Nurse Aide Program Application Packet
Application Checklist
Use the following checklist to ensure that all of your application materials are included in your packet. Application materials
may be submitted in person, faxed (303.365.8396), or mailed to:
Community College of Denver
Attn: Nurse Aide Program Manager
1070 Alton Way, Bldg 849
Denver Colorado, 80230
Pre-Application Steps
______ In order to apply for the Nurse Aide program, you must first enroll into the Community College of Denver. Once you
have enrolled, you must also complete the remaining CCD requirements, i.e. visiting the Testing Center, Academic Advising,
etc.
______ In order to register for any classes at CCD, you must complete the required medical forms at the Auraria Health
Center. Go to MSU-Denver’s Health Center website for the forms. Complete and turn into the Health Center.
______ To be accepted into the Nurse Aide Program, you must obtain the scores indicated in the chart below, by either
taking the Accuplacer Test or meeting the ACT/SAT scores. Please contact either your Academic Advisor or the Testing
Center for assistance.
Complete the course below with a
grade of C or better
Placement Score
Reading
Sentence Skills
Arithmetic
40
50
40
Or
CCR 092
CCR 092
MAT 050
ACT Score
Or
17
18
19
SAT Score
Or
430
440
460
Documents Required to Complete Nurse Aide Application
Complete the following forms as described and print to submit:
1.
______ The ‘Online Applicant Information’ form is located online and must be completely filled out.
2.
______ Read the ‘Criminal Background Check Disqualifying Offenses.’ Print, sign, and date the form.
3.
______ Read the ‘Informed Consent for Background Check’ form. Print, sign, and date the form.
4.
______ Read the ‘Nurse Aide Ability to Perform Nursing Tasks.’ Print, sign, and date the form.
5.
______ Read the ‘Nurse Aide Student Guidelines for Clinical Experience.’ Print, sign, and date it.
6.
______ The ‘Nurse Aide Program Immunizations Record’ form (Instructions are on the form).
7.
______ Complete the top box of the Program of Study Change Request with your information. Print and submit.
8.
______ Complete the ‘Hepatitis B Consent / Declination’ form. Your health care provider does not complete this form,
you will complete it. Do understand that you have the option of declining to take the Hepatitis B shots and would
therefore complete the Declination section of the form, and then sign and date it.
9.
______ Unofficial Transcripts from your college or high school are requested to be submitted with your application.
However, the Accuplacer results may be used in lieu of the unofficial transcript.
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Nurse Aide Program Application Packet
Criminal Background Check & List of Disqualifying Offenses
The Colorado Community College System (CCCS) and the State Board for Community Colleges and Occupational
Education authorize the nursing programs to conduct a background investigation of all student applicants. The clinical sites
used in the nursing programs require background checks of all potential interns. The purpose is to maintain a safe and
productive educational and clinical environment. New students who refuse to comply with the background investigation will
not be allowed to enter a CCCS Nursing Program.
An applicant will be disqualified from a CCCS nursing program based on the following guidelines:

Any violent felony convictions of homicide. (No time limit)

Crimes of violence (assault, sexual offenses, arson, kidnapping, any crime against an at-risk adult or juvenile, etc.)
as defined in section 18-1.3-406 C.R.S. in the 10 years immediately preceding the submittal of application.

Any offense involving unlawful sexual behavior in the 10 years immediately preceding the submittal of
application.

Any crime, the underlying basis of which has been found by the court on the record to include an act of domestic
violence, as defined in section 18-6-800.3 C.R.S. in the seven years immediately preceding the submittal of
application.

Any crime of child abuse, as defined in section 18-6-401 C.R.S. in the seven years immediately preceding
the submittal of application.

Any crime related to the sale, possession, distribution or transfer of narcotics or controlled substances in the
seven years immediately preceding the submittal of application.

Any felony theft crimes in the seven years immediately preceding the submittal of application.

Any misdemeanor theft crimes in the five years immediately preceding the submittal of application.

Any offense of sexual assault on a client by a psychotherapist, as defined in section 18-3-405.5 C.R.S. in the
seven years immediately preceding the submittal of application.

Crimes of moral turpitude (prostitution, public lewdness/exposure, etc.) in the seven years immediately preceding
the submittal of application.

Registered Sex Offenders. (No time limit.)

