Appendices

 

APPENDIX A

 

MGH Institute of Health Professions

School of Nursing

 

 

Notification of Change of Academic Advisor

 

 

 

Please fill out the information below and obtain the appropriate signatures.

 

 

Student: ______________________________________________

 

Program Level:           _____Generalist/Pre-RN   _____Advanced Practice/RN

 

Specialty track:           ____________________

 

Former Advisor:         ______________________________________________

 

New Advisor:              ______________________________________________

 

Effective Date:            ______________________________________________

 

 

Signature of New Advisor:     _________________________________________

 

Date:                                       ______________________

 

Signature of Former Advisor: _________________________________________

 

Date:                                       ______________________

 

 

Please return completed form to Nursing Program Office

 

 

 

 

Received in Nursing School Office: Date: _______________ by _________

 

cc to:   Student

            Former Advisor

            New Advisor

           

Rev11

 

          

                                                                                                                                                APPENDIX B 

                                                           

MGH Institute of Health Professions

School of Nursing

 

CONSENT FORM FOR PHYSICAL EXAMINATION

 

 

           

            I volunteer to have a ___________________________________ examination performed on me by a graduate ________________________student of the MGH Institute of Health Professions for the purpose of STUDENT LEARNING ONLY, as more fully described in Attachment A.

 

            I understand that the MGH Institute of Health Professions is a post-baccalaureate school dedicated to preparing skilled health care professionals, and that the student performing the examination on me is a student and not a fully trained specialist. In agreeing to volunteer, I have been informed on the following:

 

1. The tests that will be performed during the examination will not be for diagnostic purposes.

 

2. I may experience some minor discomfort during the examination.

 

3. I may ask the student to stop the examination at any time.

 

4. Any side effects either during or after the examination are described in Attachment A.

 

I agree that I will not hold the MGH Institute of Health Professions, faculty or student responsible for any problems I may encounter after this examination.

 

 

Signed: _____________________________________________

 

Date: ______________________________________________

 

 

 

Description of Examination:

 

Description of Possible Side Effects:

 

Additional Comments:

 

This form was prepared by:    _________________________________ , _________________

                                                Name of Faculty of Record                            Date


 

                                                                               

          

                                                                                                                                                 APPENDIX C 

                                                                 

MGH Institute of Health Professions

School of Nursing

 

CONSENT FORM FOR PARTICIPATION IN LEARNING ACTIVITIES

 

 

I, __________________________, volunteer to participate as a subject in classroom laboratory

            Subjects Name

 

activities for _________________ ________________________________________________.

                        Course #                                  Course Title

 

I understand that the MGH Institute of Health Professions is a graduate school dedicated to preparing skilled health care professionals, and the class activities are part of their professional preparation. The purpose of my participation is for student learning only, and will not serve diagnostic or treatment purposes.

 

In agreeing to volunteer, I have been informed of the following:

 

Who will be interacting with me and how:

 

 

Description of activities:

 

 

Potential side effects or risks and precautions:

 

 

 

Additional Comments:

 

 

I have read the descriptions provided above.  All questions have been answered to my satisfaction. I understand that I may discontinue my participation in these activities at any time. I agree that I will not hold MGH Institute of Health Professions, faculty or students responsible for any problems I may encounter as a result of my participation.

 

 

Signed: _____________________________________   Date: ___________________________

 

This form was prepared by:    _________________________________ , _________________

                                                Name of Faculty of Record                            Date

 

 

 

 

          

                                                                                                                                                 APPENDIX D

 

MGH Institute of Health Professions

School of Nursing

Honor Code

 

As a student health care professional,

I will act with honesty, integrity, and respect

in my academic pursuits and beyond.

 

Suggested placement in syllabus: in Grading Section.

Suggested use on exams: I agree to adhere to the honor code in taking this exam:

As a student health care professional, I will act with honesty, integrity, and respect in my academic pursuits and beyond.

