THE UNIVERSITY OF TEXAS AT BROWNSVILLE
AND
TEXAS SOUTHMOST COLLEGE
Associate of Applied Science
in Nursing
Application Deadline:
May 15th
ASSOCIATE DEGREE NURSING PROGRAM
The University Of Texas at Brownsville and Texas Southmost College
80 Fort Brown - Brownsville, Texas 78520 - (956) 882-5072 - Fax (956) 882-5100
Dear Applicant:
The nursing faculty at the University of Texas at Brownsville is pleased to learn of your interest in the
Associate Degree Nursing Program.
One of the most important decisions you will have to make is choosing a career. Today, nursing is one of the
outstanding fields open to both men and women. Nursing has always been influenced by medical technological
advances and by current scientific knowledge. Never has the demand for quantity and quality of health care
been so great.
Life as a registered nurse (RN) is intellectually challenging, personally satisfying, and deeply rewarding.
Nursing deals with the realities of life; it satisfies the desire to make a worthwhile contribution to the care and
comfort of the sick and to the promotion of health
Enclosed you will find other information for this program. The admission criteria listed in the brochure must be
completed and received by May 15th for the program that begins in the Fall semester and December 15th for the
program that begins in the Spring semester. Admission into the Associate Degree Nursing Program is the sole
responsibility of the Department of Nursing through the selection and concurrence of its Admission Committee.
It is the responsibility of the applicant to assure that the ADN Program has received ALL required and relevant
information prior to student selection activities.
The Admissions Committee will send letters of notification following review of applications. The letter of
notification will describe the applicant as: 1) offered admission, 2) denied admission (reason stated), or 3)
assigned as an alternate (to be among those considered in the event openings develop in the entering class). In
the event an applicant is not admitted, the applicant may visit with the Director of the program to determine
how to improve their application status for admission into a future class.
If you have any questions, please feel free to contact the Nursing Department or any member of the faculty.
Sincerely,
Joe R. Lacher, M.S.N., R.N., N.E.-B.C.
Program Director, Associate Degree Nursing
2
ADMISSION REQUIREMENTS
A. Submit an application to the University of Texas at Brownsville, MEET REQUIREMENTS FOR ADMISSION,
and obtain a UTB ID number. You may apply online at www.utb.edu/admissions/ or pick-up a paper
application at Tandy Hall T115, Phone: 956-882-8295.
B. SUBMIT THE FOLLOWING ITEMS TOGETHER IN A PACKET TO THE ADN OFFICE
IN
LHSB 2.720:
1. Associate Degree Nursing Application (last six pages of this packet).
2. High school transcript or GED score sheet, unofficial copies are acceptable (If you have previously
attended college or university please omit this step.)
3. Transcripts, unofficial copies will be accepted (ONLY UTB TRANSCRIPTS WILL BE ACCEPTED, I.E.
SCORPION ONLINE TRANSCRIPTS WILL BE ACCEPTED.) If you have never attended UTB, you must submit
your transcripts for evaluation to the Admissions Office, Tandy Hall 115, Phone: 956-882-8295. To
obtain an unofficial transcript, please visit the Office of the Registrar at Tandy Hall 105, Phone: 956882-8254. FOR STUDENTS WITH TRANSFERRED COURSES: TRANSCRIPTS MUST BE A
PRINT-OUT FROM THE OFFICE OF THE REGISTRAR).
4. Educational Background. If you have already earned a certificate, associates, bachelors, masters or
doctorate degree from any other university other than UTB/TSC, please submit evidence of such degree.
You may submit a copy of the diploma and/or a transcript (official or unofficial) from the respective
university or college and highlight the degree notation on such transcript. Also, be sure to make note of
your degree(s) on page 13 of this packet.
5.
A copy of your current CPR for the Health Care Provider certification.
6. Copy of Immunization records.
7. A minimum college GPA of 2.5 –OR– if no college experience, a high school average of 85.
8. ACT test scores, copies are acceptable– A minimum score of 18 on the Reading, English and
Composite sections is required.
 If score is more than five years old student will need to retake exam.
 Effective Fall 2010 the ACT Exam will be mandatory.
C. The Admissions Committee for the incoming class will only consider
are received by May 15th of each year.
Deadline to apply is MAY 15TH
3
COMPLETE
application packets that
PROGRESSION
A “C” is required in all General Education courses that are part of the degree plan. Students must pass all
Nursing courses (RNSG) with a minimum course grade of 74.50. Students must pass all courses at one
level/semester before progressing to the next level/semester. Complete information on grade requirements can
be found in the ADN Student Guide and/or course syllabi.
