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HEALTH CAREERS PORTERVILLE COLLEGE 100 East College Ave. PORTERVILLE CA 93257 (559) 791-2321 FAX (559) 791-2417 https://www.portervillecollege.edu/health-careers/health-careers Rev 1/16/18 PORTERVILLE COLLEGE HEALTH CAREERS DIVISION LVN TO ASSOCIATE SCIENCE NURSING PROGRAM MISSION The Porterville College Licensed Vocational Nursing Associate Degree Nursing (LVN-ADN) Program endorses the mission of Porterville College which is: “With students as our focus, Porterville College provides our local and diverse communities quality education that promotes intellectual curiosity, personal growth, and lifelong learning, while preparing students for vocational and academic success." The Porterville College LVN-ADN Program adheres to this mission when offering the Associate Degree in Nursing. The mission of the nursing program is to provide an innovative, student- centered educational program that prepares diverse students as candidates to become Registered Nurses to provide safe, quality, evidence-based nursing care in the current healthcare environment. The program is market-conscious as it prepares students to practice nursing in a variety of healthcare environments with input from the community represented through the progra m's Advisory Committee. Upon completion of the program the graduate is qualified to take the NCLEX-RN examination. In alignment with the mission of Porterville College, the LVN-ADN program also provides a solid base for continued lifelong learning as a Professional Nurse. Although the LVN-ADN program is not considered a Transfer Program, the nursing program graduates are prepared with the necessary nursing knowledge, skills, and competencies to continue their education in a higher degree program. The nursing program has articulation agreements with upper level institutions in California to assist students in their quest for a baccalaureate in nursing degree. NOTE: The California Board of Registered Nursing (BRN) protects the public by screening applicants for licensure in order to identify potentially unsafe practitioners. The law provides for denial of licensure for crimes or acts, which are substantially related to nursing qualifications, functions or duties. Conviction of any offenses other than minor traffic violations must be reported to the Board of Registered Nursing at the time of application for licensure. Business and Professions Code 480 and Nurse Practice Act article 3 section 2761. For clarification contact the ADN Program Director or the Board of Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer Identification Number Requirement: Pursuant to Section 30(c) of the Business and Professions code the California Board of Registered Nursing (BRN) will not process any application for licensure unless the applicant provides a United State SSN or Individual Taxpayer Identification Number. The Nursing Practice Act provides for a unified examination and licensing application. Once an applicant passes the examination, a license is automatically issued. Under these circumstances the BRN cannot accept applications for the examination and licensure without a SSN or Tax Payer Identification Number. CAREER OPPORTUNITIES Employment in the field for registered nurses is excellent locally and nationally. The registered nurse enjoys a well-compensated, rewarding, highly flexible career, which should continue in the future. This field is expanding and growth in the job market is projected.

PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

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Page 1: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

HEALTH CAREERS PORTERVILLE COLLEGE 100 East College Ave. PORTERVILLE CA 93257

(559) 791-2321 FAX (559) 791-2417 https://www.portervillecollege.edu/health-careers/health-careers

Rev 1/16/18

PORTERVILLE COLLEGE HEALTH CAREERS DIVISION

LVN TO ASSOCIATE SCIENCE NURSING PROGRAM

MISSION

The Porterville College Licensed Vocational Nursing Associate Degree Nursing (LVN-ADN)

Program endorses the mission of Porterville College which is: “With students as our focus, Porterville

College provides our local and diverse communities quality education that promotes intellectual

curiosity, personal growth, and lifelong learning, while preparing students for vocational and academic

success."

The Porterville College LVN-ADN Program adheres to this mission when offering the

Associate Degree in Nursing. The mission of the nursing program is to provide an innovative, student-

centered educational program that prepares diverse students as candidates to become Registered

Nurses to provide safe, quality, evidence-based nursing care in the current healthcare environment. The

program is market-conscious as it prepares students to practice nursing in a variety of healthcare

environments with input from the community represented through the progra m's Advisory Committee.

Upon completion of the program the graduate is qualified to take the NCLEX-RN examination.

