INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.

Transcription

1 Dear Prspective Student, Cntinuing Educatin Allied Health Thank yu fr yur interest in the Electrcardigraphy Telemetry Technician Certificate Prgram at Cllege f the Mainland. Cnsideratin fr acceptance int the prgram is based upn the submissin f yur cmpleted applicatin. What is an Electrcardigraphy Telemetry Technician? An ECG/EKG (as they are cmmnly referred t) Technician perates medical equipment, such as an ECG machine that recrds and measures a patients heart activity. By attaching electrdes t the chest, arms, and legs f a patient, EKG technicians mnitr, interpret and dcument the patients results. In additin t preparing patients fr Hlter and ambulatry mnitring, the EKG Technician may als trublesht technical prblems with the ECG machines. As an EKG technician, yu must fllw precise instructins t perate the machines and prvide quality test results fr diagnsis. This requires attentin t detail, hand-eye crdinatin, interpersnal and technical skills, and physical stamina. Students learn in labs and classes and gain cnnectins thrugh clinicals at lcal health care facilities. Students will als receive BLS Healthcare Prvider CPR training thrugh the American Heart Assciatin. Students successfully cmpleting this prgram will be prepared t take the EKG Technician Exam (CET), administered by the Natinal Healthcareer Assciatin (NHA). D I need a High Schl Diplma r GED? Yes; A High schl diplma r GED is required t participate in the Electrcardigraphy Telemetry Technician Certificate training prgram and may be required fr Financial Aid applicatin as well as when applying fr emplyment (depending upn the cmpany s plicies.) Hw d I begin? Interested students must apply t the Electrcardigraphy Telemetry Technician Certificate training prgram by submitting, in persn, all required applicatin dcuments t the CE Allied Health Department lcated at 200 Parker Curt, League City, Texas Please nte: INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Als, apprval f an applicatin des NOT guarantee a student a place in the class, it nly gives the ability t register Pending Space Availability. Please cntact Nichle Sullivan at (409) if yu have questins. Criminal Backgrund Checks Acceptable current Texas Department f Public Safety Criminal Backgrund Check (Instructins attached) (n lder than 12 mnths) Registratin Created 2/10/16 NJS Page 1 f 8

2 Only applicants that have been apprved fr the prgram will be allwed t register. Registratin with an apprved frm MUST be dne in persn thrugh the CE Office lcated at the Main Texas City Campus, 1200 Amburn Rd. TVB-1475, Texas City, Texas Fr mre infrmatin please call (409) Registratin is a first cme, first served basis. Classes may be clsed due t maximum enrllment r cancel withut ntice. Therefre, students are encuraged t register early. Financial Aid Financial Aid may be available fr the Electrcardigraphy Telemetry Technician Certificate training prgram if the student qualifies and if there is funding available. Cntinuing Educatin students may apply fr the Texas Public Educatin Grant (TPEG-NC). The TPEG-NC cvers a prtin f tuitin fees nly (typically 50%) & is a ONE TIME ONLY grant that is available t thse students demnstrating a financial need. The remaining prtin f the balance is the student respnsibility and is due at the time f registratin. All applicatin requirements fr TPEG MUST be cmpleted at least (2) tw weeks prir t class start date. Fr questins regarding financial assistance, please cntact Student Financial Services at (409) Students: Check yur COM ! Beginning Spring 2016 all COM business will be administered yur COM address. Students will need t setup their COM accunt in rder t receive any cmmunicatin frm the Financial Aid ffice, business ffice, Instructrs r ther. Persnal addresses will nt be used fr Cllege crrespndence. Frm the COM Hme page click n Infrmatin Technlgy under Cllege Operatins. Frm the left menu yu can find all infrmatin under Get Cnnected. Direct links: Fr mre infrmatin cntact IT at (409) Applicant: Please retain this page fr yur recrds. It des nt need t be turned in with yur applicatin. Thank yu! Created 2/10/16 NJS Page 2 f 8

3 Electrcardigraphy Telemetry Technician - Student Requirements: (Please fill ut legibly and cmpletely) Desired Class Date: Sessin: CEQ Name: DOB: Age: Address: City:, Texas Zip: Phne #: Alt #: In Case f Emergency, Please Cntact: Name (please print) Relatin t Student Phne Number OFFICE USE ONLY: APPROVED DECLINED STAFF VERIFICATION: DATE: COMMENTS: Created 2/10/16 NJS Page 3 f 8