Achievement tests are given throughout the program. If a student falls below the established standard, the
student will be assigned remedial work that is required to be completed prior to enrollment in the following
course(s). The student is responsible for the testing fees of approximately $249.00 over the two-semester course
of study.
TUITION COSTS
Tuition for nursing student, enrolled in nursing courses will be the same as for other UTB/TSC students. Uniforms,
books, various school fees and health/accident and liability insurance are additional. Students arrange for their own living
quarters, laundry and transportation between the college and clinical facilities.
Uniforms will cost approximately $333.25 and must be purchased prior to the first nursing course. Books will average
$2,011.00 for the entire program. Liability and heath/accident insurance must be purchased at registration annually.
The Student Financial Assistance programs provide financial assistance to eligible student who, without such aid, would
be unable to attend college. Financial assistance for eligible students is available in the form of grants, loans, college
work-study, veterans’ benefits, and scholarships.
ELIGIBILITY TO TAKE NCLEX-RN EXAMINATION
The Board of Nurse Examiners has identified certain circumstances that may render a potential candidate ineligible for
licensure as a registered nurse in the State of Texas. The Board provides individuals with the opportunity to petition the
Board for a Declaratory Order as to their eligibility in accordance with Article 301.257 of the Nursing Practice Act.
If you are required to answer “YES” to any of the following questions please request a Declaratory Order Petition in
writing by contacting the Education/Examination Department, Board of Nurse Examiners for the State of Texas, P.O. Box
430, Austin, Texas 78767-0430. Processing your Petition may take 6 to 12 month, or longer, after you provide all
required documentation and depending on you circumstance. Once all requested documents have been received, you will
be notified that the Petition has been transferred to the Enforcement Department for review.
1.
Have you been convicted, adjudged guilty by a court, plead guilty, no contest or nolo contendere to
any crime in any state, territory or country, whether or not a sentence was imposed, including nay
pending criminal charges or unresolved arrest (excluding minor traffic violations)? This includes
expunged offenses and deferred adjudications with or without prejudice of guilt. Please note that
DUI’s, DWI’s, PI’s must be reported and are not considered minor traffic violations. (One minor in
possession [MIP] or minor in consumption [MIC] do not need to be disclosed, therefore, you
may answer “No”. If you have two or more MIP’s or MIC’s, you must answer “Yes”.)
2.
Do you have any criminal charges pending, including unresolved arrests?
3.
Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled,
accepted surrender of, suspended, placed on probation, refused to renew a professional license or
certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise
disciplined you?
4.
Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any
other drug?
5.
Within the past five (5) years have you been diagnosed with, treated, or hospitalized for
4
schizophrenia and/or psychotic bipolar disorder, paranoid personality disorder, antisocial personality
disorder, or borderline personality disorder?
Students that have obtained a Declaratory Order Petition must notify the Director and inform them of the outcome of their
petition.
ESSENTIAL ELIGIBILITY REQUIREMENTS FOR PROFESSIONAL NURSING STUDENTS’
PARTICIPATION IN CLINICAL PRACTICE
The Associate Degree Nursing Applicant and/or student would be considered ineligible to participate in the
Associate Degree Nursing Program when his/her physical, emotional, and/or intellectual disability and/or
incapacitated state:
1. Hinders the student from being able to achieve the cognitive knowledge and/or dexterous skills
required for the Associate Degree Nursing student nurse and expected of the Registered Nurse in the
performance of the functions of which he/she is preparing to be employed.
2. Creates a potential health hazard to the student and/or recipient of health care services by the
respective student.
It assumed that a student will independently be able to:
1. Functionally use the senses of vision, hearing, smell and touch with or without technical
(mechanical) compensation. Observe a patient accurately at a distance and close at hand.
Observation necessitates the functional use of the sense of vision and somatic sensation. It is
enhanced by the functional use of the sense of smell.
2. Execute functional psychomotor activities to provide general nursing care and emergency treatment.
Such actions require coordination of both gross and fine muscular movements, equilibrium and
functional use of the senses of touch and vision.
3. Hear, observe and speak to patients in order to elicit information, describe changes in mood, activity
and posture, and perceive non-verbal communications. A student must be able to communicate with
patients and others effectively and with sensitivity. Communication includes not only speech but
also reading and writing.
4. Utilize intellectual abilities, exercise responsible judgment and complete task. Comprehend three-
dimensional relationships and understand the spatial relationships of structures.