In alignment with the mission of Porterville College, the LVN-ADN program also provides a

solid base for continued lifelong learning as a Professional Nurse. Although the LVN-ADN program is

not considered a Transfer Program, the nursing program graduates are prepared with the necessary

nursing knowledge, skills, and competencies to continue their education in a higher degree program.

The nursing program has articulation agreements with upper level institutions in California to assist

students in their quest for a baccalaureate in nursing degree.

NOTE: The California Board of Registered Nursing (BRN) protects the public by screening applicants

for licensure in order to identify potentially unsafe practitioners. The law provides for denial of licensure

for crimes or acts, which are substantially related to nursing qualifications, functions or duties.

Conviction of any offenses other than minor traffic violations must be reported to the Board of Registered

Nursing at the time of application for licensure. Business and Professions Code 480 and Nurse Practice

Act article 3 section 2761. For clarification contact the ADN Program Director or the Board of

Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350.

NOTE: Social Security Number (SSN) or Individual Taxpayer Identification Number Requirement:

Pursuant to Section 30(c) of the Business and Professions code the California Board of Registered

Nursing (BRN) will not process any application for licensure unless the applicant provides a United State

SSN or Individual Taxpayer Identification Number. The Nursing Practice Act provides for a unified

examination and licensing application. Once an applicant passes the examination, a license is

automatically issued. Under these circumstances the BRN cannot accept applications for the examination

and licensure without a SSN or Tax Payer Identification Number.

CAREER OPPORTUNITIES

Employment in the field for registered nurses is excellent locally and nationally. The registered nurse

enjoys a well-compensated, rewarding, highly flexible career, which should continue in the future. This

field is expanding and growth in the job market is projected.

Page 2: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

2

PERTINENT STATUTES & REGULATIONS

Porterville College has an established Associate Degree Nursing program and meets the

requiredcurriculum from California Code of Regulations 1426.

ENTRY CRITERIA AND SELECTION PROCESS

Refer to enrollment eligibility and enrollment process unit Item 2 Catalog Description section.

PROGRAM LEARNING OUTCOMES

1. Provide safe, quality, evidence-based, patient-centered nursing care to diverse patients across

the lifespan in a variety of healthcare settings.

2. Exercise clinical judgment to make increasingly complex patient-centered care decisions.

3. Participate in quality improvement processes to improve patient care outcomes.

4. Participate in teamwork and collaboration with members of the interprofessional team, the

patient, and the patient’s support persons.

5. Use information management systems and patient care technology to communicate, manage

knowledge, mitigate error, and support decision-making.

6. Incorporate leadership, management, legal, and ethical principles to guide practice as a

Registered Nurse.

7. Promote a culture of caring in all healthcare environments.

ENROLLMENT ELIGIBILITY

To be eligible for enrollment in the program, the student must meet the following criteria:

Possession of a current clear and active California Vocational Nurse (LVN) license at the time of

application and throughout program completion.

Intravenous Certification required.

Completion of a minimum of six months full-time equivalent LVN work experience within the past

year.

A grade of “C” or better required for all Prerequisites

2.5 minimum GPA in anatomy, physiology, and microbiology

o ANAT P110 (Human Anatomy) 4 units at Porterville College, or equivalent course at another

accredited college.

o PHYL P101 (Introductory Physiology) 5 units at Porterville College, or equivalent 4-5

semester unit physiology course at another accredited college.

o MICR P106 (Microbiology) 5 units at Porterville College, or equivalent 4-5 semester unit

microbiology course at another accredited college.

2.5 minimum GPA in remaining prerequisite courses for the nursing program.

o ENGL P101A (Expository Composition) 4 units at Porterville College, or equivalent course

at another accredited college.

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3

o MATH P051 (Intermediate Algebra) 4 units OR higher at Porterville College or equivalent

3-4 semester unit math course equivalent at another accredited college.

A grade of “C” or higher in NURS P171 LVN Transition to RN Program or NURS P170 Role

Transition: Bridging Nurse.

NOTE: The program reserves the right to make changes in the enrollment criteria, academic

requirements, grading standards, and other processes without notice at any time.

ENROLLMENT PROCESS

Eligible students are selected for the program according to the following steps:

Pre-enrollment applications and deadlines for the LVN-ADN program are available from the

Health Careers Division or program website.

