Last day to apply for a Spring 2016 Allied Health Internship is Monday, October 26, 2015

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1 Step 1 Obtain required immunizations and/or titers (students must prove immunity by either proof of immunization or titer), AZ DPS Level One Fingerprint Clearance Card, and CPR card for Health Care Providers. See attachment A for details. Step 2 If needed, request official transcripts from institutions other than Yavapai College, and have the transcripts mailed directly to the Yavapai College Registrar s Office, 1100 E. Sheldon St., Prescott, AZ Step 3 Make an appointment with an Allied Health Academic Advisor at either the Prescott Campus ( ) or the Verde Campus ( ) and obtain a completed Certificate Check Sheet signed by an academic advisor. Submit the completed check sheet with the internship application. Step 4 Fax the completed Allied Health Internship Application and all supporting documentation to Allied Health. FAX: SCAN AND TO Step 5 Allied Health will send application approval by (sent to the address on the application) giving provisional acceptance to the internship. Provisional acceptance is subject to passing a random drug test. Students will be directed to CertifiedBackground.com to purchase a drug screen at a cost of approximately $ i. Random drug testing is a standard procedure throughout Allied Health Internship Programs. ii. Allied Health students participating in internships or a clinical experience are tested for illegal drug use. Students with positive drug screens are not permitted to take Allied Health courses for a minimum of one year. A student with a history of drug-related conviction may be disqualified from participating in an internship or clinical experience and may be ineligible for certification and/or licensure. Please meet with an academic advisor for further directions. Step 6 Check your frequently for communications from YC s Allied Health Dept. Failure to meet deadlines sent to you by may result in forfeiting provisional acceptance to the internship. IMPTANT MANDATY IENTATION F ALL ALLIED HEALTH INTERNSHIP STUDENTS WILL BE: Tuesday, January 19, 2016, from 8 a.m. 12 noon (Prescott Campus Bldg. 4, Room 102) (Monday, January 18, 2016 is the Martin Luther King Jr. Holiday) Last day to apply for a Spring 2016 Allied Health Internship is Monday, October 26,

2 Applicant Information Full Name: Address: Last First M.I. Street Address or P. O. Box Apartment/Unit # Home Phone: City ST ZIP Code Yavapai College ID# address: Date of Birth: / / Academic Year: Semester: Spring Summer Fall Internship: Arizona DPS Fingerprint Clearance Card Pharmacy Technician Card #: Phlebotomy Technician Medical Coding or HIT Practicum Date Expires: TB Test Cannot expire during class. Date Read: CPR for Healthcare Provider card Cannot expire during class. Copy of Yavapai College Picture ID Medical Assistant Expiration Date: Tetanus, diphtheria, pertussis (renew every 10 yrs.) Date of immunization: MMR (Measles, mumps, rubella) (2 doses; or titer level ) Date of 1 st dose: Date of Titer verifying immunity: Date of 2 nd dose: Varicella vaccine (2 doses; or titer level) Date of 1 st dose: Date of Titer verifying immunity: Date of 2 nd dose: Hepatitis B vaccine (3 dose series; or titer level) Date of 1 st dose: Date of Titer verifying immunity: Date of 2 nd dose: Trainee License: PHARMACY TECHNICIAN INTERNSHIP STUDENTS ONLY Arizona Pharmacy Technician Trainee License (must be 18 years of age) Go to: Or call: Certificate Check Sheet Signed by an Academic Advisor showing successful completion of required courses for the certificate and/or degree program with a grade of C or better. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED PROCESSED 2

3 Affirmative Action/Equal Employment Opportunity Yavapai College is an affirmative action/equal opportunity institution. For Yavapai College s nondiscrimination statement, visit A lack of English language skills will not be a barrier to admission and participation in the programs of the college. Yavapai College es una institución de oportunidades de acción/igualdad afirmativa. Para la declaración de no discriminación de Yavapai College, visite La falta de conocimiento del idioma inglés no será una barrera para la admisión y participación en los programas de la universidad. Application Checklist for Allied Health Internship Allied Health Internship Application with: a. Certificate Check Sheet form (signed by an Academic Advisor) Negative TB Skin Test (must not expire during internship) Chest X Ray Diagnostic Report stating negative for TB (which will not expire prior to the end of your program or internship) Copy of both sides of CPR for Healthcare Providers card (must not expire during internship) YC Allied Health does not accept online CPR and: Copy of both sides of Arizona Department of Public Safety issued Level-One Fingerprint Clearance Card Copies showing proof of all immunizations or titers. ALL IMMUNIZATIONS ARE REQURED AT TIME OF APPLICATION Copy of Yavapai College or other Picture ID I will be available hours per week to complete the hour internship. I agree to timely complete internship site specific on-boarding requirements such as: fingerprinting; background check; online training or other as specifically required by clinical site. Internship Student Signature Fax the completed Allied Health Internship Application and all supporting docs to Allied Health at FAX: or scan in all documents and to: 3