Any offense in another state, the elements of which are substantially similar to the elements of any of the above
offenses.

More than one (I) D.U.I. in the seven years immediately preceding the submittal of application.
If the investigation reveals information that could be relevant to the application, the designated individual responsible for
background checks may request additional information from the applicant. The offense shall be reviewed on a case by case
basis.
Students who have successfully completed the terms of a deferred adjudication agreement will not be disqualified.
If any applicant feels the criminal background check is inaccurate, they may appeal the decision and request a review with
the specific community college for which you have applied. It is the applicant's burden to produce substantial evidence that
proves the crimes charged are incorrect.
I, ________________________________, (Print Name) understand that I may be precluded from certification should any of
the above offenses become evident in my background search.
Signature:
S Number:
Date:
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Nurse Aide Program Application Packet
Informed Consent for Background Check
The Nurse Aide Program's curricular criteria and academic standards for course credit and program achievement require
students enrolled in the program to undergo training at clinical sites. A critical element of determining a student's suitability
for participation in the program, as well as assignment at one or more clinical sites during the course of his or her program, is
to determine that the student does not have a criminal record of drug-related and/or other felonies that might place the clinical
site in jeopardy by the placement of an unsuitable student at their institution.
The Community College of Denver is required to declare to the hosting institution the suitability of every student assigned to
that institution. Therefore, all Nurse Aide students must undergo an initial criminal background check as a term and condition
of their participation in clinical experiences in the College's Nurse Aide Program.
Any and all costs associated with the aforementioned criminal records check will be borne by the Nurse Aide student. Prior
criminal records checks results will not be accepted.
Background check information will be maintained in a separate file from the student's academic record. Access to this file
will be governed by the Family Educational Rights and Privacy Act (FERPA).
General Release
I,
, (Please print) for myself, my successors, agents and estate, hereby
release the State of Colorado, the State Board for Community Colleges and Occupational Education (SBCCOE), the
Community College of Denver and all current and former employees, agents and attorneys of the State of Colorado, from any
and all claims, causes of action, liabilities, expenses, and for damages, which I may assert against any of them as a result of
my undergoing a criminal records check as required for participation in clinical experiences in the CCD Nurse Aide Program.
Furthermore, I understand that this release shall be forever binding and no rescission, modification or release there from may
be made without the express written consent of Community College of Denver and SBCCOE.
Furthermore, I have received all the information necessary to make an informed decision regarding this release. I fully
understand the terms and consequences of agreeing to this release, and acknowledge that I voluntarily, and of my own free
will, am waiving my right to assert any action against the State of Colorado, the State Board for Community Colleges and
Occupational Education, Community College of Denver, and all current and former employees, agents and attorneys of the
State of Colorado, and agents of Community College of Denver, performing services on behalf of the College, for any and all
claims, causes of action, liabilities, expenses and for damages which I may assert against any of them as a result of my
undergoing a criminal records check as required for participation in clinical experiences in the CCD Nurse Aide Program.
Limited Release of Criminal Record & Drug Screen Results
I,
, (Please print) hereby authorize any representative of the Community
College of Denver and its agents to release any and all information pertaining to my criminal record to any authorized clinical
site representative it deems appropriate in order to determine my suitability to participate in clinical experiences in the
College's Nurse Aide Program and/or to be assigned to a clinical site selected by the College. A photocopy of this release will
be sufficient to authorize the release of the aforementioned information.
Signature:
S Number:
Date:
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Nurse Aide Program Application Packet
Ability to Perform Nursing Tasks
Your clinical experience is a critical component of your nurse aide training. Clinical time allows nurse aide students to
practice under the supervision of a clinical instructor in a healthcare setting. Clinical experiences are arranged through
contractual agreements with healthcare facilities throughout the Denver Metro area that are committed to nurse aide training.
Clinical days, location, and hours are determined by the healthcare facility.
CCD strongly recommends that you work NO MORE than 30 hours per week while enrolled in the Nurse Aide Program. In
all cases, your work schedule must be flexible enough to accommodate clinical scheduling.
As a nurse aide student, you are providing nurse aide services (similar to an employee) when you are in a healthcare facility.
CCD students must follow the facilities rules and regulations. If there is a conflict between CCD and the facility policy, the
more restrictive policy will be followed.
Latex Warning: As a nurse aide student, you will be exposed to latex gloves and other products containing natural rubber
latex which may cause allergic reactions such as skin rashes; hives; nasal, eye or sinus symptoms; asthma; and (rarely) shock.
Please be advised that all students attending clinical must:

Be in compliance with basic health requirements, including current immunizations as indicated on the Nurse Aide
Program Immunization Record form, in addition to the immunization requirements by the College, found at
www.mscd.edu/healthcenter, and

Recognize that the minimal abilities of 1-8 will be expected:
1.
Work for 10 or more hours in a standing position and do frequent walking and stair climbing.
2.
Lift and transfer adult clients, up to six inches, while a stooped position; then, push or pull the adult up to three
feet.
3.
Lift and transfer adult clients, while in a stooped position, and then moving into an upright position, to
accomplish bed-to-chair and chair-to bed transfers.
4.
Perform a clinical experience for up to 10-hour duration, including standing for up to four hours at a time.
5.
Perform close and distant visual activities involving objects, persons, and paperwork, as well as discriminate
depth and color perception.
6.
Discriminate between rough/smooth and hot/cold when using hands.
7.
Communicate intelligibly in English, both orally and in writing.
8.
Listen to blood pressure sounds with a stethoscope.
Please consider carefully any physical limitations you might have that would impact your ability to perform any of the above.
If you have a diagnosed disability that may prevent you from carrying out any of these physical expectations, please discuss
your situation with the Nurse Aide Program Manager. Students who enter the program do so with the understanding that they
will be expected to meet course requirement, with or without any reasonable accommodations.
*Students who have a disability will be referred to the Accessibility Center for determination of the reasonable
accommodations that can be made. Inability to carry out any of these activities while in the program may prevent completion
of the program.
By signing below, you are acknowledging that you understand all of the above information and you will be able to perform
the above mentioned tasks and, if requested, discuss with the Center for Persons with Disabilities any accommodations that
may be appropriate to accommodate your diagnosed disability.
Printed Name:
S Number:
Signature:
Date:
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Nurse Aide Program Application Packet
Nurse Aide Student Guidelines for Clinical Experience
The Student will:
1.
2.
3.
4.
5.
6.
7.
Attend all clinical sessions for the full period of each session.
Arrive on time. Start time is 10 minutes before the start of shift. If you arrive more than five minutes after the
assigned time, you may be sent home for the day.
Be in complete uniform and wearing photo I.D. badge:
 Must be in approved scrub uniform
 Scrubs uniform must be clean and neat
 Closed-toe, closed-heel, non-skid shoes, clean, with minimal colors
Be groomed appropriately:
 No jewelry except for one small pair of stud earrings (posts) and/or a wedding ring.
 No visible jewelry in any pierced body part that is exposed, i.e., eyebrow, nose, and tongue.
 No artificial fingernails and nails must be short & clean
 Clear nail polish only
 All visible tattoos and/or hickeys must be covered
 No hair extensions and hair must be tied back, or be up, if longer than top of shoulders
 No heavy use of perfumes, colognes, and after shaves
 Minimal use of makeup
Performing direct patient care:
 Only under the direct supervision of and in the presence of the mentor CNA, the LPN or RN, or the clinical
instructor
 Use Standard Precautions when providing care
 Inform instructor of any changes in your client assignment
 Notify instructor of all procedures (skills) that need instructor supervision
 Inform instructor of any changes in client condition or their refusal of any treatment/care
Leaving the floor for break, lunch, and at the end of the shift:
 Notify instructor when leaving floor/unit for break
 Not leave the facility during break or lunch periods and lunchtime does not count as clinical
 Not give any medication
 Not witness or sign any consent forms
Pagers and cell phones must be turned off and placed in your purse or backpack. You may use them only during
your break or lunch.
Printed Name:
S Number:
Signature:
Date:
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Nurse Aide Program Application Packet
Nurse Aide Program Immunizations Form
Student Name:
S Number:
Please note that you may elect to have your health care provider complete this form. Or, you can enter all of the information
into the appropriate spaces and provide copies.
The TB skin test and the flu shot (when in flu season) are required to be completed for entry into the Nurse Aide Program.
The remaining immunizations are not required for acceptance into the Nurse Aide Program, but are highly recommended.
