NURS 100A
Nursing Assistant: Basic Patient Care
Course Content • The student must demonstrate competency of knowledge at a passing rate of 80% -- compiled score on exams, quizzes, clinical competency, and written skills/personal learning skills. • The student must demonstrate competency of skills in the practice lab and in the clinical setting. • Attendance is mandatory for successful completion of the course. • Seven (7) hours of HIV/AIDS education is required. The class is part of the course curriculum, and the student must attend. A certificate will be provided for completion of this training. • CPR and First Aid training for healthcare providers is required. This training is part of the course curriculum, and the student must attend. A CPR card and First Aid card will be provided for completion of this training. • A final grade will be recorded with the Registrar's Office. A certificate will be provided upon successful completion of this course.
Required Books “Nursing Assisting; A Foundation in Caregiving” Diana Dugan, RN Hartman Publishing Inc. 2012 3rd edition ASHI, Health Providers CPR; these books will be “signed out” to students. Damage or loss of textbook will result in a $20.00 replacement fee (damage will be determined by the instructor). Payment of damage/loss fee is mandatory. Grades will be held until full payment is received. First Aid books can be purchased at the bookstore; books for the Omak class are provided (the fee is charged with tuition).
Course Supplies A "journal" type notebook is required for journal assignments. Loose leaf paper will not be accepted. Name badge, provided by college. Scrubs: The scrub top is provided by WVC. The student is responsible for laundering the top. Lost or damaged scrub tops will result in a $50.00 fee to the student.
Course Description This eight (8) credit course introduces the basic skill and knowledge required for competency as a caregiver. It includes instruction in personal care skills, roles, and responsibilities of the nursing assistant, communication skills, and safety and emergency procedures. Successful completion of the course allows the student to take the licensure exam under OBRA, fulfilling requirements as set forth by the State of Washington for healthcare professionals. Nursing 100A meets the requirements as a prerequisite for entry into the Wenatchee Valley College Nursing Program.
Please Note: HIV/AIDS, CPR, and First Aid requirements included in the course must be successfully met prior to clinical rotation.
NURS 100A Application Rev: 09/28/2015 Page 1 of 13
Attendance Attendance is mandatory during both theory and clinical portions of the course, in order to comply with the requirements set by the State of Washington to meet the expectations for the Nursing Assistant Certified. This includes being punctual and remaining through the duration of the class. Any absences from the theory/clinical portion of Nursing 100A will be addressed with instructor on an individual basis. Failure to meet this requirement may result in non-completion of course. Exceptions may include illness. In event of illness or crisis situations, the student must contact instructor prior to the beginning of class.
Simulation Lab Information While working or practicing in the Sim Lab, the student will: Wear closed-toed shoes (no open-toed shoes or sandals). Wear his/her name badge. Wear scrubs or professional dress with a lab jacket.
Additional Course Information/Expectations Scrubs or a lab coat are to be worn at all times by students while in the Sim Lab. Open-toed shoes or sandals are prohibited at all times when in the Sim Lab. Note: Clothing should allow student to engage in all lab/patient scenarios in a professional manner. Lab jackets will be available to the student when engaged in the lab setting. A $20.00 fee will be assessed for any lost or damaged lab jacket (“damage” will be determined by the instructor.) Payment of damage/loss fee is mandatory; grades will be held until full payment is received. Use of electronic devices, including texting is not allowed during lecture or classroom activities. Students may not have cell phones on their persons during clinical rotation.
NURS 100A Application Rev: 09/28/2015 Page 2 of 13
NURS 100A – NURSING ASSISTANT APPLICATION Quarter: ______Year: ______
Complete this application and the forms that follow. Attach the required documentation and submit all forms in person to Rhonda Yenney in Wenatchee or to Sue Root in Omak. You may forfeit the processing of this application if forms and/or documentation are incomplete.
