PHLEBOTOMY TECHNICIAN PROGRAM

Transcription

1 Bldg. 150, Rm 1114 Phone: (254) Fax (254) (ATTN:PBT) Hours: M-Thur 7:30 AM-5:30 PM Fri 7:30 AM-11:30 AM PHLEBOTOMY TECHNICIAN PROGRAM APPLICATION DOCUMENTS Please complete and return to the PBT Office Revised 7/26/17 1

2 STUDENT CHECKLIST ******************************************************************************The following is a list of requirements needed before entry into the Phlebotomy Technician Program ****************************************************************************** Check off as obtained: Application (Included in this handbook) Health History (Included in this handbook) Physical form to be filled out by your doctor (Included in this handbook) 2 Reference Forms (Included in this handbook) CPR Certification (Must be AHA and Healthcare Provider Level available through CTC) High School Diploma, GED, or College Unofficial Transcripts Immunization Record including all vaccines listed below: a. Influenza Vaccine (Required every 12 months) b. TB Skin Test/PPD (Required every 12 months) c. Bacterial Meningitis Vaccination/MCV (Within 5 years) d. Tetanus/Tdap (Within 10 years) e. Hepatitis B series (series of 3 over a period of 4-6 months) f. MMR (Mumps, Measles, Rubella): MUST show 2 doses MMR g. Varicella vaccination, documentation of the disease, and/or waiver h. Polio Once accepted in the Phlebotomy Technician Program the following are required: Student ID and Parking sticker (Student Life Center, Bldg. 119) Textbooks (CTC Bookstore, Bldg. 156) Lab coat, Scrubs, Shoes - close-toed (not canvas or fabric) Nametag or badge: o Obtain from: Monarch Uniforms, 1200 Lowes Blvd.#113, Killeen, TX o White background. Should include 3 lines : Student Name Central Texas College Phlebotomy Technician Program Background Check (DO NOT get this done yet, this is based on clinical acceptance) Drug Screening (DO NOT get this done yet, this is based on clinical acceptance) US Birth Certificate (or VISA) DO NOT need until clinical orientation & badging Picture ID (Passport, Driver s License, Military ID) 2

3 APPLICATION FOR PHLEBOTOMY TECHNICIAN PROGRAM OF CENTRAL TEXAS COLLEGE Please print or type: Date Name Maiden (if applicable) SSN: Date of Birth: Present Address: Phone: Cell Phone: address: _ Permanent Address: Person to notify in case of an emergency: Name: Phone: _ Relationship: Schools attended: High school: College: List honors and activities: Employment Information: Present/Most Recent Employer Job Title Start/Finish Address City/State Zip Code Supervisor Telephone Number 3

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5 CENTRAL TEXAS COLLEGE Notification of Phlebotomy Training The MLT/PBT program provides hands on lab experiences that include performing phlebotomy procedures. These phlebotomy procedures include venipuncture, sticking a needle just beneath the skin into a vein and drawing a tube(s) of blood, and dermal puncture, sticking a small needle into the skin of a finger. The venipuncture procedures are taught and mastered using artificial phlebotomy arms. These arms are designed to give the student the most realistic training so mastery can be accomplished before sticking an individual. However, after a successful evaluation has been performed in front of the instructor using the artificial arm, each student will perform venipunctures and dermal punctures on their classmates as part of the hands-on training. In return your classmates will perform venipunctures and dermal punctures on you. The venipuncture will be performed under the supervision of an instructor. Are there risks? The needle stick may hurt. There may be a small risk of bruising, and a rare risk of infection. Any student who has a documented medical reason or feels they cannot participate in the hands-on venipuncture training for any reason should discuss this with the instructor immediately. My signature shows that I am aware that I will perform venipunctures and dermal punctures. I am also aware that venipunctures and dermal punctures will be performed on me and I agree to hold Central Texas College and instructors and students of CTC harmless for any pain or injury resulting from the venipuncture and dermal punctures. Student signature Date Printed student name Or: I agree to perform live venipunctures and dermal punctures in class and in the clinical sites but will not allow them to be performed on me due to a documented medical reason. Student signature Date Printed student name 5