Selection is based on a random selection process from among the qualified applicants and is

submit to space availability. Students must reapply each semester. There is no waiting list.

Only students who meet the educational and pre-nursing requirements and follow the pre-

enrollment procedures will be considered for the program. Meeting all these requirements does

not guarantee acceptance into the program.

PROGRAM PROGRESSION

A grade of “C” or better is required in each nursing course for progression toward the LVN-ADN

Degree.

PROGRAM APPROVAL The California Board of Registered Nursing approves the Porterville College LVN-ADN Program.

OTHER LVN-ADN REQUIREMENTS

COMM P101 (Introduction to Public Speaking) OR COMM P102 (Interpersonal

Communication)

PSYC P101A (General Psychology)

SOCI P101 (The Social World) OR ANTH P102 (Cultural Anthropology)

GENERAL EDUCATION COURSES

General education courses are required to graduate from Porterville College with an LVN-

Associate Degree in Nursing. It is suggested that most of these courses be completed prior to

beginning the LVN-ADN Program. NOTE: Some of the general education courses are also

prerequisite courses for the LVN-ADN OR other LVN-ADN requirements.

Area A: Education – NURS P100 recommended

Area B: Writing - ENGL P101A (4 units) prerequisite course for the program

Area C: Communications – COMM P101 OR COMM 102 LVN-ADN requirement

Area D: Mathematics - MATH P051 OR higher – prerequisite course for the program

Area E: Biological Science – ANAT P110, PHYL P101 AND MICR P106 – prerequisite

courses for the program

Area F: Physical Science – CHEM P106 recommended

Area G: History/Political Science – HIST P117, P118 OR POLS P101

Area H: Social/Behavioral Science – PSYC P101A AND SOCI P101 OR ANTH P102 –

LVN-ADN requirement

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4

Area I: Analytical Thinking - this area is met by completing the Associate Degree Nursing

courses

Area J: Multicultural Studies - this area is met by completing the Associate Degree Nursing

Area K: Health/Physical Education - this area is met by completing the Associate Degree

Nursing

Area L: Humanities: PHIL P112 is recommended or any course as listed in Area L of the

General Education Checklist

LVN-ADN PROGRAM CURRICULUM The following courses are taken after the student enters the Program.

THIRD SEMESTER Units

NURS P135 Concepts of Mental Health Nursing 4

NURS P136 Concepts of Nursing Care of the Adult and Older Adult III 6

FOURTH SEMESTER

NURS P138 Concepts of Nursing Care of the Adult and Older Adult 6

NURS P139 Transition to Registered Nurse 1

Total 17

NOTE: All graduation requirements of the college must be met to earn an Associate of Science in

Nursing and to take the NCLEX RN – Licensure Exam.

Challenge/Advanced Placement into the Nursing Program for Military Personnel

In compliance with Senate Bill 466, Military Personnel and Veterans may be eligible for advanced

placement into the Porterville College LVN-ADN Program. Three pathways have been established to

assist with obtaining nursing credit for previous education and experience for the Basic Medical

Technician Corpsman, the Basic Medical Technician Corpsman with an active California LVN license,

and the Independent Duty Corpsman/Advanced Army Medic/Advanced Airforce Medic.

All applicants must meet all general entrance requirements of the Associate Degree Nursing Program,

including completion of designated prerequisites. Students must pass the first and/or second semester

written challenge exams with 75% or higher and obtain a satisfactory level of achievement on skills

competency. Military Challenge students will not be admitted if they have previously failed a nursing

course at another nursing school.

CONDITIONAL ENROLLMENT

As a condition of enrollment in any Health Careers Program, students are required to submit to and

pass a designated drug and alcohol screening, a background screening, and physical examination

clearance (at the student’s expense). Please note the following:

PHYSICAL EXAMINATION

A physical examination completed by a physician of the student's choice is required when entering the

Program to demonstrate that a student meets the following technical standards necessary to meet the

Program objectives. Appropriate immunizations and TB clearance are also required and are performed

at the student's expense.

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5

ESSENTIAL TECHNICAL STANDARDS

Nursing students must meet the following essential technical standards to ensure the safety and welfare

of the patients, the healthcare team, and themselves. A physical examination performed by a medical

doctor determines whether a student meets the technical standards or any accommodations that may be

necessary.

