Lone Star College North Harris EMS Professions

Lone Star College North Harris EMS Professions Submission Information Completed applications should be submitted to Madeleine Denison, Health and Human Services Academic Advisor, located in Winship 174G. Before meeting with Madeleine Denison, students must make an appointment with Kellie Jones, clinical scheduler, to review completed immunization records, background check, and health care records. Kellie can be reached at 281-618-5764 or at Kellie.R.Jones@lonestar.edu. The last day to meet with Kellie is Tuesday June 25 th for application submission by July 1st. Completed applications should be submitted to Madeleine no later than July 1 st proceeding the Fall semester for which admission is desired. An appointment is not necessary when dropping off the program application. Please note, applications will NOT be accepted if students have not met with the clinical scheduler. Completed applications will be accepted after the deadline based on program availability. Program Contact Information Lone Star College-North Harris EMS Professions 2700 W. W. Thorne Drive Houston, Texas 77073 281-618-5781 http://www.lonestar.edu/ems-dept-northharris.htm

Page intentionally left blank

Lone Star College North Harris EMS Professions Application for Admission to the Advanced EMS Professions Program APPLICANT INFORMATION APPLICATION COVERSHEET (Do not complete this application for EMT-Basic courses) Last Name First Middle Date of Birth Social Security No. Student ID No. APPLICANT CHECKLIST I have reviewed the EMS Professions admissions requirements. I have applied and gained admission to the Lone Star College System. I have consulted with a college counselor or academic advisor and meet the TSI (reading, writing, and math prerequisites) requirements of the program, if required. I have reviewed the Texas Department of State Health Services Functional Job Description (included in this application packet) HAVE YOU ATTACHED THE FOLLOWING DOCUMENTS? Even if you have provided the below information to the college upon admission, the EMS Professions program still needs a copy for your official EMS student file. All transcripts for the EMS Professions student file can be simple photocopies and UNOFFICIAL in nature. Documentation of high school diploma or GED Copies of all relevant academic transcripts: high school, college or university, military service schools, and other (proprietary schools) A resume or curriculum vitae showing work history with emphasis on EMS or other health care experience Documentation of EMT or EMT-Intermediate certification or NREMT Registration (Students who currently are enrolled in an EMT course or who have completed EMT course work and are engaged in the credentialing process should complete the form included in this application packet) Completed LSCS Immunization Form included in this application packet Reviewed by Clinical Scheduler Completed LSCS Health History and Physical Forms included in this packet Reviewed by Clinical Scheduler Copy of the background check results from CertifiedBackground.com (Directions included in this application packet)---reviewed by Clinical Scheduler Copy of Texas Driver s License or official state ID Prepay for drug screen from an approved vendor and proof of payment (Directions included) Proof of successful completion of the American Heart Association s Basic Life Support for Health Care Providers within the previous year. Completed and notarized EMS Professions FERPA form included in application packet

Lone Star College North Harris EMS Professions Application for Admission to the Advanced EMS Professions Program APPLICATION FOR ADMISSION Date of Application Program Goal Associate of Applied Science Paramedic Certificate Intermediate Certificate APPLICANT INFORMATION Last Name First Middle Street Address Apartment/Unit # City State ZIP Phone E-mail Address Date of Birth Social Security No. Student ID No. Do you hold TDSHS or NREMT EMT credentials? YES NO If no, have you successfully completed an initial EMT-Basic course? YES NO Have you previously attended Intermediate or Paramedic training? YES NO If yes, when and where? Have you ever been convicted of a felony, Class A, or Class B misdemeanor? YES NO If yes, list all convictions and dates. Have you ever had a professional license or certification revoked, suspended, or subjected to other disciplinary proceedings? YES NO If yes, list all actions and dates. EMERGENCY CONTACT INFORMATION Last Name First Relationship Street Address Apartment/Unit # City State ZIP Phone E-mail Address EDUCATION CPR Agency Exp. Date Course Director EMT-Basic TEXAS Exp. Date Course Director NREMT NREMT Exp. Date Course Director EMT-Intermediate/AEMT TEXAS Exp. Date Course Director NREMT-Intermediate/AEMT NREMT Exp. Date Course Director OTHER Agency Exp. Date Course Director OTHER Agency Exp. Date Course Director

