Hill College. EMS Program. Student Application packet

Transcription

1 Hill College EMS Program Student Application packet

2 EMS Program Contacts Program Coordinator Paul Vogt, BAAS, LP (817) Clinical Coordinator Rhonda Watson, EMT-P (817) Dean of Instruction, Health and Community Services Lori Moseley, MSN, RN (254) or (817) Faculty Support Julie Britton (817)

3 HILL COLLEGE EMS PROGRAM STUDENT CHECKLIST Name: Date: Phone: I am submitting a complete application packet for the next available class. I used the checklist to double check my packet and have signed all necessary forms. Reminder: CLEAR COPIES of documentation only. Do not submit original documents. Complete the Hill College EMS Program requirements for admission to Hill College. Complete Hill College EMS Program Application. Acknowledge Student Responsibility Form. Criminal Background Affidavit Form. Reading Comprehension and Math Skills Requirements (Paramedic Students TSI). Criminal History Disclosure Agreement. Immunization Signature Form or Separate Documents for required Immunizations Hepatitis Information Form. Hepatitis Release of Liability Form. Health Insurance Disclosure/Agreement. HESI Testing (Paramedic Students). Copy of High School Diploma or GED (No exceptions). A valid non-expired U.S or State Govt. issued Identification. A valid non-expired American Heart Association CPR BLS for Health Care Provider Card. Proof of Personal Health Insurance. (Copy of front and back of insurance card or will purchase for clinical approval and submit at a later date). 2 TB Skin Test (within the past 6 months) FLU Shot (Current Flu strains to coincide with the Practicum/Clinical) For Office Use Only: HILL COLLEGE Reviewed by: Date: 3

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5 HILL COLLEGE EMS PROGRAM Application Form Applicants to Hill College EMS Program health courses are responsible for retaining a photocopy of all documentation submitted for their personal records. Once this documentation has been submitted to the Hill College EMS Program, the documentation becomes the sole property of Hill College EMS Program and will not be returned nor photocopied for the applicant, instructors or any other party. HILL COLLEGE STUDENT ID NO. DATE NAME BIRTHDATE / / Last First Middle Month/Day/Year PHYSICALADDRESS Street City and State ZIP TELEPHONE ( ) ( ) Home Business/Mobile EMERGENCY CONTACT: Name: Phone: Relation Have you taken an EMS course with us in the past: Yes No If yes where did you take your EMS education course/expiration Date? May we publish your work & home phone number as part of the class phone roster? Yes No Do you have a current American Heart (AHA) Health Care Provider certification? Yes No If yes expiration date: Month Year Are you at least 18 years of age? Will you submit to a criminal Background check (Required for EMS Education)? Will you submit to a drug test (Required for EMS Education)? Yes No Yes No Yes No Applicant s Signature Date 5

6 APPLICATION FORM HEALTH QUESTIONNAIRE - (To be completed by the applicant) Do you have any physical limitations which would affect your ability to lift, turn, or transfer patients? Yes No Do you have any limitations in the use of your senses, such as sight, speech or hearing, which would limit your ability to practice a health profession? Yes No Do you have any other condition which might interfere with your ability to practice a health profession? Yes No If you have answered "yes" to any of the above, you will need to detail the reason for your Yes response. I certify that the information provided by me is complete and accurate. I give Hill College EMS Program permission to submit my personal information, this includes criminal background and drug screening results and immunization and TB documentation, to any of the facilities in which I will be doing clinical practicum while I am a student at Hill College EMS Program. Applicant s Signature Date 6

