Nurse Assistant/Home Health Aide (NAT/HHA) Training ProgramGeneral,Info,Packet... · 2020-02-14 ·...

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Nurse Assistant/Home Health Aide (NAT/HHA) Training Program This 114 hour state approved program will prepare you for employment opportunities with nursing homes, home care agencies, and hospitals. While in training, you will learn necessary nursing skills through classroom lecture and skills practice in a fully equipped nursing lab. To compliment what you have learned in class, a mandatory clinical placement provides you with real life experience in a long-term care facility. Courses are offered in many different formats to fit your schedule. Please use the noncredit Course Search- Health Care Training option to view upcoming schedules. Training includes: Classroom lecture and skills practice Home Health Aide Training Certification 8 hours of Dementia Hand in Hand 24 hours of clinical experience Admission Requirements: Potential Students must be able to pass the Nurse Assistant Training Reading and Math Placement test or provide documentation of a High School Diploma or GED. Program Prerequisites: Prerequisite forms must be completed and submitted two weeks prior to start of class. You may mail, fax or hand deliver all required documents. Mail to: The Center for Workforce & Community Education Nurse Assistant Training 777 Elsbree Street C Building, Room C103 Fall River, Ma 02720 Drop off: Bristol Community College Bristol Community College 777 Elsbree Street Silver City Galleria Mall C Building, Room C103 2 Galleria Mall Drive Fall River, MA 02720 Taunton, MA 02780 Or Fax: 508-730-3273 Attn: Nurse Assistant Training Program

Transcript of Nurse Assistant/Home Health Aide (NAT/HHA) Training ProgramGeneral,Info,Packet... · 2020-02-14 ·...

Page 1: Nurse Assistant/Home Health Aide (NAT/HHA) Training ProgramGeneral,Info,Packet... · 2020-02-14 · The Textbook & Workbook that will be used for this program is Lippincott’s Essentials

Nurse Assistant/Home Health Aide (NAT/HHA) Training Program

This 114 hour state approved program will prepare you for employment opportunities with

nursing homes, home care agencies, and hospitals. While in training, you will learn necessary

nursing skills through classroom lecture and skills practice in a fully equipped nursing lab. To

compliment what you have learned in class, a mandatory clinical placement provides you with

real life experience in a long-term care facility.

Courses are offered in many different formats to fit your schedule. Please use the noncredit

Course Search- Health Care Training option to view upcoming schedules.

Training includes:

Classroom lecture and skills practice

Home Health Aide Training Certification

8 hours of Dementia Hand in Hand

24 hours of clinical experience

Admission Requirements:

Potential Students must be able to pass the Nurse Assistant Training Reading and Math

Placement test or provide documentation of a High School Diploma or GED.

Program Prerequisites:

Prerequisite forms must be completed and submitted two weeks prior to start of class. You may

mail, fax or hand deliver all required documents.

Mail to: The Center for Workforce & Community Education

Nurse Assistant Training

777 Elsbree Street

C Building, Room C103

Fall River, Ma 02720

Drop off: Bristol Community College Bristol Community College

777 Elsbree Street Silver City Galleria Mall

C Building, Room C103 2 Galleria Mall Drive

Fall River, MA 02720 Taunton, MA 02780

Or Fax: 508-730-3273 Attn: Nurse Assistant Training Program

Page 2: Nurse Assistant/Home Health Aide (NAT/HHA) Training ProgramGeneral,Info,Packet... · 2020-02-14 · The Textbook & Workbook that will be used for this program is Lippincott’s Essentials

Prerequisite Forms:

Certificate of Physical Examination and Immunization (Physical Forms)

Must have received a physical exam within the last year

Must provide documentation of: Tetanus, Varicella, MMR, Hepatitis B or declination

form for Hepatitis B

o Students without a current influenza vaccine will be required to wear a mask

during time spent at any clinical facility.

Criminal Offender Record Information (CORI) Report

Must submit the CORI Application. A positive CORI may prevent students from

completing requirement of the program

Sex Offender Record Information (SORI) Report

Must submit the SORI Application. A positive SORI may prevent students from

completing requirement of the program

Completed Tuberculosis Skin Test Form

TB test must have been done within the past year

Hepatitis B Declination Test Form

You are required to fill out this form if you request not to receive the Hepatitis B

Immunization series.

