Advanced EMT (AEMT) Program Application
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- Vanessa Carr
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1 Advanced EMT (AEMT) Program Application Thank you for your interest in the Advanced EMT course. This course is presented in two formats; a blended format which includes the online component through Desire2Learn (D2L) and mandatory lab sessions and the traditional classroom. Please note which format you would like to take in the Class Section # portion of the application. Tuition for the AEMT program is $ Tuition does not include the textbook. Textbook: Advanced EMT: A Clinical Reasoning Approach, 2nd Edition, Alexander & Belle Brady Books, 2017 ISBN-13: This textbook may be obtained directly from the publisher at or other retailers such as Amazon. The completed application and all prerequisites must be sent to: HACC Shumaker Public Safety Center EMS Education Unit, N101 1 HACC Drive Harrisburg, PA All prerequisites must be completed and submitted 30 days prior to the start of the program. Students will be contacted for registration upon receipt and verification of application. The submission of your application does not imply enrollment. Any questions regarding the application process can be answered by contacting the EMS Training Unit at emstrng@hacc.edu or
2 Course prerequisites for admission into the AEMT Program are: 1. Submission of current copy (dated within one year of application ) of the following background checks in accordance with Act 34 and Act 151 as amended. a. Pennsylvania State Criminal History Record: b. Department of Public Welfare Child Abuse Report: c. Federal (FBI) Criminal History Report The fingerprint-based background check is a multiple-step process. Information and instructions can be found at: 2. Completion and submission of the HACC Health examination form (form is included in this document) 3. Submission of the following certifications: a. Current PA EMT certification b. Current CPR certification obtained within one year from the start of class (copy of both front and back) Only the following CPR certifications are acceptable: i. American Heart Association BLS for the Healthcare Provider ii. American Red Cross CPR/AED for the Professional Rescuer and Healthcare Provider iii. American Safety & Health Institute CPR Pro for the Professional Rescuer iv. American Academy of Orthopaedic Surgeons Emergency Care & Safety Institute -Healthcare Provider CPR c. Emergency Vehicle Driver Training d. IS-100.b (ICS-100) e. IS-200.b f. IS-700a g. IS-800.b h. Hazardous Materials Awareness Panel Drug and Alcohol Screens; the results will be sent directly to HACC. All students must complete the drug and alcohol screen process through Students will not be admitted into the program with a disqualifying criminal history, child abuse clearance, or drug and alcohol screen result, or failure to meet the specified deadline. College policy can be found under the Prohibitive Offense Procedure for Health Career Programs on
3 Advanced EMT Application Full Name: Date of Birth: Last First M.I. Address: Street Address Apartment/Unit # City State Zip Code Phone: ( ) Address: Class Section #: Current PA DOH EMT #: Shirt Size (S, M, L, XL, XXL, Tall): PA DOH EMT Expiration Date: Emergency Contact: Emergency Contact #: Relationship: Checklist HACC Health Examination Form with the following: o Tuberculosis o *Varicella (Chicken Pox) o Measles o Mumps o *Rubella (German Measles) o Tetanus/Diptheria/Pertussis o Influenza (Not required March through October) o Hepatitis B (Optional Requires Waiver) o Hepatitis A (Optional) Required Certifications Pennsylvania State Criminal History Record Department of Human Services Child Abuse Clearance Federal (FBI) Criminal History Report Current CPR Card 12 Panel Drug and Alcohol Receipt *Students will not be permitted to attend the class without a documented Rubella (German Measles) or Varicella (Chicken Pox) positive titer result. Hepatitis B and A, while not required, is highly recommended.