Standing and/or walking most of a shift.

Bending or crouching several times per hour.

Lifting and carrying a minimum of 30 pounds several times an hour.

Lifting and moving up to 300 lbs. with the assistance of 2-3 persons.

Reaching overhead above the shoulder 90 degrees.

Utilizing eyesight to observe clients and manipulate equipment under various illumination levels.

Hearing to communicate with the patient and healthcare team.

Manipulating medical equipment and accessories, including but not limited to switches, knobs,

buttons, keyboards, patient lines, and tubes, utilizing fine and gross motor skills.

Performing the assigned job responsibilities with the intellectual and emotional functions

necessary to ensure patient safety and exercise independent judgment and discretion.

Utilizing sufficient verbal and written skills to efficiently communicate in English with the

patient and healthcare team.

Utilizing the above standards/functions to respond promptly to the patient’s needs and/or

emergency situations.

DRUG / ALCOHOL SCREENING

As a condition of application in any Nursing/Allied Health Program with a clinical laboratory

component, students are required to submit to and pass a designated drug and alcohol screening.

BACKGROUND SCREENING

Every student offered space in the program will be required to submit to a background screening (at the

student’s expense) as part of his or her clinical requirements for admission. Please note the following:

A history of felony conviction(s) or any bar, exclusion or other ineligibility for federal program

participation could render a student ineligible for clinical placement, as determined by the clinical

agencies.

If a student cannot obtain background clearance from the clinical agencies, it will not be possible

to place the student in the clinical areas, which is a required component of the program.

In the event that a student cannot obtain a background clearance, the space will be forfeited.

Students who are found to be ineligible for clinical placement by the clinical agency after

admission to the nursing program shall be subject to dismissal from the program, as they will be

unable to complete mandatory clinical rotations.

BASIC LIFE SUPPORT – BLS (formerly CPR)

Prior to the beginning of the nursing program, and then throughout the program, students are required to

show proof of a valid American Heart Association BLS – Healthcare Provider. This BLS card must

be valid until the end of the Program. It is your responsibility to provide a copy of the current BLS

card to the nursing department and to carry a copy of this card while attending clinical in the healthcare

facilities, preferably in your portfolio.

PROGRAM SUPPLY INFORMATION

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6

Students will be required to purchase uniforms, textbooks and selected equipment, provide transportation

to off-campus clinical education sites and pay current college fees. An estimated cost for books,

uniforms, fees and required equipment for the first term of the Program is approximately $2000.00. In

addition to registration fees and books, the Nursing Program fourth semester’s expenses will include

Program Completion activities, Program pin and State Board application fees. Total program cost is

approximately $3,400.00.

AFFIRMATIVE ACTION /EQUAL OPPORTUNITY STATEMENT

In accordance with the requirements of the Civil Rights Act, Porterville College provides services and

benefits to students regardless of race, color, national origin, ancestry, gender, age, religion, marital

status, medical condition or disability. The lack of English language skills will not be a barrier to

administration and participation in vocational education programs. (Title VI and VII of the Civil Rights

Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 503 and 504 of

the Rehabilitation Act of 1973, as amended.)

Page 7: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

HEALTH CAREERS PORTERVILLE COLLEGE 100 East College Ave. PORTERVILLE CA 93257

(559) 791-2321 FAX (559) 791-2417 https://www.portervillecollege.edu/health-careers/health-careers

Rev 1/16/18

PORTERVIILE COLLEGE

HEALTH CAREERS

LVN-ADN PROGRAM

APPLICATION REQUIREMENTS/ INSTRUCTIONS

APPLICATION PERIOD

February 1 - February 28 for the program/courses scheduled to start in the FALL semester.

The application period for previous RN students transferring to 2nd or 4th semester is September 1 -

September 30 for courses scheduled to start in the SPRING semester.

REQUEST FOR TRANSCRIPT EVALUATION DEADLINE Deadline for courses taken from any college other than Porterville College

October 15 – for program/courses scheduled to start in FALL semester

The Request for Transcript Evaluation Deadline for previous RN students transferring to 2nd or 4th semester

is June 15th for courses scheduled to start in the SPRING semester.

