immediate dismissal from the nursing program.Incident(s) will be documented on the Student Progress Report and signed by both the instructor and the student and kept in the student’s file.At the discretion of the instructor, the student may be required to leave the classroom or clinical unit for the remainder of the day.Violation(s) of certain standards or specific behaviors may require a meeting with the Program Head, the instructor, and the student. A Student Progress Conference Record will be completed at that time. A behavioral contract may be developed with an action plan for remediation. Immediate dismissal from the Nursing Program may result from a single violation of the policy.Reviewed August 2018XI.HEALTH STATUS CHANGE POLICYWhen matters concerning the student's health require medical and or obstectrical intervention, a statement from the attending healthcare provider must be submitted to the nursing department with recommendations regarding class and/or clinical participation before the student resumes attendance. Failure to provide this documentation may result in unsuccessful clinical performance.Reviewed August 2018XII.EMERGENCY MEDICAL TREATMENT POLICYEmergency medical treatment for injuries and illnesses which may occur during clinical time shall be provided by the clinical facility. Treatment must be covered by the student's own health care plan or personal resources. Reviewed August 2018XIII.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) POLICY Maintaining confidentiality is an integral part of nursing practice. Federal regulations guide the scope of practice of health care workers to safeguard protected health information (PHI) through the Department of Health and Human Services and the Health Insurance Portability and Accountability Act (HIPAA). Protected Health Information is defined by Health and Human Services to mean demographic and health information that makes the individual identifiable. This information includes but is not limited to names, addresses, date of birth, social security or medical records numbers. As a student in the Thomas Nelson Community College Nursing Program, you are required to learn about and abide by the health information privacy requirements HIPAA. All clinical agencies require that students are trained and familiar with the HIPAA regulations.Students who violate HIPAA requirements may be subject to disciplinary action, which could lead to dismissal from the program. The following guidelines are to be followed by students and faculty:Maintain confidentiality by only sharing PHI with those who are considered individuals who need to know.When you need to discuss PHI, hold conversations in private areas where others cannot hear the conversation.Shred PHI, which is no longer necessary to maintain in approved shredding bins, if shredding bins are not available, destroy the document before disposal.Do not use patient names, date of birth, medical record number or social security numbers on any written course or clinical assignments. Do not share PHI with family members, peers or those individuals who are not directly involved with care of the rmation shared during the clinical day and pre/post conference is not to be shared outside of the conference area and cannot be discussed outside of the clinical setting (i.e. home, work, other public settings)Students may not access any electronic health records outside of the assigned clinical facility.Students may not leave/save any patient, family, faculty, clinical facility or student information on any open access desktop or hard-drive.PHI is not to be left open in public areas.PHI (medical record) is not to leave the clinical puter screens and electronic health records with PHI are not to be left unattended, students are expected to log out before leaving the workstation.Students are not allowed to share their personal login or password information.PHI and even descriptions of clinical cases should never be shared or addressed over electronic communications including email, text and social media (i.e. Facebook, Twitter, etc).Reviewed August 2018XIV.CELL PHONE POLICY:Students are not allowed to use cell phones in class, lab, clinical, or simulation unless permission is granted by the instructor. For emergency situations, students may give the assigned clinical facility’s phone number or the main number for the nursing office (757-825-2808). Cell phones may not be used as calculators during the pharmacological calculations tests.Revised August 2018XV. SOCIAL MEDIA POLICYBackground“Social networks and the internet provide unparalled opportunities for rapid knowledge exchange and dissemination among many people, but this exchange does not come without risk. Nurses and nursing students have an obligation to understand the nature, benefits, and consequences of participating in social networking of all types. Online content and behavior has the potential to enhance or undermine not only the individual nurse’s career, but also the nursing profession.”ANA’s Principles for Social NetworkingNurses must not transmit or place online individually identifiable patient information. Nurses must observe ethically prescribed professional patient-nurse boundaries.Nurses should understand that patients, colleagues, institutions, and employers may view postings.Nurses should take advantage of privacy settings and seek to separate personal and professional information online.Nurses should bring content that could harm a patient’s privacy rights or welfare to the attention of appropriate authorities. Nurses should participate in developing institutional policies governing online conduct.Six Tips to Avoid ProblemsRemember that standards of professionalism are the same online as in any other circumstance.Do not share or post information or photos gained through nurse-patient relationships.Maintain professional boundaries in the use of electronic media. Online contact with patients blurs this boundary.Do not make disparaging remarks about patients, employers, or co-workers, even if they are not identified.Do not take photos or videos of patients on personal devices, including cell phones.Promptly