4 Students entering the Electrcardigraphy Telemetry Technician Certificate prgram must meet the fllwing minimum requirements: (THIS AREA TO BE COMPLETED BY COM STAFF ONLY) Required Immunizatins dcument signed and dated by yur Healthcare Prvider and accmpanying sht recrds MUST include: Hepatitis B (3 shts),, (t be cmpleted by COM Staff ONLY) Tdap (within the last 10 years) (t be cmpleted by COM Staff ONLY) MMR (2 shts), (t be cmpleted by COM Staff ONLY) Varicella (2 shts)/titer, (t be cmpleted by COM Staff ONLY) TB Skin Test Negative (within 12 mnths) (t be cmpleted by COM Staff ONLY) Negative 10 Panel Drug Screen Test w/list f items tested fr (within 12 mnths) [Drug panels that are less than 10 panel will NOT be accepted] Cmpleted and Signed Student Acknwledgement f Hepatitis B frm Cmpleted and Signed Dcumenting Histry f Varicella frm Current COM Healthcare Physical dcument cmpleted and signed and dated by yur Healthcare Prvider (n lder than 12 mnths) Cpy f signed Scial Security Card (MUST match Pht ID) Cpy f Driver s License r Gvernment Issued Pht ID (MUST match Scial Security Card) [Expired ID will nt be accepted] Signed and dated Ntice t Students Frm Acceptable current TXDPS Criminal Backgrund Check (Instructins attached) (n lder than 12 mnths) Cpy f High Schl Diplma r GED Created 2/10/16 NJS Page 4 f 8

5 PHYSICAL EXAM & IMMUNIZATION DOCUMENTATION All Sectins are t be Cmpleted ONLY by Healthcare Prfessinal (STUDENTS ARE NOT TO COMPLETE ANY PART OF THIS FORM) Student s Name Last M/I First Sex DOB: (DD/MM/YYYY) / / Weight Height Pulse Temp Bld Pressure S D List any current illnesses r injuries: Is student currently pregnant: If s, what is the due date: List any permanent medical cnditins r physical limitatins: Medical Histry: (Check if applicable) Asthma Heart Disease Tuberculsis Measles Diabetes Seizures Emphysema Hypglycemic Hepatitis Rheumatism Small Px Tuberculsis Diphtheria Influenza Pneumnia Infantile Paralysis Ostearthritis Mumps Other (Please specify) (If checked abve please explain): Tests: (*Attach prf f finding) (Please attach prf f results. Must be n mre than 1 year ld t the date f the class. If results are psitive, a chest x-ray is required) TB Skin Test Ps Neg Date read Initials TB Chest X-ray Ps Neg Date read Initials (*Attach prf f finding) Immunizatins (Give mst recent date) Hepatitis B (3 shts) Tdap (w/in last 10 yrs) MMR (2 shts) Varicella (2 shts)/titer I certify that I have examined this individual and he/she is suitable physically and emtinally t participate in the CE Allied Health ELECTROCARDIOGRAPHY TELEMETRY MONITORING Prgram t which they are applying fr: Yes N (If n, please explain) Date: M.D. Signature Address & Office Phne Created 2/10/16 NJS Page 5 f 8