5. Demonstrate the emotional health required for full utilization of intellectual abilities and exercise of
good judgment. The student must be able to promptly complete all responsibilities attendant to the
care of the patients, families, and groups from a variety of social, emotion, cultural, and intellectual
backgrounds and develop mature, sensitive and effective relationships with them. A student must be
able to tolerate physically taxing workloads and function effectively under stress. The student must
be able to adapt to changing environments, display flexibility and learn to function in the face of
uncertainties inherent in the clinical problems of many patients. Compassion, integrity, concern,
other interpersonal skills, interest and motivation are all personal qualities that will be assessed
during admission and the educational process. A student who cannot function in any of the abilities
mentioned above may receive individual consideration for admission or retention.
For
consideration, request must be submitted to the Director.
5
ADA Guidelines apply to all qualified disabled persons. A qualified disabled person is a person with a
disability who, with or without reasonable modifications to rules, policies, or practices, the removal of
architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets
the essential eligibility requirements for the receipt of services, or the participation in programs or activities
provide by a public entity and who can perform the “essential eligibility requirements” of the position. Any
student who, because of a disabling condition, may require some special arrangements in order to meet course
requirements should contact the Director as soon as possible to make necessary accommodations. Students
should be prepared to present a disability verification form from their physician and update that information
periodically.
HEALTH REQUIREMENTS
A current up-to-date immunization record is required prior to entering the program and must be submitted
attached to the admission application. Immunizations include Measles/Mumps/Rubella (MMR – or
confirmation of Immunity/protective titer), Varicella, Tetanus/Diphtheria (TD – Immunization received within
the last 10 years), Tuberculin Test (PPD – administered and read within the last 12 month) and Hepatitis B
Series (or confirmation of Immunity/protective titer).
When submitting the admission application packet you must provide documentation of current C.P.R. for the
Health Care Provider.
Students are encouraged to carry health insurance and must carry professional liability insurance. Students
needing health insurance may obtain information in the Student Health Services Office. Professional liability
insurance coverage in at least a minimum amount of $1 million limit each claim and $3 million aggregate is
required. Cost for the professional liability insurance in included in the fees ($18.78) paid during each fall
semester. The professional liability insurance is only applicable to students in their student role, not in their
employment role.
6
Curriculum Outline 2008-2009
Texas Southmost College FICE 003643
A.A.S. Associate Degree Nursing
FIRST YEAR
First Summer Session
BIO
2301
BIOL
2101
MATH
1332
HEGIS 8021
CIP 51.1601
Hours
Lecture
3
0
3
6
Anatomy and Physiology I
Anatomy and Physiology I
Math for Liberal Arts
Total Hours
Second Summer Session
BIO
2302
Anatomy and Physiology II
BIOL
2102
Anatomy and Physiology II
PSYC
2301
Introduction to Psychology
Total Hours
LEVEL I
First Semester
*RNSG
1108
Dosage Calculations for Nursing
*RNSG
1205
Nursing Skills
*RNSG
1215
Health Assessment
*RNSG
1309
Introduction to Nursing
*RNSG
1260
Clinical: Nursing RN: Introduction to Nursing
Total Hours
LEVEL II
Second Semester
*RNSG
1301
Pharmacology
*RNSG
1110
Introduction to Community Based Nursing
*RNSG
1331
Principles of Clinical Decision-Making
*RNSG
1347
Concepts of Clinical Decision-Making
*RNSG
1261
Clinical: Nursing RN: Principles and Concepts of
Clinical Decision-Making
PSYC
2314
Lifespan Developmental Psychology
Total Hours
SECOND YEAR
First Summer Session
BIO
2320
BIOL
2121
*RNSG
2213
*RNSG
2263
First Semester
SPCH
1318
ENGL
1301
*RNSG
2201
*RNSG
2262
*RNSG
1251
*RNSG
2261
LEVEL III
Second Semester
*RNSG
2341
*RNSG
2360
*RNSG
*RNSG
ELCT
2121
2166
Lab
0
4
0
4
Clin
0
0
0
0
Contact
48
64
48
160
0
4
0
4
0
0
0
0
48
64
48
160
Lab
4
4
4
0
0
12
Clin
0
0
0
0
8
8
Contact
64
80
80
48
128
400
3
1
3
3
0
0
0
0
0
0
0
0
0
0
8
48
16
48
48
128
3
1
3
3
2
3
13
0
0
0
8
48
336
3
15
3
0
3
6
Lecture
0
1
1
3
0
5
Microbiology
Microbiology lab
Mental Health-Nursing
Clinical: Nursing RN: Mental Health Nursing
Total Hours
Interpersonal Communication
Composition I
Care of Children and Families
Clinical: Nursing RN: Care of Children and Families
Care of the Childbearing Family
Clinical: Nursing RN: Care of Childbearing Family
Total Hours
Advanced Concepts of Clinical decision-Making
Clinical: Nursing RN: Advanced Concepts of
Clinical Decision-Making
Management of Client Care
Practicum (Capstone) * *
Humanities (Art, Music, Philosophy
Total Hours
Grand Total
Credit
3
1
3
7
3
1
3
7
Credit
1
2
2
3
2
10
Lecture
3
0
2
0
5
Lab
0
4
0
0
4
Clin
0
0
0
8
8
Contact
48
64
32
128
272
Credit
3
1
2
2
8
Lecture
3
3
2
0
2
0
10
Lab
0
0
0
0
0
0
0
Clin
0
0
0
8
0
8
16
Contact
48
48
32
128
32
128
416
Credit
3
3
2
2
2
2
14
3
0
0
0
0
12
48
192
3
3
1
0
3
7
0
0
0
0
0
10
0
22
16
160
48
464
1
1
3
11
2304
72
*All WECUM Courses
Underline all General Education Courses
Practicum RNSG 2166 is a course taught in the last semester. The learning experiences in this course result in a consolidation of the program content.
