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1 Department of PHARMACY TECHNICIAN Student Application Forms P a g e 1

2 P a g e 2 Dear Prospective Student: Thank you for your interest in the Pharmacy Technician Program at San Jacinto College North. To give an overview of what our program can offer in just three terms, please review the following: Certificate of Technology Upon completion of the program, students will receive a certification that is accredited by the American Society of Heath-System Pharmacists (ASHP). IV Certification Offered through the National Pharmacy Technician Association (NPTA). Students have the opportunity to become IV certified, which enables them to prepare sterile products in any pharmacy setting. CPR Certification As part of the program students obtain training in Basic Life Support (BLS) Healthcare Provider CPR through the American Heart Association. Experience Students practice and gain experience in retail and hospital settings during two clinical rotations. Pass the Pharmacy Technician Certification Exam Upon completion of the program, students gain the knowledge and skills to pass the national exam. Regular Informational Session dates, detailed program information and application forms are available on our website: or you may pick up an application packet in our office located in Allied Health & Science Building N A package can also be ed to you be contacting Mandatory Orientation for Fall 2015 Student must attend ONE: August 11, :00pm-7:30pm August 14, :00pm 1:30pm We know this is an important decision and we would be happy to talk with you about how three semesters in our program can prepare you for a successful career as a certified pharmacy technician. We look forward to having you as a student in our program. If you have any questions, please feel free to call me at x7348 or me at the address below. Our new Allied Health & Science Building is now open. Incoming students will enjoy our new state-of-the art facility. Sincerely, Irene Banuelos-Villatoro, BS, CPhT, RPhT Pharmacy Technology Interim-Program Director San Jacinto College North

3 This application and this checklist must be filled out completely and brought to the Pharmacy Technician Department during the application period for the semester you want to attend. You must bring all items listed below before we will accept your application. Please check all check boxes as each item is accounted for. P a g e 3 North Campus N17- Health/Natural Sciences 5800 Uvalde Rd. Houston, TX Fall Semester Morning/Afternoon Fall Semester Part-Time Afternoon South Campus S1-Heatlh/Natural Sciences Beamer Rd. Houston, TX Fall Semester Morning/Afternoon Spring Semester Evenings College and Program Application Apply to San Jacinto College Apply to Pharmacy Technician Program (drop off or application form) Background Check and Drug Test Go to: and place order by using the package codes: North Campus: Background Check: SQ27bg ($29.00) Drug Test: SQ27dt ($27.00) Additional Background Check and Drug Test will be conducted again for Clinical Placement Immunization Records Go to: and place order by using the package code: South Campus Background Check: SV21bg ($29.00) Drug Test: SV21dt ($27.00) North Campus: Medical Document Manager:SQ27im ($30.00) South Campus Medical Document Manager:SV21im ($30.00) Tetanus-diphtheria (Tdap): proof of 1 dose less than 10 years old. Measles, Mumps, and rubella (MMR): proof of 2 doses. If previously vaccinated and shot records are lost or unavailable, immunity can be validated with a titer level (blood) confirmation. Hepatitis B: proof of 3 doses. If previously vaccinated and shot record lost or unavailable, immunity can be validated with a titer level (blood) confirmation. Please note that series takes 4-6 months to complete. Varicella (Chickenpox): proof of 2 doses or documentation of having had varicella or blood test (titer). Influenza (Flu) Vaccine: flu vaccines are good for one year. TB Skin Test (TB/PPD): If you have had a previous positive TB skin test or the BCG (TB) vaccination you must have a chest x-ray performed. TB Skin Tests and Chest X-Rays are good for 1 year.

4 P a g e 4 PHARMACY TECHNICIAN CERTIFICATE PROGRAM APPLICATION FORM Personal Information (Please type or print clearly) Application Date: / / Name: Home Address: Last First Middle Street City State Zip Social Security No.: Student ID #: Date of Birth: Phone Number(s): (Home) (Cell) (Work) address: Emergency Contact: Name Please select one of the following: Full-time Part-time Phone Number Have you previously applied to any San Jacinto College Health Sciences program: Yes No If yes, what program? Educational Background When: High School: City, State Completion Date: College: City, State Completion Date: Special Schooling: Completion Date: List any licenses or certifications you hold (i.e. LVN, EMT etc.) Have you had prior work experience in Pharmacy? If yes, describe: Employment History Position: Employer: Dates: Position: Employer: Dates: *Optional Information *Gender: *Date of Birth: *Age: *Ethnicity: *Place of Birth: San Jacinto College does not discriminate on the basis of race, color, creed, national origin, religion, age, gender, sexual orientation, political affiliation, or physical disability. I hereby certify that the information contained in this application to be true and complete to the best of my knowledge. Applicant Signature Date

5 P a g e 5 List of Required Textbooks for the Pharmacy Technician Program Name of Course Image of Book Name of Book PHRA 1301 Introduction to Pharmacy Manual for Pharmacy Technicians 4th Edition ISBN: PHRA 1305 Drug Classification PHRA 1309 & PHRA 1347 Pharmaceutical Mathematics I & II HPRS 1206 Essentials of Medical Terminology PHRA 1313 Community Pharmacy Practice & PHRA 1349 Institutional Pharmacy Practice PHRA 1441 Pharmacy Drug Therapy Sigler s Prescription Drug Cards 30th Edition ISBN: Pharmaceutical Calculations for Pharmacy Technicians: A Worktext 2nd Edition ISBN: Medical Terminology Get Connected 1st Edition ISBN: Pharmacy Practice for Technicians 5th Edition ISBN: Pharmacology for Technicians 5th Edition ISBN: PHRA 1345 Intravenous Admixture and Sterile Compounding Sterile Products and Aseptic Techniques 2nd Edition ISBN: PHRA 1243 Pharmacy Technician Certification Review No Image TBA

6 P a g e 6 Approximate Total Costs Pharmacy Technician Program as of Fall 2013 Fee In-District Cost Out-of-District Cost General Service Fee Incidental Fee Tuition Lab Fees Insurance Background & Drug Screen Immunizations Books Uniforms TSBP Registration Estimated Total Dual Credit Student Pharmacy Technician (4PHAR) First Term Fall Semester PHRA 1301 Introduction to Pharmacy 3 PHRA 1305 Drug Classification 3 PHRA 1313 Community Pharmacy Practice I 3 Subtotal 9 Second Term Spring Semester HPRS 1206 Essentials of Medical Terminology 2 PHRA 1309 Pharmaceutical Mathematics I 3 PHRA 1349 Institutional Pharmacy Practice 3 Subtotal 8 Third Term Fall Semester PHRA 1347 Pharmaceutical Mathematics II 3 PHRA 1345 Compounding Sterile Preparations and Aseptic Technician *ACPE I.V 3 Certificate PHRA 1441 Pharmacy Drug Therapy and Treatment 4 Subtotal 10 Fourth Term Spring Semester PHRA 1360 Clinical- Community Pharmacy 3 PHRA 2360 Clinical- Institutional Pharmacy * 3 PHRA 1243 Pharmacy Technician Certificate Review 2 Subtotal 8 Certificate of Technology Total 35 *Capstone Experience Note: Student must pass each course listed in the certificate for Pharmacy Technician with a grade of C or higher to be eligible to receive a certificate of technology. Students must have all clinical requirements to be placed in clinical rotation. Transportation must be provided by the student to complete 160 unpaid clinical hours for each clinical course

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