Name: ______Email Address: ______First, Middle, Last
Mailing Address: ______Street or P. O. Box City State, Zip
Phone Numbers: ______Telephone Cell Phone Alternate Telephone
WVC Student Identification Number: ______
Are you at least 18 years old? Yes No Birthdate: ______Month/Day/Year
Are you a High School graduate? Yes No GED? Yes No
Year you received your diploma or certificate: ______
Do you plan to apply for an Allied Health program? If so, please identify which program:
Nursing Program Radiologic Technology Program Medical Assistant Program
Medical Laboratory Technology Program Other: ______(Please specify program)
In what year/quarter do you plan to enter the Allied Health program indicated above? ______
Completion of this application does not guarantee admission to the NURS 100A course. Applications will be accepted the first day of open registration for new students (generally three [3] days after the last day continuing students register), for the following quarter. Applications for the Wenatchee campus must be submitted in person to Rhonda Yenney, Allied Health Department, Wenatchi Hall, Room 2221. Applications for the Omak campus must be submitted in person to Sue Root, Mary Henrie Friendship Hall, Room 210. Applications will be reviewed to assure that the requirements for enrollment in the course have been met. If requirements have been met, you will be given a registration form to take to Registration.
NURS 100A Application Rev: 09/28/2015 Page 3 of 13 COURSE PREREQUISITES
Background Check/Negative Drug Screen
Background Check Washington State law (RCW 43.43.832) permits businesses or organizations that provide services to children, vulnerable adults, or developmentally disabled persons to request criminal history records. Facilities used for clinical work experience require clearance prior to the student being allowed to work in the facility. The background check cannot be dated more than 45 days before the start of the program.
Students need to be aware that conviction of certain crimes may prevent completion of the clinical course requirements of the Program and may also prevent future licensing and employment in the health field.
Create an account at http://www.wenatcheevalleycompliance.com. Students are required to purchase the criminal check through this Complio website before acceptance into the program. (and the drug screen if on Omak campus)
A DSHS background check is required as well. Please see the attached DSHS background form. Fill it out from section 2 item 6 to item 20. Please with an N/A or Same. Do not leave any of the questions blank. Be sure to sign and date the form.
Negative Drug Screen Students attending on the Omak Campus only must provide results of a standard, ten-panel drug screen, either urine-based or oral swab, dated not more than forty-five (45) days prior to the beginning of the Program. The drug screen can be completed at the Omak Clinic in Omak (916 Koala Drive, 826-1800).
Drug screens are required to be purchased through Complio. Purchase the drug screen along with the criminal check at http://www.wenatcheevalleycompliance.com.
Immunizations
Official documentation is required: Each record must be on the healthcare provider’s letterhead, have the student’s name, have the date of immunization, have the signature of the person administering the immunization, and the lot number of the vaccine administered.
Two-Step PPD An initial negative two-step PPD is required, which means that two (2) separate tuberculin skin tests have been placed one to three weeks apart. Each test is read 48 to 72 hours after it has been placed. This is a four-visit procedure. Documentation must show the dates and results of the tests, as well as the lot numbers of the vaccine. Students should not get any other vaccination with the first PPD.
Students with a positive PPD must provide documentation of a chest x-ray, treatment (if necessary), and a release to work in a healthcare setting from a doctor or healthcare provider.
NURS 100A Application Rev: 09/28/2015 Page 4 of 13 Tuberculin skin tests are required each year (annual renewal) and must be placed and read within one year following the initial two-step PPD.
As some facilities now utilize the QuantiFERON® TB Gold Test in place of the PPD, WVC will accept this method. This does not require a two-step initial skin test; however, the test must be performed annually.
Hepatitis B Vaccine (complete series of three [3] injections) Students must have the first injections prior to entering the Program. Adults getting Hepatitis B vaccine should get three (3) doses, with the second dose given four (4) weeks after the first and the third dose five (5) months after the second. Your healthcare provider can tell you about other dosing schedules that might be used in certain circumstances. Positive titer (blood test) is acceptable.
Flu Vaccine Depending on the availability of flu vaccine, each student is required to be vaccinated by the announced date.
Insurance
Medical Insurance (pertains to student accidents during clinical experiences) Clinical affiliates associated with WVC require that students provide proof of accident insurance. Students refusing to provide proof of accident insurance will not be allowed access to clinical agencies to complete clinical course work. Students must maintain this coverage throughout the Program to cover any accident that might occur while at a clinical site. Even though a clinical facility may provide necessary emergency care or first aid for an accident (i.e., needle stick), a clinical facility has no obligation to furnish medical or surgical care to any student. The student bears responsibility for the cost of such care, as well as for any follow-up care.
For students who do not have insurance, the WVC recommends the carrier approved by the Washington State Board of Community and Technical Colleges. The cost is approximately $45 per quarter. The student may enroll online at www.summitamerica-ins.com.