Credentialing NCLEX-RN exam.
CREDIT HOUR SUMMARY
Nursing
42 Credit Hours
General Education
30 Credit Hours
Total
72 Credit Hours
7
Name:
I.D. #:
A.D.N. ADMISSION POINT GRID
CATEGORY
POSSIBLE
POINTS
POINTS
AWARDED
ACT Composite
18-21
22-25
26-29
30+
1
2
3
4
ACT Reading Score
18-21
22-25
26-29
30+
1
2
3
4
ACT English Score
18-21
22-25
26-29
30+
1
2
3
4
Overall GPA
College:
2.5-2.8
2.9-3.2
3.3-3.6
3.7-4.0
Certificates/
Degrees Earned
1
2
3
4
LVN/1 yr Certificate
1
Associates
Bachelors
Masters & above
2
3
4
Grand Total:
8
High School:
85-89
90-92
93-96
97+
To sign-up for the
ESL Exam please
contact The
Language Institute
at (956) 882-4178.
They are located at
ITEC-Workforce
Training Area.
Contact Person is
Mr. Joel Garza.
There is a $10.00
charge for the
exam payable with
Money Order,
Credit Card or
Debit Card,
NO CASH.
Revised: 10/2008
9//2008
6/2005
2/2005
4/2003
3/2003
4/2002
5/2000
6/2009
The University of Texas and Texas Southmost College
ASSOCIATE OF APPLIED SCIENCES in NURSING
ESTIMATED COST LISTING
1st Year - Fall
ACT Exam
CPR Certification
Immunizations*
*Required before
applying
Firstpoint Resources
Tuition
Fees
Books
Uniforms, etc.
Meds Publishing
1st Year - Spring
Tuition
Fees
HESI Exams
Books
Meds Publishing
College Entrance Exam
Health provider CPR course
MMR #1
MMR #2
Tetanus (TD) Booster
Varicella Vaccine
Hepatitis B Vaccine Series ($45.00/ea)
Annual TB (PPD) Test
Criminal Background Check (required for clinical practice clearance)
RNSG 1108 Dosage Calculations (WWW)
RNSG 1205 Nursing Skills
RNSG 1215 Health Assessment
RNSG 1309 Introduction to Nursing
RNSG 1260 Clinical: RN: Introduction to Nursing
Estimate for 10 credit hours (for resident in-district)
Estimated for 10 credit hours (for non-resident tuition)
Parking Fees
Liability Insurance (included with tuition statement)
1 book
RNSG 1108 Dosage Calculations
2 books
RNSG 1205 Nursing Skills
2 books
RNSG 1215 Health Assessment
7 books
RNSG 1309 Introduction to Nursing
4 books
RNSG 1260 Clinical: RN: Introduction to Nursing
2 Tops (regular sizes)
2 Bottoms (regular sizes)
1 Clinic Coat
2 Caribbean Blue Scrubs
Shoes (tennis, crocs, any closed shoe MUST be all white; no logos)
Nurse Packs
Name Tag & Patches (name tag $5.25/each; 5 patches $4.00 each)
Learning software
Estimated Total for Semester with RESIDENT (In-District/Out-of-District) Status:
Estimated Total for Semester with NON-RESIDENT Status:
RNSG 1301 Pharmacology
RNSG 1110 Intro to Community-Based Nursing
RNSG 1331 Principles of Clinical Decision Making
RNSG 1347 Concepts of Clinical Decision Making
RNSG 1260 Clinical: RN: Introduction to Nursing
Estamated for 12 credit hours (for resident in-district
Estimate for 12 credit hours (for non-resident)
Parking Fees
Mid-Curriculum HESI Exam (included w/tuition)
RNSG 1301 Pharmacology
2 books
RNSG 1110 Intro to Community-Based Nursing
1 book
RNSG 1331 Principles of Clinical Decision Making
Already have
RNSG 1347 Concepts of Clinical Decision Making
Already have
RNSG 1260 Clinical: RN: Introduction to Nursing
3 book
Learning software
Estimated Total for Semester with RESIDENT (In-District/Out-of-District) Status:
Estimated Total for Semester with NON-RESIDENT Status:
9
$
$
$
$
$
$
$
$
$
35.00
40.00
65.00
65.00
20.00
101.00
135.00
10.00
40.00
$ 1,936.00
$ 4,706.30
$
$
$
$
$
$
$
20.00
18.00
65.00
132.00
141.00
400.00
