Medication Aide. Program Application Packet. Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution.

Transcription

1 Medication Aide Program Application Packet Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution. 1

2 NORTHEAST TEXAS COMMUNITY COLLEGE Continuing Education Health Sciences Medication Aide Program APPLICATION Program description: This certificate program consists of 144 contact hours of lecture, lab and clinical training for students to become Medication Aides. Upon successful completion of the Medication Aide Program, students will receive a certificate of completion and will be eligible to sit for the state exam. The Application Process: All prospective students for the Medication Aide Program should contact the Health Sciences Continuing Education Coordinator at or set an appointment for more information. The Medication Aide program application is available on the NTCC website at The applicant must gather and submit the following required documentation to the NTCC Health Sciences Continuing Education Coordinator to begin the application for admission process: 1. Completed application 2. Completed Student Statement of Understanding 3. Proof of age (submit copy of driver s license or birth certificate) 4. Proof of high school graduation or GED. Certified copy of High School Diploma or GED is required, no exceptions (must be an official high school transcript with school seal or a notarized copy of diploma). 5. Submit unofficial college transcripts showing college level course work completed within the United States. Those applicants who have never taken college level course work within the United States will be referred for the appropriate academic assessment (TABE) on the Northeast Texas Community College Campus located in the Academic Skills Center in the Humanities Building office Proof of CPR for Healthcare Providers. (submit copy of CPR card) 7. Verification of required immunizations (page 6) 8. Complete DADS General Statement Enrollment Form (pages 7-8) 9. Students must be a CNA current on the state registry and working in a licensed Medicaid/Medicare facility. Students must complete DADS Experience Documentation Report Form (page 9). 10. DADS registry check authorization (page 10). Class Information: Classes: NURA hours 100 hours of classroom instruction and training; 30 hours of returned skills demonstration laboratory; 10 hours of clinical experience, including clinical observation and skills demonstration under the direct supervision of a licensed nurse in a facility, and 4 hour state exam review. o Tuition/fees $688 Financial Aid: Qualifying students may be eligible for financial aid. The Texas Public Education Grant (TPEG) is available to assist non-credit students with tuition expenses only. TPEG application directions can be obtained by submitting proof of eligibility from the NTCC financial aid office. Students are encouraged to apply at least one month prior to registration. Following submission of the TPEG application, students should follow up with the advisors in the Northeast Texas Community College Financial Aid Department for specific details related to the approval and disbursement of awards. Students may also check with Continuing Education staff members to verify the posting of TPEG awards. Students that do not qualify for financial aid can set up a payment plan with Northeast Texas Community College. Additional limited assistance may be available. Contact the Continuing Education Department for more information on the student payment plan, at

3 NORTHEAST TEXAS COMMUNITY COLLEGE Continuing Education Health Sciences MEDICATION AIDE PROGRAM NAME: ADMISSION CHECKLIST APPLICANT At least 18 years old QUESTIONNAIRE/PARAGRAPH GED/HIGH SCHOOL DIPLOMA (CERTIFIED COPY) TABE, THEA (or equivalent) SHOT RECORDS COMPLETE (BOOSTERS NEEDED: ) PROOF OF CPR FOR HEALTHCARE PROVIDERS COMPLETION DADS GENERAL STATEMENT ENROLLMENT FORM DADS EXPERIENCE DOCUMENTATION REPORT FORM REGISTRY CHECK Notes: 3

4 NORTHEAST TEXAS COMMUNITY COLLEGE Continuing Education Health Sciences MEDICATION AIDE PROGRAM Admissions Application Form 1. Name: Last First Middle 2. Home Address: Street City State Zip 3. Student ID #: Date of Birth: 4. Phone Number(s): (Home) (Cell) (Work) 5. address: 6. Educational History: Completion Date: High School: College: 7. Please explain your interest in the Medication Aide career: 8. Applicant Signature Date Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution. 4