4 INCOMING HEALTH CAREER STUDENT HEALTH EXAMINATION PLEASE PRINT ALL INFMATION Name: HACC ID: Date: HAWKMAIL Address: Phone #: DOB: STUDENT INFECTIOUS DISEASE SUMMARY In order to participate in any clinical experience/observation where there is potential for direct patient contact (hands-oncare to observing within a radius of 4 feet) it is necessary that the following information be provided and verified by your physician/nurse practitioner/physician s assistant. To meet the requirements of our affiliating clinical agencies, the following diseases, immunizations or titers MUST be documented. TUBERCULOSIS STATUS BLOOD TEST TB INTERFERON ASSAY (must be valid for the program year) Date: Results: positive negative If result is indeterminant, proceed with 2-Step PPD test. 2-Step Mantoux Skin Test (PPD) (must be valid for the program year) The two tests must be a minimum of 10 days and a maximum of 21 days apart. Date #1: Result: Negative Positive mm Date #2: Result: Negative Positive mm Those students with proof of previously documented 2-step and continuous yearly testing (attach evidence): Annual PPD Date: Result: Negative Positive mm IF POSITIVE: Date of 2 View Chest X-ray (completed within 1 years of date of admission): result Isoniazid Prophylaxis Rx Yes No Dates: VARICELLA (CHICKEN POX) STATUS Varicella IgG Antibody titer Date: 2 Doses Varicella Vaccine given 1 month apart: Dates: MEASLES Rubeola IgG Antibody titer Date: Vaccination (given with MMR) 2 injections live virus vaccine on or after first birthday Date (s)/ Type (2 injections): Booster dose recommended for those vaccinated prior to MUMPS Mumps IgG Antibody titer Date: Vaccination (given with MMR) on or after first birthday 2 injections live virus vaccine on or after first birthday Date (s)/ Type (2 injections): RUBELLA (GERMAN MEASLES) STATUS No student will be permitted in the clinical area without a documented positive titer result Rubella IgG Antibody titer Date: If negative or equivocal to the above, an MMR with followup testing is required. MMR Administered: Date: Rubella IgG Antibody titer Date: (Follow-up test 4 to 8 weeks post vaccine) Booster dose recommended for those vaccinated prior to TETANUS/DIPTHERIA/PERTUSSIS STATUS All students MUST show proof of 1 dose of Tdap administered after the age of 18. Date: If Tdap date is >8 years old, student must have Td booster Date:
5 REVIEW OF ESSENTIAL QUALIFICATIONS I have obtained a health history, performed a physical examination, and reviewed immunization status and required laboratory tests. In my estimation, the student is able to participate fully in the Advanced EMT Program clinical experience in health care agencies. Please refer to the attached Essential Qualifications required by the program specific course (see below). Yes No COMMENTS: Does the student have any activity limitations? Yes No COMMENTS: Does this student have any medical problems with which the school should be concerned? Yes No If yes, please identify: Is the student subject to conditions that may precipitate a medical emergency, such as: Epilepsy Diabetes Allergies Fainting Heart conditions Other Please identify Does the student possess sufficient emotional stability to accurately perceive situations and make unimpaired observations and judgments regarding patient care in the clinical experiences of the health care program? Yes No COMMENTS: Is there need for follow-up treatment? Yes No If yes, please specify: Does the student require a device or substance (including medications) to enable him/her to carry out the abilities required by the program? Yes No If yes, specify: Essential Qualifications required by the program specific course: Verbally communicate in person and via telephone and telecommunications using the English language. Hear spoken information from co-workers, patients, physicians and dispatchers and sounds common to the emergency scene. Lift, carry and balance a minimum of 125 pounds equally distributed (250 pounds with assistance), a height of 33 inches, a distance of 10 feet. Read and comprehend written materials under stressful conditions. Verbally interview patient, family members and bystanders and hear their responses. Document physically in writing all relevant information in prescribed format. Demonstrate manual dexterity and fine motor skills, with ability to perform all tasks related to quality patient care. Bend, stoop, crawl and walk on uneven surfaces. Meet minimum vision requirements to operate a motor vehicle within the state. Function in varied environmental conditions such as lighted or darkened work areas, extreme heat, cold and moisture.
6 INFLUENZA STATUS All students are required to have the annual influenza vaccine if attending clinical between October and March. Date Administered: LOT # Manufacturer VISION EXAM (Snellen Eye Chart or similar exam) Normal Referred for Correction: Recommended Vaccinations (waiver available from PD) HEPATITIS B STATUS Hepatitis B (dates of 3-dose vaccination series and post vaccination testing for anti-hbs required) Dates: Results of anti-hbs testing 1 to 2 months after 3 rd dose: Date: Immune status: Positive *Negative For those students who completed the Hepatitis B series but were not tested for immunity; testing is required to confirm immunity: Hepatitis B surface antibody titer (anti-hbs 10 IU/mL). Date: Immune status: Positive *Negative Previous Vaccinations (not required) Hepatitis A Vaccine Dates: Dates: Dates: Pneumococcal Vaccine Meningococcal Vaccine Haemophilus Influenzae type B (Hib) Dates: *If no, repeat 3 dose vaccination series and follow with anti- HBs testing 1 to 2 months after 3 rd dose. Dates: anti-hbs testing (1 to 2 months after 3 rd dose) Date: Immune status: Positive **Negative **If negative, follow up testing for Hepatitis B (HBsAg) and counseling recommended to student. Date: (If series is not complete at time of examination, indicate series initiated. Subsequent dates must be indicated when complete.) Signature of Physician/ Nurse Practitioner/ Physician Assistant Date Printed Name Address: Phone Number:
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Immunization Policy & Forms. 33 Prospect Hill Road Cromwell, Connecticut / Tel. (860) Fax: (860) /
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