240.00
$
$
$
$
$
$
$
$
86.00
58.00
59.00
55.00
50.00
115.00
25.25
97.50
$ 4,008.75
$ 6,779.05
$ 2,273.30
$ 5,597.30
$
20.00
$
40.00
$ 137.00
$
50.00
$
$
$ 125.00
$
97.50
$ 2,742.80
$ 8,809.60
2nd Year - Summer
Tuition
Fees
HESI Exams
Books
2nd Year - Fall
Tuition
Fees
HESI Exams
Books
Meds Publishing
2nd Year - Spring
Tuition
Fees
HESI Exams
Books
Meds Publishing
Graduate Pin
Graduation Fee
Graduate Nurse Cap
NCLEX Exam
BON Application Fee
RNSG 2213 Mental Health Nursing
RNSG 2263 Clinical: RN: Mental Health Nursing
Estimate for 4 credit hours (for resident in-district)
Estimate for 4 credit hours (for non-resident)
Parking Fees ($10.00 per summer session)
Mental Health Nursing(PSY)
RNSG 2213 Mental Health Nursing
2 books
RNSG 2263 Clinical: RN: Mental Health Nursing
No text
Estimated Total for Semester with RESIDENT (In-District/Out-of-District) Status:
Estimated Total for Semester with NON-RESIDENT Status:
RNSG 2201 Care of Children and Families
RNSG 2262 Clinical: RN: Care of Children and Families
RNSG 1251 Care of the Child-Bearing Family
RNSG 2261 Clinical: RN: Care of the Child-Bearing Family
Estimate for 7 credit hours (for resident in-district)
Estimated for 7 credit hours (for non-resident)
Parking Fees
Liability Insurance (included with tuition statement)
Pediatric Nursing(PEDI)
Maternity Nursing(OB)
RNSG 2201 Care of Children and Families
1 book
RNSG 2262 Clinical: RN: Care of Children and Families
1 book
RNSG 1251 Care of the Child-Bearing Family
1 book
RNSG 2261 Clinical: RN: Care of the Child-Bearing Family
1 book
Learning software
Estimated Total for Semester with RESIDENT (In-District/Out-of-District) Status:
Estimated Total for Semester with NON-RESIDENT Status:
RNSG 2441 Advanced Concepts of Clinical Decision Making
RNSG 2360 Clinical: RN: Adv. Concepts Clinical Decision-Making
RNSG 2121 Management of Client Care
RNSG 2166 Practicum (Capstone)
Estimate for 9 credit hours (for resident in-district)
Estimate for 9 credit hours (for non-resident)
Parking Fees
Exit Exam ($37 each time you take exam; 1st included in tuition)
RNSG 2441 Advanced Concepts of Clinical Decision Making
4 book
RNSG 2360 Clinical: RN: Adv. Concepts Clinical Decision-Making
Already have
RNSG 2121 Management of Client Care
1 book
RNSG 2166 Practicum (Capstone)
No text
Learning software
Prices range from $35.00 to $250.00
UTB/TSC Graduation Application Fee
UTB/TSC Barnes & Noble Bookstore
Pearson Vue (www.pearsonvue.com)
Board of Nursing-Criminal Background Clearance
Estimated Total for Semester with RESIDENT (In-District/Out-of-District) Status:
Estimated Total for Semester with NON-RESIDENT Status:
Estimated GRAND TOTAL for A.D.N. Program for RESIDENT (In-District/Out-of-District) Status:
Estimated GRAND TOTAL for A.D.N. Program NON-RESIDENT Status:
10
$ 789.15
$ 1,913.15
$
10.00
$
21.00
$ 159.00
$
$ 979.15
$ 3,082.30
$ 1,430.80
$ 3,369.80
$
20.00
$
18.00
$
21.00
$
21.00
$
85.00
$
40.00
$
85.00
$
40.00
$
97.50
$ 1,858.30
$ 5,655.60
$ 1,767.80
$ 4,260.80
$
$
$
$
$
$
$
$
20.00
111.00
262.00
50.00
97.50
35.00
$
25.00
$
9.00
$ 200.00
$ 139.00
$ 2,716.30
$ 7,925.60
$ 12,305.30
$ 32,252.15
THE UNIVERSITY OF TEXAS AT BROWNSVILLE and TEXAS SOUTHMOST COLLEGE
SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF NURSING
APPLICATION FOR ADMISSION □
APPLICATION FOR READMISSION □
Mark box corresponding to the program of application:
Vocational Nursing
Associate Degree Nursing
Bachelor of Science in Nursing (Full-Time)
Master of Science in Nursing
956-882-5072
956-882-5073
956-882-5070
956-882-5070
Part-time Vocational Nursing
LVN Advanced Placement
Bachelor of Science in Nursing (Part-Time)
BSN to MSN Bridge Program
956-882-5072
956-882-5073
956-882-5070
956-882-5070
Note: See individual programs for application requirements and processes.
PLEASE TYPE OR USE BLACK INK. DO NOT USE NICKNAMES. FAILURE TO ANSWER
ALL QUESTIONS COMPLETELY MAY DELAY PROCESSING OF YOUR APPLICATION.
-
Date of Application:
-
Mo.
Day
Yr.
UTB Student ID #
This application is for admission into the program beginning:
/
Semester
Year
Full legal name:
Last
First
Maiden name:
Middle
E-mail address:
(Required)
Current mailing address:
Street
City
Telephone #:
(
State
Zip
)
Alternate #: (
)
(Please give a number where you can be reached weekdays between 8 a.m. and 5 p.m.)
Permanent address:
Street
Note: This address
should be a constant
one where you can be
reached now and in
future years.
City
State
Telephone: (
)
Zip
-
If you have previously attended any school under a name other than that given above, specify on line
below.
PERSONAL INFORMATION
The following voluntary information is needed for affirmative action purposes. The information you provide will not
affect your admission to the ADN program.

Male

Female
Date of Birth:
/
(mm)
Race/Ethnicity:
 Hispanic
 Puerto Rican
 Black
 Asian
 white/Caucasian
 Other Spanish Surname
/
(dd)
(yyyy)
 American Indian/Alaskan
 Pacific Islander
Are you an International / Non United States Citizen applicant?
 Yes  No
If yes, see “Admission of International Student” in the UTB/TSC Undergraduate Catalog for additional requirements.
11
IN CASE OF AN EMERGENCY, PLEASE NOTIFY:
Name: ______________________________________________
Address: ____________________________________________
Telephone: ( ) _______________________
Relationship: __________________________
City, State, Zip: ________________________
DISABILITIES
In order to provide better services for people with disabilities, the following voluntary information is needed. This
is for affirmative action purposes. The information you provide will not affect your admission to the School of
Health Sciences and will be kept confidential.
Please check all that applies to you:


physical disability
other disability:

learning disability
Will you need special accommodations in order to succeed in the program for which you are applying?
 No
 Yes, please specify:
EDUCATIONAL BACKGROUND
If you have not attended college/university, list the high school you graduated from on the line below and request that
an OFFICIAL TRANSCRIPT (showing your rank in the class & GPA) be sent directly to: Associate Degree Nursing
Program, School of Health Sciences, University of Texas at Brownsville, 80 Fort Brown, Brownsville, Texas 78520.
High School:
Name
City/State
Graduation Date
Please list each college or university that you have attended or will attend prior to enrolling at UTB/TSC. Be sure to
submit a transcript from each institution to the ADMISSIONS OFFICE in TANDY 115 for evaluation.
NAME OF SCHOOL
CITY
STATE
DATES OF ATTENDANCE
Mo./Yr. TO
Mo./Yr.
DIPLOMA/DEGREE
or Sem. Hours
If you have attended more than four colleges, please list on a separate sheet.