7 STATEMENT OF STUDENT RESPONSIBILITY Review and initial each section as verification that you have read and understand this information: I acknowledge that this information packet contains policies, regulations, and procedures in existence at the time this publication went to press. I also acknowledge that Hill College EMS Program reserves the right to make changes at any time to reflect current Board policies, administrative regulations and procedures, and applicable State and Federal regulations. Furthermore, I understand that this packet is for information purposes only and does not constitute a contract, expressed or implied, between any applicant, student or faculty member and Hill College. I accept full responsibility for submitting a complete application packet and understand incomplete materials including missing or incomplete forms, immunizations records, and CPR certification will disqualify my application. I also accept the responsibility of informing Hill College EMS Program of any change in my status, address, telephone number, or other information that would affect my application status. I understand that if accepted to Hill College EMS Program Emergency Medical Services Program, all forms, immunization records, etc. submitted with my packet becomes the property of Hill College EMS Program and will not be returned nor photocopied for me. Therefore, I am responsible for keeping my own photocopies of these documents before I submit them with program application packet materials. I also authorize the release of these records to any of my clinical sites which may require them. I acknowledge that if admitted to Hill College EMS Program, I may be assigned to clinical rotations at area healthcare facilities which may require additional proof of immunity or additional inoculations/immunizations. I acknowledge that a criminal background check and mandatory drug screening are required prior to the beginning of my EMS course. I understand that the results of these screenings become the property of Hill College EMS Program and will not be released to me or any other third party. I also understand that positive drug screen results will result in my dismissal from Hill College EMS Program if I cannot provide the required documentation to SurScan personnel. I acknowledge that I must comply with class and clinical requirements, if I am absent from classroom instruction or clinical internship for physical or mental illness, surgery or pregnancy reasons, I must present a written release to return to the program, from a physician before being allowed to return to the Hill College EMS Program. Applicant s Printed Name/Signature Date Program Coordinator Signature Date 7

8 CRIMINAL HISTORY Important Disclosure and Agreement Student Name: Student Address: Field of Study: Student has requested admission or has been admitted to Hill College EMS Program to seek a degree or certificate in the above field of study. A portion of the curriculum which the Student must complete involves a clinical rotation or observation at a hospital or health care facility. If Student completes the field of study and obtains the degree or certificate sought, Student might have to be licensed or certified by the State of Texas or other jurisdiction before Student can be employed in his or her chosen field. Before beginning or continuing Student s field of study at Hill College EMS Program, Students should be aware that a criminal record may have adverse consequences on Student s ability to reach Student s ultimate goal of certification/licensure and employment. For instance, Students may not be able to complete clinical rotations or observations if a Student has a criminal record. Likewise, such a record may prevent Student from being licensed, certified, or employed. A criminal background check may and probably will be required in connection with Student s clinical rotation/observation, licensure/certification, and employment. Hill College EMS Program and its faculty, officers, and employees cannot determine with certainty whether Student s criminal record, if any, will have any adverse effect on Student s ability to complete the field of study, obtain the degree sought, be licensed/certified, or be employed. Student understands that the decision as to whether the Student can attend clinical or observation at a hospital or health care facility, obtain certification, and be employed by a health care provider is the decision of the hospital, health care facility, or certifying agency. For a complete list of offense please refer to the section on Criminal Background Checks found earlier in this packet. Student, by signing below, acknowledges receipt of this document and understands its contents. Student covenants never to so sue or seek damages from Hill College EMS Programs a result of any adverse consequences described above which maybe suffered by Student as a result of Student s criminal record. Student acknowledges that Hill College EMS Program or a health care provider may have to obtain are part of Student s criminal record or other required information at some time in the future to place Student in a clinical rotation or observation. Student must sign all forms necessary for the College or a health care provider to obtain this criminal report or other required information in order to be admitted into a clinical rotation or observation. Name of Student/ Signature Date 8

