Montana Technological University 
Bachelor of Science in Nursing
fall 2022
Application

PLEASE PRINT

•	Please carefully read the application and review it for completeness before signing.
AN INCOMPLETE AND/OR UNSIGNED APPLICATION WILL NOT BE PROCESSED.

Last Name_______________________________      
First Name_______________________________
Student ID __________________________________

Mailing Address: ____________________________________________
City_______________________________________________________  
 State______________________________________________________  
 Zip_______________________________________________________
**Notification of acceptance/non-acceptance will be mailed to this address

Telephone Number: ___________________________ Cell:  ________________________   
Tech Email_______________________________________________________________			

•	Applications Accepted : November 1st , 2022. 
•	Application Deadline:  November 29th, 2022 (Close of business 4:00 p.m.)

	Complete applications must include the following by the deadline: 

	Unofficial Transcript
	Official printout of the TEAS examination with a proficiency score of 70% or higher. (The TEAS can only be taken once in the semester you are applying)
	Completed and signed Grade Worksheet (attached)
	Completed and signed Immunization and CPR Verification Form (attached)
	Copies of the following (from the Immunization and CPR Verification Form):
	Current (infant through adult) CPR certification. (The ONLY Accepted CPR courses are: American Heart Association for the Health Care Provider OR American Red Cross for the Professional Rescuer)
	Current Influenza Vaccination (Must be completed annually)
	Current evidence of freedom from active Tuberculosis (TB skin test or chest x-ray.  Must be completed annually)
	Tdap vaccine within the last 10 years.
	Two MMR vaccines or MMR positive titers
	Completion of Hepatitis B vaccine series or positive titer
	Varicella vaccination series or positive titer
		Completed, signed, and initialed application form

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.

Grade Worksheet
Please complete the information requested with a letter grade and semester.  If you are currently enrolled in pre-requisite courses, simply indicate the semester you are taking the course and do not fill in a letter grade.

•	General Education courses must have been completed within 10 years, unless a previous Bachelor’s degree has been awarded.
•	Science courses must have been completed within 5 years.
•	A grade of “C+” or higher is required for all nursing and a “C” or higher is required for all non-nursing courses.
•	Pre-requisite courses may only be repeated one time.  GPA calculation is based on the grade from the retake of the course.

Course	Name	Grade/Semester 
of INITIAL course

This column is ONLY for the first grade of a course that has been repeated.  Leave blank if you have only taken the course once. 	Grade/Semester

This column is for courses taken only once, OR for grade from a repeat of a course.
	Faculty Verification/Initials	
BIOH 201	Anatomy & Physiology I				
BIOH 202	Anatomy & Physiology I Lab				
BIOH 211	Anatomy & Physiology II				
BIOH 212	Anatomy & Physiology II
Lab				
CHMY 121	Introduction to General Chemistry				
CHMY 122	Intro to General Chemistry Lab				
WRIT 201 	College Writing II				
M 121	College Algebra				
NUTR 258	Fundamentals of Nutrition				
PSYX 230	Developmental Psychology				
BIOM 250	Microbiology For Health Science Lecture				
BIOM 251	Microbiology Lab				
NRSG 107	Perspectives in Professional Nursing				
WRIT121	Introduction to Technical Writing				
PSYX 100	Introduction to Psychology				
SOCI 101	Introduction to Sociology				
STAT 216	Intro to Statistics or Biostatistics 				
HCI 316	Healthcare Ethics				
HUMN XXX	Humanities				

 ______________________________________  	_______________________________________ 	
Student Signature 	 	 	Date 	
______________________________________  	_______________________________________ 	
Faculty Signature 	 	 	 	 	 	Date	

Montana Tech Nursing Department
Immunization & CPR Verification Form   

Name of Student__________________________________Student ID_____________________ 
 	 	 	 	(Last, First) Please Print 

Please insert dates and check boxes below as applicable.  	 	 	      
 
