Nurse Aide
Program Requirements Checklist & Forms
In order to participate in the Nurse Aide course, participants must complete all of the following
requirements prior to the first day of class. You must bring all completed documents to the first class.
Please allow at least one month prior to the first class to complete the enrollment requirements. Please use guide
below to ensure all requirements are satisfied prior to the first class.
Four weeks prior to course start date:
• Complete Pennsylvania State Police Background Check
• Complete FBI background check, only if you have not resided in PA for past two consecutive years
Three weeks prior to course start date:
• Complete physical examination and NCC Health Form
• Have step one of tuberculin test administered and read
Two weeks prior to course start date:
• Have step two tuberculin test administered and read
Requirements Checklist
Must be completed prior to the first class. All forms are included in this electronic packet.
Must be at least 18 years of age to attend class.
Completed Pennsylvania Criminal Background Check (dated less than one year through class completion date).
FBI Clearance must be completed only if you have not resided in PA for the past two consecutive years.
Please note: background checks may not contain prohibitive offenses as cited in Act 14. The Act 14
documentation is included in this electronic packet.
Completed verification of Residency Form. Two (2) forms of identification must be brought to the first class.
Identification documents must include at least one photo ID and one with your signature.
Completed NCC Health Form with physical examination, dated less than one year through class completion date.
Documentation must include participant is: 1) able to lift 50 pounds to waist level without any physical limitation/
restrictions, and 2) free from communicable disease in the communicable state. The physical form must be
signed by either an M.D., P.A., N.P. or D.O.
Two Step Tuberculin Test. Both steps must be administered and both results read prior to the course start date.
Proof of High School Diploma or GED.
Uniform: Solid white uniform pants and shirt or solid white scrubs; solid white uniform shoes or white leather/vinyl
sneakers and a watch with a second hand.
Proof of personal health insurance. For those not currently enrolled in a healthcare plan, you may obtain personal
health insurance through the College. For more information please visit www.northampton.edu/studentinsurance.
Completed NCC Student Information Form.
Enroll in the course. Register online at northampton.edu/lifelearn by clicking on search courses or by calling
1-877-543-0998. Please reference course code NAIDE100 when registering. Course fee is due at the time of
registration via credit card.
YOU MUST BRING ALL COMPLETED DOCUMENTS TO THE FIRST CLASS.
Refund Policy
Students who wish to withdraw must formally request a withdrawal with the College
and will be eligible for a refund as follows:
100% Refund - Withdraw 5 business days prior to the first day of class
50% Refund - Withdraw 3-4 business days prior to the first day of class
0% Refund - Withdraw less than 3 business days prior to the first day of class
Refunds resulting in a credit balance on the account are reimbursed by check
made payable to the student within 14 days. Formal withdraw may be made by
phone toll-free at 1-877-543-0998 or by fax at 610-861-5551.
Please call 610-332-6585 or e-mail healthcare@northampton.edu with any questions.
Northampton Community College
Fowler Family Southside Center
511 East Third Street
Bethlehem, PA 18015
www.northampton.edu/cbi
HOW TO OBTAIN A PA CRIMINAL BACKGROUND CHECK THROUGH PATCH
The Pennsylvania State Police established a web-based computer application called “Pennsylvania Access
to Criminal History” or PATCH. Using this system, a requestor can apply for a criminal background check
on an individual basis.
The information provided by the requestor will be checked against the criminal history database
maintained by the Pennsylvania State Police Central Repository. If the subject’s information does not hit
on any information in the database, the requestor will receive the results instantly over the Internet and
the requestor can print out the “No Record” certificate. Eighty percent of the time, “No Record”
certificates are returned immediately through the Internet to the requestor. If the subject’s information
hits on something in the database, the requestor receives an immediate “Request under Review”
response.
A “Request under Review” response does not necessarily mean that the individual has a record; it does
indicate the information is being manually reviewed. After review, the status will be updated to “No
Record” or “Record”. The requestor should check the PATCH website periodically for an updated status of
their request.
For all “No Record” responses, the certificate must be printed out at the requestor’s computer.
All “Record” responses will be mailed to the requestor at the address provided by the
requestor. It may take up to two weeks for the status to be updated from a “Request under
Review” to a “No Record” or “Record”.
TO SUBMIT A NEW RECORD CHECK:







