Phlebotomy Technician Program – Fall 2014 Program Information: Thank you for your interest in Certified Phlebotomy Technician Training at Tunxis Community College! This 150 hour program has been approved by the National Health Career Association. This program that includes classroom and a hand-on laboratory is limited to 15 students accepted on a first come, first served basis. Course content includes: basic aspects of medical terminology, anatomy and physiology, venipuncture, specimen collection procedures, safety and universal precautions, common laboratory tests with clinical significance to body systems and disease processes, and laboratory equipment. Upon successful completion, the student is eligible to sit for the National Certification examination, to be administered at the college, and for a clinical externship. Program Requirements: You must be at least 18 years of age with a high school diploma or GED, and complete the following:  Fill out the enclosed PT application cover sheet, Questionnaire, Physical Verification form and Health form (original health form due by Oct. 10).  Mail or bring the application and forms along with a non-refundable $35 administrative fee (credit or debit card, check or money order payable to TCC – no cash please), to Continuing Education, Tunxis Community College, 271 Scott Swamp Road, Farmington, CT 06032. Your application will then be forwarded to the Allied Health Coordinator for consideration. Upon acceptance, you will be notified in writing and given further instructions to complete your enrollment. Once you are accepted, the tuition must be paid to the College within five business days of notification. Refunds may be obtained ONLY if your written withdrawal is submitted to Continuing Education three business days prior to the first class meeting. Health Form: Each student that applies to the program must submit a completed health form. See Associated Cost Sheet for details. No one can be permitted to participate in the lab portion of the program or externship without this requirement. The original form must be submitted to the Allied Health Coordinator and cannot be faxed (due Oct. 10). Please be advised that if you have been convicted of a felony, you may not be eligible for clinical experiences, internships, externships or certifications associated with certain Allied Health courses or programs. Those with previous convictions may also find it difficult to secure employment within a health care agency or institution. Course Dates, Times and Location: Day Program: Sept. 22 – Dec. 16 Mon & Tues 9am-2pm Lab: Mondays, room 326 Lecture: Tuesdays, room 6-173 Evening Program: Sept. 22 – Dec. 17 Mon, Tues & Wed 5:30-8:45pm Lecture: Mondays, room 313 Lab: Tuesdays & Wednesdays, rooms 313/326 **No Class Monday, Oct. 13** For more information, please call the Continuing Education Office at (860) 255-3666. COSTS ASSOCIATED WITH THE TUNXIS PHLEBOTOMY PROGRAM FALL 2014 Fees Due Directly to Tunxis Community College: $35 non-refundable administrative fee payable to TCC at the time of registration $1,850 tuition includes malpractice insurance (personal health insurance is recommended in case of injury or exposure) Payment Plan Option: (includes a $25 installment fee) $975 – due within five business days of acceptance $925 – due Nov. 6 Payment Plans are initiated and completed at the Business Office. Please visit or notify the Continuing Education office first. Costs Associated With the Program but Not Payable to TCC: $125 National Health Career Association Certification Examination fee $200 (estimated) Textbook/Workbook/Review book and white lab coat payable to Follett Bookstore at TCC $100 (estimated) for uniform: light grey scrub top and pants sneakers or nursing shoes (not open toed) Health Form requirements: Physical Exam within the last year Verification of measles, mumps, rubella vaccinations or rubella and rubeola titers Chickenpox – verbal history of disease, date(s) of vaccination, or blood titers Tuberculosis testing – chest x-ray if positive results Hepatitis B series (optional) or waiver signature Tetanus shot within the last 10 years NOTE: This form must be in place by the deadline date (listed on previous page) in order for a student to be eligible for clinical and externship. BANNER ID ____________________________________ FEE PAID ON ____________________________ CC ______________ CRN _____________________ TUNXIS COMMUNITY COLLEGE PHLEBOTOMY TECHNICIAN PROGRAM 2014 Spring Program Choice (check only one): DAY Summer Fall EVENING Please Note: Evening program not available during summer. Name_________________________________________________ Date of Birth_______________________ last first middle Home Address____________________________________________________________________________ street city state zip E-mail Address____________________________________________________________________________ Phone___________________ Work / Cell Phone____________________ SSN#_______________________ Gender: Male Female Ethnic/Racial (optional): White Primary Language__________________________________ Black Hispanic Asian Native American Other Emergency Contact Name________________________________________ Phone #___________________ Are you a U.S. Citizen? Yes No If no, are you an alien who has the legal right to work? Have you ever been convicted of a felony or misdemeanor? No Yes No Yes—briefly explain below. *An arrest record could affect your ability to obtain employment as a CPT. EDUCATIONAL INFORMATION High School or GED Certification______________________________________________________________ U (school attended and year graduated or certified) College or University _______________________________________________________________________ (school attended, degree and year graduated) Are you competent in reading comprehension and able to do math computation? Yes No If no, please explain. List employment history below. Tuition Payment Source Self Agency (Agency Name, Caseworker and phone # Required below): ________________________________________________________________________________________ Application Fee Paid By: Check Number Money Order MasterCard/Visa/Discover: Agency Exp. Date I understand the refund policy means I must contact the CE office three business days prior to the start of class and that no refunds will be issued after that time under any circumstances. The information provided on this CPT registration form is complete and accurate. Signed____________________________________________________ Date______________________ TUNXIS COMMUNITY COLLEGE CERTIFIED PHLEBOTOMY TECHNICIAN PROGRAM Name: _________________________________________________________________ Do you have transportation? Yes No Tell us about yourself. List five qualities you possess that would make you a good candidate for the program. Do you know what being a Phlebotomist entails? Briefly describe. Why do you want to take this course? How can Tunxis be assured that you will be committed to the program? Do you have any physical limitations? If yes, please explain. Have you ever been arrested? If yes, please explain. What are your career goals? How did you hear about this course? Student Signature: ______________________________________Date: ____________ Name: ___________________________________________ Date: ________________ Check if you Agree, Disagree, or ‘N/A’ if it doesn’t apply. 1. I have trouble knowing what to study for a test. Agree Disagree 2. I need a friend with whom to discuss important things. 3. I am swamped by details and facts when I study. Agree Agree Disagree Disagree 4. I have recently endured the death of a family member or pet. Agree 7. I usually work best against a tight deadline. 8. I seem never to have enough leisure time. 9. It is not easy for me to make friends. 10. I need more time for my family. Agree Agree Agree Disagree 11. I rarely have enough money to meet expenses. N/A N/A Disagree Agree Agree N/A N/A Agree 12. I have recently gained a new family member. 13. I have had a change in my financial state. Disagree Disagree Disagree N/A Disagree Agree Disagree Agree Disagree N/A N/A Agree 5. There has recently been a change of health for a family member. 6. I am overburdened with responsibility. N/A N/A Disagree Disagree N/A N/A 14. Money is going to be very tight for me this year. Agree Disagree N/A 15. I am experiencing a great deal of family friction. Agree Disagree N/A 16. I have to do jobs I can’t cope with. Agree 17. I am experiencing a change in living conditions. 18. Most health care personnel are overworked. Disagree Agree Agree N/A Disagree Disagree N/A N/A N/A N/A Tunxis Community College 271 Scott Swamp Road Farmington, Connecticut 06032 CERTIFIED PHLEBOTOMY TECHNICIAN PROGRAM PHYSICAL VERIFICATION FORM Name of Student__________________________________________________________________________________ Address_________________________________________________________________________________________ City___________________________________________ State___________ Zip Code_______________________ Check the appropriate answer. Please answer as honestly as possible. If yes is checked, please provide an explanation. Allergies? Yes No Pregnant? Yes No On Medication? Yes No Please list any medications here: Mental Health Concerns? Yes No _______________________________________ Hearing Problems? Yes No _______________________________________ Back Problems? Yes No _______________________________________ Knee Problems? Yes No Recent Surgeries? Yes No Lifting Restrictions? Yes No Yes No (i.e. arthritis, injury, surgeries, etc.) Latex Allergy? If you are pregnant, have any back problems/lifting restrictions, or a medical condition that is being monitored by a physician, a form will be provided by the College that must be completed by your physician along with your signature. Please list any other conditions that you feel may present a risk for you or that your Instructor should be aware of to protect your well-being and safety. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Student Signature _____________________________________________ Date:__________________________ For Office Use Only BANNER ID @_________________ Certified Nurse Aide Phlebotomy Technician HEALTH FORM Name_______________________________________________________________________________________________ Address______________________________________________________________________________________________ Date of Birth_________________________ Telephone #_______________________________________________________ __________________________________________ was examined and found to be in good health on (Name) __________________________. (Date of Examination) He/she is in good health, free of any communicable disease and has no known deficits that would interfere with the ability to participate in the lab/clinical setting. A pregnant student requires OB/GYN assessment. __________________________________________________________ Healthcare Provider Signature ______________________________ Healthcare Provider Phone # __________________________________________________________ Address ______________________________ Date Immunization CT state laws require that any student/instructor born on or after January 1, 1957 be protected against measles and rubella (MMR). Please complete your immunization history. **The Department of Public Health requires 2 doses of the measles vaccine, with at least one dose being given after 1980. Proof of one dose of the rubella (German measles) vaccine administered after the student’s first birthday must also be provided to the college. #1_________________ #2__________________ Date Date If you have no MMR vaccine, then you must report your rubeola and rubella titers: MMR ___________________________ ________________ _________________________________ ___________ Rubeola titer Date Rubella titer Date History of Disease: Yes: ___ Date ____________________________ No: ___ If no, Titer must be reported Varicella Titer _____________________________________________ Results Date Date(s) of Immunization:_____________________________________ VARICELLA (Chicken Pox) Tetanus Booster - Date: ______________________ (**Must be done within last 10 years) Flu vaccine – Date:_______________________ (Fall and Spring Applicants only) TUBERCULOSIS PPD: NEG ___________________ POS _____________________ Date–within past 9 mos Date Done by: __________________________________ Signature - Title Date If positive, results of chest x-ray (within past 6 months) _______________________________________________ **A copy of the X-ray report must be submitted with this form** Results Date HEPATITIS B Hepatitis vaccination is recommended but not required. You should discuss the option with your physician and either begin vaccination or sign waiver. Employers may provide opportunity upon hire. #1 ___________________________ #2 ___________________________ #3 ___________________________ Date Date Date I waive Hepatitis B vaccination at this time: Signature___________________________________ Date:____________ For Office Use Only BANNER ID @_________________ HEPATITIS B RISK FORM I understand that due to my potential exposure to blood, body fluids and other potential infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. Because I have not completed the Hepatitis B vaccination series or waived having the series, I understand that I continue to be at risk of acquiring Hepatitis B, a serious disease. I understand that if I experience an exposure to blood, body fluids or other infectious materials, I must notify my preceptor and/or instructor immediately. I will be directed to the Emergency Department where I will be offered the Hepatitis B virus immune globulin (HBIG), an injection(s). This injection provides temporary passive immunity from Hepatitis B. I will need to continue or start the Hepatitis B vaccination series. By my signature below I acknowledge understanding that I (the student) am solely responsible for payment of all services, injections, vaccinations and other costs associated with my exposure to blood, bodily fluids or other infectious materials while in the Program even though I have not completed the Hepatitis B vaccination series. I further understand that the College, its employees and clinical sites, will not be responsible for any services, injections, vaccinations or other costs associated with my exposure to blood, bodily fluids or other infectious materials while in the Program even though I have not completed or waived the Hepatitis B vaccination series. I have received information about Hepatitis B and the risks of exposure to blood, body fluids and other potential infectious materials and my responsibility in reporting any incident of possible exposure. I waive Hepatitis B vaccination at this time. _________________________________________ Student’s name – please print _________________________________________ Student’s Signature ________________ Date