A copy of the student’s current personal medical insurance OR a copy of the student’s Summit America receipt are to be submitted with this application.
Documentation of student immunization status is essential to ensure the health and safety of students and the patients/clients/residents in healthcare agencies that provide clinical learning experiences. Lack of compliance with any of these requirements will prevent you from entering the clinical area and completing your clinical training.
Wenatchee Valley College reserves the right to add to or modify these requirements as needed.
This packet will be on file in the Allied Health Office.
I certify with my signature that I have read and understand the above requirements and that the information above and documentation submitted pertaining to me is complete and accurate.
NURS 100A Application Rev: 09/28/2015 Page 5 of 13
Date: ______Signature: REMINDER: Keep your original documents for your personal records. NURS 100A APPLICATION (Continued)
Explanation of Interest
1. Why do you want to take the NURS 100A class?
2. How do you plan to use the training you receive in the NURS 100A class? Will you be working for an agency after you complete the class?
3. Do you plan to pursue a certificate/degree in another health related program?
NURS 100A Application Rev: 09/28/2015 Page 6 of 13
Student Disclosure Form
1. Have you ever been convicted of a crime? Yes No
2. If yes, please list the crimes for which you have been convicted and the level of those convictions.
______
3. Do you understand that some criminal convictions may prevent you from completing a program of study?
Yes No
4. Do you understand that you need to provide documentation of specified immunizations or evidence of immunity to specified diseases in order to participate in most programs in Allied Health?
Yes No
5. Are you aware that you must provide a negative drug screen for most Allied Health programs?
Yes No
6. Do you understand that your behavior during the time of training for a particular occupation needs to comply with both the Wenatchee Valley College Student Code of Conduct (see the WVC Student Handbook) and the code of conduct/ethics/standards that regulate the occupation for which you will be trained?
Yes No
7. Do you understand that by breaking the code of conduct for an occupation or the WVC Student Code of Conduct you may be subjected to disciplinary action including suspension from the program?
Yes No
8. Do you understand that there are procedures and policies at Wenatchee Valley College that govern student grievances and disciplinary actions?
Yes No
Student Name (Please print)
Student Signature Date
NURS 100A Application Rev: 09/28/2015 Page 7 of 13
Child and Adult Abuse Information Act Disclosure Pursuant to RCW 43.43.834
Answer each item. If the answer is YES to any item, indicate the charge or finding, the date, and the court(s) involved.
1. Have you ever been convicted of any crimes against children or other persons, as follows: aggravated murder; first or second degree murder; first or second degree kidnapping, first, second, or third degree assault; first, second or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second, or third degree child molestation, first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution? ANSWER _____ If YES, explain
2. Have you ever been convicted of crimes relating to the financial exploitation if the victim was a vulnerable adult, as follows: first, second, or third degree theft; first or second degree robbery: forgery? ANSWER _____ If YES, explain
3. Have you ever been found guilty in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have physically abused any minor? ANSWER If YES, explain
4. Have you ever been found in any domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor? ANSWER If YES, explain
5. Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult? ANSWER If YES, explain
6. Have you ever been found in any protection proceeding under chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult? ANSWER If YES, explain
Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
NURSING ASSISTANT PROGRAM (please check one): Omak Wenatchee
*Your signature must be witnessed by a non-family member.
______Name (Please print) Signature Date
______*Witness Signature Business or Organization Address
NURS 100A Application Rev: 09/28/2015 Page 8 of 13
Personal Medical Record
Part I: General Information
Full Name: Program: (Please print)
DOB: Academic Year:
Current Address/Phone Number:
Address: ______Address City State Zip
Phone Numbers: ______Telephone Cell Phone Alternate Telephone
In case of emergency please notify:
Name: Phone:
Part II: Health History
Date of last health examination:
Name of health care provider (optional):
Please identify any health conditions/illnesses or injuries that required medical treatment (please check all those that apply):
Heart Defect/Disease Musculoskeletal problem/condition Hypertension Any infection within last year Asthma or other respiratory condition Any traumatic injury within last year Diabetes or other endocrine condition Mental and/or emotional condition Seizure Disorder Substance abuse Neurological problem Other Bleeding or clotting disorder
Further explanation of any items that are checked:
______
NURS 100A Application Rev: 09/28/2015 Page 9 of 13 Personal Medical Record (Cont’d.)