Log onto https://epatch.state.pa.us and select “Submit a New Record Check” under credit card
users. The fee for the report is $10.00.
When submitting a new record you must enter personal data including your address, social
security, birth date, phone number, etc. You will be asked to verify the data entered on every
screen to continue the process.
Do not use spaces when entering your credit card number.
Please note that the PATCH system will not let you proceed unless you enter the requested
information correctly and completely.
The screen will ask you to wait until the process is complete then click on the control number to
view record. (An example of a control number is #R0712222.) Write down your personal control
number in the event you need to go back to the site to check on anything.
The next screen will display the details of a particular record request. To view/print the
certification form for this request, click the CERTIFICATION FORM link. You should see and print
a report which has a state seal in the background.
IMPORTANT: WE WILL ONLY ACCEPT THE REPORT WITH THE STATE SEAL IN THE
BACKGROUND.
CUSTOMER SERVICE:
Customer service is no longer being handled by the Pennsylvania State Police Help Desk.
Effective immediately, for any questions concerning your criminal background check, the new telephone
numbers are: toll free at 1-888-QUERYPA (1-888-783-7972) or (717)425-5546.
7/09
Procedural Process for Procuring an FBI Report and
Letter of Approval for Nurse Aide Training
PROCEDURAL PROCESS
Step 1 - Applicant Registers with Cogent Systems

1-888-439-2486 Monday - Friday
8 a.m. - 6 p.m. EST
 www.pa.cogentid.com (available 24 hours/day)
Select the Pennsylvania Department of
Education (PDE) icon then select any item
listed as the reason for fingerprinting.
PREPARATION
 Credit/debit card acceptable for online
registration $28.75 Money Order/Cashier’s
Checks ONLY
 Have demographic information available (i.e.
name, address, Social Security number, etc.)
NOT AN OFFICIAL COPY. It is for the applicant’s
use only and cannot be used for admission into a
state-approved nurse aide training program.)
Follow Steps #2, #3, #4, and #5

No scheduled appointments
 www.pa.cogentid.com to view listings

Have PAE registration number available
 Location determined during phone call

 Applicant Livescan Operator (ALO) will identify
the applicant and scan all 10 digits
Have photo identification available (driver’s
license)

To see other types of ID go to
www.pa.cogentid.com
Step 3 - Cogent Forwards Fingerprints to FBI and
Returns Report to Cogent
Step 4 - Applicant Contacts PDE Designated and
Approved Staff

Have PAE registration number available
Arthur Richardson 717-772-0814 arichardso@pa.gov

Valid demographic information
Step 5 - PDE Mails Applicant an Official Letter of
Approval or Denial on State Letterhead

Registration ID Number will be given to
applicant i.e. PAE123B456789000000

FBI reports are not transferable between
Departments. If another Department, such as
Department of Public Welfare is accidentally
selected, PDE cannot process the FBI report.
The applicant will be required to complete a
second registration process and fee.

Students who are employed or offered
employment by a long term care facility must
access FBI reports through the Department of
Aging at 717-265-7887.

Report is available (online) within 2 days.

One reprinting is available, if needed. Cogent
will contact applicant.

If fingerprints are rejected or unreadable,
reprinting can be applied one time only after
which a name check would be performed
through the FBI.

