1 Phoenix College Medical Laboratory Science Program (MLT) Application Associate in Applied Science in Medical Laboratory Science Program Submission : September 6, 2013 Submit application to Phoenix College Advisement, 1202 W. Thomas Road, Phoenix, AZ by 4pm on September 6, 2013 We appreciate your interest in the Medical Laboratory Science Program (MLT Level program) at Phoenix College. Please follow this checklist carefully to insure that your application and documentation are in order for the selection committee. Completed Medical Laboratory Science Program (MLT) Application Completed Program Immunizations & Health Declaration Completed and signed Health Declaration signed after August 1, 2013 by health care provider Copy of MMR vaccination records or proof of positive titers for Measles, Mumps, and Rubella Copy of Varicella vaccination records or proof of positive titer for Varicella Copy of Tetanus/Diphtheria (Td) vaccination records completed after January 1, 2004 Copy of Hepatitis B vaccination records or proof of positive titer for Hepatitis B Copy of Negative TB skin test or chest x-ray completed after August 1, 2013 Copy of CPR card for the Health Care Provider must be valid through December 31, 2014 Unofficial high school/college transcript showing completion of prerequisite course work or signed waiver for prerequisites Copy of high school diploma or GED Completed reference form, to be mailed separately Completed experience or statement of understanding Medical Laboratory Science form Copy of valid Fingerprint Clearance Card (both sides of the card) Sign the MCCCD Background Check Requirements form I have completed this form and attached all of the required documentation listed above. Signature Print Name Student Number If you have any questions about this process please contact Advisement at (602) ALL DOCUMENTATION MUST BE SUBMITTED AT THE SAME TIME, excluding the reference letter. NO PARTIAL PROGRAM APPLICATION WILL BE ACCEPTED. THE COLLEGE DOES NOT GUARANTEE ALL APPLICANTS TO BE ACCEPTED INTO THE MEDICAL LABORATORY SCIENCE (MLT) PROGRAM DUE TO LIMITATIONS OF CLINICAL PLACMENTS AND ACCREDITATION RESTRICTIONS.
2 Medical Laboratory Science (MLT Level) Program Application Name Last First Middle Former Name(s) (Maiden) (names that may identify transcripts) Student Identification Number Telephone work home Mailing Address Street City State Zip Permanent Address Street City State Zip Address Medical Laboratory Science reapplication? yes, I applied in 2012 at Phoenix College no Are you a legal Arizona resident as defined in the Phoenix College catalog? yes no present stay in Arizona began Month Day Year ( of birth if Arizona resident since birth) Most recent state of legal residence prior to moving to Arizona What date did you leave that state? Month Day Year Part I Education List each college attended COLLEGE PRINT FULL NAME CITY AND STATE DATES ATTENDED Check each level of education you have completed: GED High School Diploma AA Degree Other (please specify) Submission due date is September 6, 2013
3 Part II Checklist Complete EACH of the following steps to insure that you receive proper credit: Submit the following to: Advisement, Coordinator Medical Laboratory Science (MLT) Admissions Office 1202 West Thomas Road Phoenix, AZ Completed Medical Laboratory Science Application postmarked OR hand-delivered ALL UNOFFICIAL TRANSCRIPTS FROM EACH UNDERGRADUATE COLLEGE AND UNIVERSITY ATTACHED TO APPLICATION Course work approved as substitute or equivalent must have written documentation. Verbal consent will not be accepted. Request one Reference Form be completed by an employer and mailed directly to Advisement (address above). Complete EACH of the following steps to insure that you receive proper credit: Submit the following to: Phoenix College Admissions & Records 1202 W. Thomas Road Phoenix, AZ Phoenix College Student Information Form (application), if not currently enrolled. Official transcripts from all colleges and universities must be sent directly from issuing institution(s) and officially evaluated by the Phoenix College Office of Admissions and Records (at the written request of the student) as follows: STEP 1: Contact those colleges or universities requesting that your official transcripts be sent to Phoenix College Admissions and Records Office. There may be a charge for official transcripts. STEP 2: After 3 to 4 weeks, check with Phoenix College Admissions and Records Office at to verify arrival of all transcripts. If transcripts have not been received, contact the former institutions. STEP 3: (This step does not apply to schools within the Maricopa Community College District) - Complete Transcript Evaluation Request Form and submit it to the Office of Admissions and Records. - Official evaluation of your credits will be made AFTER all transcripts have been received. - Following 3 to 5 weeks from the date that your last transcript has been received, you will receive a copy of the evaluation. Courses considered freshman level (numbered 100 or above) and grades of C or better may be transferred. Only credits from regionally accredited college(s) identified in the college catalog will be evaluated. If you have questions about this report, please contact your advisor. STEP 4: If you did not receive credit for a specific prerequisite or corequisite, you may have to provide a course description for review by Admissions and Records. International Transcripts Please contact the Admissions and Records Office for evaluation of transcripts from institutions outside the United States. Submission due date is September 6, 2013