Consent for Drug/Alcohol Testing Form

Must be signed and dated

Nursing Assistant Training Program Standards Form

Describes Standards of the program, must be signed and dated

Completed Contact Information Form

Nurse Assistant Training Reading and Math Placement test

Must submit a copy of High School Diploma or GED prior to or on first day of class.

Must be able to pass the Nurse Assistant Training and Math Placement test or if you

cannot provide documentation of a High School Diploma or GED

Contact program coordinator at 508-678-2811 ext. 2663 to set up time to take the placement test.

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Frequently Asked Questions/Important Information:

What will I need to have/prepare for the first day of class?

You will need the required textbook and workbook. The textbook and workbook that will be used for

this program is Lippincott’s Essentials for Nursing Assistants: A Humanistic Approach to Caregiving,

Fourth Edition Pamela J. Carter ISBN: 978-1-4963-7546-9 and ISBN: 978-1496344250.

All textbooks can be purchased from BCC’s bookstores, check BCC website for locations and hours.

You will need to read the first three chapters of the text prior to class

Bring any remaining program forms/ paperwork the first day of class with you

You will not need your uniforms the first weeks of class

What kind of uniforms can we wear?

Ceil blue (light blue) scrubs-basic v neck

What type of shoes are acceptable?

White nursing shoes/sneakers, no open backed shoes, no clogs

When are the clinics held?

Clinical times and locations will be provided to you by the program coordinator when available. Clinical

assignments are often held during the last weeks of the program, mostly on weekends, also during the

week if available, subject to change.

Students are required to attend a clinical orientation at the designated clinical facility.

The Program Coordinator will inform you of the clinical dates as soon as they are available.

You will be required to attend a clinical orientation at the facility approximately one week before

clinical begins; date is based on class schedule and facility availability

Are there any other items I am required to purchase?

Items that are required to purchase are: The textbooks, hospital blue scrubs and white shoes. Book can

be purchased at the BCC bookstore

It is recommended to have a watch with a second hand, notebook for class, a small pocket notebook for

clinical

The NAT program coordinator will provide with specific registration information and dates for the testing once

classes begin.

Please contact us at 508-678-2811 ext. 2527 for assistance.

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NURSE ASSISTANT/HOME HEALTH AIDE TRAINING PROGRAM

STUDENT CONTACT INFORMATION

PLEASE PRINT

Name: ________________________________________________________________________

Address: ______________________________________________________________________

______________________________________________________________________

Email address: _________________________________________________________________

Home phone: __________________________________________________________________

Cell/Alternate phone: ____________________________________________________________

Emergency contact name: ________________________________________________________

Emergency contact phone: ________________________________________________________

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STATE APPROVED NURSE ASSISTANT/HOME HEALTH TRAINING

PROGRAM STANDARDS

PROGRAM REQUIREMENTS:

The following are program requirements and must be completed.

GED/ High School Diploma – must provide a copy.

CRIMINAL OFFENDER RECORD INFORMATION FORM - Must submit a CORI Application. A

positive C.O.R.I may prevent students from completing the clinical requirement of the program.

SEX OFFENDER RECORD INFORMATION FORM - Must submit a SORI Application. A positive

SORI may prevent students from completing the clinical requirement of the program.

PHYSICAL FORM -Must have received a physical exam within the last year.

IMMUNIZATION FORMS- Must provide documentation of Immunizations; including Tetanus,

Varicella, MMR, and Hepatitis B.

o Students without a current influenza vaccine will be required to wear a mask during time spent at

any clinical facility.

TUBERCULOSIS SKIN TEST (TB TEST) – Must be done within the past year.

CONSENT FOR DRUG/ALCOHOL TESTING FORM – Must be signed and dated.

CONTACT INFORMATION FORM – Must provide current contact and emergency information,

HEPATITIS DECLINATION FORM - Must sign and date if you have not yet received the Hepatitis B

Vaccine series.

CLASS ATTENDANCE

Report to all classes and clinical assignments on time. Successful completion of this program is

dependent upon full participation in all scheduled activities. Hours for the program are required by the

State in order to sit for the Red Cross exam.

All absences, tardiness, or early dismissals must be reported to program coordinator.

o Be prepared to provide documentation if asked to do so.

o Tardiness is cause for dismissal from the program.

o One excused absence.

o Contact Program coordinator when you are absent from class. Program is not responsible to

provide make up classes

You are responsible for completing all assignments on time.

