San Juan College Veterinary Technology Distance Learning Program 4601 College Boulevard Farmington, NM 87402 Off Campus Clinical Instruction (OCCI) Site Application for Companion Animal Facilities INSTRUCTIONS 1. This application is to be completed by the DVM, VMD or credentialed veterinary technician applying to act as primary preceptor for the facility 2. All fields of this form are required and must be filled out 3. Once the form has been completed electronically, use the submit button to email the application 4. If you experience problems, or require further instructions, contact Cindy Painter at 505 566 4047 orpainterc@sanjuancollege.edu FACILITY NAME ADDRESS CITY STATE ZIP CODE Please Select a state FACILITY PHONE FACILITY FAX FACILITY WEBSITE URL List names of all San Juan College VTDLP students who will be completing their OCCI requirements at your facility. Please note that additional students may be added at any time by notifying this office. Companion Animal Facility Equipment List The following equipment items must be present at clinical instruction site(s) and available for use by the VTDLP student to complete the required AVMA clinical tasks. However, if a facility does not have all of the listed equipment, the facility should still apply to be approved under the condition that the student may need to locate a secondary facility for certain clinical tasks or the ability of the instructor to provide an alternative solution within guidelines.sample AVMA
"" indicates that your facility has the equipment on site, "no" indicates that it does not. Anesthesia Equipment Anesthetic machine small animal Isoflorane inhalant anesthetic agent available Sevoflorane inhalant anesthetic agent available n rebreathing system Waste anesthetic gas exhaust system Surgical Instrumentation, related Equipment, and Supplies Autoclave Basic surgical instruments (spay pack, etc.) Electric clippers Warming device Orthopedic equipment Surgical table Surgical lights Emergency crash kit with accessible drugs, supplies and equipment Monitoring Equipment Blood pressure monitoring equipment Esophageal stethoscope Pulse oximeter Capnograph Cardiac monitor Defibrillator Temperature monitoring device Examination and Treatment Equipment Bandaging/casting material Bathing equipment Cages complying with federal regulations Examination tables Ophthalmoscope Oral dosing equipment small and lab animal Otoscope Scales StethoscopeSAMPLE
Syringes and disposable needles Tonometer Tourniquet Tubes feeding and gavage Vaginal Speculum Dental Instruments Ultrasonic scaler Dental polisher Dental instruments Radiology Equipment Aprons and gloves, lead lined Automatic film processor Calipers Cassette holders Film Film identification markers High speed/rare earth screens Lead thyroid collars Radiation safety badges Storage racks for gloves and aprons Radiographic machine fixed Radiographic machine portable Radiographic viewer Laboratory Equipment Blood mixer/rocker Centrifuge Clinical chemistry and analyzer Differential blood cell counter Electronic blood cell counter Hand tally cell counter Hemocytometer Incubator Microhematocit centrifuge Microscope Refractometer laboratorysample Scales,
Other Essential Equipment Controlled drug cabinet Elizabethan collars Endotracheal tubes Microchip scanner Restraint pole Muzzles Nail trimmers Restraint equipment rabbit rodent First Name of Primary E mail Address of Primary Middle Initial Daytime Phone Primary By completing and submitting this application, I agree to act as the primary preceptor for the facility named on this application. I further acknowledge that I have reviewed the application in its entirety and verify that, to the best of my knowledge, the information contained herein is accurate. I have reviewed the information on the VTDLP website at http://www.sanjuancollege.edu/pages/3439.asp and agree to act as the primary preceptor for this facility. As the primary preceptor and authorized agent of this Off Campus Clinical Instruction Site I agree that I will notify the program staff if there are significant changes in the physical structure of the facility, such as relocation, fire, etc., changes in my credential status, my employment or association with this facility, or I no longer wish to act as primary preceptor. I AGREE TO THE ABOVE STATEMENTS I Agree I Do t Agree Facility Standards: To be approved as an off campus clinical instruction (OCCI) site for the San Juan College Veterinary Technology Distance Learning Program, veterinary care facilities must meet certain minimum standards regarding hospital staff, equipment, and practice quality. Each OCCI site must agree to follow these standards in order to be approved. These minimum standards must be met in order to assure that students receive adequate exposure to quality veterinary medical practices and equipment. Click to review Facility Standards I have reviewed the Facility Standards through the link above and agree to insure that my facility upholds these standards. I Agree SAMPLE I Do t Agree Last Name of Primary Type Maiden or former name as may appear on license or diploma Please Select...
Indicate your credentials below: DVM VMD RVT* (MUST provide a current copy of state RVT credentials) LVT* (MUST provide a current copy of state LTV credentials) CVT* (MUST provide a current copy of state CVT credentials) Vet Tech Graduate * (MUST provide a copy of diploma or official transcript indicating graduation from an AVMA approved veterinary technology program) * Required documentation above should be faxed (505 566 3570) or emailed to painterc@sanjuancollege.edu Additional comments or clarification: Full name of person submitting this application: Date Submitted: 8/21/2015 SAMPLE