9 HEPATITIS B IMMUNIZATIONS Information Hepatitis B is a serious disease caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Short-term consequences of Hepatitis B include an average of seven (7) weeks lost from work and the risk of permanent liver damage. Long-term consequences include chronic active Hepatitis, cirrhosis of the liver, and liver cancer. In the health care setting, Hepatitis B patients are difficult to identify. In many cases, they do not show symptoms and it may not be known that they are infected with the Hepatitis B virus. The virus is primarily spread to health care workers through contact with infected blood or other body fluids. Health care workers have three (3) to five (5) times the risk of the general public of acquiring Hepatitis B. Hepatitis B represents the major occupational infectious disease hazard of health care workers. THE CENTER FOR DISEASE CONTROL (CDC) AND THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) RECOMMEND VACCINATION OF ALL HEALTH CARE WORKERS. As a student in a health care field, you will have direct contact with patients who could be Hepatitis B carriers. THEREFORE, IT IS REQUIRED THAT YOU OBTAIN THE SERIES OF THREE (3) IMMUNIZATIONS FOR HEPATITIS B, OR PROVIDE PROOF OF SEROLOGIC CONFIRMATION OF IMMUNITY TO HEPATITIS B VIRUS OR YOU MUST QUALIFY FOR ONE OF THE EXCLUSIONS LISTED IN RULE I, _, hereby affirm that I have been well advised and thoroughly informed of the hazards of not obtaining the Hepatitis B immunizations. _I understand that participating in clinical rotations involves certain risks, and injuries can occur that result in extensive treatments, personal injury and even death. I understand that it is my responsibility to obtain the Hepatitis B immunizations and to provide proof of such to HILL COLLEGE EMS PROGRAM. _I have already been vaccinated against Hepatitis B and will provide proof of these to HILL COLLEGE EMS PROGRAM. _I will immediately start and obtain the entire series of Hepatitis B immunizations prior to any clinical rotations or other activities involving patient care and will provide proof of these to Hill College EMS Program. Completion of the Hepatitis B series takes approximately four (4) to six (6) months to complete. Please see schedule regarding admission requirements. Watch your dates closely. I Choose NOT to obtain the Hepatitis B immunizations. I understand if I choose not to obtain the Hepatitis B immunizations and I do not qualify for any of the Exclusions in Rule 97.62, I will not be considered for admission into this program. EXECUTED this day of, 20. Signature: Printed Name: 9

10 Release of Liability In consideration of being allowed to enroll in clinical rotation courses, I hereby affirm that REGARDLESS OF MY HEPATITIS IMMUNIZATION STATUS, I DO HEREBY RELEASE, DISCHARGE AND COVENANT NOT TO SUE HILL COLLEGE EMS PROGRAMCOLLEGE, ITS GOVERNING BOARD, ITS EMPLOYEES, INSTRUCTORS, AGENTS, AND REPRESENTATIVES (THE RELEASED PARTIES ), FROM ALL LIABILITY WHATSOEVER TO ME FOR PERSONAL INJURY, DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR GROSS NEGLIGENCE OR BY ANY STATUTORY VIOLATION, OR CAUSED BY MY CONTRACTING HEPATITIS OR ANY CONTAGIOUS DISEASE WHATSOEVER, INCLUDING INJURIES OR DISEASES CAUSED BY SHARP CUTS, NEEDLE STICKS, OR EXPOSURE TO PATIENTS OR THEIR BODILY FLUIDS OR RESPIRATIONS, AND I EXPRESSLY HEREBY DISCHARGE AND RELEASE THE SAID RELEASED PARTIES ABOVE NAMED FROM ANY CLAIM, DEMAND, CAUSE OF ACTION OR DAMAGE OF ANY DESCRIPTION IN ANY WAY RELATED TO MY CONTRACTING INFECTIOUS DISEASES AND MY OBTAINING OR FAILING TO OBTAIN IMMUNIZATIONS AGAINST THESE DISEASES. THIS RELEASE WILL BE APPLICABLE TO DAMAGES SUSTAINED BY ME CAUSED BY THE JOINT OR CONCURRENT NEGLIGENCE OF THE RELEASED PARTIES, EVEN IF THEY ARE DISCHARGED OR PROTECTED AGAINST THEIR OWN NEGLIGENCE. I further state that I am of lawful age and legally competent to sign this waiver and release of liability; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document of my own free act. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS RELEASE OF LIABILITY BY READING IT AND THE HILL COLLEGE EMS PROGRAM HEPATITIS B INFORMATION DOCUMENT BEFORE SIGNING BELOW. EXECUTED this day of, 20 SIGNATURE Printed Name: Hep B Rev February

11 Health Insurance Disclosure and Agreement The profession and activities that you will undertake as part of your educational experience will expose you to risks. The dangers include, but are not limited to, ambulance crashes, assaults, hazardous materials exposures, infectious diseases, lower back injuries, abrasions, cuts, and exposure to extreme temperatures. Students are provided liability insurance through Hill College EMS Program for the purposes of the clinical rotations only. This is not health insurance and does not equate to medical benefits. The facilities in which you will be learning do not provide worker compensation or other medical benefits to the student. If the student becomes sick or injured as a result of participating in the Hill College EMS Program the student will be responsible for any and all costs that are associated with the treatment. As such, students are highly encouraged to purchase personal health care coverage while participating in these courses. I understand that Hill College EMS Program and affiliated clinical sites have no responsibility for providing health care services in the event of illness or injury. In addition, students may be requested to acknowledge and sign additional liability release forms from clinical sites. Date: Signature: Printed Name: 11