Breaks: 15 minute break during 3-4 hour class session. Two 15 minute breaks and a ½ hour lunch

break during full day classes. During clinical assignments, you will be scheduled a ½ hour break.

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PHYSICAL APPEARANCE

While in training, at clinical and when representing Bristol Community College, you must maintain a neat and

clean appearance at all times.

Fingernails must be clean and neat.

Clothing must be clean and neat.

Clothing must be appropriate for a classroom learning environment, including while lifting and moving

during skills instruction.

Tattoos must be covered for clinical.

Facial/body piercings jewelry must be replaced with clear spacers for clinical.

GRADING

All students enrolled in the nurse assistant training must maintain a passing grade of 75%, complete 114 hours

of classroom lecture, skills lab, and pass a supervised clinical practice in a long term care facility.

You must pass the course final exam in order to receive a certificate of completion.

You must complete all classroom, lab and clinical hours in order to receive your certificate of

completion, and to be eligible to sit for the state certification exam.

Information regarding quizzes and exams will be provided on the course syllabus per the instructor.

A Final Exam will be given at the completion of the class.

Any quiz or exam grade below 70% must be retaken in order to pass the course.

TEXTBOOKS

The Textbook & Workbook that will be used for this program is Lippincott’s Essentials for Nursing Assistants:

A Humanistic Approach to Caregiving, Fourth Edition. Pamela J. Carter ISBN: 978-1-4963-3956-0 (Textbook)

and ISBN: 978-1496344250 (Workbook). Textbooks can be purchased from the College Book Store. You must

have a textbook for the first class.

LABORATORY/SKILL PRACTICE

During lab/skill practice you are only to practice the skills assigned by the instructor and use only the assigned

equipment. Seek assistance from an instructor for any procedure with which you are not familiar or comfortable

with. 100% competency is required on skills check list.

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Skills are first demonstrated by an instructor, followed by practice time and then return demonstration

by each student. Skills are practiced on mannequins and fellow classmates. Class participation is

required by all students.

CLINICAL ASSIGNMENT/APPEARANCE AT CLINICAL SITE

The clinical experience is conducted at an area Long Term Care Facility and consists of hands on training.

Each student will be responsible for the care of assigned patients.

o The student must demonstrate safe and accurate care of patients under the supervision of the

clinical instructor.

All students must pass clinical and complete all skills required on the assigned training skills list form in

order to and take the state exam.

No unexcused absences are allowed during clinical rotation.

o There is no option for clinical make-ups. If an excused absence occurs during clinical with

approved documentation and you have given 24 hours’ notice of your absence you may be

allowed to make up a maximum of 1 clinical day with the next clinical rotation if space allows.

You must complete the required hours of clinical training to receive your certificate.

Clinical times and locations will be provided to you by the program coordinator when available. Clinical

assignments are often held during the last weeks of the program, mostly on weekends, also during the

week if available, subject to change.

Students are required to attend a clinical orientation at the designated clinical facility.

Appropriate dress to clinical sites is required at all times. Students must adhere to the following

guidelines:

o Only the BCC uniform is to be worn to the facility (Ceil blue- light blue color). White flat soled

nursing shoes, or white sneakers, no open back shoes, no clogs allowed.

o Name tag must be worn at all times.

o Uniforms should be cleaned and pressed before each clinical.

o Hair should be worn up and off collar, with little or no hairspray

o Minimal jewelry and makeup, no perfume/cologne, nails trimmed

o Adhere to the health care facility policies at all times

o No Cell Phones

CLASSROOM & CLINICAL CONDUCT

Any student who fails to comply with program guidelines or who demonstrates inappropriate or unsatisfactory

behavior may be dismissed from the program.

No Cell Phone/Texting usage during class, cell phones must be off the desk and silenced during class.

Disrespectful, interruptive, disruptive, impatient behavior toward the instructors, fellow students, and

staff at clinical will not be tolerated at any time.

You will be dismissed during any portion of this class should your conduct be inappropriate.

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You may be dismissed if you are caught cheating, suspected of alcohol or drugs use on campus or before

class.

You may be dismissed if the instructors suspect you are a safety risk in clinical due to a questionable

behavioral or physical issues.

You will be dismissed for fighting, or for the use of profanity, or demonstrating an attitude to

fellow students or instructors.

If you are dismissed from class for any reason you are not eligible for a refund.