4 Part III Course Work 1. At least five prerequisites and all general education requirements must be completed and grades posted prior to the Medical Laboratory Science Program start date, December 13, Only those grades completed and posted by the application deadline date will be considered for evaluation. 3. All courses must reflect a grade of C or better. Prerequisites Course Grade College BIO 156 Introductory Biology for Allied Health or higher Completed In Progress (Check) CHM 130 and CHM 130 LL MAT 102 HCC 130 HCC 145 AA HCC 109 or EMT 101 Fundamental Chemistry and Lab or higher Math Concepts or higher level math specify course: Fundamentals in Health Care Delivery Medical Terminology I or comparable course CPR for HC Provider or Current CPR Certificate E (HC or Rescuer Level) General Education Courses that must be completed prior to submitting a program application Completed Course Grade College ENG101 or 107 First Year Composition ENG102 or ENG 108 or ENG 111 COM100 or 110 or 225 or 230 CRE101 BIO160 or CHM151 First Year Composition Communication Critical & Evaluative Reading I or exempt by assessment Humanities & Fine Arts any approved course Social & Behavioral Sciences any approved course BIO160 Introduction to Human Anatomy & Physiology or CHM151 General Chemistry I In Progress (Check)
5 Part IV Experience in the Medical Laboratory Science Field OR Statement of Understanding Attach the completed documents, Experience in the Medical Laboratory Science Field (or letter from employer) OR Statement of Understanding the Field of Medical Laboratory Science to your application. Part V - Reference Form Request an employer to complete and mail the Reference Form directly to Advisement. Part VI I certify that: 1. All information provided in this application is true and complete. 2. I understand that I must have completed at least four prerequisites and be enrolled in the fifth prerequisite, prior to enrolling in the Medical Laboratory Science courses. 3. It is my responsibility to provide all requested information to complete my file. Failure to provide all requested information may adversely affect my evaluation. 4. Admission to the program is conditional until all requirements have been satisfactorily completed. 5. I understand and agree to actively participate in the learning process as required. Applicant Signature Submission due date is September 6, 2013
6 Part VII Additional Information Describe any special skills you may possess that would enhance your application to the Admissions Committee. Equal Opportunity Statement Phoenix College, one of the Maricopa Community Colleges, does not discriminate on the basis of race, color, gender, national origin, religion, handicap or age in application, admission, participation, access and treatment of persons in instructional or employment programs and activities. Submission due date is September 6, 2013
7 Experience in the Medical Laboratory Science Field ONLY complete this section if you have relevant work experience in laboratories. Name Student Identification Number 1. Briefly describe your duties while working in the Medical Laboratory Science field: 2. Experience Select one of the following indicating your total length of experience in the Medical Laboratory Science field: 6 months to less than 1 year full-time experience 1 year to less than 2 years full-time experience 2 years to less than 3 years full-time experience 3 years to less than 4 years paid full-time experience 4 years to less than 5 years full-time experience 5 years or more full-time experience 3. Work Experience Summary Employer From To Number of hours per week Example: Arizona Clinical Laboratory Jan./ 2009 Jan./ I verify that all of the above information is true and correct. I understand that any falsification could result in nonacceptance into the program or dismissal from the program. Failure to complete and sign this document will result in non-consideration of work/observation experience. Applicant Signature I verify that has worked for me as listed above and that all of the above information is true and correct. Supervisor Signature PRINT Supervisor Name Notary (or attach letter from supervisor on supervisor s letterhead) Submission due date is September 6, 2013
8 Statement of Understanding the Field of Medical Laboratory Science Applicants with no relevant work experience in medical laboratories must complete this Statement of Understanding (Attach to your application) Name Student Identification Number Briefly describe, in one page of less, your understanding of the Medical Laboratory Science field for Laboratory professionals in the Medical Laboratory Technician scope of practice. Please also document in your narrative response the resources used to acquire your understanding of the Medical Laboratory Science field (examples web site, observation, interview of a current Laboratory professional, etc.).