Wait at least 2 days, then check “Proof of
Transaction” at https://www.pa.cogentid.com/
index_pde.htm

PDE reviews reports and then determines
eligibility for enrollment into a state-approved
nurse aide training program

Applicant submits the official letter of approval
on state letterhead to the state-approved nurse
aide training program.
 Have a pen/pencil and a piece of paper
available
 Request a copy for $2.50 extra (The COPY is
Step 2 - Applicant Goes to a Fingerprint Location
OUTCOME
Revised April 2014
RELEASE of APPROVAL LETTERS
I, ___________________________________ authorize the PA Department of
(Requester - Print Name Clearly)
(Address of the Requester - Please print)
Education - Nurse Aide Training Program, to release my approval letter for enrollment in
a state-approved nurse aide training program based on my FBI Criminal Background
Check provided by Cogent Systems. I understand that only approval letters will be
released. If additional information is needed to complete the FBI clearance process, a letter
will be mailed to the above address. To complete this release request, the requester (the
Applicant’s name as printed above) must provide the following:
Name of Facility Representative: Judith Rex
Educational institution/sponsor
Name of Facility: Northampton Community College - Healthcare Education
Address: Fowler Center, 511 E. Third Street, Room 510
City: Bethlehem
State: PA
Office Number: (610)332-6585
Zip: 18015
Fax Number: (610)332-6556
Registration Number provided by Cogent: PAE____________________________
If applicable
Fax or mail form to the: Department of Education: Attention: NATCEP 11thFloor,
333 Market Street, Harrisburg, PA 17126
Fax: (717) 783-6672.
I hereby declare that the above information is complete, accurate, true and correct and I authorize the
above named facility to receive by fax or mail this information. I make this declaration subject to the
penalties of 18 PA.C.S. 4904 relating to unsworn falsification to authorities.
_____________________________
(Signature of Requester/Student)
____________
(Date signed)
Please allow a minimum of 48 hours for this request to be processed. Thank you. 4/10
VERIFICATION OF PENNSYLVANIA RESIDENCY
Please print legibly in ink
Date of Application ________________________ Proposed Date of NA Class Enrollment _____________________
Name _____________________________________________________________________________________
Provide an official photo identification showing a PA address. Verified by _____________________________________
Signature of an Authorized NATCEP Representative
YES
NO I have lived in Pennsylvania for at least 2 consecutive years prior to the date of NATCEP application.*
Current Pennsylvania Address __________________________________________________________________
Number of Months______Years______ at this Address
Telephone: (_______) _________________
*If you resided at your current PA address less than two years, record previous addresses and months and years of residency
on the back of this form. It is important that you record at least two (2) years of residency in Pennsylvania.
I understand that by submitting this completed form for Verification of Pennsylvania Residency to enroll in a Nurse
Aide Training Program, I am certifying that all of the information I have provided on this application is complete,
accurate, true and correct. I make this declaration subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn
falsification to authorities.
_________________________________________________________
Applicant’s Signature
__________________________________
Date
ATTESTATION OF COMPLIANCE WITH ACT 14

All candidates must submit an original or copy of an original PA CHRI obtained through the Pennsylvania State Police
during the year prior to enrolling in a PA NATCEP as required by Act 14. If a candidate has not been a resident of
Pennsylvania for the last two (2) consecutive years, a PA CHRI and an FBI report are required prior to enrollment.

As evidence that you have not been convicted of any of the Prohibitive Offenses Contained in 63 P.S. § 675, check the box
and sign and date the Attestation of Compliance with Act 14.