NON CREDIT CLASS REFUND POLICY

For classes that meet one time a week: If you withdraw during the first week of classes, you will receive

a full refund, from which a $10 processing fee will be held. If you withdraw during the second week of

class you will receive a 50% refund, if you withdraw during the third week of class or thereafter, you are

ineligible for any refund

For classes that meet more than one time per week: If you withdraw from a course after the first class

meeting but before the second class meeting, you will receive a full refund, from which a $10 processing

fee will be held. If you withdraw from the course after the second-class meeting, but before the third

class you will receive a 50% refund. If you withdraw from the course after the third class meeting or

thereafter, you are ineligible for any refund.

You will not be issued a refund in the case of failing the class, failing the clinical portion, unexcused absences

or not meeting the mandatory program requirements.

MESSAGES

If you have any questions or concerns during the program please contact the Program coordinator at 508-678-

2811 ext. 2663 or ext. 2527 if you need to speak with someone immediately, or email

[email protected]. Emergency calls should be directed to Campus Police at ext. 2292 or ext. 2218.

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I have read and understand the STATE APPROVED NURSE ASSISTANT/HOME HEALTH TRAINING

PROGRAM STANDARDS. I understand that my failure to comply with the above standards will cause dismissal

from the program. I have been given a copy of the standards.

______________________________________________________________________________

Print Name

______________________________________________________________________________

Signature Date

______________________________________________________________________________

Parent/Guardian (if student is under18 years of age) Date

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Student Name: ________________________________

PHOTOGRAPHY RELEASE

I hereby allow Bristol Community College to photograph me for use in any type of media BCC deems

appropriate. This can include but is not limited to newspaper stories, printed literature and online information. I

hereby give BCC its legal representative and assigns, those for whom BCC is acting, and those acting with its

permission, or its employees the right and permission to copyright and/or use, reuse and/or republish

photographic pictures.

______________________________________________________________________________

Signature Date

______________________________________________________________________________

Parent/Guardian Signature (if student is under 18 years of age) Date

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Student Name: ___________________________________

CONSENT FOR DRUG/ALCOHOL TESTING

Nurse Assistant/Home Health Aide Training Program

If you are offered and accept to take part in Bristol Community College (BCC) Certified Nurse Assistant

Training Program in the interest of safety for all concerned, you may be required to take a urine test for drug

and/or alcohol use.

I, __________________________, have been fully informed of the reason for this urine test for drug and/or

alcohol (I understand what I will be tested for), the procedure involved, and do hereby freely give my consent.

In addition, I understand that the results of this test will be forwarded to Bristol Community College and

become part of my record.

If this test is positive, and for this reason I am not admitted to the program, I understand that I will be given the

opportunity to explain the results of this test.

I hereby authorize these test results to be released to Bristol Community College, Nurse Assistant Training

Program, The Center for Workforce and Community Education.

___________________________________________________________________________

Signature Date

___________________________________________________________________________

Witness Date

HEPATITIS B VACCINATION DECLINATION FORM

I understand that due to my occupational exposure to blood or other potentially infectious materials. I may be at

risk for acquiring Hepatitis B. I have been given the opportunity to be vaccinated with Hepatitis B vaccine.

However I decline the Hepatitis B vaccine at this time. I understand that by declining this vaccine, I continue to

be at risk for of acquiring hepatitis B a serious disease.

_____________________________________________________________________________

Signature Date

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Student Name: ___________________________________

TUBERCULOSIS SKIN TEST FORM

Healthcare Professional/Patient Name: ______________________________________________

Testing Location: _______________________________________________________________

Date Placed: _____________________________

Site: ___Right ___Left

Lot#: _____________________________ Expiration Date: ________________

Signature (administered by):_______________________________________________________

RN__ MD__ Other: ________________________

Date Read (within 48-72 hours from date placed): _____________________________________

Induration (please note in mm): ____________________________mm

PPD (Mantoux) Test Result: __Negative __Positive

Signature (results read/reported by): ________________________________________________

RN__ MD__ Other: ________________________

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Center for Workforce & Community Education

Nurse Assistant /Home Health Aide Training Program

Health Care Provider’s Examination

Name: ___________________________________________________________________________________________

Date of Birth: _____________________________________________________________________________________

Pertinent Medical History

Current Health Issues

Y N

Allergies: Please list: Medications _______________________ Food__________________

Other __________________________________________________________________________________

History of Anaphylaxis to _________________________________________ Epi-Pen Yes No

Asthma

Diabetes: Type I Type II

Seizure disorder____________________________________________________________________________________

Other (Please specify) _______________________________________________________________________________

Current Medications (if relevant to the student's health and safety)

Physical Examination

Date of Examination: ___________________________

Height: ________ (_____ %) Weight :_________(_____%) BMI: _________ (_____ %) BP: _________

(Check = Normal / If abnormal, please describe.)