Do you have any allergies? If yes, please specify: ______
______
Please list all medications that you take regularly: ______
______
Part III: Statement of Ability to Function as a Student in an Allied Health Program:
Yes No
Do you have a visual impairment? If so, is it corrected?
Do you have a hearing impairment? If so, is it corrected?
Can you list up to fifty (50) pounds?
Can you carry up to twenty (20) pounds?
Can you sit for four (4) hours?
Can you stand and/or walk unassisted for up to twelve (12) hours?
Can you use both hands?
Always Usually Not Always Seldom Please rate your ability to cope with stressful situations: I am able to cope with stress:
NURS 100A Application Rev: 09/28/2015 Page 10 of 13
Student Release Form
The clinical facilities you will be working in may require copies of your abuse statement, background check and immunization records. Please sign and return this form to the WVC Allied Health Department as your approval for releasing this information.
If requested by the clinical facility to which I have been assigned, you have my permission to release my abuse statement, background check, and immunization records to that clinical facility.
Student Name: ______Program: ______(Please print)
Student Signature: ______Date: ______
NURS 100A Application Rev: 07.20.15 Page 10 of 13
Student Confidentiality Statement
Student Name: ______Program: ______(Please print)
Address: ______(Street or P. O. Box) City State Zip
Confidentiality Statement: I understand that, as an Allied Health student at Wenatchee Valley College, I am not considered to be an employee of the clinical agency where I may participate in clinical learning experiences. I agree to abide by all Wenatchee Valley College policies, procedures, standards, and regulations that guide my conduct. I understand and agree that, in the performance of my duties as a student at Wenatchee Valley College, I must hold medical information in confidence. Further, I understand that intentional or involuntary violation of confidentiality may result in punitive action, immediate termination of access to further data, and the immediate termination of my participation in any clinical learning experience at Wenatchee Valley College.
______(Student signature)
______(Date)
NURS 100A Application Rev: 07.20.15 Page 11 of 13
Community Relations P: 509.682.6420 / F: 509.682.6401 1300 Fifth Street Wenatchee, WA 98801
Wenatchee Valley College (WVC) may take and use photographs of me or excerpts of statements I provided to be used for promotional purposes, such as college publications, the Web site, displays, video presentations, and advertisements, with the understanding that my image and statements will be used to promote WVC only. I do this willingly, expecting no compensation or gratuity of any kind from WVC.
Name: ______E-mail: ______(Please print)
Address: ______(Street or P. O. Box) City State Zip
Telephone Numbers: ______Telephone Cell phone Alternative phone
Signature: ______Date ______
NURS 100A Application Rev: 07.20.15 Page 12 of 13 PROCESSING CODE Background Check Authorization
SECTION 1. ENTITY INFORMATION (COMPLETED BY DSHS STAFF, PROVIDER, APPLICANT, LICENSEE, AND/OR CONTRACTOR) 1A. ENTITY REQUESTING THE BACKGROUND CHECK 1B. ENTIRE ADDRESS OF ENTITY LISTED IN BOX 1A 1C. NAME OF SECONDARY ENTITY
2. REQUIRED: NAME AND SIGNATURE OF PERSON REQUESTING THE BACKGROUND CHECK
PRINTED NAME: SIGNATURE: 3. REQUIRED ONLY FOR DSHS STATE EMPLOYMENT DSHS POSITION NUMBER (WRITE NONE IF NONE) DSHS JOB CLASSIFICATION: PERSONNEL IDENTIFICATION NUMBER: Permanent appointment Non-permanent appointment Work study / student internship Volunteer Acting 4. REQUIRED: BCCU ACCOUNT NUMBER 5. DSHS ID NUMBER OR NAME
SECTION 2. THIS SECTION IS FOR APPLICANT INFORMATION ONLY (THE PERSON TO BE CHECKED IS THE APPLICANT) 6. SOCIAL SECURITY NUMBER 7. REQUIRED: DATE OF BIRTH (MM/DD/YYYY) 8. PRINT YOUR E-MAIL ADDRESS
9. REQUIRED: PRINT YOUR NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR OTHER PHOTO ID. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER. FIRST: MIDDLE: LAST: 10. REQUIRED: PRINT ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER. FIRST: MIDDLE: LAST:
REQUIRED: SELF DISCLOSURE QUESTIONS. SEE INSTRUCTIONS. You must answer Questions 11A through 14. Attach an additional sheet of paper if you need to list additional crimes or pending charges. 11A. Have you been convicted of any crime? If yes, fill in the blanks below...... Yes No Degree: State: Conviction date: / / 11B. Do you have charges (pending) against you for any crime? If yes, fill in the blanks below...... Yes No Degree: State: 12. Has a court or state agency ever issued you an order or other final notification stating that you have sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult? ...... Yes No 13. Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government agency was taking action against you for failing to care for children, juveniles, or vulnerable adults? ...... Yes No 14. Has a court ever entered any of the following against you for abuse, sexual abuse, neglect, abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile or child? ...... Yes No Permanent* vulnerable adult protection order / restraining order, either active or expired, under RCW 74.34. Sexual assault protection order under RCW 7.90. Permanent* civil anti-harassment protection order, either active or expired, under RCW 10.14. See instructions for description of “permanent.” 15. REQUIRED: PRINT YOUR DRIVER’S LICENSE OR STATE IDENTIFICATION NUMBER (WRITE NONE IF NONE) REQUIRED: PRINT THE NAME OF THE STATE ON YOUR LICENSE OR ID