Candidates who were convicted of a Federal or out-of-State offense similar in nature to those crimes listed under
paragraphs (1) and (2) of the Prohibitive Offenses Contained in 63 P.S. § 675 must provide a PA CHRI and an FBI report
to determine eligibility for enrollment in a PA Nurse Aide Training Program.
Attestation of Compliance with Act 14
Nurse Aide Resident Abuse Prevention Training Act, 63 P.S. § 671 et seq.
This form represents my request to enroll in a nurse aide training program and verification of Compliance with Act 14 – Nurse
Aide Resident Abuse Prevention Training Act, 63 P.S. § 671 et seq.
I have reviewed the list of Prohibitive Offenses Contained in 63 P.S. § 675 and hereby testify that I have not been convicted of
any of the criminal offenses set forth in 63 P.S. §§ 675(a)(1)-(3).
(1) an offense designated as a felony under the act known as “The Controlled Substance, Drug, Device and Cosmetic Act”,
(2) an offense under one or more of the following provisions of Title 18, and
(3) a Federal or out-of-State offense similar in nature to those crimes listed under paragraphs (1) and (2).
By checking this box I state that I have not been convicted of any of the Prohibitive Offenses Contained in Act 14 of 1997
(set forth in 63 P.S. § 675 and found on the following page).
I understand that if I have been convicted of any of the criminal offenses set forth in 63 P.S. §§ 675(a)(1)-(3), it is possible that I
will not be eligible for employment in a long term care or other health care setting. A potential employer is also responsible for
reviewing my Criminal History Record Information report.
By signing this form, I certify under penalty of law that the information I have provided on this application is true,
correct and complete. I understand that false statements herein shall subject me to criminal prosecution under
18 Pa. C.S. § 4904, relating to unsworn falsification to authorities.
________________________________________________
Applicant’s Signature
____________________________
Date
7/8/2014
Nurse Aide Resident Abuse Prevention Training Act 14 of 1997 (P.L. 169)
Prohibitive Offenses Contained in 63 P.S. § 675
In no case shall an applicant for enrollment in a State-approved nurse aide training program be approved for admission into
such program if the applicant’s criminal history record information indicates the applicant has been convicted of any of the
following offenses:
(1) An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The Controlled Substance,
Drug, Device and Cosmetic Act.” (See 35 P.S. § 780-101 et seq.)1
(2) An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes:
Prohibitive Offense Description
Type/Grading of Conviction
CC2501
CC2502
CC2503
CC2504
CC2505
CC2506
CC2507
CC2702
CC2901
CC2902
CC3121
CC3122.1
CC3123
CC3124.1
CC3125
CC3126
CC3127
CC3301
CC3502
CC3701
CC3901
CC3921
CC3922
CC3923
CC3924
CC3925
CC3926
CC3927
CC3928
CC3929
CC3929.1
CC3929.2
CC3929.3
CC3930
CC3931
CC3932
CC3934
CC4101
CC4114
CC4302
CC4303
CC4304
CC4305
CC4952
CC4953
CC5902B
CC5903C or D
CC6301
CC6312
Criminal Homicide
Murder
Voluntary Manslaughter
Involuntary Manslaughter
Causing or Aiding Suicide
Drug Delivery Resulting in Death
Criminal Homicide of Law Enforcement Officer
Aggravated Assault
Kidnapping
Unlawful Restraint
Rape
Statutory Sexual Assault
Involuntary Deviate Sexual Intercourse
Sexual Assault
Aggravated Indecent Assault
Indecent Assault
Indecent Exposure
Arson and Related Offenses
Burglary
Robbery
Theft
Theft by Unlawful Taking
Theft by Deception
Theft by Extortion
Theft by Property Lost
Receiving Stolen Property
Theft of Services
Theft by Failure to Deposit
Unauthorized Use of a Motor Vehicle
Retail Theft
Library Theft
Unlawful Possession of Retail or Library Theft Instruments
Organized Retail Theft
Theft of Trade Secrets
Theft of Unpublished Dramas or Musicals
Theft of Leased Properties
Theft From a Motor Vehicle
Forgery
Securing Execution of Document by Deception
Incest
Concealing Death of a Child
Endangering Welfare of a Child
Dealing in Infant Children
Intimidation of Witnesses or Victims
Retaliation Against Witness or Victim
Promoting Prostitution
Obscene and Other Sexual Materials and Performances
Corruption of Minors
Sexual Abuse of Children