report a breach of confidentiality or privacy.Potential ConsequencesPotential consequences for inappropriate use of social and electronic media may be reported to the Board of Nursing (BON). The laws outlining the basis for disciplinary action by a BON vary between jurisdictions. Depending on the laws of a jurisdiction, a BON may investigate reports of inappropriate disclosures on social media by a nurse on the grounds of: unprofessional conduct, unethical conduct, moral turpitude, mismanagement of patient records, revealing a privileged communication, and breach of confidentiality. If the allegations are found to be true, the nurse may have disciplinary action by the BON, including a reprimand or sanction, assessment of monetary fine or temporary fine, or temporary or permanent loss of licensure. [American Nurses Association Retrieved from www/ & National Council of State Boards of Nursing (2011). White paper: a nurse’s guide to the use of social media. Retrieved from ].All of these principles apply to nursing students. The nursing faculty adhere to the professional standards of the nursing profession and will discipline any nursing student who fails to adhere to the professional standards outlined above. Discipline may take various forms, but could result in suspension, course failure, or dismissal from the nursing program. Reviewed August 2018XVI.ADA REQUIREMENTSTitle 11 of the ADA prohibits discrimination against a "qualified individual with a disability." This term is defined as an individual with a disability who can perform the "essential functions" of a position, with or without reasonable accommodation.In order for a student with a disability to be admitted to the Thomas Nelson Community College Nursing Program, the student must:meet the prerequisite admission standards as defined in the college catalog.B.perform the essential functions for participation in the nursing program with or without reasonable accommodation.Generally, the term essential functions includes those fundamental duties that the individual who holds the position must be able to perform, either unaided or with the assistance of a reasonable accommodation. A reasonable accommodation is "any change in the student environment or in the way things are customarily done that enables an individual with a disability to enjoy equal opportunities." In order to be considered for appropriate accommodations the student must make a request with Disabled Student Services (Room 323 Hastings Hall). Since the ADA expressly prohibits inquiries regarding disabilities, the responsibility of disclosure is borne by the individual having the disability.The reasonableness of an accommodation is determined on a case by case basis. The accommodation offered does not have to be the "best available" but needs to be sufficient to meet the needs of the individual being accommodated. The nursing faculty has determined that to successfully complete the classroom and clinical components of the Thomas Nelson Community College Nursing Program, the student must be able to perform defined essential functions. These essential functions include but are not limited to the following:Attendance:Regular classroom and clinical attendance as defined by the nursing department student policies.Essential Mental Abilities:1.Maintain reality orientation accompanied by short and long term memory.2.Adapt to school and clinical environment.3.Follow rules and instructions.4.Assimilate and apply knowledge acquired through lectures, discussions, demonstrations, and readings.prehend and apply basic mathematical skills.6.Demonstrate safe nursing practice within the defined clinical time period.7.Demonstrate critical thinking skills by the comprehension and application of abstract concepts.8. Adhere to the ethical/legal standards of nursing practice.Essential Communication Skills:1.Speak clearly in order to communicate with patients, families, health care team members, peers and faculty.2.Interact appropriately and communicate effectively with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds.municate and organize thoughts in order to prepare written documents.4.Prepare written documents that are correct in style, grammar and mechanics.Essential Physical Abilities:1.Stand and walk for six to eight hours/day.2. Walk for prolonged periods from one area to another over an eight hour period.3.Bend, squat and kneel.4.Assist in lifting or moving patients of all age groups and weights.5.Perform CPR, i.e., move above patient to compress chest and manually ventilate patient.6.Work with arms fully extended overhead.7.Use hands for grasping, pushing, pulling, and fine manipulation.8.Demonstrate eye/hand coordination for manipulation of equipment, i.e., syringes, procedures, etc.Essential Sensory Abilities:1.Possess tactile ability to differentiate changes in sensation.2.Possess tactile ability sufficient for physical assessment.3.Possess auditory acuity to note slight changes in the patients condition, i.e. lung sounds, etc.4.Possess auditory acuity to hear patient calls for assistance without facing the patient.5.Possess auditory acuity to interpret various equipment signals and use the telephone.6.Possess visual acuity to read and distinguish colors, to read handwritten orders, and other handwritten and printed data.7.Possess visual acuity to clearly view monitors and scales in order to correctly interpret data.8.Possess olfactory ability sufficient to detect differences in odorReviewed August 2018 STUDENT POLICY AGREEMENT(Student Copy)Please sign and keep this form for your records.I have read and agree to adhere to the 2020 Nursing Program Policies set forth by the Thomas Nelson Community College Nursing Department.Signature _____________________________________________________Date _________________________________________________________826135-207645NURSING DEPARTMENT - BUSINESS PARTNER STUDENT RELEASE OF INFORMATION FORMEnrollment and participation in the Thomas Nelson Community College Nursing program(s) requires that students provide proof of general and specific health status, immunization records, CPR certification, criminal background