4 ATTACHMENT A Immunizations Students should submit copies of their immunization records, and retain the originals for their own files. The Department of Allied Health is unable to provide copies of these records to replace lost originals. Students are responsible for remaining in compliance with all mandated immunizations, immunization records, and students must adhere to all deadline requirements. Copies of updates to immunization records must be submitted to the Allied Health Administrative Assistant for the student files as mandated by the Division in order to continue in the program. All immunization records must include your name and the name and signature of the healthcare provider giving the immunization and the date. Required Immunizations 1. MMR (measles/rubeola, mumps, rubella) Options to meet this requirement: a. Attach a copy of proof of two previous MMR vaccinations to the health declaration form. b. If you have had all three illnesses you have received the vaccinations but have no documented proof, you must have a titer drawn for each illness. i. If the titer results are POSITIVE, attach a copy of the results to the health declaration form. ii. If the titer results are NEGATIVE, you must get two MMR vaccinations (each 30 days apart) and attach documentation to the health declaration form. 2. Varicella (chicken pox) Options to meet this requirement: a. Attach a copy of proof of a POSITIVE IgG titer for Varicella. b. If the titer is NEGATIVE, attach a copy of proof to the health declaration form that you received two Varicella vaccinations (each 30 days apart) and attach documentation to the health declaration form. 4

5 3. Tetanus/Diphtheria and Pertussis (Tdap) immunization within the past 10 years. Attach a copy of proof of Tdap vaccination to the health declaration form. 4. Tuberculosis Options to meet this requirement: a. Attach a copy of proof of a recent TB skin test (PPD), TB skin test must be current. Records for PPD (skin testing for tuberculosis) require name and signature of the healthcare provider and findings. b. If you have a POSITIVE TB skin test you must submit a chest x-ray diagnostic report stating negative for TB and must be current. 5. Hepatitis B In order to apply to the Program, you must complete at least one injection and stay on track with the subsequent two injections according to the timeline set forth in c, below. Options to complete this requirement: a. Attach a copy of proof of completion of three Hepatitis B injections to the health declaration form. b. Attach a copy of proof of a POSITIVE HbsAB titer to the health declaration form. c. If you have not received the injections in the past, you must obtain the first injection and attach a copy of proof of the injection to the health declaration form. Then, you must receive the 2 nd injection in one month and the 3 rd injection five months after the second injection. Submit documentation to Allied Health Administrative Assistant. 5

6 Arizona DPS Fingerprint Clearance Card Fingerprinting is available through the Yavapai College Campus Police office on the Verde Valley and the Prescott campuses. The Campus Police office will provide you with a card of your fingerprints and the Arizona DPS Fingerprint Clearance Card application. Students must mail their fingerprints, the application and the required fee to the Department of Public Safety for processing. Processing may take 6-13 weeks. Copies of both sides of the card are required as part of your documentation. Fingerprint clearance cards can be obtained from the Yavapai College Campus Police Departments on Wednesdays during the hours of 9:00 a.m. 12 noon, at no charge. Prescott campus: Campus Police is located in the Welcome Center, Building 28, Rm Telephone: (928) Verde Valley campus: Telephone: (928) For additional information please click here for the AZ Dept. of Public Safety. CPR for Health Care Providers Internship applicants must have current CPR for Health Care Providers certification that will not expire prior to the end of your internship or program. CPR for Health Care Providers must be pre-printed on the card. Yavapai College offers this half credit course, EMS123, in a one day session year round. If you are using another provider, it is your responsibility to ensure that it meets the program/ internship requirements. Yavapai College Allied Health Department does not accept online CPR certifications. IMPTANT MANDATY IENTATION F ALLIED HEALTH INTERNSHIP STUDENTS Tuesday, January 19, 2016, from 8 a.m. 12 noon (Prescott Campus Bldg. 4, Room 102) Last day to apply for a Spring 2016 Allied Health Internship is Monday, October 26,

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