Medical Assisting Program Application

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1 Medical Assisting Program Application PHOENIX COL E.,E Phoenix College The Center for Excellence in Healthcare Education 3144 N 7th Ave. Phoenix, AZ Submit completed application and paperwork to: Phoenix College Allied Health Advisor in the PC One Stop Center (Advisement) by 4:00 p.m. according to the due dates below: [Check program choice: Fall 2016 (day-8:15 a.m. to 5:00 p.m.), deadline 5/7/16 ] Please print clearly. Name: 17 Spring 2016 (eve.-5:30 to 9:30 p.m.), deadline-12/7/15 (First) (Middle Initial) (Last) Maricopa Student ID #: Phone Number: Permanent Address: (street) (city) (state) (zip) Maricopa Address: Required Documents: 1. Completed Application 2. Copy of High School Diploma or GED 3. Unofficial Transcripts showing passing grades in HCC 130 and 145; 4. Unofficial Transcripts showing passing grades in other Prerequisite classes (see next page), Placement tests showing you tested out of ENG 101 and 102; CRE 101; MAT 091 (or equivalent) 5. Health and Safety Documentation form signed by a M.D., D.O., N.P., or P.A., PLUS copies of immunization records or lab titer indicated below: *Two MMR vaccinations or positive titer *Two Varicella vaccinations or positive titer Negative 2-step TB skin test or chest x-ray within the previous 12 months *Three Hepatitis B vaccinations or positive titer results (or signed waiver form) *Influenza vaccination TDaP (Tetanus and Pertussis) within the last 10 years 6. Copy of current CPR card for Healthcare Provider from the American Heart Association 7. Copy of both sides of your current DPS Level 1 Fingerprint Clearance Card

2 Note: Upon provisional acceptance into the Medical Assisting Program, all students are required to submit to a background check performed by the Maricopa Community College District approved vendor. This is done at the student's expense. Proof of this must be submitted to the MA Program Director. Program Pre-Requisite Courses (classes must be passed with a grade of "C" or better) College In Progress Date Completed & Grade HCC 130 Fundamentals In Health Care Delivery ( HCC 130 AA-130 AF) HCC 145 Medical Terminology ENG 101 and 102 ( Attach Placement Test Scores to this application showing exemption) CRE 101 Critical Reading ( Attach Placement Test Scores to this application showing exemption) MAT 091 MAT 092 Introductory Algebra ( Attach Placement Test Scores to this application showing exemption) SPA 117 Healthcare Spanish (can be taken after admittance into the Program) I attest to Understanding and 1. The information Provided in this application is true and complete to thebest of my any of my contact information changes, I will rifc)rni the Medical Assisting Program Director. 2. I must be able to attend classes: in the day MA Program on Tuesdays, Wednesdays, and Thursdays from 8:15 a.m. to 5:00 p.m., in the evening MA program on Mondays, Tuesdays, Wednesdays, and Thursdays from 5:30 p.m.=t-ci_9:30 It is my responsibility to keep up w ith course fees so as not to be dropped from the program. I agree to Purchase required textbooks PRI _ij_th_e first_-day-of class. I understand I am required to have health and safety documentation complete prior to clinical instruction, including immunizations, TL. 3. screening medical clearance, completion of a drug screening, back ground clearance, the acquisition of a DPS Lev-el One Fingerprint Clearance card, CPR certification, and other requirements as prescribed by MCCD -Phoenix College or the Program. I understand that I will be financially responsible for obtaining and i maintaining these_ requirements. (Details are Provided by the MCCD Healthcare Education O ffice www healthcaredharicopa eclat) 5. Admission into the MA Program i s conditional until all requirements have been satisfactorily comi pleted. I understand that I must participate fully in program activities. f I have a chronic illness, understand I must maintain current treatment and be able to participate n direct Pa_tien_t_c!re_. 6 I Understand that to remain in the MA. Program requires. successful completiongrade required ses in ṭhe MA Program, and the Passing of Practical and Final Exams withaiett efiar II o be understand that manyprocedures performed 7. Pose me to ph demanding k and b oodborne pathogens, requiring an adherence to safety and infection control tols, w71 richl taught in My Pre-clinical instruction.. 8. I understand that if I have any physical disability or special need, I will consult Disabi ity Resource Services PRI to a for admission. -G to: for more information. = 9. I understand I must complete a daytime Clinical Externship when required MA classes are finished. Applicant Signature Date

3 IVIARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS HEALTH AND SAFETY DOCUMENTATION Student Name: Date: Home Phone: Cell Phone: Student ID Number: A. MMR (Measles/Rubeola, Mumps, Rubella): Requires documented proof of two MMRs in lifetime or a positive titer for each of these diseases. 1st MMR Date: 2nd MMR Date: Date and results of titer: Measles/Rubeola Mumps Rubella B. Varicella (Chickenpox): Requires documented proof of two (2) vaccinations or positive IgG titer. 1st Varicella Date: Date & results of IgG titer: 2nd Varicella Date: C. TDaP immunization within the past 10 years. (Td is NOT sufficient for the Medical Assisting Program). TDap Date: D. 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 Date Read Result SECOND TEST (1-3 weeks after initial test): Test Given: Date Read: Result Annual TB skin test (PPD): Test Given Date Read Result Previous Positive PPD test: Provide documentation of negative chest x-ray/evidence of TB disease free status Date 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, 4th Edition, 2000.

4 MMARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS HEALTH AND SAFETY DOCUMENTATION 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. Date of 1st injection: Hep B Titer Date: Date of 2nd injection: Titer Results: Date of 3rd injection: Signed Declination Form attached E. Influenza: Documented evidence of influenza vaccination within the past year or declination. Date of injection: Signed Declination Form attached F. 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 health student as described above. If not, explain: or WILL NOT be able to function as an allied Licensed Healthcare Provider (MD, DO, NP, or PA) Verification of Health and Safety Print Name: Title: Signature: Date: Address: City: State: Telephone:

5 Signature Date IMPTANT! PLEASE NOTE Upon notification of provisional acceptance into the Evening Medical Assisting Program for Spring 2016, all students must submit to a background check to be performed by the Maricopa County Community College District approved vendor. This will be done at the student's own expense. The Medical Assisting Program Director must receive proof that the student has passed this background check, from the background check vendor, before the student will be permitted to register for medical assisting classes. If this proof is not received, the student will not be given permission to register and will be unable to participate in the Spring 2016 Evening Medical Assisting program. More information on obtaining the background check will be provided to students who are granted provisional acceptance.

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