check, social security number, driver's license/photo identification card, academic records, urine/blood tests for drug screening and any other information that may be required by the college, clinical facility and/or field agency policy or legal mandate to establish students’ fitness to care for live patients in a clinical and/or field setting.The Health Professions Division, Nursing Department/Program is required to share some or all of the aforementioned information with clinical facility and/or agency partners who provide sites for the required clinical and internship/training portions of the programs courses.Additionally, the Health Professions Division, Nursing Department/Program is required to share some or all of the aforementioned information with other entities for accreditation, course validation, certification eligibility, testing, certification issuance and/or other purposes in support of the student and/or the educational program.Further, the Thomas Nelson Community College Health Professions Division, Nursing Department/Program utilizes the services of third-party software vendors for some educational/course work, as well as for the clinical and field verification and documentation purposes (a list of current software, clinical and field locations is available upon request). The Health Professions Division, Nursing Department/Program is also required to enter some or all of the aforementioned information into software programs and/or databases not contracted by and out of the control of the College, i.e. Virginia Department of Health, American Heart Association, ACEN, etc.Pursuant to the Family Educational Rights and Privacy Act of 1 74, 20 U.S.C. 1231g (“FERPA”), the college and/or any of it agents may not release information without the written consent of the student; subject to the exceptions specified under FERPA. You may obtain more information about Student Rights and Responsibilities (FERPA) from your course catalog, student handbook, or college website tncc.edu. The clinical facilities and/or field agencies are required to maintain the confidentiality of these records and may only use them to determine that a student meets the standards of the institution and thus does not present a threat to their patients or staff.Choosing to not provide permission for the release of this information will prohibit participation in Thomas Nelson Community College Health Professions Division, Nursing Department/Program as it will result in a ban from the clinical facilities where students are required to complete the clinical portions of training. Admission to and successful completion of the clinical training portions of Nursing courses are required for program enrollment and completion.895350-1460500NAME OF STUDENT (Last, First, Middle Initial) STUDENT ID NUMBER9144001651000ADDESS (Street, City, Zip)9144001651000EMAIL ADDRESSNursing Department/ProgramStudent Release of Information FormPage 2PART II understand that some of my records are protected under the Family Educational Rights and Privacy Act of 1974 and cannot be released without my written consent. I hereby grant permission for access to and/or the release of all applicable records described above to clinical facilities and/or field agencies and grant access to those records by agents of those clinical facilities, field agencies, agents of third-party software used for records retention and clinical/field competency validation in use by the program/courses as required for my participation in and/or completion of the Thomas Nelson Community College Health Professions Division, Nursing Department/Program and/or courses in which I am or intend to be enrolled.I certify that this consent has been given freely and voluntarily. I may revoke this consent at any time by providing written notice of such revocation to the Thomas Nelson Community College Health Professions Division Health Professions Division, Nursing Department. Further, I understand that revocation of this consent will result in ineligibility to enroll in and/or continue in any Thomas Nelson Community College Nursing programs/courses. This authorization is in effect for the duration of my participation and enrollment in Thomas Nelson Community College Health Professions Division, Nursing Department/Programs and/or courses, unless revoked in writing, photocopies of this release form may be accepted, when presented in person with appropriate identification.895350-1460500Student Printed Name Student Signature Date895350-158750089535017970500PART IIALL AFFILIATED STUDENTS REQUIRED TO COMPLETE THE INFORMATION BELOW Business Partner/Employer Release of Information AuthorizationIn accordance with the aforementioned documentation pertaining to the release of information and the various types of information to be released, I do hereby grant permission to Thomas Nelson Community College, the Health Professions Division, Nursing Department/Program and its authorized agents/representatives to release any and/or all of the aforementioned information to:9144002286000Company/Organization Authorized Agents/Representatives9144002286000Address9144002349500City State Zip CodeUpon request of the Company/Organization Authorized Agent/Representative.895350-1460500Student Printed NameStudent SignatureDateIMPORTANT INFORMATION FOR ALL STUDENTSFAILURE TO EXECUTE PART I OF THIS FORM BY THE ESTABLISHED DEADLINE WILL RESULT IN YOUR ADMINISTRATIVE WITHDRAWAL FROM THE NURSING PROGRAM/COURSE. FAILURE OF AFFILIATED STUDENTS (WHO REQUIRE INFORMATION RELEASES TO THEIR EMPLOYER) TO COMPLETE PART I AND II OF THIS FORM RESULT IN YOUR ADMINISTRATIVE WITHDRAWAL FROM THE NURSING PROGRAM/COURSE.US Department of Education Statement for Nursing ProgramsPursuant to United States Department of Education (US DOE) regulation 34 CFR 668.43 (a) (5) (v), Thomas Nelson Community College, Associate Degree in Nursing (ADN) program provides the following information for all prospective and current students:?The?Thomas Nelson Community College?ADN program meets all Virginia Board of Nursing requirements for pre-licensure nursing education programs in the Commonwealth of Virginia.? In