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13 IMMUNIZATION FORM Two ways to submit immunizations: (1) Use this form, each line requires a doctor s signature or verification from your health center and date of immunization or dates of lab results indicating positive titer (seropositivity) required. You must include the lab results. (2) Or immunization records recorded on a separate document such as a hospital printout/health department card. Date of If Seropositive, Doctor s Signature Immunization Date of Positive Titer (Attach Lab Results) or Health Center Signature valid only if injection was given 1. Measles 2 doses since 01/01/68 or positive Titer; Exempt if born on or before 01/01/1957 #1 #2 2. Mumps 1 dose if born on or after 01/01/57; or positive Titer ; Exempt if born on or before 01/01/ Rubella 1 dose or positive Titer 4. Tetanus/diphtheria/pertussis (TDaP) 1 dose within past 10 yrs. DOES NOT APPLY 5. Varicella (chickenpox) - 2 doses or positive Titer #1 #2 6. Hepatitis B series 1 st initial dose 2 nd dose after 1 month #1 #2 #3 *3 rd dose after 5 months Or, Twin RIX series Or Positive Titer DOES NOT APPLY 7. Influenza- 1 dose within past 12 months TUBERCULOSIS SCREENING Documentation requires a physician's signature or verification from a Health Center. Intradermal PPD (Mantoux) - within six (6) months unless previously positive Date Results Physician's Signature Chest X-ray - within two (2) year if PPD positive (Must also include positive PPD verification above.) Date Results 13 Physician's Signature

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15 CRIMINAL BACKGROUND INFORMATION What would prevent me from being eligible for certification or cause me to lose my EMS certification/license? Certain offenses will prevent an individual from receiving an EMS certification in Texas or result in the revocation of an EMS certificate or license. Any person that has been convicted of, placed on deferred adjudication community supervision, or deferred disposition for any of the criminal offenses listed below are NOT qualified to obtain or maintain an EMS certification: (1) murder [Texas Penal Code (PC) Section 19.02]; (2) capital murder [PC Section 19.03]; (3) indecency with a child; [PC Section (a)(1)] (4) aggravated kidnapping; [PC Section 20.04] (5) aggravated sexual assault; [PC Section ] (6) aggravated robbery; [PC Section 29.03] (7) substance abuse offenses, as described in Health and Safety Code, Chapter 481, for which punishment is increased under: (a) Health and Safety Code, , regarding the use of a child in the commission of an offense; or (b) Health and Safety Code, (c), (d), (e) or (f), regarding an offense committed within a drug free zone, if it is shown that the defendant has been previously convicted of an offense for which punishment was increased under one of those subsections; (8) sexual assault; [PC Section ] (9) An offense, other than an offense committed on or after September 1, 2009, for which the person is subject to register as a sex offender under Code of Criminal Procedure, Chapter 62. All other criminal offenses are considered on a case by case basis. The following includes some of the factors the Department uses to determine whether a criminal offense directly relates to the duties and responsibilities of EMS personnel and uses to determine the person s ability to carry out those duties and responsibilities. the nature and seriousness of the crime the relationship of the crime to the purposes for requiring a certification to engage in emergency medical services the extent to which certification might offer an opportunity to engage in further criminal activity of the same type as that in which the person previously had been involved the relationship of the crime to the ability, capacity, or fitness required to perform the duties and discharge the responsibilities of EMS personnel the extent and nature of the person s past criminal activity the age of the person when the crime was committed the amount of time that has elapsed since the person s last criminal activity the conduct and work activity of the person before and after the criminal activity evidence of the person s rehabilitation or rehabilitative effort while incarcerated or after release evidence the person has maintained a record of steady employment; supported their dependents; maintained a record of good conduct; paid all outstanding court costs, supervision fees, fines and restitution ordered in any criminal case. In addition, the Department will also apply the above referenced factors in considering same or similar criminal offenses, resulting in a conviction, deferred adjudication or deferred disposition under other state law, federal law or the Uniform Code of Military Justice. Date: Signature: Printed Name: 15