5 NORTHEAST TEXAS COMMUNITY COLLEGE Continuing Education Health Sciences MEDICATION AIDE PROGRAM STATEMENT OF UNDERSTANDING I understand that if I miss more than 10% of a class, I may not be able to make it up and will have to retake the class. I also understand that if I am tardy to class, points may be taken off my final grade and/or it may be added to the 10% of hours missed in class. The syllabus will explain the method the instructor will use to determine the grade. He/She will determine if the absence can be excused. I understand that prior to official registration that I must be a CNA current on the state registry and working in a licensed Medicaid/Medicare facility. I understand that prior to official registration that I will be required to: 1. provide proof of immunizations or serologic proof of immunity to Measles, Mumps, Rubella, Varicella (Chickenpox), Hepatitis B, Tetanus/Diphtheria/Pertussis, Influenza, and Bacterial Meningitis (required for adults aged 22 and under ) at my own expense; 2. provide proof of current negative TB test at my own expense; 3. submit proof of current CPR for Healthcare Providers card; 4. submit DADS General Statement Enrollment Form and Experience Documentation Report Form; 5. submit a certified copy of high school diploma or GED; and 6. submit to a registry check through the Department of Aging and Disability Services. I understand I must be employed on or before the first day of the training program and must have signed documentation provided to the Continuing Education office. All required forms must be returned to the Continuing Education office at the time of registration. Refunds must be requested through the Continuing Education Office and will be made according to the following schedule: 100% if notification is received prior to the first class meeting. 80% prior to the second class meeting. NO refund after the second class meeting. Refunds will be mailed by the College Business Office. Students should allow two to three weeks for processing. Courses may be postponed or cancelled without notification. I certify that I have read each of the above statements and understand their meanings. I also have been given the opportunity to ask questions regarding these statements. Applicant s Signature Date Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution. 5

6 NORTHEAST TEXAS COMMUNITY COLLEGE Continuing Education Health Sciences MEDICATION AIDE PROGRAM Immunization Records *Students must submit immunization records with dates, or serologic tests confirming immunity. Varicella Vaccination Date: (2 lifetime) Vaccine 1 Vaccine 2 Influenza Vaccine 1 (annual) Tetanus / Diphtheria Booster: (every 10 years) MMR Vaccination Date: (2 lifetime) Vaccine 1 Vaccine 2 Meningitis Vaccine 1 (if under the age of 22) Hepatitis B Vaccination Date: (3 lifetime) Vaccine 1 Vaccine 2 Vaccine 3 Tuberculosis Screening Date: (annual) (attach results) Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution. 6

7 TEXAS DEPARTMENT OF AGING & DISABILITY SERVICES MEDICATION AIDE PROGRAM MAIL CODE E416 P.O. BOX AUSTIN, TX / GENERAL STATEMENT ENROLLMENT FORM All required forms must be completed and returned to the above address NO LATER THAN 30 DAYS after the date of the first scheduled class in which you are enrolled. Include a $25.00 NONREFUNDABLE combined application & examination fee made payable to the TEXAS DEPARTMENT OF AGING & DISABILITY SERVICES (DADS). If any portion of the application is incomplete, it cannot be processed. 1. NAME 2. Social Security # 3. MAILING ADDRESS_ Street or P.O. Box City State Zip County 4. Home Telephone (with area code) _ 5. Date of Birth 6. Name of approved training school_ City 7. Date of first scheduled class of instruction 8. Are you able to read, write, speak and understand English? Yes No 9. Are you at least 18 years old? Yes No 10. Submit an Experience Documentation Report form documenting current employment of the first official day of the training program in a facility licensed under Health and Safety Code Chapter 242 in the capacity of a CERTIFIED NURSE AIDE or in a Assisted Living Facility licensed under Health and Safety Code 247, State Supported Living Center, or ICF-IDD facility as a nonlicensed direct care staff person. (HOME HEALTH AGENCIES, STAFFING AGENCIES & HOSPITALS ARE NOT LICENSED FACILITIES UNDER THE MEDICATION AIDE REGULATIONS). 11. Submit an Experience Documentation Form documenting 90 days of employment in an Assisted Living Facility licensed under Health and Safety Code Chapter 247, State Supported Living Center or ICF-IDD facility as non-licensed direct care staff. This employment must have been completed within the 12-month period preceding the first official class date. AN APPLICANT EMPLOYED AS A CERTIFIED NURSE AIDE IS EXEMPT FROM THE 90 DAY REQUIREMENT. 12. Submit a certified copy or a photocopy which has been NOTARIZED as a true copy of an unaltered original of a high school graduation diploma or transcript or a general equivalency diploma 13. Are you, to the best of your knowledge, free of contagious diseases and in a suitable physical and emotional health to safely administer medications? Yes No. 14. Have you ever been convicted or a felony or misdemeanor? Yes No. If yes, provide the following information. Date of Conviction Where Convicted. Charge:. If conviction was set aside, give date and explanation using additional pages if necessary: 15. Have you received a copy of the Medication Aide Training Program Rules? Yes No. If No, obtain a copy from the training school or call this office. 7