addition, the?Thomas Nelson Community College?ADN program meets all requirements for nationally recognized accreditation by the Accrediting Commission for Education in Nursing.? ?The Commonwealth of Virginia participates with 32 other states in the National Council of State Boards of Nursing (NCSBN) National Licensing Compact (NLC) to allow nurses licensed in one state to provide nursing care across state lines in other compact states.? The Uniform Licensing Requirements (ULRs) are found at: currently in the NLC are found at:??.? Prospective and current students are strongly encouraged to evaluate all state requirements in jurisdictions where they intend to practice nursing.? A list of all state requirements is found at:?? Nelson Community College has not determined if the ADN program meets the requirements of any other states.?This statement serves to meet the USDOE regulation until further notice.??Nursing Information Release Form 1142018Appendix ANational Student Nurses’ Association, Inc.Code of Academic and Clinical ConductPREAMBLEStudents of nursing have a responsibility to society in learning the academic theory and clinical skills needed to provide nursing care. The clinical setting presents unique challenges and responsibilities while caring for human beings in a variety of health care environments. The Code of Academic and Clinical Conduct is based on an understanding that to practice nursing as a student is an agreement to uphold the trust with which society has placed in us. The statements of the Code provide guidance for the nursing student in the personal development of an ethical foundation and need not be limited strictly to the academic or clinical environment but can assist in the holistic development of the person.A CODE FOR NURSING STUDENTSAs students are involved in the clinical and academic environments we believe that ethical principles are a necessary guide to professional development. Therefore within these environments we:1.Advocate for the rights of all patients.2.Maintain patient confidentiality.3.Take appropriate action to ensure the safety of patients, self, and others.4.Provide care for the patient in a timely, compassionate and professional manner.municate patient care in a truthful, timely and accurate manner.6.Actively promote the highest level of moral and ethical principles and accept responsibility for our actions.7.Promote excellence in nursing by encouraging lifelong learning and professional development.8.Treat others with respect and promote an environment that respects human rights, values and choice of cultural and spiritual beliefs.9.Collaborate in every reasonable manner with the academic faculty and clinical staff to ensure the highest quality of patient care10.Use every opportunity to improve faculty and clinical staff understanding of the learning needs of nursing students.11.Encourage faculty, clinical staff, and peers to mentor nursing students.12.Refrain from performing any technique or procedure for which the student has not been adequately trained.13.Refrain from any deliberate action or omission of care in the academic or clinical setting that creates unnecessary risk of injury to the patient, self, or others.14.Assist the staff nurse or preceptor in ensuring that there is full disclosure and that proper authorizations are obtained from patients regarding any form of treatment or research.15.Abstain from the use of alcoholic beverages or any substances in the academic and clinical setting that impair judgment.16. Strive to achieve and maintain an optimal level of personal health.17.Support access to treatment and rehabilitation for students who are experiencing impairments related to substance abuse and mental or physical health issues.18.Uphold school policies and regulations related to academic and clinical performance, reserving the right to challenge and critique rules and regulations as per school grievance policy.Appendix BNOTICE TO ALL STUDENTS PARTICIPATING IN PRACTICUMS, CLINICALROTATIONS, AFFILIATIONS AND INTERNSHIPS AND QUALIFYING FORPROFESSIONAL LICENSINGWelcome to the Associate Degree Nursing Program at Thomas Nelson Community College. We hope you will succeed in both the academic and practical aspects of your course of study. College policy does not require students to undergo criminal background checks, drug screenings, credit checks or the like as a condition of acceptance or enrollment. Clinical experiences or field internships, however, may be an integral part of your academic program and many of the clinical affiliates with which the College contracts to provide such clinical experiences, do require criminal background checks, health screenings or drug screens as a condition of allowing students to participate in the clinical experience. Some affiliates may also require credit checks, DMV records check, and review of professional disciplinary records, registry searches of certain types of sex offenders and/or verification of Social Security Numbers or legal residency. Students assigned to a clinical rotation or internship at an outside facility are personally responsible for completing the required checks or screenings and assuring that results are obtained by the facility that asks for them. This means that students also may be required to bear the costs of such tests. It will be the decision of the clinical affiliate whether the student will be allowed to participate in the clinical activities. Thomas Nelson Community College does not assume any responsibility for obtaining or evaluating the results of a criminal background check, drug screen or other check, maintaining the records of results or for delivering them to clinical sites. Please select one of the following: 241301587500Students may not request to be assigned only to those sites that do not require such checks. Students who refuse to undergo a criminal background check or drug screen or other required check may not be able to be placed at another facility and consequently may not be able to complete program requirements. 