Please list all college or university COURSES which DO NOT PRESENTLY APPEAR on your transcript, but in which
you are currently enrolled or will have completed before enrolling at UTB. Final official transcripts must be sent
DIRECTLY to UTB ADMISSIONS OFFICE in TANDY 115 from the institution you are attending when course
work is completed for evaluation.
COLLEGE OR UNIVERSITY
COURSE NO.
COURSE TITLE
12
SEM HRS
TERM/YR
Note: All ADN and VN students must complete the following eligibility questions.
Please review the “Eligibility to take the NCLEX-RN Examination” in the information packet to answer these questions. If you
answer yes to any of the following questions you must provide a written explanation.
1. ___ Yes ___ No
For any criminal offense, including those pending appeal, have you:
A. Been convicted of a misdemeanor?
B. Been convicted of a felony?
C. Pled nolo contendere, no contest, or guilty? 7
D. Received deferred adjudication?
E. Been placed on community supervision or court-ordered probation, whether or not
adjudicated guilty?
F. Been sentenced to serve jail or prison time? Court-ordered confinement?
G. Been granted pre-trial diversion?
H. Been arrested or any pending criminal charges?
I. Been cited or charged with any violation of the law?
J. Been subject of a court-martial; Article 15 violation; or received any form of military
judgment/punishment/action?
(You may only exclude Class C misdemeanor traffic violations.)
NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be
disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It
is recommended that you submit a copy of the Court Order expunging or sealing the record in question to our office with
your application. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, will at a
minimum, subject your license to a disciplinary fine. Non-disclosure of relevant offenses raises questions related to
truthfulness and character.
NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov’t Code § 552.142(b), if you have criminal matters that are the
subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a
criminal matter that is the subject of an order of nondisclosure may become a character and fitness issue. Pursuant to
other sections of the Gov’t Code chapter 411, the Texas Nursing Board is entitled to access criminal history record
information that is the subject of an order of non-disclosure. If the Board discovers a criminal matter that is the subject of
an order of non-disclosure, even if you properly did not reveal the matter, the Board may require you to provide
information about that criminal matter.
2. ___ Yes ___ No
3. ___ Yes ___ No
4. ___ Yes ___ No
5. ___ Yes ___ No
Are you currently the target or subject of a grand jury or governmental agency investigation?
Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled,
accepted surrender of, suspended, placed on probation, refused to renew a professional license,
certificate or multi-state privilege held by you now or previously, or ever fined, censured,
reprimanded or otherwise disciplined you?
Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or
any other drug?
Within the past five (5) years have you been diagnosed with, treated, or hospitalized for
schizophrenia and/or psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial
personality disorder, or borderline personality disorder?
If “YES” indicate the condition: [ ] schizophrenia and/or psychotic disorders, [ ] bipolar
disorder, [ ] paranoid personality disorder, [ ] antisocial personality disorder, [ ] borderline
personality disorder
If you answered “YES” to any of the questions listed above, attach a letter of explanation that is dated and signed
indicating the circumstances(s) you are reporting to the Board.
*If you are licensed as an LVN in the State of Texas and are currently participating in the Texas Peer Assistance
Program for Nurses you may answer “NO” to questions #4 and #5.
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APPLICATION CHECKLIST
A. Submit an application to the University of Texas at Brownsville, MEET REQUIREMENTS FOR ADMISSION, and obtain a UTB ID
number.
B. SUBMIT THE FOLLOWING ITEMS TOGETHER IN A PACKET TO THE DEPARTMENT OFFICE, LHSB 2.720, BEFORE THE
DEADLINE DESCRIBED BELOW.H :
□
Completed Nursing Application (last four pages of this packet).
□
High school transcript or GED score sheet, unofficial copies are acceptable (If you have previously attended
college or university please omit this step.)
□
UTB Transcripts, unofficial copies will be accepted (ONLY UTB TRANSCRIPTS WILL BE ACCEPTED, if you have
never attended UTB you must submit your transcripts for evaluation to the Admission’s Office).
□
Proof of Immunizations for Measles/Mumps/Rubella (MMR – or confirmation of Immunity/protective titer);
Tetanus/Diphtheria (TD – Immunization received within the last 10 years); Hepatitis B Series (or confirmation of
Immunity/protective titer); Tuberculin Test (PPD – administered and read within the last 12 months); and Varicella.
□
Proof of CPR for the Healthcare Provider.