16. REQUIRED Have you lived in any state or country other than Washington State within the last three years (36 months)? Yes No
17. A. REQUIRED: PRINT YOUR MAILING ADDRESS WHERE WE CAN SEND YOU CONFIDENTIAL INFORMATION APT. NO. CITY STATE ZIP CODE B. REQUIRED: PRINT THE STREET ADDRESS WHERE YOU LIVE NOW (WRITE “SAME” IF YOUR STREET ADDRESS IS THE SAME AS YOUR MAILING ADDRESS) APT. NO. CITY STATE ZIP CODE C. REQUIRED: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED
18. I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to work with vulnerable adults, juveniles or children. I understand and agree my signature in box number 19 means: I give DSHS permission to check my background with any governmental entity and law enforcement agency. My background check result may include prior self-disclosure information and fingerprint results that are contained in the DSHS Background Check System and that this information will be reported as allowed by federal or state law. If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result. DSHS will give my background check result to the persons or entities named in Section 1 and may release my background check results to other persons or entities when the law authorizes or requires DSHS to do so. Fingerprint rap sheets are provided if allowed by federal or state law. The entity requesting this background check must submit this form to the Background Check Central Unit within the timeframe required by the DSHS oversight program. 19. REQUIRED: YOUR SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18. 20. REQUIRED: TODAY’S DATE (MM/DD/YYYY)
PROGRAM USE – FOLLOW INSTRUCTIONS PROVIDED BY YOUR DSHS OVERSIGHT PROGRAM
DSHS 09-653 (REV. 04/2015) Instructions for Completing the Background Check Authorization DSHS 09-653 These instructions provide general directions for completing the Background Check Authorization form. This form is used by multiple DSHS programs to meet varying background check needs. The DSHS oversight program requiring the background check may have additional instructions that you must follow. The Background Check Central Unit (BCCU) cannot complete the background check unless all required boxes are complete. Required boxes have the word REQUIRED: next to the box number as shown in the example below: 4. REQUIRED: BCCU ACCOUNT NUMBER IMPORTANT: If you do not provide all required information, your background check will be delayed. ATTENTION ENTITIES AND DSHS STAFF: Only submit this authorization form once. Multiple submissions of the same authorization form causes delays in processing background checks. PROCESSING CODE: If you use a priority processing code or “fingerprint required”, enter it in this box. Priority processing codes include new hire, initial contract, initial license, approved rush, Community Protection, and DSHS state employee. SECTION 1: TO BE COMPLETED BY THE ENTITY REQUESTING THE BACKGROUND CHECK This section must be completed by the entity requesting the background check. Entities are most often DSHS programs, hiring authorities, and external providers who submit background check requests to the Background Check Central Unit. Box No. Instructions 1A Enter the name of the entity requesting the background check. 1B Enter the full address of the entity listed in Box 1A. 1C Enter the name of the secondary entity associated with the background check. A secondary entity may be a contractor, subcontractor, or other entity associated with this background check. Your oversight program will provide instructions on how to use this box. 2 Provide the printed name and signature of the person requesting the background check. This is the person who is submitting the background check on behalf of the entity listed in Box 1A. 3 Complete this box ONLY if the background check is for DSHS employment purposes. External providers should not complete this box. 4 Enter your BCCU account number in this box. You can find your BCCU account number at http://www.dshs.wa.gov/fsa/bccu/account-numbers. DSHS state employment account numbers are available on the BCCU intranet webpage. 