24130190500School may try to arrange for alternative placement sites with less intensive background screening under certain circumstances. The College will make reasonable efforts to place all enrolled students in clinical training. Students are also reminded that licensing boards for certain occupations and professions may deny, suspend or revoke a license or may deny the opportunity to sit for an examination if an applicant has a criminal history, is convicted, or pleads guilty or nolo contendere to a felony or other serious crime. Students should consult the licensing board of their intended profession for further information. Successful completion of a program of study at Thomas Nelson Community College does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant occupation. Appendix CSimulation Lab Latex Response PlanPOLICY: It is the policy of the THOMAS NELSON Nursing Program to make students and employees aware that when working in the clinical setting or the nursing simulation labs, faculty and students may be exposed to latex and other allergens. PURPOSE: To provide annual education, screening and a review of guidelines for faculty and students to reduce the likelihood of a sensitivity or exposure reaction to latex or any other substance while in the Nursing Simulation Laboratory and to provide action steps in case of a life-threatening reaction in a nursing simulation lab.PROCEDURE:Latex Products in Use signage will be posted in each Nursing Simulation Laboratory.All faculty and students will complete and sign the Latex sensitivity section at the bottom of this policy, annually.Students or faculty with a known latex sensitivity/allergy should consult with their primary health care provider about their sensitivity/allergy, risks, treatment, and that in your current school/employment you will be exposed to Latex and other possible allergens.Students are to inform their classroom instructor, their clinical instructor and the simulation lab supervisor of your sensitivity/allergy to Latex.Latex-free gloves will be provided to you. Know that the lab environment and clinical facilities are NOT Latex rm the members of your educational team noted above of your plan to respond to a reaction. In case of a life-threatening reaction in a nursing lab, an ambulance will be summoned immediately.Any faculty member or student may dial 911 on a personal cell phone or school phone, state that you have a life threatening “Latex emergency” and need an ambulance. Epinephrine will be needed.Do not handle the victim with any latex products.Student/faculty member will be transferred to a hospital in the community by ambulance. It is helpful for the ambulance personnel to know the victims allergies, current medications and any medical conditions. A copy of this form will be given to each student/faculty member yearly. The signed original will be placed in the student /employee’s permanent file.I have reviewed the above policy and understand that questions regarding this policy are to be directed to the Nursing Program Director and Nursing Simulation Lab Supervisor.Student/Faculty signature______________________________Date:_____________________Printed Name_______________________________________Appendix DDocumentation of Student/FacultyPhoto/Videotape Release FormPOLICY: It is the policy of the THOMAS NELSON Nursing Program to have each student participating in Nursing Simulation in the Simulation Lab to sign the Thomas Nelson, Photo/Videotape Release Form below.PURPOSE: To receive permission from students to photograph or videotape while in the Nursing Simulation Laboratory.PROCEDURE: Prior to the first nursing simulation experience the students will be given the THOMAS NELSON Photo/Videotape Release Form and will complete and pleted forms will be turned in to the Simulation Lab Supervisor to be logged in and forms will be filed in the students’ record on campus._________________________________________________________________________________________________I certify that my signature being affixed below on this consent form gives permission to Thomas Nelson Community College the full right to use my photograph(s), videotaped image and sound byte in its marketing, public relations, promotional or instructional efforts. I willingly agreed to have my photograph(s), videotaped image, sound byte taken knowing that it could be used in various publications.I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith, or the use to which may be applied. I hereby release, discharge and agree to save Thomas Nelson Community College or its employees from any liability by virtue for any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said pictures, or in any processing tending towards the completion of the finished produce.Student Name:________________________________________________________Address:_____________________________________________________________Tel:________________________ E-mail:___________________________________Signature: _____________________________Date:__________________________For students under 18 years old, parent’s signature is requiParents' Name: ________________________________________________ Tel: ______________________ Email: _________________________Signature:___________________ ______________Date: ___________________Please tell us the reason why you enrolled at Thomas Nelson Community College.