6 Emplyability & Criminal Histry Checks fr ECG Telemetry Technician Backgrund Check A criminal histry check frm the Texas Department f Public Safety is required t be presented by the student fr COM s Cntinuing Educatin Allied Health prgrams. Please g t the Texas Department f Public Safety website at t btain instructins n hw t request a criminal histry check. The apprximate cst fr getting a backgrund check is $3.57 fr each last name f applicant. This must be turned in with checklist infrmatin required fr yur desired prgram. Backgrund checks MUST be btained frm the Texas DPS website. Reprts prcessed thrugh city plice, cunty sheriff r ther will NOT be accepted as they are nt all inclusive f the state f Texas. Backgrund checks lder than 12 mnths t the class date yu are applying fr will nt be accepted. Criminal histry clearance thrugh Cllege f the Mainland CE Allied Health des nt cnstitute clearance thrugh ptential emplyers r hiring entities. It is understd that I am t prvide Cllege f the Mainland with a Criminal Histry backgrund check. Please initial. Release Agreement While caring fr patients during my clinical rtatins, I hereby release and discharge Cllege f the Mainland and all its emplyees frm all liability fr all injury, expsure r damage arising frm health risks f caring fr patients during my clinical rtatin r during scheduled class r skills lab. I understand that I may be expsed t cmmunicable diseases (including bld-brne pathgens) r persnal injury. I am aware f the health risks f caring fr such patients. Please initial. Immunizatin Acknwledgement I am als aware that the Cllege f the Mainland CE Allied Health Department, which versees the Electrcardigraphy Telemetry Technician Certificate Prgram, requires that I have the required immunizatins befre my clinical rtatins. I understand that I will nt be allwed t enter the clinical facility fr clinical purpses if I d nt have the required immunizatins. Please initial. Applicant s Statement I certify that I have read the abve statements and that initialing my name means that I agree with the abve statements. If accepted int the Cllege f the Mainland Electrcardigraphy Telemetry Technician Certificate Prgram, I agree t abide by the rules set frth by the schl and the prgram. Student Signature: Date: Created 2/10/16 NJS Page 6 f 8

7 STUDENT ACKNOWLEDGEMENT OF HEPATITIS B VACCINE Department f State Health Services Disease Preventin & Interventin Sectin Immunizatin Branch POLICY STATEMENT 1.0 Cmpletin f Hepatitis B vaccine series prir t direct patient care The Texas Department f State Health Services (DSHS) rule 97.64, Required Vaccinatins fr Students Enrlled in Health-Related and Veterinary Curses in Institutins f Higher Educatin [25TAC 97.64, April 2004], requires students enrlled in health-related curses, which will invlve direct patient cntact in medical r dental care facilities t cmplete a three dse series f hepatitis B vaccine prir t direct patient care. This rule applies t all medical interns, residents, fellws, nursing students, and thers wh are being trained in medical schls, hspitals, and health science centers and students attending tw-year and fur-year clleges whse curse wrk invlves direct patient cntact regardless f the number f curses taken, number f hurs taken, and the classificatin f student. Website fr Texas Department f State Health Services Adult Immunizatins Schedule: Please check ne f the fllwing bxes as it applies t yur Hepatitis B series: I have cmpleted the Hepatitis B 3 sht series I nly have 1 sht remaining f the 3 sht series: 3rd sht due I have cmpleted my first sht and the dates fr the next tw shts are: and Based upn the clinical/extern site rules and regulatins I understand & acknwledge that if I have nt cmpleted the Hepatitis B 3 sht series, I may nt be able t participate in the clinical/externship prtin f the prgram. I have read and understand the Texas Department f State Health Services plicy n Hepatitis B vaccine series. Student Printed Name Student Signature Date: Created 2/10/16 NJS Page 7 f 8

8 Dcumenting Histry f Illness: Varicella (Chickenpx) This frm summarizes the Exceptins t Immunizatin Requirements (Verificatin f Immunity/Histry f Illness) fr Varicella (Chickenpx). A written statement frm a parent (r legal guardian r managing cnservatr), r physician attesting t the student s psitive histry f varicella disease (chickenpx), r f varicella immunity, is acceptable in lieu f a vaccine recrd fr that disease. Cllege f the Mainland shall accurately recrd the existence f any statements attesting t previus varicella illness r the results f any serlgic tests supplied as prf f immunity. If a student is unable t submit such a statement r serlgic evidence, varicella vaccine is required. Dcumentatin f prir varicella illness can be prvided by the fllwing methds: 1. A serlgic cnfirmatin f varicella immunity (psitive varicella IgG result). 2. A written statement frm a physician r the student s parent r guardian cntaining wrding such as: This is t verify had varicella (Printed name f Student) disease (chickenpx) n r abut and des nt need (Apprximate mnth/year) the varicella vaccine. (Printed name f persn cmpleting frm) (Signature f persn cmpleting frm) (Relatinship t student) (Date) Fr mre infrmatin abut Varicella cntact: Texas Department f State Health Services Immunizatin Branch (800) Created 2/10/16 NJS Page 8 f 8