[   ] Yes, I agree

 

 

Approved SON Faculty Apr. 15, 2015

 

 

 

 

 

 

 

 

APPENDIX E

 

STUDENT INCIDENT REPORTING FORM

(Submit to Program Director)

 

Student Name:                                                            Date of Report:

 

E-mail address:                                                               Preferred Phone Contact: Email

 

Program Enrolled:                                                            Date of Incident:

 

Location of Incident: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

  

Parties involved:

 

 

Description of Incident:

 

 

 

 

 

Witness(es):

 

 

Who Reported to:                                                                                              Date:

 

Student Signature                                                                                              Date:

 

Attached additional pages if needed.

 

TO BE COMPLETED BY PROGRAM DIRECTOR:

 

Description of Follow-up: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Action taken: _________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Resolution: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

 

Date(s) reported back to student: _________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

 

(Attach Copy of email communications sent to student)

 

Inquiry ongoing?              ____yes              ____no

 

Date inquiry closed with final resolution: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Program Director Signature: ________________________________ Date: __________________

 

Reported to: 

 

_____ SON Dean’s Office _____ Dean of Student Services and Alumni Services

 

_____ Operations/Security          _______ Other _______________________________________

 

Attached additional pages if needed.

 

 

 

 

APPENDIX F

 

MGH Institute of Health Professions

School of Nursing

Prelicensure Programs

 

Policy Statement Regarding ATI Assessments

 

The MGH Institute of Health Professions School of Nursing has adopted Assessment Technologies Institute (ATI) curriculum support tools to optimize student readiness for the NCLEX examination and to increase their confidence with and understanding of nursing content. ATI is an assessment-driven, comprehensive review program that includes multiple resources including review materials, practice assessments, proctored assessments, and remediation tools.

 

Recommendations Regarding Practice and Proctored Assessments

 

Timing

Practice assessment A: once 75% of the course content has been delivered Practice assessment B: once 85% of the course content has been delivered

Proctored assessments: once 90% or more of the course content has been delivered.

 

Rationales will be turned off during the period that practice assessments are open for testing. Once this period has ended, rationales will be opened for student review.

 

Students should receive at least one week to complete the remediation for both practice and proctored assessments.

 

 

The following ATI proctored assessments will be administered in the prelicensure courses:

  • Fundamentals Administered in Pharmacology

     

  • Mental Health Administered in Bio behavioral

     

  • Medical Surgical Nursing Administered in Common Problems

     

  • Pharmacology to be administered in either (Policy or Leadership TBD)

     

  • Community Health Administered in Community

     

  • Leadership Administered in Leadership and EBP

     

  • Maternal and Newborn Nursing and Nursing Care of Children (Combined) Administered in Maternal Child Health

     

  • RN Comprehensive Predictor Administered in Immersion

     

     

     

    Grading

     

    ATI assessments and remediation comprise 5% of the total course grade in those courses that use ATI with the following exceptions:

     

  • Maternal Child Nursing and Nursing Care of Children assessments and remediation will comprise a total of 6% of the Maternal Child Health course grade;

     

  • Comprehensive predictor assessments and remediation will comprise 10% of the Role Immersion grade.

     

     

     

    Proctored and Practice Assessments

     

  • Course syllabi will state the due dates and times for completion of proctored and practice assessments and completion and submission of remediation

     

  • Proctored assessments are mandatory and comprise a portion of the course grade as noted above.

     

  • A total of 2 practice assessments will be given prior to the proctored assessment. (Except Maternal and Newborn Nursing, Nursing Care of Children, which only take 1 practice assessment per specialty)

     

  • Students must complete the practice assessment and remediation prior to the proctored assessment by the assigned date and must scan and upload proof of remediation and all active learning templates to the designated D2L assignment folder.

     

  • Students must upload proof of remediation and active learning templates to the designated D2L assignment folder for the proctored assessments by the assigned due date listed in the course syllabus. No points will be given for late submissions.