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Appendix ETHOMAS NELSON COMMUNITY COLLEGEASSOCIATE DEGREE NURSING PROGRAMPRE-ENTRANCE MEDICAL EXAMINATIONA pre-entrance medical examination is required for all students enrolled in the THOMAS NELSON Nursing Program. This form must be completed by a health care provider and returned directly to the nursing office by the designated date. Please be sure it is filled out completely, and retain a copy for your records.Name of Applicant: _______________________________________________________________________(Last Name)(First Name)(Middle Initial)Address: _______________________________________________________________________________(Number and Street) _________________________________________________________________________________(City)(State)(Zip Code)Telephone Number: ____________________________________________________________________Date of Birth: ____________________________________________________________________ (Month)(Day)(Year)To be completed by Student:STUDENT’S HEALTH HISTORYCheck any conditions that apply if you have (or have had in the past) these problems. Provide details of positive answers below.AnemiaAsthmaBleeding DisorderCancer Colon problemDiabetesEating disorderEye disorderKidney infection or stoneHearing loss Heart diseaseHepatitis or liver diseaseHigh blood pressureHospitalizationsLung diseaseMental healthMigraine headachesMononucleosisOrgan transplantPneumoniaRheumatic feverRheumatoid arthritisSeizure disorderStomach problemsSubstance abuseThyroid troubleTuberculosisOther ____________________________ Details: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ALLERGIES: Medications, Foods, Pollen, etc. (include reaction) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MEDICATIONS List medications (including birth control, acne drugs, antidepressants, etc.) you are currently taking (include medication/dosage and reason for taking them).Drug___________________________________ Dose_______________ Reason__________________________________Drug___________________________________ Dose_______________ Reason__________________________________Drug___________________________________ Dose_______________ Reason__________________________________Drug___________________________________ Dose_______________ Reason__________________________________Drug___________________________________ Dose_______________ Reason__________________________________Hospitalizations/Surgeries (List procedures and dates): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FAMILY HISTORYCheck any that apply, if condition exists in your family (immediate family, grandparents, aunts, uncles, cousins)AllergiesAsthmaBleeding DisordersCancerDiabetesEye disordersHeart diseaseHigh blood pressureLung diseaseMental illnessRheumatic feverStrokeTuberculosisUlcerNoneOther_______________________Statement of Understanding Regarding Pre-Entrance Medical ExaminationThe answers that I have given regarding my health status are true to the best of my knowledge. Falsification of any information in the questionnaire may result in dismissal from the THOMAS NELSON Nursing Program. I understand that the information will be used to determine whether I am capable of performing the physical requirements for the nursing program. My signature below indicates my understanding of the above statement.Date: ____________________Student Signature: ______________________________________To Be Completed by the Health Care Provider:Please assess the following systems. Describe fully any abnormal findings. Use additional sheet if needed.Height: ______________ Weight: ______________ WNL WNLYES NO YES NOHead, Ears, Nose or Throat o o_________________________Musculoskeletalo o_________________________Eyes o o_________________________Metabolic/Endocrine o o_________________________Respiratory o o_________________________Neuro o o_________________________Cardiovascular o o_________________________Psychiatric o o_________________________Gastrointestinal o o_________________________Skino o_________________________Genitourinary o o_________________________DIAGNOSIS:OExcellent health with no chronic medical problems OROOther diagnosis and recommendations – please list:______________________________________________________________________________________The nursing faculty has determined that to successfully complete the classroom and clinical components of the Thomas Nelson Community College Nursing Program, the student must be able to perform defined essential functions. These essential functions include but are not limited to the following:Attendance:Regular classroom and clinical attendance as defined by the nursing department student policies.Essential Mental Abilities:Maintain reality orientation accompanied by short and long term memory.Adapt to school and clinical environment.Follow rules and instructions.Assimilate and apply knowledge acquired through lectures, discussions, demonstrations, and prehend and apply basic mathematical skills.Demonstrate safe nursing practice within the defined clinical time period.Demonstrate critical thinking skills by the comprehension and application of abstract concepts.Essential Communication Skills:Speak clearly in order to communicate with patients, families, health care team members, peers and faculty.Interact appropriately and communicate effectively with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual municate and organize thoughts in order to prepare written documents.Prepare written documents that are correct in style, grammar and mechanics.Essential Physical Abilities:Stand and walk for six to eight hours/day.Walk for prolonged periods from one area to another over an eight hour period.Bend, squat and kneel.Assist in lifting or moving patients of all age groups and weights.Perform CPR, i.e., move above patient to compress chest and manually ventilate patient.Work with arms fully extended overhead.Use hands for grasping, pushing, pulling, and fine manipulation.Demonstrate eye/hand coordination for manipulation of equipment, i.e., syringes, procedures, etc.Essential Sensory Abilities:Possess tactile ability to differentiate changes in sensation.Possess tactile ability sufficient for physical assessment.Possess auditory acuity to note slight changes in the patient’s condition, i.e., lung sounds, etc.Possess auditory acuity to hear patient calls for assistance without facing the patient.Possess auditory acuity to interpret various equipment signals and use the telephone.Possess visual acuity to read and distinguish colors, to read handwritten orders, and other handwritten and printed data.Possess visual acuity to clearly view monitors and scales in order to correctly interpret data.Possess olfactory ability sufficient to detect differences in odor. At this time, are you aware of any health conditions that would affect this individual’s progress in the nursing program?