EDUCATION High School or GED Address From To Did you graduate? YES NO Degree College Address From To Did you graduate? YES NO Degree College Address From To Did you graduate? YES NO Degree Trade or Professional Address From To Did you graduate? YES NO Degree RELEVANT EMS/MEDICAL EMPLOYMENT OR VOLUNTEER HISTORY Company Phone ( ) Street Address Supervisor City State ZIP Job Title From to Hours per week Responsibilities Company Phone ( ) Street Address Supervisor City State ZIP Job Title From to Hours per week Responsibilities DISCLAIMER INITIALS AND SIGNATURE Criminal History: Applicants who wish to become certified or licensed with the Texas Department of State Health Services and/or the National Registry of EMTs need to be aware that any criminal history may prevent them from such action. The Lone Star College System s EMS Professions programs are not able to, or responsible for, advising a student with criminal history on whether they are eligible for certification or licensure. All questions regarding eligibility should be directed to both the Texas Department of State Health Services and the National Registry of EMTs. Clinical Requirements: Texas mandates required immunizations for all EMS Professions students. Criminal background checks utilizing an LSCS approved vendor are required of all students who attend a clinical rotation. Standards for the background check are established by our clinical affiliates. Clinical affiliates require completion of satisfactory drug screenings. Additionally, clinical affiliates may require personal medical insurance, and additional immunizations. College Admission: This application is intended for program purposes ONLY and does not constitute application to the college or college system. To be admitted to the EMS Professions program, applicants must first meet all entrance requirements for and be properly admitted to Lone Star College. Successful admission to Lone Star College does not constitute automatic admission or enrollment in the EMS Professions program. I certify that I have read and understand the admission requirements for the EMS Professions program. Additionally, I certify that the information given in this application packet is complete and correct. Falsification or omission may subject me to admission disqualification or immediate dismissal from the EMS Professions program and/or LSCS. Signature Date

Name: Address: City/State/Zip: Telephone: HEALTH HISTORY (This Page To Be Completed By Student) Date: Age: Sex: DOB: Program Applying For: (circle one) Physician: Rad Tech Pharm Tech OTA/PTA Hospital of Choice: EMS Nursing Surg Tech Should any condition change during enrollment, it is your responsibility to notify the department. Answer each of the following questions truthfully. Falsification of information will result in dismissal. Have you now, or ever had: Yes No Frequent Headaches/Migraines Eye, Ear, Nose, Throat Trouble Difficulty in Hearing Wear Contacts/Glasses Sinus Trouble/Frequent Colds Asthma/Difficulty Breathing Lung Trouble/Pneumonia Chest Pains Rheumatic Fever Heart Disease/ Murmur Hepatitis/Jaundice Hernia/Rupture Excessive Bleeding from Cuts Thyroid Disease List All Medications Taken Regularly: Have you now, or ever had: Yes No Varicose Veins Kidney/Bladder Trouble Menstrual Trouble Foot Trouble Sprained/Strained Back/Ruptured Disc Arthritis/Painful/Swollen Joints Back Trouble/Injury/Unable to lift 50 lbs Epilepsy/Fits/Seizures Frequent Dizziness/Fainting Nervous Breakdown/Memory Loss Eating Disorder/Bulimia/Anorexia High/Low Blood Sugar/Diabetes Take any Prescribed Medication Regularly *Allergies/Reactions to Medications/Drugs *Please Specify Any Drug Allergies: Do you have any serious illness/injury not listed above, or do you have any present concern pertaining to your health which may interfere with activities of the health care program to which you are applying? Yes No (If yes, please explain) In Case of Emergency, Please Notify: Name Relationship Home Phone: Work Phone: I certify that all of the above information is true and correct to the best of my knowledge. Date: Signature:

C O M P L E T E P H Y S I C A L Lone Star College System Physical Examination Name Age Date Height Weight B/P / Pulse Vision R 20/ L 20/ Corrected: Yes No Pupils Cardiopulmonary Pulses Heart Lungs Skin Abdominal Genitalia Musculoskeletal Neck Shoulders Elbow Wrist Hand Back Knee Ankle Foot Normal Abnormal Findings Initials Other Clearance: A. Cleared B. Cleared after completing evaluation/rehabilitation for: C. Not cleared for: Lifting / Transferring 50 lbs / Carrying 25 lbs. Reaching / Stretching / Bending Pushing 100 lbs Standing / Walking for 8-12 hours Due to: Recommendation: I certify that I have examined this individual and have found no condition(s) that would appear to prevent him/her from participating in all activities of the Program. Further, I have found no condition, which might represent a potential hazard to the health of other students or to that of clients/employees in clinical facilities. Date Phone # Physician Signature PRINT NAME OF PHYSICAN and ADDRESS