9 Reference Form - Phoenix College Medical Laboratory Science (MLT) Program Applicant Instructions: This reference is required to complete your application. It must come from an employer who knows you well and can comment on your academic ability, employment skills and your suitability and preparation for a career in Medical Laboratory Science. Please give the form to your designated reference, providing him or her with a stamped envelope, addressed to: Advisement, Phoenix College Hannelly Center, 1202 W. Thomas Road, Phoenix, AZ References written in confidence are often of greater value in assessing an applicant s qualifications. Please read the statement below and indicate your preference with regard to the confidentiality of this evaluation. In accordance with the Family Educational Rights and Privacy Acts of 1974 (Public Law ), I understand that I have the right of access to this reference but may choose to waive that right. My preference is noted below: I waive my right of access to this reference form I do NOT waive my right of access to this reference form Applicant s signature Applicant s name (please print) Student Identification # Evaluator Instructions: Please complete the following information and return directly to the Phoenix College Hannelly Center in the stamped envelope provided by the applicant. Sign the envelope on the back across the sealing flap. Name Title/Occupation Address Street City State Zip Phone ( ) How long have you known the applicant as an employee?: In what capacity? (check all that apply): Employer Supervisor Please indicate your evaluation of the applicant with a check mark: Intellectual Ability Communication Skills Emotional Maturity Adaptability Team Player Dependability Conflict Resolution Awareness of Limitations Reaction to Criticism Personal Integrity/Honesty Overall Evaluation Exceptional Excellent Good Average Below Average Not Observed Overall recommendation for admission to the Medical Laboratory Science Program: This applicant has my highest recommendation. I recommend the applicant with no reservation. I recommend the applicant with some reservations. I do not recommend this applicant. Additional comments optional. You may attach a separate sheet. Signature This form must be postmarked NO LATER THAN September 3, 2013
10 Allied Health and Nursing Programs Maricopa County Community College District Summary of Criminal Background Check Requirements effective September 1, 2011 Overview of the Requirements In order for students to be admitted to or maintain enrollment in good standing in Maricopa County Community College District s ( MCCCD ) Allied Health and Nursing programs ( Programs ) beginning on September 1, 2011, students must provide with their application to a Program all of the following: A copy of an Arizona Department of Public Safety Level One Fingerprint Clearance Card ( Card ). Students are required to pay the cost of applying for the Card. Cards that are NOT Level One status will not be accepted An original version of the Criminal Background Check Disclosure Acknowledgement form attached to this Summary signed by the student. Once a student has been offered placement in a nursing or allied health program they will be given information on how to complete the MCCCD supplemental background check with MCCCD s authorized vendor Certified Background. To enter the program the student must be able to provide documentation demonstrating that the student has achieved a Pass status on the MCCCD supplemental background check. Students are required to pay the cost of obtaining the background check. Students whose background checks on the date of actual admission to a Program that are more than 6 months old or students who have been in a Program for more than 12 months may be requested to obtain an updated background check. The addition of this criminal background check is due to the fact that some of MCCCD s largest clinical experience partners have established standards that are more stringent than those for obtaining a Card. At all times during enrollment in a Program, students must obtain and maintain BOTH a valid Level-One Fingerprint Clearance Card and passing disposition on supplemental background check performed by MCCCD authorized vendor. Admission requirements related to background checks are subject to change as mandated by clinical experience partners Implementation of the Requirements 1. Students that are denied issuance of a Card may be eligible for a good cause exception through the Arizona Department of Public Safety. It is the student s responsibility to seek that exception directly with the department. Until the student obtains a Card and meets the other requirements for admission, he or she will not be admitted to a Program. 2. Students admitted to a Program whose Card is revoked or suspended must notify the Program Director immediately and the student will be removed from the Program in which they have been admitted or are enrolled. Any refund of funds would be made per MCCCD policy. 3. The Criminal Background Check Disclosure Acknowledgement directs students to disclose on the data collection form of the MCCCD authorized background check vendor all of the requested information as well as any information that the background check may discover. Honesty is important as it demonstrates character. Lack of honesty will be the basis for denial of admission or removal from a Program if the information that should have been disclosed but was not would have resulted in denial of admission. Failure to disclose other types of information constitutes a violation of the Student Code of Conduct and may be subject to sanctions under that Code. Students have a duty to update the information requested on the [background check vendor] data collection form promptly during enrollment in a Program. The [background check vendor] data collection form may ask for the following information but the form may change from time to time: Legal Name Maiden Name Other names used Social Security Number of Birth Arrests, charges or convictions of any criminal offenses, even if dismissed or expunged, including dates and details. Pending criminal charges that have been filed against you including dates and details. Participation in a first offender, deferred adjudication or pretrial diversion or other probation program or arrangement where judgment or conviction has been withheld.