6 CENTRAL TEXAS COLLEGE Criminal Background Check and Drug Screen I understand a Criminal Background Check and Drug Screen must be performed prior to entering PBT I understand a criminal felony or a positive drug screen will prevent me from participating in the PBT Release of Information I agree to allow the CTC MLT/PBT program director to release the negative results of the Criminal Background Check and Drug Screen to the clinical facilities to which I will be assigned during enrollment in PBT I agree to inform the program director and/or clinical facility if criminal activity or substance abuse occurs after the initial Criminal Background Check and Drug Screen is completed. I agree to a for cause Drug Screen at a site identified by the college should a faculty member, clinical instructor or the program director deem it necessary. Signature Date 6

7 STUDENT HEALTH HISTORY TO THE STUDENT: A health history is required for all CTC Phlebotomy Technician Program students. This health information is confidential. Please read the form carefully; answer ALL questions on the form. Name (Last, First, MI) Home Address: City, State, ZIP: DOB: SSN: Expected Entrance Semester: Year Fall/Spring Person to notify in care of emergency: Name: Relationship: Address: Telephone # Name of Physician: Telephone # Physician s Office Address: Are you covered by hospitalization insurance? NO YES If yes, complete this form: Name of Insurance Company or Covering Agency: Address of Insurance Company/Agency: If Blue Cross or Blue Shield gives Certificate N. /Group No.:_ If other policies, or other types of coverage, give policy ID numbers: _ Name of Policy Holder: Address of Policy Holder: Relationship to student: _ 7

8 INSTRUCTIONS: 1. Mark X in the Yes column if you have a history of any of the items listed in a given question; otherwise, mark X in the No column. 2. For any Yes answer: a. Circle the appropriate item within the question. b. In the remarks section, indicate the number of the question and give a brief statement of the problem or condition. 3. Sign and date Have you a history of any of the following? YES NO Hospitalization, fractures, surgery, or serious illness Continuing use of prescribed medications Drug allergies or other allergies, please specify Rheumatic fever, heart murmur, cyanosis, abnormal or irregular heart rate or rhythm, or recurrent chest pain Shortness of breath at rest or after mild exertion, heart failure, swelling of hands or feet Excessive or prolonged cough or sputum production, coughing up blood, or chest pain on breathing deeply Pneumonia, bronchitis, tuberculosis, sinusitis, asthma, or frequent sore throats or ear infection Vomiting of blood, blood with a bowel movement, black stools, jaundice, or recurrent episodes of nausea, vomiting diarrhea or persistent abdominal pain Disorder of liver, gall bladder, colon, or stomach; peptic ulcer Diabetes mellitus, sugar in the urine, under active or overactive thyroid gland; goiter (thyroid lump); disease of any endocrine gland Double vision, fainting spells, epilepsy or seizure disorder, recurrent severe headache, color blindness Numbness, paralysis, tremor, persistent of progressive weakness Urinary tract infection (bladder or kidney infection) (Males only Females mark NO) Prostate infection Blood, pus, protein, sugar, or stone in the urine (Females only, males mark NO) Abnormal or irregular menstrual period, disorder of the ovary, recurrent vaginal infection Counseling or treatment for emotional problems in the last five years Advised to seek further counseling for emotional problems 8

9 Have you a history of any of the following? YES NO Any physical handicap which may cause difficulty in performance of normal activities? (Blindness, hearing loss, difficulty walking, speech defects, missing limbs, etc.) Abnormal chest x-ray (if yes, give date and place of x-ray, details of abnormalities, if known) Positive skin test for tuberculosis, cancer, diabetes mellitus, high blood pressure, and inherited disease or unusual illness Family history tuberculosis, cancer, diabetes mellitus, high blood pressure, any inherited disease or unusual illness Would you like to see a counselor or other staff person to discuss any of the items above or others? Not mentioned: Remarks: (Use additional pages if necessary) Signature: Date: 9