     

  • Students who do not upload their transcript and remediation on the day of the proctored assessment will receive 50% of the points they achieve on the proctored assessment.

     

     

     

     

     

    Proctored and Practice Assessments: Maternal and Newborn Nursing and Nursing Care of Children

     

  • Course syllabi will state the due dates and times for completion of proctored and practice assessments and completion and submission of remediation

     

  • One practice assessment will be completed for each specialty rotation to establish baseline knowledge.

     

  • Students who do not upload their transcript and remediation on the day of the proctored assessment will receive 50% of the points they achieve on the proctored assessment.

     

  • Students must complete the practice assessment and remediation for the practice assessment prior to the proctored assessment (see general guidelines below).

     

  • A total of one proctored assessment will be given at the end of each specialty course.

     

     

     

    Comprehensive Predictor Assessment

     

  • A total of one proctored assessment will be given.

     

  • Students must complete the practice assessments and remediation by the assigned date prior to the comprehensive predictor and must scan and upload proof of remediation and all active learning templates to the designated D2L assignment folder.

     

  • Students who do not upload their transcript and remediation on the day of the proctored assessment will receive 50% of the points they achieve on the proctored assessment.

     

  • Students must upload proof of remediation and active learning templates to the designated D2L assignment folder for the comprehensive predictor by the due date assigned by the course faculty.

     

  • Course syllabi will state the due dates and times for completion and submission of remediation. No points will be given if these are completed past the due date.

 

The charts below describe point allotment for both the proctored assessments and the comprehensive predictor assessment:


POINT ALLOTMENT FOR PROCTORED ASSESSMENTS

(with exception of Maternal and Newborn Nursing and Nursing Care of Children)

 

Practice Assessments, Remediation, and Proctored 5-point total

 

Practice Assessment

Maximum 1 point

Practice assessment A Remediation:

Completion of Active Learning Templates, determined by raw score on practice assessment A

0.5 point earned for completion of Practice Assessment A and Remediation

Practice assessment B Remediation:

Completion of Active Learning Templates, determined by raw score on practice assessment

0.5 point earned for completion of Practice Assessment B and Remediation

 

Practice Assessment Remediation

 

Raw Score on Practice Assessments A and B

Remediation Required

Raw Score 100%

No Remediation Required

Raw Score 86-99%

No Remediation Required

Raw Score 77-85%

No Remediation Required

Raw Score 70-76%

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

Raw Score £ 69%

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed

 

Students must upload completed remediation assignments in the designated D2L assignment folder by assigned due date.

 

All Active Learning Templates must be handwritten with all sections completed.


 

 

Proctored Assessments

 

 

 

 

 

 

 

 

 

 

 

 

 

Proficiency level on ATI Proctored Assessment

 

Points Awarded

Level 3 Proficiency

4

Achieves maximum points for this level, no remediation required

Level 2 Proficiency

3

Achieves maximum points for this level, no remediation required

Level 1 Proficiency

0.5

Points awarded for level achieved and 1.5 added if remediation complete.

Below Level 1 Proficiency

0

Points awarded for level achieved and 1.5 added if remediation complete.

 

Proctored Assessment Remediation

 

A maximum of 1.5 points is awarded if required remediation is completed in accordance with Proficiency Level scored on Proctor Assessment

 

Students must upload completed remediation assignments in the designated D2L assignment folder by assigned due date.

 

All Active Learning Templates must be handwritten with all sections completed.