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
Any
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
----------- 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
1 Felony or 2 Misdemeanors
Any
Any
Any
Any
Any
Any
Any
Any
Felony
Any
Any
Any
(3) A Federal or out-of-State offense similar in nature to those crimes listed under paragraphs (1) and (2) above.
For questions pertaining to codes, offenses, or convictions, contact PA Department of Education at (717) 772-0814 or ra-natcep@pa.gov.
1
These offenses could be designated as “CS” on a criminal rap sheet.
294 (Rev 5/2011, 7/8/2014)
Any (1) F or (2) M’s within the 3900 Series (CC3901-CC3934)
Offense Code
NURSE AIDE TRAINEE ATTENDANCE POLICY
1. In compliance with Regulation Section 483.152 of “OBRA and Section 3 of Act 14, a student must complete a
minimum of 16 hours in the 5 content areas below before any client contact. Therefore if you are tardy or
absent on a day when the following content is taught you may not continue in the class, and the administration
will determine if you will be permitted to attend a future class:
 Communication and interpersonal skills
 Infection control
 Safety/emergency procedures including abdominal thrust
 Promotion of clients’ independence
 Respecting clients’ rights
2. Trainees are expected to be in the classroom before the start of each class and after breaks and lunch.
Attendance is validated by the use of the clock in the classroom. You should be in your seat and ready to begin
by set time. Attendance after that is considered tardy. First offense will receive a verbal warning, second
offense is a written warning, and third offense could result in termination from class.
3. Absence from class without the instructors’ authorization will result in immediate termination. In the event of
an urgent situation, the student will call designated party and note time and name of party spoken to.
4. Excused absences include an acute illness of the trainee or dependent, death of an immediate family member,
or court hearing. A note from the physician, death notice, or court order will be required. Proper notification
must be made before 3:30 p.m. weekdays for the evening class or by 6:00 a.m. on the day of the absence for the
day class or a clinical instruction day. The phone number to call is (610) 332-6585 and the instructor should
also be called if class will be missed. In addition, a message should be left with the supervisor at the clinical site
if a clinical instruction day will be missed. PLEASE NOTE: No excuse can be considered for any part of the
first 16 hours of class as required by OBRA.
5. Any other personal requests for excused absence including late arrivals or early dismissals must be discussed
in advance of course start date and will be granted at the discretion of the Program Coordinator. All excused
absences require proper documentation (physician’s statement, etc.) prior to the last day. Documentation is a
prerequisite to taking the final exam and is also required for make-up time approval.
6. All excused time must be made up and paid for in advance using the rates listed below. The make-up time will
be at the discretion of the Program Coordinator but no later than one week after the completion of the course.
Any deviation from this 7-day window of opportunity will require special permission by the Program
Coordinator. Make-up days for excused absences are limited to a total of 16 hours. Note: there is a very
limited amount of make-up time built into the program. A fee will be charged to trainees for any make up time.
If a student requires make-up sessions, they will be charged: 0-4.0 Hours at $125; 4.25-8.0 Hours at $250. All
make-up days must be scheduled and paid for prior to the beginning of the make-up session.
7. The trainee is considered a graduate when all classroom, lab requirements and clinical rotations are
fulfilled. Certificates of Completion will be issued when all payments have been made.
I have read and understand the Attendance Policy for the Northampton Community College Nurse Aide
Program necessary for successful completion of the Nurse Aide Training Program.
Student Name (Please Print):
Signature:
Date:
Permanent File- Original
FOR OFFICIAL USE ONLY