APPLICATION PROCEDURES

Read these guidelines carefully to ensure your application experience runs smoothly. It is the applicant’s

responsibility to complete ALL application requirements/procedures. FAILURE TO MEET ALL

APPLICATION REQUIREMENTS/PROCEDURES WILL RESULT IN AN INCOMPLETE

APPLICATION AND WILL NOT BE CONSIDERED FOR SELECTION.

1. COMPLETE ALL PREREQUISTIE COURSES BEFORE YOU SUBMIT YOUR PORTERVILLE

COLLEGE NURSING APPLICATION. Courses in progress will not be accepted.

2. APPLY TO PORTERVILLE COLLEGE BY SUBMITTING AN ONLINE APPLICATION

A. Students who have never attended Porterville College must submit an online application.

https://www.portervillecollege.edu/getting-started/becoming-student

B. First time students to Porterville College will be issued a Student ID number and Gmail address.

The ID is to be used for all college transactions and Gmail is the mode of communication used

by the college to students.

4. GET YOUR STUDENT ID NUMBER and LOGIN TO YOUR PORTERVILLE COLLEGE GMAIL

ACCOUNT.

5. COURSES FROM ANY COLLEGE OTHER THAN PORTERVILLE COLLEGE.

A. Pre-requisites taken from colleges other than Porterville College need to be evaluated by

Admissions and Records. (Please note, it takes about 18 weeks for this evaluation process to be

completed by Porterville College Admission and Records Office.)

Page 8: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

B. Complete Request for Transcript Evaluation form. Form can be obtained from Admissions and

Records or the PC Health Careers webpage https://www.portervillecollege.edu/health-

careers/our-programs

C. Submit OFFICIAL transcripts and Request for Transcript Evaluation form to Admissions and

Records prior to the deadline. (LVN School Transcripts – see below #6)

D. Bakersfield College and Cerro Coso Community College official transcripts DO NOT need to

be submitted to Admission and Records however, a Request for Transcript Evaluation form

DOES need to be submitted to Porterville College Admission and Records Office prior to the

deadline.

E. Once your transcripts have been evaluated and posted to your Porterville College transcripts,

print your unofficial Porterville College transcripts.

6. LVN SCHOOL TRANSCRIPTS

Submit with your application unofficial transcripts from Porterville College, Bakersfiled College or

Cerro Coso College. Submit with your application official transcripts from all other LVN schools.

7. PRINT and ATTACH UNOFFICAL PORTERVILLE COLLEGE TRANSCRIPTS to application.

8. NURSING PROGRAM APPLICATION

Print and complete the LVN to ADN program application from

https://www.portervillecollege.edu/health-careers/our-programs.

9. SUBMITTING YOUR APPLICATION.

Submit completed application with unofficial Porterville College transcripts, LVN school official/

unofficial transcripts, copy of LVN license with IV certification, BLS certification, and proof of 6

months job experience within the past year to the Health Careers office during the appropriate

application period.

APPLICATION STATUS

1. APPLICATION SUBMITTED

2. DO NOT CALL the Health Careers office to inquire about the status of your application as verification

will not be given over the phone. With over hundreds of applications to carefully review, we will update

you on your status as soon as possible. We appreciate your patience. You will be notified regarding the

results approximately EIGHT (8) WEEKS AFTER THE CLOSING DATE.

3. APPLICATION QUALIFIED

We have reviewed your application and have determined that you meet all program requirements and

are qualified for selection to the Nursing Program.

1. ACCEPTED FOR CONDITIONAL ENROLLMENT

Congratulations! You have been selected for conditional enrollment to the Nursing Program. You will

be notified by email and/or phone and mailed further instructions.

2. ALTERNATE

You have been selected as an alternate. You will be notified by email and/or phone and mailed further

instructions.

Page 9: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

3. NOT SELECTED

You are qualified and your application was not selected for this enrollment period. You are eligible to

reapply as a returning qualified applicant.

4. APPLICATION NOT QUALIFIED

We have reviewed your application, and based on program requirements, your application is not

qualified. You will be mailed further information.