10 CENTRAL TEXAS COLLEGE PHLEBOTOMY TECHNICIAN PROGRAM PHYSICAL EXAMINATION FORM (TO BE FILLED OUT BY APPLICANT AND SHOWN TO PHYSICIAN AT TIME OF PHYSICAL) IDENTIFYING INFORMATION: Name: Enrollment Date: Home Address:_ Telephone: PERSONAL & FAMILY HISTORY: (To be filled out by the student) Mark yes or no under the 1st or 2nd column and indicate the relative under the 3rd column. SELF FAMILY RELATIVE Back Pain Tuberculosis Diabetes Heart Trouble Stomach Trouble Asthma, Hay fever, Hives Epilepsy, Seizure, Fainting Mental Illness Have you any chronic illness: No Yes: Nature: Attending Physician: Date last seen: List any medications that you are presently taking prescribed by a physician: What operations/or diseases have you had? Give dates where possible: For female students Does menstruation interfere with your normal activities? If yes explain _ Any known reaction to any medicines? YES NO If yes, explain: Family Physician: Address Telephone First Aid Treatment consent for student less than 21 years of age: _ Parent or Guardian's Signature _ Relationship Date 10

11 CENTRAL TEXAS COLLEGE PHLEBOTOMY PROGRAM PHYSICAL EXAMINATION (TO BE FILLED OUT BY YOUR PHYSICIAN) NAME: SEX: M F DOBWEIGHT HEIGHT (Last, First, MI) VISION: Uncorrected R20/ L20/ Corrected R20/ L20/ Color Vision Normal/ Abnormal Check under the appropriate column. If abnormal, explain NORMAL ABNORMAL HEARING: SKIN: THROAT: TEETH: LUNGS: HEART: ABDOMEN: KIDNEYS & BLADDER: THYROID: GLANDS: SPINE: EXTREMITIES: REFLEXES: REQUIRED FOR ADMISSION: All students are required to show proof of complete Hepatitis B series immunizations. All students born on or after must show proof of: (1) 2 doses of measles vaccine administered on or after their 1st birthday and at least 30 days apart, (2) 1 dose of mumps vaccine administered after 1st birthday (3) 1 dose of rubella vaccine after 1st birthday or immunity to measles, mumps and rubella. Please fill out all applicable dates for immunizations: IMMUNIZATION DATE GIVEN RESULT VALID DATES PPD (TB Tine) Within 12 months Or chest x-ray Within 12 months Influenza Within 12 months Meningococcal (MCV4) Within 5 years Tetanus (Td/Tdap) Within 10 years Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 MMR #1 MMR #2 Polio (IPV/OPV) Varicella (VZV) OR DATE OF POS TITER 11

12 CLASSIFICATION FOR PHYSICAL ACTIVITIES: CENTRAL TEXAS COLLEGE PHLEBOTOMY PROGRAM PHYSICAL EXAMINATION FORM (TO BE FILLED OUT BY YOUR PHYSICIAN) A. Unlimited B. Limited If limited, explain: MEDICATIONS OR INJECTIONS TO BE AVOIDED: In your opinion, is this individual in suitable physical and emotional condition for training in the Phlebotomy Technician Program? YES NO If not, why: Signature of Physician Date of Physical (Typed Name & address or stamp of physician) 12

13 PHLEBOTOMY TECHNICIAN REFERENCE FORM has applied for admission to the Phlebotomy Technician Program and has given your name as a reference. Please fill out the form as completely as possible. Thank you for your assistance in the evaluation of this student. How long have you known the applicant? Less than a year 1-5 year s 5-10 year s Longer In what capacity have you known the applicant? Personal only Personal and Professional Professional only Areas of concern: Please check appropriate column Insufficient Information Needs Improvement Average Above Average Excellent (Maximum number of total points: 36) Ability to learn 2. Initiative 3. Persistence 4. Priorities 5. Judgment 6. Quality of work 7. Ability to work 8. Ability to relate to others 9. Communication ability Name: Position: Date: Signature: 13

14 PHLEBOTOMY TECHNICIAN REFERENCE FORM has applied for admission to the Phlebotomy Technician Program and has given your name as a reference. Please fill out the form as completely as possible. Thank you for your assistance in the evaluation of this student. How long have you known the applicant? Less than a year 1-5 year s 5-10 year s Longer In what capacity have you known the applicant? Personal only Personal and Professional Professional only Areas of concern: Please check appropriate column Insufficient Information Needs Improvement Average Above Average Excellent (Maximum number of total points: 36) Ability to learn 2. Initiative 3. Persistence 4. Priorities 5. Judgment 6. Quality of work 7. Ability to work 8. Ability to relate to others 9. Communication ability Name: Position: Date: Signature: 14