Verification of Residency
PA Driver’s License
NURSE AIDE TRAINING PROGRAM
PA Identification Card
Student Information Sheet
Social Security Card
PLEASE PRINT
United States Passport
Name
Debit/Credit Card
Address
Other:
City/State/Zip
Photo ID Taken
County
Phone (H)
(C)
Date of Birth:
Soc. Sec. #:
Initials:
Date:
*HAVE YOU RESIDED CONTINUOUSLY IN THE STATE OF PENNSYLVANIA FOR THE PAST TWO YEARS?*
E-mail Address
MALE
No
FEMALE
Please check here if we may email you updates about our classes and programs.
MARITAL STATUS:
Single
WHO PAID FOR YOUR NURSE AIDE TRAINING?
Self
Yes
CareerLink *
OVR *
Married
Widowed
New Choices/New Options *
Divorced
Separated
Other
*Please provide Name, Address, Phone, and Email Information of your Case Manager/Point of Contact:
SCHOOL BACKGROUND
1. Are you a high school graduate?
Yes
No
3. Have you previously attended college?
Yes
No
2. If not a high school graduate, do you have a G.E.D.?
Yes
Degree(s) earned
No
4. Do you plan to continue your education after this class?
Yes
No
Are you currently employed?
Yes
No
WORK EXPERIENCE
Name and location of employer:
What is your job title?
MINORITY INFORMATION
The following information is requested to monitor the compliance posture of the institution and will be used only to collect and
maintain data on the race, sex, and ethnic identity of all students. This information may be requested on national and state
statistical reports. Please check all that apply to you. (OPTIONAL)
American Indian
Asian
Black/African American
Primary Language Spoken:
Caucasian
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
Secondary Language Spoken:
Other
Have you taken ESL courses?
Yes
G:\CMNTY-ED\CHE-Center for Healthcare Education\NON-CREDIT COURSE INFO\NA\FORMS\Student Information\Student Info Sheet.doc
No
2/25/2015
HEALTHCARE EDUCATION
Nurse Aide Health Form
Name:
Last
Address:
First
Middle
City/State/Zip:
Phone:
Date of Birth:__________/__________/
Health Insurance (Required):
Name of Company:
Address/City/State/Zip:
Agreement/ID Number:
Guarantor:
Phone number:
Group Number
Student Eligibility Requirements for Nurse Aide Training:
• Physical exam must be completed by MD, DO, CRNP, or PA
• The student must pass a physical examination and must be free of communicable diseases.
• The student must be able to lift 50 pounds to waist level without restrictions.
• Student must have an administered and read two-step tuberculin skin test prior to the Requirements Due Meeting.
• Student must provide proof of an influenza vaccine.
PLEASE NOTE: All students must undergo a physical examination as well as a two-step tuberculin skin test. Both are
acceptable only if performed within one year and must be submitted at the Requirements Due Meeting. A tuberculin test
expiring during the course of the class will require an annual (one-step) test in addition to proof of the two-step test.
Students are also required to obtain a current season influenza vaccine.
TWO-STEP TUBERCULIN SKIN TESTING IS REQUIRED (Form is not complete until the results are read and reported.)
**7-21 days after the first test is read, Step 2 must be administered**
(For example: if 1st is administered Monday (2/5) and read Wednesday (2/7), the 2nd is administered Thursday (2/14)
TB TESTS
Date Applied
Site
Date Read
Step 1
Results (mm)
 (+)
Step 2
 (+)
 (-)
 (-)
Signature
_____mm
_____mm
* If induration of either test is greater than 5 mm, a chest x-ray is required. Attach written copy of x-ray report.
Influenza Vaccine
Date Administered
Signature
Required if participating September through April
Yes
No
I certify that the applicant is free from communicable diseases in the communicable state.
Yes
No
Is the applicant able to lift 50 pounds to waist level?
Yes
No
I certify that the applicant has no medical conditions or restrictions which will prevent the
applicant from performing the essential functions of the job. (If the applicant has restrictions that
require accommodation, please note them in the comments section below.)
Comments (if applicant has any limitations, please explain):
Date of Examination:
Examiner’s Name and Title:
Examiner’s Signature:
Address:
City/State/Zip/Phone:
2/2011, Rev. 1/2013, 3/2014, 2/2015
(MUST BE COMPLETED BY MD, DO, CRNP OR PA)