General________________ Lungs__________________ Extremities_____________

Skin___________________ Heart___________________ Neurologic_____________

HEENT________________ Abdomen_______________ Other__________________

Dental/Oral_____________ Genitalia________________

Laboratory Results: Other__________________________________________________________________________________

The entire examination was normal:

Targeted TB Skin Testing: Med-to-High risk (exposure to TB; born, lived, travel to TB endemic countries; medical risk factors):

Date of PPD: ____; Results: ____mm. NEGATIVE POSITIVE

Referred for evaluation to: ______________________________________________________________ Low risk (no PPD done)

This student has the following problems that may impact his/her educational experience:

Vision Hearing Speech/Language Fine/Gross Motor Deficit

Emotional/Social Behavior Other

Comments/Recommendations: ____________________________________________________________________

Y N Based on your evaluation, do you feel this person can meet the program requirements without doing harm to him/

herself.

This student is capable of performing those activities required by enrollment in the NA/HHA Training Program.. If no, please

list restrictions: _____________________________________________________________________________________________

Y N Immunizations are complete: If no, give reason: Please attach Massachusetts Immunization Information System

Certificate or other complete immunization record.

_____________________________________________________________________________________________

Signature of Examiner DATE: Print name of Examiner

_____________________________________________________________________________________________

Address State Phone

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CERTIFICATE OF IMMUNIZATION

Name:___________________________________________________________________________________________________

Date of Birth: / /

Vaccine Date/Vaccine Type Vaccine Date/Vaccine Type

Hepatitis B

(e.g., HepB, HepB-

Hib, DTaP-HepB-IPV)

1 Measles, Mumps,

Rubella

(MMR)

Varicella (Var)

1

2 2

3 1

Diphtheria, Tetanus,

Pertussis

(e.g., DTaP, DT,

DTaP-Hib,

DTaP-HepB-IPV, Td)

*Td booster required

every 10 years

1 2

2 Hepatitis A

(HepA) 1

3 2

4 Influenza

Inactivated

(Intramuscular) or

Live (Intranasal)

1

5 2

I certify that this immunization information was transferred from the above-named individual’s medical records.

_____________________________________________________________________________________________

Doctor or Nurse’s Name (PLEASE PRINT)

_____________________________________________________________________________________________Signature

Date

Serologic Proof

of Immunity

Check One

Chickenpox History

Test (if done) Date of Test Positive Negative Check the box if this person has a physician-certified reliable

history of chickenpox.

Reliable history may be based on:

physician interpretation of parent/guardian description of chickenpox

physical diagnosis of chickenpox, or

serologic proof of immunity

Measles / /

Mumps / /

Rubella / /

Varicella* / /

Hepatitis B / /

* Must also check Chickenpox History box.

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THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150 TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS

Criminal Offender Record Information (CORI)

Acknowledgement Form

To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing purposes.

______________Bristol Community College_____________________________ is registered under the (Organization)

provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the

DCJIS. I hereby acknowledge and provide permission to _____________Bristol Community College________ (Organization) to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my

signature. I may withdraw this authorization at any time by providing ______Bristol Community College___

(Organization) with written notice of my intent to withdraw consent to a CORI check. FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The _____________________ Bristol Community College______________________________ may conduct (Organization)

subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that

______________________________ Bristol Community College_____________, must first provide me (Organization)

with written notice of this check.

By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

___________________________________________________________ _________________________________

Signature of CORI Subject Date

Please indicate your status with Bristol Community College

by providing program of study (student), position title (employee), or volunteer title:

Title: Nurse Assistant Training Program

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THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services 200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973 MASS.GOV/CJIS

SUBJECT INFORMATION

Please complete this section using the information of the person whose CORI you are requesting.

The fields marked with an asterisk (*) are required fields.