11 The authorized MCCCD background check vendor will be asked to pass or fail each student based on the standards of MCCCD s clinical experience partners that have established the most stringent requirements. The sole recourse of any student who fails the background check and believes that failure may have been in error is with the background check vendor and not MCCCD.
12 ACKNOWLEDGEMENT OF CRIMINAL BACKGROUND CHECK REQUIREMENTS APPLICABLE TO STUDENTS SEEKING ADMISSION TO ALLIED HEALTH OR NURSING PROGRAMS ON OR AFTER SEPTEMBER 1, 2011 Maricopa County Community College District In applying for admission to a Nursing or Allied Health program ( Program ) at the Maricopa County Community College District, you are required to disclose on the Arizona Department of Public Safety (DPS) form all required information and on the MCCCD authorized background check vendor data collection form any arrests, convictions, or charges (even if the arrest, conviction or charge has been dismissed or expunged), or participation in first offender, deferred adjudication, pretrial diversion or other probation program on this form. Additionally, you must disclose anything that is likely to be discovered in the MCCCD supplemental background check that will be conducted on you. Please complete the DPS form, the MCCCD authorized background check vendor form and any clinical agency background check form honestly and completely. This means that your answers must be truthful, accurate, and complete. If you know of certain information yet are unsure of whether to disclose it, you must disclose the information, including any arrest or criminal charge. Additionally, By signing this acknowledgement, you acknowledge the following: 1. I understand that I must submit to and pay any costs required to obtain a Level One Fingerprint Clearance Card and an MCCCD supplemental criminal background check. 2. I understand that failure to obtain a Level One Fingerprint Clearance Card will result in a denial of admission to a Program or removal from it if I have been conditionally admitted. 3. I understand that I must submit to and pay any costs required to obtain an MCCCD supplemental background check. 4. I understand that failure to obtain a pass as a result of the MCCCD supplemental criminal background check will result in a denial of admission to a Program or removal from it if I have been conditionally admitted. 5. I understand that, if my Level One Fingerprint Clearance Card is revoked or suspended at any time during the admission process or my enrollment in a Program, I am responsible to notify the Program Director immediately and that I will be removed from the Program. 6. I understand that a clinical agency may require an additional criminal background check to screen for barrier offenses other than those required by MCCCD, as well as a drug screening. I understand that I am required to pay for any and all criminal background checks and drug screens required by a clinical agency to which I am assigned. 7. I understand that the both the MCCCD supplemental or the clinical agency background check may include but are not limited to the following: Nationwide Federal Healthcare Fraud and Abuse Databases Social Security Verification Residency History Arizona Statewide Criminal Records Nationwide Criminal Database Nationwide Sexual Offender Registry Homeland Security Search 8. By virtue of the MCCCD supplemental background check, I understand that I will be disqualified for admission or continued enrollment in a Program based on my criminal offenses, the inability to verify my Social Security number, or my being listed in an exclusionary database of a Federal Agency. The criminal offenses for disqualification may include but are not limited to any or all of the following: Social Security Search-Social Security number does not belong to applicant Any inclusion on any registered sex offender database Any inclusion on any of the Federal exclusion lists or Homeland Security watch list Any conviction of Felony no matter what the age of the conviction Any warrant any state Any misdemeanor conviction for the following-no matter age of crime
13 o violent crimes o sex crime of any kind including non consensual sexual crimes and sexual assault o murder, attempted murder o abduction o assault o robbery o arson o extortion o burglary o pandering o any crime against minors, children, vulnerable adults including abuse, neglect, exploitation o any abuse or neglect o any fraud o illegal drugs o aggravated DUI Any misdemeanor controlled substance conviction last 7 years Any other misdemeanor convictions within last 3 years o Exceptions: Any misdemeanor traffic (DUI is not considered Traffic) 9. I understand that I must disclose on all background check data collection forms (DPS, MCCCD background check vendor and a clinical agency background check vendor) all required information including any arrests, convictions, or charges (even if the arrest, conviction or charge has been dismissed or expunged), or participation in first offender, deferred adjudication, pretrial diversion or other probation program. That includes any misdemeanors or felonies in Arizona, any other State, or other jurisdiction. I also understand that I must disclose any other relevant information on the forms. I further understand that non disclosure of relevant information on the forms that would have resulted in failing the background