5 Enter a DSHS ID number or name if required by your DSHS oversight program. SECTION 2: TO BE COMPLETED BY THE APPLICANT This section must be completed by the applicant. The applicant is the person whose background we are checking. Except as noted in these instructions, DSHS staff must not complete Section 2 for the applicant. Note: Adult Protective Services program staff may complete the applicant information for an APS investigation background check. Box No. Instructions 6 You may choose to provide your Social Security Number. Your Social Security Number helps the Background Check Central Unit match your name and date of birth to existing records in our database and may speed up completion of your background check. 7 Print your date of birth listing the month, day, and year. 8 Provide an e-mail address where we can reach you. 9 Current Name: List your first, middle, and last name as they are listed on your current Driver’s License or other primary photo ID. (See example below.) Accepted government-issued photo ID includes any federal, state, or local government-issued ID, US military ID, US or foreign passport, or federally recognized tribal ID. Write N/A in each field that you do not have a name to enter. 9. REQUIRED: PRINT YOUR NAME AS IT IS ON YOUR DRIVER’S LICENSE OR OTHER PHOTO ID. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER. FIRST: Susan MIDDLE: Jane LAST: Smith
10 Other Names: Print all other first, middle, or last names you have used. Other names include nicknames, birth names, maiden names, etc. If you have not used any other first, middle, or last names, you must enter N/A in the appropriate box. Do not leave any of the boxes blank. (See examples below) Example 1 – entering two nicknames and one maiden name. No other middle names have been used.
10. REQUIRED: PRINT ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER. FIRST: Sue, Susie MIDDLE: N/A LAST: Jones
DSHS 09-653 (REV. 04/2015) Example 2 – entering N/A because no other first, middle, or last names have been used.
10. REQUIRED: PRINT ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER. FIRST: N/A MIDDLE: N/A LAST: N/A
See important information about answering self-disclosure questions following the description for Box 20. Box No. Instructions 11A You must check YES or NO. If you check YES, you must enter the crime name, degree (if any), state, and the conviction date (MM/DD/YYYY). If you need to list additional convictions, attach a separate piece of paper to the Background Check Authorization form. Include your name and all the required information listed above. 11B You must check YES or NO. If you check YES, you must enter the pending charge name, degree (if any), and state. If you need to list additional pending charges, attach a separate piece of paper to the Background Check Authorization form. Include your name and all the required information listed above. 12-14 Read each question carefully before answering. You must check YES or NO. *Question 14: Permanent means the order was issued either following a hearing or by stipulation of the parties. 15 Enter your Driver’s License or state-issued ID and the state where it was issued. 16 If you have continuously lived in Washington State without living in another state or country for the last three years (36 months), answer NO. If you have lived in any state or country other than Washington State within the last three years (36 months), answer YES. 17 17a - Enter your mailing address where BCCU can send you confidential information such as a copy of your background check results. 17b – Enter your street address if it is different than your mailing address. If your street address and mailing address are the same, enter SAME. 17c – Enter the daytime phone number where you can be reached. 18. Read the statements in Box 18. Your signature in Box 19 means you have read, understand, and agree to the statements listed in Box 18. 19. Sign your name as it is listed in Box 9. If you are not 18 years old, a parent or guardian must sign for you. 20. Enter the month / day / year (MM/DD/YYYY) you signed Box 19. IMPORTANT INFORMATION ABOUT ANSWERING SELF-DISCLOSURE QUESTIONS: Your answers to self-disclosure questions become part of your background check history and are stored in the DSHS database. Self-disclosures are reported as part of your background check result like any other background check history we receive. It is important that your answers to self-disclosure questions are accurate and consistent. It is strongly recommended that you answer self- disclosure questions the same way each time you complete the Background Check Authorization form unless the question has changed or the previous answer was wrong. It is also recommended that you refer to charging papers, court records, or other official documents and that you list criminal convictions, pending charges, dates and other information exactly as they are listed in those documents. If you have questions about the Background Check Central Unit background check process, contact BCCU at [email protected] or call 360-902-7555.
DSHS 09-653 (REV. 04/2015)