Lone Star College System Emergency Medical Services Professions DOCUMENTATION OF REQUIRED IMMUNIZATIONS Name: (Last) (First) (MI) Date of Birth: SS#: _XXX-XX- Enrollment Date: All students enrolled in health related courses that have or will have any direct patient contact must show proof of the following immunizations prior to starting the clinical component of their course. MEASLES MUMPS RUBELLA: Healthcare provider signature verifying record of date of illness or two (2) DOSES on or after first birthday or a laboratory report of a positive titer. Date of Illness Date of MMR #1 Date of MMR #2 Date of TITER Healthcare Provider Signature ATTACH LAB REPORT TB TEST: Negative PPD or Quantiferon-TB Gold Test is required upon admission and yearly thereafter. Students with a history of a positive PPD test should obtain a chest X-ray or a negative Quantiferon-TB Gold Test. Test Date Results of Test Date of Chest X-ray Results of X-ray Healthcare Provider Signature PPD or GOLD ATTACH REPORT DIPHTHERIA-TETANUS-PERTUSIS: All students must submit proof of a booster shot within the past three years or TDaP if taking now. Type of Vaccine Date of Booster Vaccine Healthcare Provider Signature TD or TDaP CHICKEN POX: Two varicella injections or titer (attached). Date of Varicella #1 Date of Varicella #2 Date of TITER Healthcare Provider Signature ATTACH LAB REPORT SEASONAL INFLUENZA: Required for Fall/Spring. Date of Vaccine Healthcare Provider Signature HEPATITIS B: All students must submit proof of series or serum antibody titer. Date of Vaccine Healthcare Provider Signature Hepatitis B Vaccination #1 Hepatitis B Vaccination #2 Hepatitis B Vaccination #3 Date of TITER ATTACH LAB REPORT 22 February 2011

About CertifiedProfile STUDENT INSTRUCTIONS FOR LONE STAR COLLEGE NORTH HARRIS EMS PROFESSIONS CertifiedProfile is a secure platform that allows you to order your background check online. Once you have placed your order, you may use your login to access additional features of CertifiedProfile, including document storage, portfolio builders and reference tools. CertifiedProfile also allows you to upload any additional documents required by your school. Order Summary Required Personal Information In addition to entering your full name and date of birth, you will be asked for your Social Security Number, current address, phone number and e-mail address. Payment Information During the online order process you will be prompted to enter your Personal Identification Number (PIN). Place Your Order View Your Results Go to: www.certifiedbackground.com and enter package code in the place order field: LD69 You will then be directed to set up your CertifiedProfile account. Your results will be posted directly to your CertifiedProfile account. You will be notified if there is any missing information needed in order to process your order. Although 95% of background check results are completed within 3-5 business days, some results may take longer. Your order will show as In Process until it has been completed in its entirety. Your school's administrator can also securely view your results online with their unique username and password. If you have any additional questions, please contact Student Support at 888-914-7279 or email studentservices@certifiedprofile.com.

Welcome to the Drug Screening Registration site for LSC - North Harris College The following webpage will guide you through the quick and easy process of fulfilling your drug test requirement. As part of the admission process, all students are required to complete this specific drug test. This is done in order to obtain access to clinical rotation. SurScan has been chosen to provide this service for all incoming students. The process is simple: http://www.surscan.com/nhc2030.html 1. Go to the link above 2. Press Continue 3. Select EMS 4. You will enter the requested personal and payment information (we accept most credit cards). 5. After you have submitted your registration (step 1), you will receive an e-mail that is your "Auto- Receipt". Be sure to keep this for your records. 6. Once you have registered on-line you have completed everything you need to do for your drug test.