□
Program Required test scores required (ACT, TEAS, TASP, GRE*) * These vary by program
C. Students are encouraged to carry health insurance. Students needing health insurance may obtain information in the Student
Affairs website. Students must carry professional liability insurance. Professional liability insurance coverage in at least a
minimum amount of $1 million limit each claim and $3 million aggregate is required. Cost for the professional liability insurance
in included in the fees paid during each fall semester. The professional liability insurance is only applicable to students in their
student role, not in their employment role.
NOTE: All VN applicants must demonstrate graduation from high school or completion of a GED.
List the high school you graduated from on the line below and request that an OFFICIAL TRANSCRIPT (showing your rank
in the class & GPA) be sent directly to: Vocational Nursing Program, School of Health Sciences, University of Texas at
Brownsville, 80 Fort Brown, Brownsville, Texas 78520.
High School:
Name
City/State
Graduation Date
If you did not graduate from high school include a copy of GED certificate with this application.
NOTE: All ADN applicants who have not attended university must complete the following.
List the high school you graduated from on the line below and request that an OFFICIAL TRANSCRIPT (showing your rank
in the class & GPA) be sent directly to: Associate Degree Nursing Program, School of Health Sciences, University of Texas at
Brownsville, 80 Fort Brown, Brownsville, Texas 78520.
High School:
Name
City/State
14
Graduation Date
Note: All students must sign the following disclaimer question.
I understand that the Department of Nursing will not regard this application as "complete" until all supporting
papers have been received; therefore, it is to my interest to see that these are submitted as promptly as possible.
It is also my understanding that official transcripts must be sent directly from each school to the ADMISSIONS
OFFICE in TANDY 115 to a Transcript Evaluator.
If selected for admission to this program I will at all times conduct myself in accordance with the rules and
regulations of the College, Program and its clinical affiliates. I certify that the information in this application is
complete and correct and understand that the submission of false information is grounds for rejection of my
application, withdrawal of any offer of acceptance, cancellation of enrollment, or appropriate disciplinary
action. I certify that I can perform the essential eligibility requirements for participation in clinical nursing with
or without reasonable modifications to rules, policies, or practices, the removal architectural, communication, or
transportation barriers, or the provision of auxiliary aids and services as described in the information packet. I
hereby grant permission to UTB/TSC to verify any and all information submitted/stated.
I understand that my acceptance to any nursing program is only conditional, until such time as I have
cleared a criminal background/security clearance screening.
NOTE:
All applicants must submit a complete application package in order to be considered for admission. No application package will be accepted if incomplete .
If there are circumstances that may have an influence on your admission that you would like for those reviewing your application to know about, please describe on
a separate sheet and attach.
Signature of Applicant
Date
DEADLINES FOR RECEIPT OF APPLICATION AND ALL REQUIRED DOCUMENTS:
ASSOCIATE DEGREE NURSING PROGRAM
- MAY 15TH
ASSOCIATE DEGREE NURSING PROGRAM
LVN ADVANCED PLACEMENT
- MAY 15TH
- DECEMBER 15TH
VOCATIONAL NURSING PROGRAM
- JUNE 1ST
- NOVEMBER 1ST
BACHELOR OF SCIENCE IN NURSING PROGRAM
-JULY 1ST
-NOVEMBER 1ST
BSN TO MSN BRIDGE PROGRAM
-JULY 1ST
-NOVEMBER 1ST
MASTER OF SCIENCE IN NURSING PROGRAM
-SEE GRADUATE CALENDAR DEADLINES
Application, transcripts, and supporting documents should be turned in a packet together to respective programs.
Program Name
The University of Texas at Brownville
and Texas Southmost College
Life & Health Science Building, 2.720
80 Fort Brown
Brownsville, TX 78520-4993
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DEPARTMENT OF NURSING
THE UNIVERSITY OF TEXAS AT BROWNSVILLE AND TEXAS SOUTHMOST COLLEGE
80 Fort Brown · Brownsville, Texas 78520 · (956) 882-5071 · Fax (956) 882-5100
Immunization Record
Name: ______________________________ ID#_________________
Program: (circle program):
VN
ADN BSN MSN
Date
Result
MMR#1
MMR#2
Tetanus(TD) Booster
Varicella Vaccine
1#
2#
Illness
Hepatitis B Vaccine
1#
2#
3#
Hepatitis B Waiver signed
Comments: _____________________________________________________________
_______________________________________________________________________
Please bring a copy of this form to your physician/health care provider and have them fill out and sign. Return
with your completed application. This form MUST be completely filled out even if you are attaching copies of your
immunization record.
______________________________
Health Care Provider Signature
_________________
Date
___________________________________________________
Address
16