check will result in denial of admission to or removal from a Program. Finally, I understand that my failure to disclose other types of information of the forms will result in a violation of the Student Code of Conduct and may be subject to sanctions under that Code. 10. I understand that, if a clinical agency to which I have been assigned does not accept me based on my criminal background check it may result in my inability to complete the Program. I also understand that MCCCD may, within its discretion, disclose to a clinical agency that I have been rejected by another clinical agency. I further understand that MCCCD has no obligation to place me when the reason for lack of placement is my criminal background check. Since clinical agency assignments are critical requirements for completion of the Program, I acknowledge that my inability to complete required clinical experience due to my criminal background check will result in removal from the Program. 11. I understand the Programs reserve the authority to determine my eligibility to be admitted to the Program or to continue in the Program and admission requirements or background check requirements can change without notice. 12. I understand that I have a duty to immediately report to the Program Director any arrests, convictions, placement on exclusion databases, suspension, removal of my DPS Fingerprint Clearance Card or removal or discipline imposed on any professional license or certificate at any time during my enrollment in a Program. Signature Printed Name Desired Health Care Program
14 Medical Laboratory Sciences Essential Functions A student must be able to perform the following essential requirements to complete the activities necessary to participate in the Medical Laboratory Sciences program: 1. Characterize the color, consistency and clarity of biological specimens or reagents. 2. Employ a clinical grade binocular microscope to discriminate among fine differences in structure and color (hue, shading, and intensity) in microscopic specimens. 3. Read and comprehend (English) text, numbers and graphs displayed in print and on a video monitor. 4. Move freely and safely about a laboratory. 5. Perform moderately taxing continuous physical work uisng proper body mechanics and ergonomics, often requiring prolonged sitting over several hours. 6. Reach laboratory bench tops and shelves, patients lying in hospital beds or patients seated in specimen collection furniture. 7. Maneuver phlebotomy equipment to collect laboratory specimens. 8. Manual dexterity to manipulate laboratory equipment using proper ergonomics (i.e., pipettes, inoculating loops, test tubes) and adjust instruments to perform laboratory procedures. 9. Manipulate an electronic keyboard to operate laboratory instruments and to calculate, record, evaluate, and transmit laboratory information. 10. Read and comprehend technical and professional materials (i.e., textbooks, magazine and journal articles, handbooks and instruction manuals). 11. Follow oral and written instructions in order to correctly perform laboratory test procedures. 12. Effectively, confidentially, and sensitively converse with health care team members regarding laboratory tests. 13. Communicate with faculty members, student colleagues, staff and other health care professionals orally and in a recorded format (writing, typing, graphics or telecommunications). 14. Be able to manage the use of time and be able to systematize actions in order to complete professional and technical tasks within realistic constraints. 15. Possess the emotional health necessary to effectively use her or his intellect to exercise appropriate judgment. The candidate must be able to provide professional and technical services while experiencing the stresses of task-related uncertainty (i.e., ambiguous test ordering, ambivalent test interruption), emergent demands (i.e., "STAT" test orders), and a distracting environment (i.e., high noise levels, complex visual stimuli). 16. Be flexible, creative and adapt to professional and technical change. 17. Recognize potentially hazardous materials, equipment and situations and proceed safely in order to minimize risk of injury to self and nearby personnel. 18. Be honest, compassionate, ethical and responsible. The student must be forthright about errors or uncertainty. The student must be able to critically evaluate her or his own performance, accept constructive criticism and look for ways to improve (i.e., participate in continuing education activities). The student must be able to evaluate the performance of colleagues and professionals and tactfully offer constructive comments. If you are unable to meet the Essential Functions, please contact the Program Director or Disability Resource Center to discuss needed accommodations. ESSENTIAL FUNCTIONS REQUIREMENTS SIGNATURE I have read and have had the opportunity to have all of my questions answered regarding the Essential Functions for the Phoenix College Medical Laboratory Science Program. My signature represents that I understand these requirements. Signature/date