http://www.dshs.state.tx.us 1100 West 49th Street Austin, Texas 78756-3199 512/458-7111 FUNCTIONAL POSITION DESCRIPTION ECA/EMT/EMT-I/EMT-P Introduction We are providing the following position description for ECA/EMT/EMT-I/EMT-P. This should guide you when giving advice to anyone who is interested in understanding what qualifications, competencies and tasks are required of the ECA/EMT/EMT-I/EMT-P. Qualifications: Successfully complete a department approved course. Verification of skills proficiency and achievement of a passing score on the written certification examination. Must be at least 18 years of age. Generally, the knowledge and skills required show the need for a high school education or equivalent. Ability to communicate verbally; via telephone and radio equipment; ability to lift, carry, and balance up to 125 pounds (250 with assistance); ability to interpret written, oral and diagnostic form instructions; ability to use good judgment and remain calm in high-stress situations; ability to be unaffected by loud noises and flashing lights; ability to function efficiently throughout an entire work shift without interruption; ability to calculate weight and volume ratios and read small print, both under life threatening time constraints; ability to read English language manuals and road maps; accurately discern street signs and address numbers; ability to interview patient, family members, and bystanders; ability to document, in writing, all relevant information in prescribed format in light of legal ramifications of such; ability to converse in English with coworkers and hospital staff as to status of patient. Good manual dexterity, with ability to perform all tasks related to highest quality patient care. Ability to bend, stoop, and crawl on uneven terrain; and the ability to withstand varied environmental conditions such as extreme heat, cold, and moisture. Ability to work in low light and confined spaces. An Equal Employment Opportunity Employer

COMPETENCY AREAS ECA Emergency Care Attendant Must demonstrate competency handling emergencies utilizing all Basic Life Support equipment and skills in accordance with all behavioral objectives in the DOT/First Responder Training Course and the FEMA document entitled "Recognizing and Identifying Hazardous Materials", and to include curricula on aids to resuscitation, blood pressure by palpation and auscultation, oral suctioning, spinal immobilization, patient assessment, and adult, child, and infant cardiopulmonary resuscitation. The automated external defibrillator curriculum is optional. EMT - Basic Must demonstrate competency handling emergencies utilizing all Basic Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic curriculum and the FEMA document entitled "Recognizing and Identifying Hazardous Materials". EMT 1994 curriculum includes objectives pertaining to the use of the pneumatic antishock garment, automated external defibrillator, epinephrine auto-injector and inhaler bronchodilators. EMT- Intermediate Must demonstrate competency handling emergencies utilizing all Basic and Advanced Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic and EMT-I curriculum. The curriculum will include objectives pertaining to endotracheal intubation. Paramedic Must demonstrate competency handling emergencies utilizing all Basic and Advanced Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic, EMT-I curriculum, and the Paramedic curriculum. The Paramedic has reached the highest level of pre-hospital certification. An Equal Employment Opportunity Employer

Description of Tasks Receives call from dispatcher, responds verbally to emergency calls, reads maps, may drive ambulance to emergency site, uses most expeditious route, and observes traffic ordinances and regulations. Determines nature and extent of illness or injury, takes pulse, blood pressure, visually observes changes in skin color, makes determination regarding patient status, establishes priority for emergency care, renders appropriate emergency care (based on competency level); may administer intravenous drugs or fluid replacement as directed by physician. May use equipment (based on competency level) such as but not limited to, defibrillator, electrocardiograph, performs endotracheal intubation to open airways and ventilate patient, inflates pneumatic anti-shock garment to improve patient's blood circulation. Assists in lifting, carrying, and transporting patient to ambulance and on to a medical facility. Reassures patients and bystanders, avoids mishandling patient and undue haste, searches for medical identification emblem to aid in care. Extricates patient from entrapment, assesses extent of injury, uses prescribed techniques and appliances, radios dispatcher for additional assistance or services, provides light rescue service if required, provides additional emergency care following established protocols. Complies with regulations in handling deceased, notifies authorities, arranges for protection of property and evidence at scene. Determines appropriate facility to which patient will be transported, reports nature and extent of injuries or illness to that facility, asks for direction from hospital physician or emergency department. Observes patient en route and administers care as directed by physician or emergency department or according to published protocol. Identifies diagnostic signs that require communication with facility. Assists in removing patient from ambulance and into emergency facility. Reports verbally and in writing observations about and care of patient at the scene and in-route to facility, provides assistance to emergency staff as required. Replaces supplies, sends used supplies for sterilization, checks all equipment for future readiness, maintains ambulance in operable condition, ensures ambulances cleanliness and orderliness of equipment and supplies, decontaminates vehicle interior, determines vehicle readiness by checking oil, gas, water in battery and radiator, and tire pressure, maintains familiarity with all specialized equipment. An Equal Employment Opportunity Employer