MMR (measles, mumps, rubella)  *2 doses or positive titer*
MMR Record 1 ______/______/_______   Record 2 ______/______/_______ 
Use below only if measles, mumps and rubella vaccinations were administered separately. 
Measles ____/____/_____, mumps____/____/_____, rubella____/____/_____ 
Measles ____/____/_____, mumps____/____/_____, rubella____/____/_____    
OR 
Positive titer dates for Measles ____/____/_____, mumps____/____/_____, and rubella____/____/_____  

	Varicella (chickenpox)  *2 doses or positive titer*
Vaccination dates_____/_____/_____ AND _____/_____/_____ (two recommended by the CDC) 
OR positive titer date____/____/_____ 

	Hepatitis B   *Completion of 2 or 3 dose series or positive titer*	 	 	 	 	 
(Engerix-B)  Record 1_____/_____/_____Record 2_____/_____/______Record3_____/_____/______   OR
(Heplisav-B)  Record 1_____/_____/_____Record 2_____/_____/______  OR
	             Positive Titer date ____/_____/______

tDap (tetanus/pertussis)  *Within the past 10 years	.  Note this must be Tdap not TD or DPT*
Date received____/____/_____  

Influenza Vaccine  * Completed annually* 
	Date received____/____/_____  

TB (PPD-tuberculosis)  * Completed annually* 
	Date received____/____/_____    OR     Date of chest x-ray____/____/_____

CPR * BLS Provider or American Red Cross Professional Rescuer.  Recertification every 2 years*
	Date received____/____/_____    

 ______________________________________  	_______________________________________ 	
Student Signature 	 	 	Date 	
______________________________________  	_______________________________________ 	
Faculty Signature 	 	 	 	 	 	Date	
		
Proof of this information is to be kept and maintained by the Nursing Department

 

 
Date: ____________ 

 
CMS COVID – 19 Mandate Information 
 
As you may know, the CMS COVID-19 mandate is in effect.  In short, this rule requires that all students in the Montana Tech Nursing program receive a COVID-19 primary vaccination series or have an approved medical or religious exemption in place.  A primary vaccination series is considered one of the following: 
 
•	Two doses of Pfizer-BioNTech vaccine given 3 weeks (21 days) apart. 
•	Two doses of Moderna vaccine given 4 weeks (28 days) apart. 
•	One dose of Johnson & Johnson’s Janssen (J&J/Janssen) vaccine. 
 
While primary vaccination or exemption is not required for program placement, it is required for clinical placement. As completion of a Bachelor of Science in Nursing degree requires participation in multiple clinical rotations in healthcare facilities, all students accepted will be required to provide documentation of either your completed primary vaccination series or approved medical or religious exemption no later than January 6th, 2023.   

 
 
____________________ 						__________________________  
Student’s Signature 							Student’s Name   (Print Clearly) 

Date: ____________

REGISTRATION WAIVER – Fall 2022

I have applied for acceptance into the BSN clinical component for spring 2023.  I realize I will be automatically dropped from NRSG 230, Nursing Pharmacology, NRSG 210, Foundations of Professional Nursing, NRSG 215 Assessment of Health Promotion, and NRSG 256 Pathophysiology if I am not accepted.

____________________				__________________________	
Student’s Signature					Student’s Name   (Print Clearly)

Please initial each line.  With initialing and signing below, the student verifies understanding of the information.  It is the student’s responsibility to contact the nursing department with questions PRIOR to initialing and signing the application.

_____	I understand that the selection to the Nursing Program will be comprised of 60% weighted GPA and 40% TEAS. The TEAS can only be taken one time in the semester you are applying.
_____	I have applied for acceptance into the BSN clinical component for Spring 2023.  I will be automatically registered for NRSG 230 (Nursing Pharmacology), NRSG 210 (Foundations of Professional Nursing), NRSG 215 (Assessment and Health Promotion), and NRSG 256 (Pathophysiology).  If I am not accepted into the nursing program, I will be automatically dropped from these courses.
_____	I will be notified by US and electronic Mail, postmarked no later than December 21st, 2022, whether or not I have received spring 2023 placement in the BSN program.  No information will be provided over the phone.
_____	Students who meet minimum requirements and are not offered placement will automatically be placed on the spring 2023 wait list. The wait list is maintained only until the first week of spring semester 2023.
_____ 	Upon admission to the program and each semester, mandatory orientation is required. Orientation may be held prior to the beginning of the academic semester.
_____	Attendance to the new student orientation and the first week of class is mandatory.  If unable to attend, I must decline admission placement.
_____ I have no history of a felony conviction.  Applicants who have been convicted of a felony will not be 
	admitted or allowed to continue in the nursing program. 
_____	Acceptance to and graduation from the Nursing Program does not assure eligibility to sit for the nursing licensing examination. The Montana Board of Nursing makes all final decisions on issuances of licenses.

Print Name_______________________________________                		
 		
Student Signature _________________________________		Date______________________________				
Faculty Signature _________________________________	          	Date______________________________