 

Proficiency Level on ATI Proctored Assessment

Remediation Required

Level 3 Proficiency

No Remediation Required

Level 2 Proficiency

No Remediation Required

Level 1 Proficiency

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

Below Level 1 Proficiency

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed


Total Possible Points

 

Proficiency Level

Practice Assessments

Proctored Assessment

Remediation

Total

Level 3 Proficiency

1

4

Not needed

5

Level 2 Proficiency

1

3

Not needed

4

Level 1 Proficiency

1

0.5

1.5

3

Below Level 1 Proficiency

1

0

1.5

2.5

 

 

 

POINT ALLOTMENT FOR MATERNAL NEWBORN AND NURSING CARE OF CHILDREN

 

Practice assessment, remediation and proctored 6point total

 

Practice assessments

Maximum 1 points

Maternal Newborn

Practice assessment A with Remediation:

0.5 point earned for completion of practice assessment and remediation

Nursing Care of Children

Practice assessment A with Remediation:

0.5 point earned for completion of practice assessments and remediation

 

 

Practice Assessment Remediation

 

Raw Score on Practice Assessments A and B

Remediation Required

Raw Score 100%

No Remediation Required

Raw Score 86-99%

No Remediation Required

Raw Score 77-85%

No Remediation Required

Raw Score 70-76%

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

Raw Score £ 69%

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed

 

Students must upload completed remediation assignments in the designated D2L assignment folder by assigned due date.


 

Proctored Assessments

 

Maximum 3 points combined

 

 

 

 

 

 

 

 

 

 

 

 

 

Proficiency level on ATI Proctored Assessment

 

Points Awarded Maternal Newborn

 

Points Awarded

 

Nursing Care of Children

Level 3 Proficiency

2.5

2.5

Level 2 Proficiency

2.0

2.0

Level 1 Proficiency

1.5

1.5

Below Level 1 Proficiency

0

0

 

 

 

 

Proctored Assessment Remediation

 

A total of 2-point maximum (1 for each proctored assessment remediation) are awarded if required remediation is completed in accordance with Proficiency Level scored on Proctor Assessment

 

Students must upload completed remediation assignments in the designated D2L Dropbox by assigned due date.

 

Proficiency Level on ATI Proctored Assessment

Remediation Required

Level 3 Proficiency

No Remediation Required

Level 2 Proficiency

No Remediation Required

Level 1 Proficiency

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

Below Level 1 Proficiency

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed


POINT ALLOTMENT FOR COMPREHENSIVE PREDICTOR PRACTICE & PROCTORED

 

Practice Assessments & Remediation and Proctored = 10-point total

 

Practice Assessment

Maximum 5 points

Practice assessment A Remediation:

Completion of Active Learning Templates, determined by raw score on practice assessment A

2.5 point earned for completion of Practice Assessment A and Remediation

Practice assessment B Remediation:

Completion of Active Learning Templates, determined by raw score on practice assessment B

2.5 point earned for completion of Practice Assessment B and Remediation

 

Practice Assessment Remediation

 

Raw Score on Practice Assessments A and B

Remediation Required

Raw Score 100%

No Remediation Required

Raw Score 86-99%

No Remediation Required

Raw Score 77-85%

No Remediation Required

Raw Score 70-76%

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

Raw Score £ 69%

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed

 

Students must upload completed remediation assignments in the designated D2L assignment folder by assigned due date.

 

 

Comprehensive Predictor Assessment

 

Maximum points 5

 

All Active Learning Templates must be handwritten with all sections completed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Predicted probability of passing NCLEX

 

 

Points Awarded

95% on Comprehensive Predictor

5

86% - 94% on Comprehensive Predictor

4


 

81% - 85% on Comprehensive Predictor

1

< 80% on Comprehensive Predictor

0

 

 

 

Comprehensive Predictor Remediation

 

A total of 2 points maximum are awarded if required remediation is completed in accordance with Predicted % scored on Comprehensive Predictor.

 

Students must upload completed remediation assignments in the designated D2L assignment folder by assigned due date.

 

All Active Learning Templates must be handwritten with all sections completed.

 

Predicted % on Comprehensive Predictor

Remediation Required

³ 95% on Comp Predictor

No Remediation Required

86% - 94% on Comp Predictor

No Remediation Required

81% - 85% on Comp Predictor

Completion of a total of 2 Active Learning Templates chosen from the top any of the eight topics missed

< 80% on Comp Predictor

Completion of a total of 4 Active Learning Templates chosen from the top any of the ten topics missed