Page 10: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

HEALTH CAREERS PORTERVILLE COLLEGE 100 East College Ave. PORTERVILLE CA 93257

(559) 791-2321 FAX (559) 791-2417 https://www.portervillecollege.edu/health-careers/health-careers

Rev 1/16/18

Full Name: ________________________________________________________________________________________________________

Last First M.I Previous Last

Address: ________________________________________________________________________________________________________

Street Address Apartment/Unit #

_________________________________________________________________________________________________________________ City State Zip Code

Home Phone: ( ____ )___________________________ Cell Phone: ( ____ )_______________________________________

Birth Date:____________________________________ Student ID# :_______________________________________________

Email:_____________________________________________________________________________________________________________

U.S. Citizen: Yes No Served on active duty in the U.S. Armed Forces /are the spouse of an eligible veteran? Yes No

Do you have a valid Social Security number? (The CA Board of Registered Nursing requires a SS number to apply for licensure) Yes No

Have you ever applied to PC’s RN program? Yes No If yes, when __________________ Were you an alternate? Yes No

Have you ever been enrolled in a nursing program at another college? Yes No If yes, where and when? ____________ _

California LVN License (present original for verification) #: _ Expiration Date: ________________________

Are you presently under any license restrictions or disciplinary action imposed by the BVNPT? Yes (explain in writing and attach) No If during the course of the nursing program any disciplinary action is taken against your LVN license (revocation, suspension, or probation) you are required to notify the Program Director immediately.

Attach Porterville College unofficial transcripts, LVN school unofficial/official transcripts, LVN license, IV certification, BLS Healthcare Provider certification and proof of 6 months work experience.

Admission to: Fall Spring Year: _____________________ Nursing Semester: LVN-ADN 30-Unit Option

Personal Information

Mail to: Porterville College Health Careers

100 E. College Ave. Porterville, CA 93257 Attn: Applications

PORTERVILLE COLLEGE LVN to ADN Application

Job Information

Name of Employer: Position:________________________________________________

Education

College Name(s) City/State Years Attended Degree Awarded

I have read and understand the above regulations and certify that to the best of my knowledge, the information provided on this document is complete and accurate. I understand that any misinformation, intentional or otherwise, may result in removal of consideration for the program.

Signature: Date:

03/12/2015

It is the applicant’s responsibility to keep the Health Careers Office informed of any changes in personal information, including telephone numbers or addresses.

Page 11: PORTERVILLE COLLEGE HEALTH CAREERS …...Registered Nursing, P.O Box 944210, Sacramento, California, 94244-2100, (916) 322-3350. NOTE: Social Security Number (SSN) or Individual Taxpayer

HEALTH CAREERS PORTERVILLE COLLEGE 100 East College Ave. PORTERVILLE CA 93257

(559) 791-2321 FAX (559) 791-2417 https://www.portervillecollege.edu/health-careers/health-careers

Rev 1/16/18

Please complete the following survey: Male Female Unknown ESL (English as Second Language) : Yes No Your age ________

Ethnic background (please mark one of the following) Black/African American Native American/Alaskan Native Asian/Pacific Islander

Asian Indian Filipino Native Hawaiian/ Non-Filipino Pacific Islander

Hispanic/Latino Mixed race

White/Caucasian Other race

Unknown race

(Please mark all that apply) Autism/Asperger’s Spectrum

ADD/ADHD

Blind or Visually Impaired

Brain Injuries

Deaf/Hard-of-Hearing

Intellectual Disabilities

Learning Disabilities

Medical Disabilities/Chronic Illness

Physical Disabilities

Psychiatric Disabilities

Communication/Speech and

Language Disabilities

Other________________

Unknown

(Please mark all that apply) Academic Counseling

Disability- Related

Counseling/Referral

Adaptive Equipment/Physical

Space/Facilities

Interpreter and Captioning

Services

Exam Accommodations

(modified/Extended

Time/Distraction Reduced Space)

Assistive technology/Alternative

Format

Note-Taking

Services/Reader/Audio

Recording/Smart Pen

Priority Registration

Reduced Courseload

Transportations/Mobility

Assistance and Services/Parking

Other___________________

Completion of this Page is Optional Demographic Information

7/21/2015