15 MARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS HEALTH AND SAFETY DOCUMENTATION Please attach documentation (test results, etc. for all immunization to this Health and Safety Documentation Home Phone: Cell Phone: Student ID Number: A. MMR (Measles/Rubeola, Mumps, and Rubella): Requires documented proof of two MMRs in lifetime or a positive titer for each of these diseases. 1 st MMR : 2 nd MMR : OR and results of titer: Measles/Rubeola Mumps Rubella B. Varicella (Chickenpox): Requires documented proof of two (2) vaccinations or positive IgG titer. 1 st Varicella : 2 nd Varicella : OR & results of IgG titer: C. Tetanus/Diphtheria (Td) immunization within the past 10 years. Td : D. Tdap once in past Tdap : E. Tuberculosis: Two-Step Testing** for initial skin testing of adults who will be retested periodically TWO-STEP TESTING Use Two-Step Testing for initial skin testing of adults who will be retested periodically. - If first test positive, consider the person infected. - If first test negative, give second test 1-3 weeks later. - If second test positive, consider person infected. - If second test negative, consider person uninfected. - If both parts of Two step test are negative then subsequent testing is done annually with one step procedure INITIAL TEST: Test Given Read Result SECOND TEST (1-3 weeks after initial test): Test Given: Read: Result OR Annual TB skin test (PPD): Test Given Read Result OR Previous Positive PPD test: Provide documentation of negative chest x-ray/evidence of TB disease free status of chest x-ray Result *If applicant has ever had a positive reaction, the test is not to be repeated. Other evidence that the applicant is free from Tuberculosis will be required. **Core Curriculum on Tuberculosis What the Clinician Should Know, Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination, Atlanta, Georgia, 4 th Edition, (continued)
16 F. Hepatitis B: Documented evidence of completed series or positive antibody titer or declination. If beginning series, first injection must be according to your Program s required timeline and the series must be completed within 6 months. of 1 st injection: of 2 nd injection: of 3 rd injection: OR Hep B Titer : Titer Results: OR Signed Declination Form attached G. Influenza: Documented evidence of influenza vaccination within the past year or declination. of injection: OR Signed Declination Form attached H. For Dental programs-documented evidence of completed Ophthalmic Exam or Exam I. For Dental programs-documented evidence of completed Dental Exam of Exam J. Clearance for Participation in Clinical Practice It is essential that allied health students be able to perform a number of physical activities in the clinical portion of their programs. At a minimum, students will be required to lift patients and/or equipment, stand for several hours at a time and perform bending activities. Students who have a chronic illness or condition must be maintained on current treatment and be able to implement their assigned responsibilities. The clinical allied health experience also places students under considerable mental and emotional stress as they undertake responsibilities and duties impacting patients lives. Students must be able to demonstrate rational and appropriate behavior under stressful conditions. I believe the applicant WILL OR WILL NOT be able to function as an allied Health student as described above. If not, explain: Licensed Healthcare Provider (MD, DO, NP, or PA) Verification of Health and Safety Print Name: Title: Signature: : Address: City: State: Telephone:
17 VACCINATION DECLINATION (PRINT) Student Name (Complete the sections that are appropriate for this student.) Hepatitis B Vaccination Declination I understand that due to my exposure to blood or other potential infectious materials during the clinical portion of my allied program, I may be at risk of acquiring Hepatitis B virus (HBV) infection. The health requirements for the allied health program in which I am enrolled, as described in the Student Handbook, include the Hepatitis B vaccination series as part of the program s requirements. I have been encouraged by the faculty to be vaccinated with Hepatitis B vaccine; however, I decline the Hepatitis B Vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. By signing this form, I agree to assume the risk of a potential exposure to Hepatitis B virus and hold the Maricopa Community College Allied Health Program as well as all health care facilities I attend as part of my clinical experiences harmless from liability in the event I contract the Hepatitis B virus. Student Signature Faculty Signature Influenza Vaccination Declination I understand that due to the nature of health care and the volume of individuals that I may come in contact with, I may be at risk of acquiring an influenza virus. The health requirements for the allied health program in which I am enrolled, as described in the Student Handbook, include the current influenza vaccination as identified by the Centers for Disease Control for the current influenza season as part of the program s requirements. I have been encouraged by the faculty to be vaccinated; however, I decline the influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring influenza. By signing this form, I agree to assume the risk of potential exposure to influenza and hold the Maricopa Community College Allied Health Program as well as all health care facilities I attend as part of my clinical experiences harmless from liability in the event I contract the virus. I also understand that, due to the contagious nature of the virus, that a health care setting may not accept my placement if I refuse vaccination. Student Signature Faculty Signature