REQUIRED FOR ACCEPTANCE INTO THE NURSE AIDE PROGRAM
1.
Tuberculosis skin test (TB skin test):
Tuberculosis testing results must be less than one year old.
2.
Date Tested: ________
Date Read: ________
Pos / Neg
If positive, date re-tested: ________
Results: ________
Pos / Neg
If positive, date of Chest X-ray:
Date: ________
If positive, treatment dates:
Start: ________ End: ________
Flu Shot (during flu season):
Date: ______________
(#1 - 4 (below) are highly recommended.
However, they are not required for entry into the Nurse Aide Program.)
1.
Varicella (chickenpox) requires one of the following:
Option 1: Two varicella shots (at least 28 days apart)
Option 2: Positive titer for varicella
2.
Date: ________ Date: ________
Date: ________ Results: ________
Measles, mumps, rubella (MMR) Discuss this immunization with your health care provider:
Students born after 1957: Must have dates that show at least two MMR vaccinations, at least one month
apart, at age 12 months or older.
Students born before and during 1957: Age chickenpox was contracted or date of exposure to and may
require a booster.
Vaccinations:
Date: ________ Date: ________
Booster:
Date: ________
NOTE: You may receive the MMR & the varicella at the same time, unless your health care provider stipulates otherwise.
3.
Tetanus, diphtheria and pertussis (TDAP):
Date: ________
(The TDAP shot must be within the last ten years.)
4.
Hepatitis B (Note: If you are declining the Hep B series, please fill out the ‘Declination’ section of the Hepatitis B
form.)
Option 1: 3 doses required for complete series:
Doses Dates: #1________ #2: ________ #3: _______
(Student may sign the Hepatitis B Declination form)
Option 2: Serologic immunity (Hep B blood test)
Date: ______
Results:
Print Health Care Provider Name / Title verifying the above immunizations and tests
Signature of Health Care Provider
Date
Provider Address
Phone Number
Hepatitis B
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Nurse Aide Program Application Packet
Consent to Receive, or Decline, the Hepatitis B Series of Shots
Last Name:
First:
MI:
S Number:
Address:
Street Address
City
State
Zip Code
Phone Number
Please read the information below, which will help you to make an informed decision regarding Hepatitis B.
Hepatitis B is one of three viruses that cause a systemic infection, with major pathology in the liver. The others are the
Hepatitis A virus, and the Non-A, Non-B virus (Hep C).
Hepatitis B virus is an important cause of viral hepatitis. There is no specific treatment for this disease. It has been estimated
that more than 170 million people in the world today are infected with Hepatitis B virus. The serious complications of
Hepatitis B infection include massive hepatic necrosis, cirrhosis of the liver, chronic active hepatitis, and hepatocellular
carcinoma. The vehicles for transmission of the virus are often blood and blood products. Viral antigen has also been found
in tears, saliva, breast milk, urine, semen, and vaginal secretions. Infection may occur when Hepatitis B virus, transmitted by
infected blood fluids, implanted via mucous surfaces, or percutaneously introduced through accidental or deliberate breaks in
the skin.
Vaccination is recommended in personnel of all ages who are or will be at increased risk of infection with the Hepatitis B
virus.
Groups identified as being at risk of infection are health care professionals, i.e. doctors, nurses, nurse aides, & ancillary staff.
Choose only one option below.
Consent to receive the Hepatitis B series of shots:
I, ________________________ have read and understand the above information on Hepatitis B virus and I hereby consent to
receiving the Hepatitis B vaccine from my private physician, a clinic or the Health Department.
I will not hold the Community College of Denver, my designated provider, or any person administering these vaccinations
liable for any adverse effects which may result.
Date of first shot: ________________________
I have already received the Hepatitis B series of shots (please provide copies of these shots):
I previously have received the Hepatitis B Vaccine Series on the dates of:
Shot #1: ________
Shot #2: ________
Shot #3: ________
I decline to receive the Hepatitis B series of shots:
By declining the Hepatitis B vaccine shots, I understand that, due to my occupation’s potential exposure to body fluids, or
other infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. However, I decline the Hepatitis B
vaccination at this time.
I understand that by declining this vaccine, I will continue to be at risk of occupational exposure, and if I want to be
vaccinated with the Hepatitis B vaccine, I may still do so in the future.
Printed Name:
S Number:
Signature:
Date:
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