_________ Yes_________ NoRecommendations: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date: _______________ Healthcare Provider’s Signature: ________________________________________________ Healthcare Provider’s Printed Name: _____________________________________________ Nursing Student Immunization Form (Please attach supporting documentation for each titer.)Student’s Name: Date: Ref#VaccineDatesTiter1MMR/ / M D Y/ / M D YOR/ /M D YImmune: Yes______ No______2Varicella(Chicken Pox)/ / M D Y/ / M D YOR/ /M D YImmune: Yes______ No______3Hepatitis B/ / M D Y/ / M D Y/ / M D YOR/ /M D YImmune:Yes______ No______ORI have reviewed the Hep. B information sheet. I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease for which there is no cure.____________________Signature/Date4Tetanus(Td)AND/ / M D YMust be within the last 10 yearsPertussisOR/ / M D YTetanusWith Pertussis(TdaP)/ / M D YMust be within the last 10 years5Tuberculin Test(PPD Yearly)Step 1 and 21st Academic YearStep 1/ /Date Given/ / Date ReadTest Results:____mmChest X-Ray is required if PPD is positiveChest X-Ray Results:___________Date:__________________1st Academic YearStep 2/ /Date Given/ / Date ReadTest Results:____mm2nd Academic Year/ /Date Given/ / Date ReadTest Results:____mm6Influenza(0.5 mL Injection Preferred)First Academic Year/ /Date GivenRequired annually by October 1st.Second Academic Year/ /Date GivenRequired annually by October 1st. Appendix FTHOMAS NELSON COMMUNITY COLLEGEREMEDIATION FORMSTHOMAS NELSON COMMUNITY COLLEGENURSING PROGRAMHESI Remediation Plan and Contract (Initial contract):Student Name - ________________________________________Date – ___________________Exam Type (specialty or exit) - FundamentalsOverall HESI Score - _________Identify lowest category in Nursing Process1)Identify lowest category in Client Needs1)Identify three lowest categories in Nursing Concepts1)2)3)Based on overall HESI score, hours of HESI online post exam remediation to be completed-____Adaptive Quizzing Topics /s (10 question custom quiz – must achieve 80%) - # quizzes - _______Case Studies Topic/s (must achieve 80%) –# case topics - __________Other – Plan approved by – ____________________________________________________________Date - _____________________THOMAS NELSON COMMUNITY COLLEGENURSING PROGRAMHESI Remediation Plan and Contract (Plan completed):Student Name - ________________________________________Date – ___________________Exam Type (specialty or exit) - FundamentalsOverall HESI Score - _________Identify lowest category in Nursing Process1)Identify lowest category in Client Needs1)Identify three lowest categories in Nursing Concepts1)2)3)Based on overall HESI score, hours of HESI online post exam remediation to be completed-____Adaptive Quizzing Topics /s (10 question custom quiz – must achieve 80%) - # quizzes - _______Case Studies Topic/s (must achieve 80%) –# case topics - __________Other – After plan is completed, submit this form to your nursing instructor. I ________________________ (name) verify that I have completed the above remediation plan by ___________ (date).Verified by – ____________________________________________________________Date - _____________________Recommended Student Remediation Plans based on HESI scores are as follows*-HESI Score 800 or aboveComplete online remediation provided in HESI Student Access specific to the Exam. A minimum of four hours of study is required.**Develop two 10 question custom quizzes in Adaptive Quizzing two content area of weakness based on your HESI Exam Student Report. Continue to take quizzes in that content area until 80% correct is achieved.***HESI Score 750 – 799Complete online remediation provided in HESI Student Access specific to the Exam. A minimum of five hours of study is required.**Develop three 10 question custom quizzes in Adaptive Quizzing three content area of weakness based on your HESI Exam Student Report. Continue to take quizzes in that content area until 80% correct is achieved.***Select one HESI Case Study in a content area of weakness based on your HESI Exam Student Report and complete with 80% score.****HESI Score 700 - 749Complete online remediation provided in HESI Student Access specific to the Exam. A minimum of six hours is required.**Develop four 10 question custom quizzes in Adaptive Quizzing four content area of weakness based on your HESI Exam Student Report. Continue to take quizzes in that content area until 80% correct is achieved.***Select one HESI Case Study in a content area of weakness based on your HESI Exam Student Report and complete with 80% score.****HESI Score 699 or belowComplete online remediation provided in HESI Student Access specific to the Exam. A minimum of six hours is required.**Develop four 10 question custom quizzes in Adaptive Quizzing four content area of weakness based on your HESI Exam Student Report. Continue to take quizzes in that content area until 80% correct is achieved.***Select two HESI Case Studies in a content area of weakness based on your HESI Exam Student Report and complete with 80% score.*****Student can develop other forms of remediation that are subject to faculty approval (document how this completion of remediation will be determined). **Student must be logged into their HESI Student Access account and the online test specific remediation content for the number of hours specified. Don’t print and log out of HESI remediation to study. Time spent in remediation content is monitored and student can break up the required remediation hours into multiple sessions.