Roger W. Schulꜩ, Ph.D. Superintendent/sident Board of Trustees Tom Ashley Vicki Carpenter Sherrie Guerrero, Ed.D. Mt. San Jacinto Communi College District Dorothy McGargill 1499 N. State Street, San Jacinto, CA 92583 Ann Moe JUNE 1, 2020 Dear CNA Student, Aached is your Pre-registration packet for the Ceified Nursing Assistant Program. Once you have completed the packet, submit it electronically through the virtual drop box on the CNA website. • Physical Exam (6 pages total), • Proof of Hep B • Proof of most current Flu vaccine (Due September 15, 2020) • Proof of TB - QuantiFERON-TB Gold Test or Mantoux (Skin Test) • Copy of CPR Card (American Hea Association/Healthcare provider/BLS) Paʦ wi be a space a the is fu no more paʦ wi be ated Once all requirements are completed and approved, your Request r Live Scan, Class Schedule, Book List and Instructor Consent form will emailed to you at a later date. If you have any questions, please email me jbrandenburg@msjc.edu Respecully, Janet 'ranaenrg AH Clerical Assistant IV jbrandenburg@msjc.edu San Jacinto Campus Menifee Valley Campus San Gorgonio Pass Campus 1499 N. State Street 28237 La Piedra Road 3144 W. Westward Avenue San Jacinto, CA 92583 Menifee, CA 92584 Banning, CA 92220 951.487.6752 951.672.6752 951.922.1327
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Roger W. Schultz, Ph.D.
Superintendent/President
Board of Trustees
Tom Ashley
Vicki Carpenter
Sherrie Guerrero, Ed.D.Mt. San Jacinto Community College District
Dorothy McGargill 1499 N. State Street, San Jacinto, CA 92583
Ann Motte
JUNE 1, 2020
Dear CNA Student, Attached is your Pre-registration packet for the Certified Nursing Assistant Program. Once you have completed the packet, submit it electronically through the virtual drop box on the CNA website.
• Physical Exam (6 pages total), • Proof of Hep B • Proof of most current Flu vaccine (Due September 15, 2020) • Proof of TB - QuantiFERON-TB Gold Test or Mantoux (Skin Test) • Copy of CPR Card (American Heart Association/Healthcare provider/BLS)
Packets will be accepted while space is available. Once the class is full no more packets will be accepted.
Once all requirements are completed and approved, your Request for Live Scan, Class Schedule, Book List and Instructor Consent form will emailed to you at a later date.
Nursing and Allied Health Department www.msjc.edu/alliedhealth
This is a 167 .5 hour course including lecture and clinical practice which prepares students to take the State Certification as a Nursing Assistant.
Co-requisite: NURSE 084A This 26 hour course provides the opportunity for students enrolled in skill based certified nursing program to practice and master skills necessary for safe patient care.
1) Pre-registration Packets will be available October 1st for the SPRING Semester and
May 1st for the FALL Semester.
Completed packets need to be submitted to the Nursing and Allied Health Department
via Virtual Dropbox on the website.
2) Instructor Consent Forms will be distributed to the first 30 students who complete the preregistration packet. The Nursing & Allied Health Department will be the ONLY department to distribute the instructor consent forms.
Pre-Registration Requirements:
1. Medical History Statement/Examination
2. Titer Levels are required for the following: Hep B
3. Test required for the following QuantiFERON®-TB GOLD test or Mantoux test (Skin Test)
4. Immunizations are required for the following: Flu (Sept.1 - March 31)
5. Request for Live Scan Service
6. CPR Card - American Heart Association/Health Care Provider/BLS Card will be the ONLY card accepted.
(Costs depends on where you go) • CPR Card (American Heart Association/Healthcare Provider) • Medical History Statement/Examination
(Cost will vary according to physician/personal insurance, etc.) • Photo ID (Obtain from Admission Office) • Uniform Top only (MSJC Book Store) • Solid Black Scrub Pants
(Cost will vary according to where you purchase) • Supplies:
(Cost will vary according to where you purchase) Gait Belt Stethoscope Watch with Second Hand Small Note Pad Pen/Black ink Scantrons (full size pink ones)
MT. SAN JACINTO COLLEGE Certified Nursing Assistant (CNA)
MEDICAL HISTORY STATEMENT/EXAMINATION CNA Student Clinical Internship Medical Exam
Instructions:
• Fill out the questionnaire completely and accurately. Keep in mind that all statements are subject to verification; deliberate inaccuracies or incomplete statements may bar or remove you from the program.
• This form must be completed and presented when reporting for your medical examination.
• This medical history statement is confidential. The information you provide will be part of your student file and is used simply to ensure your safety as well as patient's safety during internships.
• Print legibly (in ink).
Student ID # ___________ {must have, do not leave this blank)
I SECTION I: STUDENT IDENTIFICATON 1. STUDENT'S NAME (Last, Fi rst, Middle)
2. ADDRESS (Street/ PO Box)
3. CITY 4. STATE/ZIP CODE
S. CURRENT CONTACT NUMBER 6. ALTERNATE NUMBER (If applicable)
7. SEX 8. BIRTHDATE (MM/DD/YEAR)
9. MSJC STUDENT E-MAIL-AII co r respondence will be 10. PERSONAL E-MAIL through you r Student MSJC email.
