Cntinuing Educatin: Allied Health Prgrams Student Requirements Desired Class Date Name Address City Phne Email Alt Phne CEQ Zip STAFF VERIFICATION: DATE: COMMENTS: PROGRAM (check ne): Dental Assistant Patient Care Technician Electrcardigraphy Technician Phlebtmy Technician Dental Assistant: High Schl Diplma r GED cpy Required Immunizatins dcument signed and dated by yur Healthcare Prvider and accmpanying sht recrds must include: Hepatitis B (3 shts) TB Skin Test Negative (within 1 year) Student Acknwledgement f Hepatitis B Vaccine Current Healthcare Physical dcument signed and dated by yur Healthcare Prvider (n lder than 3 mnths) Criminal Histry/Backgrund Check (Instructins attached) Cpy f 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] This curse trains students fr emplyment as a dental assistant and prepares them t take the State f Texas Registered Dental Assistant (RDA) exam. T register fr this exam, students must als cmplete an nline curse, csting apprximately $155. Additinal fees payable t the State f Texas will include a $36 applicatin fee, $150 state test fee & ther assciated fees. These requirements will be discussed at the first class meeting. Patient Care Technician: High Schl Diplma r GED cpy Must have cmpleted the fllwing curses: Certified Nurse Aide (CNA) Electrcardigraphy Tech (ECG) Phlebtmy Criminal Histry/Backgrund Check (Instructins attached) Valid AHA CPR fr Healthcare Prviders Certificatin/Card Cpy f 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] This curse prepares students fr a jb as a patient care technician, wh perfrms a rle similar t that f a certified nurse assistant but with mre respnsibility. Patient care techs acquire patient vital signs, gather bld samples and are a key member f the medical team.
Cntinuing Educatin: Allied Health Prgrams Electrcardigraphy (ECG)/Telemetry Technician: High Schl Diplma r GED cpy Required Immunizatins dcument signed and dated by yur Healthcare Prvider and accmpanying sht recrds must include: Hepatitis B (3 shts) Tdap (within the last 10 years) MMR (2 shts)/titer Varicella* (2 shts)/titer TB Skin Test Negative (within 1 year) Student Acknwledgement f Hepatitis B Vaccine Dcumenting Histry f Varicella frm* Current Healthcare Physical dcument signed and dated by yur Healthcare Prvider (n lder than 3 mnths) Criminal Histry/Backgrund Check (Instructins attached) Cpy f 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] This curse prvides an verview f basic cardivascular terminlgy, anatmy and physilgy. It fcuses n the prper placement f ECG leads and maintenance f equipment t btain an accurate 12-lead ECG. Students will learn t recgnize cardiac arrhythmias. The curse utlines respnsibilities f ECG technicians and prvides clinical labratry pprtunity t develp entry-level skills. **There will be an additinal apprximate expense f $35 fr a 10 panel drug screening Seasnal Flu Vaccine may be required by clinical/extern site. Requirement will be discussed in class. Phlebtmy Technician: Must have High Schl Diplma r GED cpy Required Immunizatins dcument signed and dated by yur Healthcare Prvider and accmpanying sht recrds must include: Hepatitis B (3 shts) Tdap (within the last 10 years) MMR (2 shts)/titer Varicella* (2 shts)/titer TB Skin Test Negative (within 1 year) Student Acknwledgement f Hepatitis B Vaccine Dcumenting Histry f Varicella frm* Current Healthcare Physical dcument signed and dated by yur Healthcare Prvider (n lder than 3 mnths) Criminal Histry/Backgrund Check (Instructins attached) Cpy f 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] This curse trains students in the safest methds f drawing bld with as little patient discmfrt as pssible. Students are intrduced t basic knwledge and skills f the phlebtmy prfessin. Students will learn varius types f bld cllectins utilizing the prper techniques and universal precautins. On cmpletin f the curse, a Natinal Healthcare Assciatin CPT exam will be administered. **There will be an additinal apprximate expense f $35 fr a 10 panel drug screening Seasnal Flu Vaccine may be required by clinical/extern site. Requirement will be discussed in class. Fr mre infrmatin: Cntact Nichle Sullivan, Administrative Assistant, 409-933-8645, nsullivan1@cm.edu
Cntinuing Educatin: Allied Health Prgrams Physical Exam & Immunizatin Requirements 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: 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: (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) Date read TB Skin Test Ps Neg Date read Initials TB Chest X-ray Ps Neg Initials (*Attach prf f finding) Immunizatins (Give mst recent date) Hepatitis B (3 shts) 1. 2. 3. Tdap (w/in last 10 yrs) MMR (2 shts) Varicella (2 shts)/titer Seasnal Flu I certify that I have examined this individual and he/she is suitable physically and emtinally fr the Cllege f the Mainland Allied Health Prgram t which they are applying fr: Yes N (If n, please explain) Date: M.D. Signature Address
Cntinuing Educatin: Allied Health Prgrams Backgrund Check A backgrund 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 www.txdps.state.tx.us 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 lder than 2 mnths t the class date yu are applying fr will nt be accepted. Release Agreement 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 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. Please initial. I am als aware that the Cllege f the Mainland Allied Health Department requires that I have the required immunizatins befre my clinicals. I understand that I will nt be allwed t enter the clinic 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 Allied Health Prgram, I agree t abide by the rules set frth by the schl and the prgram. Student Signature: Date: Student Printed Name:
Cntinuing Educatin: Allied Health Prgrams 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: http://www.dshs.state.tx.us/immunize/adult_sched.shtm 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. https://www.dshs.state.tx.us/immunize/dcs/schl/hepb_plicy.pdf Student Printed Name X Student Signature Date:
Cntinuing Educatin: Allied Health Prgrams 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 (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) 252-9152 www.immunizetexas.cm