***When using Adaptive Quizzing as remediation after HESI exams, use Custom Exams and not Mastery Exams. Additionally it is advised that only one content area be selected for each weakness area (as opposed to combining multiple topic areas into a quiz with more questions). ****HESI Case Studies that are not used in class assignments can be used. (Students will get access to Case Studies and Practice Tests during the first semester, after all HESI payments are processed.)HESI Remediation for Exit-1 (Last Semester of Program)Deadline for Completion: __________. If you score:900 or aboveComplete individualized online HESI remediation for 4-hours-REQUIREDComplete the Multidisciplinary Practice Quiz: Student must get 90% on the quiz- REQUIREDReview CPE-1, 2 ,3-Recommended Complete at least 1 case study from the following sections: Fundamentals, Medsurg, OB, Peds (redo- if done before) RecommendedReview CPE- 1, 2 ,3-RecommendedIf you score: 850-899Complete individualized online HESI remediation for __6________hours- REQUIREDComplete the Multidisciplinary Practice Quiz: Student must get 90% on the quiz- REQUIREDComplete at least 1 case study from the following sections: Fundamentals, Medsurg, OB, Peds (redo- if done before) RecommendedReview CPE- 1, 2 ,3-RecommendedIf you score: 800-849Complete individualized online HESI remediation for __8________hours- REQUIREDComplete the Multidisciplinary Practice Quiz: Student must get 90% on the quiz- REQUIREDReview CPU 1, 2 ,3- REQUIREDComplete at least 1 case study from the following sections: Fundamentals, Medsurg, OB, Peds (redo- if done before)- REQUIREDIf you score: 799 or belowComplete individualized online HESI remediation for __10________hours- REQUIREDComplete the Multidisciplinary Practice Quiz: Student must get 90% on the quiz- REQUIREDReview CPU 1, 2 ,3- REQUIREDComplete at least 1 case study from the following sections: Fundamentals, Medsurg, OB, Peds (redo- if done before)- REQUIREDRemediation hours and activity will be monitored within evolve to verify the required hours and activity details Student must keep up with their own hours. ONLY ONLINE STUDY TIME UNDER REMEDIATION COUNTS FOR REMEDIATION. Failure to complete remediation= Students will not be able to take the Exit-2 For remediation to be considered completed (determined by the course instructor)) the student must spend the required time doing the following:Access all recommended categories of remediation in the HESI remediation for the specific exam.Access and Review the online remediationReview Specialty and Sub specialty areasQuick book reviewIn-depth Book reviewView and submit practice questions in each area that included in the HESI remediation packet if applicableView and submit case studies if applicable. View multimedia if applicable. Only creating and printing study packets will not count as doing remediation, student must spend time studying the material that is recommended.The total time spent under the online remediation will count towards the required remediation hours. HOW TO ACCESS YOUR REMEDIATIONGo to: on "HESI" tabUnder Get Started: you will find several links. Please review these links and this will tell you how to access your remediation for your HESI exams. TECHNICAL SUPPORT HESI/EVOLVE: CALL 1-800-222-9570ASSUMPTION OF THE RISK FORMI agree that as a participant in the ____________________________________________at ___________________________ associated with ________________________Community College (the “College”) scheduled for __________________ to __________________, I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to slips and falls, needle pricks, and contracting diseases such as COVID-19, also known as the coronavirus disease. COVID-19 is a pandemic of respiratory disease that spreads from person-to-person. COVID-19 can cause mild to severe illness; most severe illness occurs in older adults. Nevertheless, people of all ages with severe chronic medical conditions including, but not limited to, heart disease, lung disease, and diabetes are also at a higher risk of developing serious COVID-19 illness. Healthcare workers caring for patients with COVID-19 have a higher risk of exposure and I understand that the clinical facility may have patients recovering from COVID-19. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it.Symptoms of COVID-19 include fever, cough, and shortness of breath. Reported illnesses range from very mild (including some with no reported symptoms) to severe, including death. If I feel sick, I agree not to go to the clinical facility and that I will stay home, except to receive medical attention if necessary. I also agree to take all necessary precautions recommended by the Centers for Disease Control and Prevention, including but not limited to washing my hands thoroughly and often, avoiding gatherings of ten or more people, covering my mouth and nose if I cough or sneeze, and avoiding public transportation, ride-sharing, or taxis.I agree to abide by any and all specific requests by the College and the clinical facility for my safety or the safety of others, as well as any and all of the College’s and the clinical facility’s rules and policies applicable to all activities related to this program. I understand that the College and the clinical facility reserve the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others.In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury or illness which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury or illness is directly due to the negligence of the College and/or the clinical facility. I understand that this Assumption of Risk form will remain in affect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with ______________________________________, at which time my visits to or participation in the program will cease.In case an emergency situation arises, please contact (name) at (phone number).I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal risks and conditions of my own free will. I represent that I am 18 years of age or older and legally capable of entering into this agreement._____________________________________ Participant’s signature_____________________________________ Date_______________________________________________________________________________________________________________AddressIf participant is less than 18 years of age, the following section must be completed: My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this program, and I agree to be responsible for his/her behavior and safety during this event._____________________________________ Child’s Name_______________________________________________________________________________________________________________Address_____________________________________Parent’s or guardian’s signature_____________________________________ Date ................
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