* First Name: ________________________________________________________ Middle Initial: _________________

* Last Name:_________________________________________________________ Suffix (Jr., Sr., etc.): _____________ Former Last Name 1:_______________________________________________________________________________ Former Last Name 2:_______________________________________________________________________________ Former Last Name 3:_______________________________________________________________________________ Former Last Name 4:_______________________________________________________________________________

* Date of Birth (MM/DD/YYYY): ___________________ Place of Birth: ________________________________________

Last SIX digits of Social Security Number: ___ ___ ‐‐ ___ ___ ___ ___ ☐ No Social Security Number

Sex: _________________ Height: _____ ft. _____ in. Eye Color: _______________ Race: ______________________

Driver’s License or ID Number: ______________________________________ State of Issue: _________________ Father’s Full Name: ________________________________________________________________________________ Mother’s Full Name: _______________________________________________________________________________

Current Address

* Street Address: ___________________________________________________________________________________

Apt. # or Suite: _____________ *City: __________________________ *State: ________ *Zip: _______________

SUBJECT VERIFICATION

The above information was verified by reviewing the following form(s) of government‐issued identification: _______________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________ Verified by: ___________________________________________________________ Print Name of Verifying Employee

___________________________________________________________ _________________________________ Signature of Verifying Employee Date

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Commonwealth of Massachusetts Sex Offender Registry Board

M.G.L. c. 6, § 178I REQUEST FOR SEX OFFENDER REGISTRY INFORMATION

All requests for sex offender information must be made on this

form and mailed to the Sex Offender Registry Board, Attn:

SORI Coordinator, P.O. Box 392, N Billerica, MA 01862, along with a self-addressed stamped envelope. The Board

will provide a report that includes the following information: whether the person identified is a sex offender with an obligation to register, the

offense(s) for which the offender was convicted or adjudicated, and the date(s) of the conviction(s) or adjudication(s). Please be advised that the

law only permits the public to receive information on sex offenders required to register and finally classified by the Board as a level 2

(moderate risk) or level 3 (high risk) offender. Therefore, information is not available to the public if the identified individual is a level 1 (low risk)

offender or if he/she has not yet been finally classified by the Board.

All requests shall be recorded and kept confidential, except to

assist or defend in a criminal prosecution.

For Human Resources Use Only Requestor’s name: Human Resources -_______________________________________________ Date of birth: ________________________

Organization name: (if any)_____ Bristol Community College_______________________________________________________

Address: __777 Elsbree Street________________________ Telephone number: (_774_)__357-2195

__ Fall River, MA 02720________________________________________________________ I swear under the pains and penalties of perjury that I am the above-named person, at least 18 years of age, and I am requesting

information for my own protection, the protection of a child under 18 years of age, or for the protection of another person for whom I

have responsibility, care or custody.

Requestor’s signature: _____________________________________________ Date: ____________________________

I hereby request that the following information be used to determine whether the identified individual is a sex offender required to register in

Massachusetts.

Subject’s LAST NAME:

Subject’s FIRST NAME:

Subject’s MIDDLE INITIAL:

Date of birth or approximate age:

M M / D D / Y Y Y Y AGE

Address (PRINT): ________________________________________________________________________

Personal identifying characteristics:

Sex: ______ Race: ______ Height: ______ Weight: ______ Eye Color: ______ Hair Color: ______

Other information (e.g. license plate number, parents’ names, etc.): _____________________________________________

________________________________________________________________________________________________________________

If additional information is needed, please contact the Requestor at the telephone number above.

**********WARNING********** SEX OFFENDER REGISTRY INFORMATION SHALL NOT BE USED TO COMMIT A CRIME OR TO ENGAGE IN ILLEGAL DISCRIMINATION OR HARASSMENT OF AN OFFENDER. ANY PERSON WHO USES INFORMATION DISCLOSED PURSUANT TO M.G.L. C. 6, §§ 178C – 178Q FOR SUCH PURPOSES SHALL BE PUNISHED BY NOT MORE THAN TWO AND ONE HALF (2 ½) YEARS IN A HOUSE OF CORRECTION OR BY A FINE OF NOT

MORE THAN ONE THOUSAND DOLLARS ($1000.00) OR BOTH (M.G.L. C. 6, § 178N). IN ADDITION, ANY PERSON WHO USES REGISTRY

INFORMATION TO THREATEN TO COMMIT A CRIME MAY BE PUNISHED BY A FINE OF NOT MORE THAN ONE HUNDRED DOLLARS ($100.00)

OR BY IMPRISONMENT FOR NOT MORE THAN SIX (6) MONTHS ( M.G.L. C. 275, § 4). SOR Form 4 (12/18)

SORB USE ONLY