8 With few exceptions, you have the right to request and be informed about the information that DADS obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect. (Government Code Sections , , ) To find out about your information and your right to request correction, please contact this office. PLEASE READ CAREFULLY In making application to the Department of Aging & Disability Services Medication Aide Program for the issuance of a permit as a Medication Aide, I have read and agree to abide by the Medication Aide Training Program Rules. I also agree to complete all application requirements and take all examinations necessary for the processing of my application. Upon issuance of a permit, I agree to be bound by the Allowable and Prohibited Practices of a Permit Holder (95.105). I further understand that the materials submitted for consideration become the property of the Department and are nonrefundable. I am aware of the schedule of fees (95.109) and understand that additional fees must be paid to keep the permit current. I further agree that if issued a permit, upon the denial, suspension or revocation of that permit, I shall return the permit to the Department. The information that I have provided in this application is truthful. I understand that to falsify any information submitted to DADS may result in voiding of this application and my failing to be granted a permit, or the revocation of my permit. DATE SIGNATURE OF APPLICANT THE STATE OF ) COUNTY OF ) BEFORE ME. The undersigned authority, on this day personally appeared Known to me to the person whose name is subscribed to the foregoing instrument, and having been by me first duly sworn on oath, acknowledged that he/she had executed the same for the purposes and consideration therein expressed and the foregoing statements are true and correct. Given under my hand and seal of office, this day of, Notary Public in and for County, Texas or Signature of Notary _ Name of Notary Commission Expiration Date Page 2 of 2 09/2013 8

9 EXPERIENCE DOCUMENTATION REPORT FORM TEXAS DEPARTMENT OF AGING & DISABILITY SERVICES MEDICATION AIDE PROGRAM - MAIL CODE E416 P. O. BOX AUSTIN, TX APPLICANT SOCIAL SECURITY # TRAINING SCHOOL **************************************************************************************** Form must be filled out in its entirety by the individual certifying that the information submitted is correct. I,, certify that I have employed (FACILITY ADMINISTRATOR/PROGRAM DIRECTOR/DON) from to_ and that I (Applicant) know of my own knowledge that said person was employed continuously in this facility which is licensed under Health & Safety Code Chapter 242, as a certified nurse aide; or in this facility which is a licensed Personal Care Facility under Health & Safety Chapter 247, or in this State Supported Living Center, ICF-IDD as a non-licensed direct care staff person under the direct supervision of a licensed nurse on duty or on call. 1. Place of Employment 2. Address Street No. City State Zip 3. Phone Number including Area Code 4. Type of Facility 5. Job Title of Applicant 6. Nurse Aide Certificate Number (if applicable) Expiration date 7. Type of work performed (be specific) On this day of, 20, in, _ I certify under penalty of perjury that the information submitted is true and correct. SIGNATURE OF ADMINISTRATOR/PROGRAM DIRECTOR/DON Facility Vendor Number Before me, a Notary Public in County, Texas on this day personally appeared, known to me to be the ADMINISTRATOR/PROGRAM DIRECTOR/DON) person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office this day of, 20. (Signature of Notary) Photocopy if additional copies are needed 9

10 Date: I understand and agree that I must undergo a Nurse Aid registry check with the Department of Aging and Disability Services, prior to entrance into the Certified Nurse Aide program. I am furnishing my information and understand that if my Nurse Aid registry checks return with questionable findings, it can result in not being able to enroll in the Nurse Aid program. Signature Full Name (PRINT CLEARLY) Other names (maiden, married) Date of Birth Social Security # Driver s License # Texas Issued Y N NTCC witness: 10