Physical Therapist Assistant Program Program Information Manual 2014-15 Academic Year Mohave Community College Physical Therapist Assistant Program Table of Contents Equal Opportunity Policy Statement .................................................................................................................................................2 Accreditation Status ..................................................................................................................................................................................2 Frequently Asked Questions .................................................................................................................................................................4 Program Of Study .......................................................................................................................................................................................9 Program Requirements............................................................................................................................................................................9 Program Costs ........................................................................................................................................................................................... 11 Clinical Needs Check List...................................................................................................................................................................... 14 Physical Examination Form ................................................................................................................................................................ 15 Department Of Public Health Pricing ............................................................................................................................................. 17 Application Packet ................................................................................................................................................................................... 18 Application Checklist ............................................................................................................................................................................. 19 Admission Requirements And Selection Criteria: .................................................................................................................... 20 Application .................................................................................................................................................................................................. 21 Admission Application Disclaimer .................................................................................................................................................. 22 Drug Screening Disclaimer .................................................................................................................................................................. 23 Criminal Background Self-Disclosure ............................................................................................................................................ 23 Essential Functions Requirements .................................................................................................................................................. 25 Observation Hours .................................................................................................................................................................................. 27 Observation Hours Verification ........................................................................................................................................................ 29 Background Checks ................................................................................................................................................................................. 30 Fingerprint Cards ..................................................................................................................................................................................... 30 Student Demographic Information ................................................................................................................................................. 31 EQUAL OPPORTUNITY POLICY STATEMENT Mohave Community College does not discriminate on the basis of sex, color, race, religious preference, age, disability, national origin, Veteran status or any other legally protected class in any of its policies, practices, and procedures, and it is an affirmative action and equal opportunity employer. For more information, call the Human Resources Office at 928.757.0835, 1971 Jagerson Ave., Kingman, AZ 86409. Grievance procedures are available at the Mohave Community College libraries in Bullhead City, Colorado City, Kingman and Lake Havasu City. ACCREDITATION STATUS NOTICE TO STUDENTS Physical Therapist Assistant Program at Mohave Community College is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, Virginia 22314; telephone: 703-706-3245; email: [email protected]; website: www.capteonline.org. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 2 of 31 Mohave Community College Physical Therapist Assistant Program Dear Prospective Student: Thank you for your interest in the Physical Therapist Assistant Program at Mohave Community College. Please review the application form prior to completion. Once you have made your decision to apply to the program, complete all the required steps. Due to limited amount of seats that are available in this program, and the amount of applications that we receive, the applications into the program will only be accepted during the designated application period of January 5, 2015 to April 24, 2015. Twenty (20) students will be selected for admission into the PTA program. See the Admission Criteria and rating system located in this packet for more information. Applications will be considered as students apply. Please note that the curriculum and prerequisites for the program will be revised periodically. It is the applicant’s responsibility to remain aware of changes that occur. For additional information, please access one of the resources below: 1. Website: www.mohave.edu PTA Information: http://www.mohave.edu/academics/certificates/pta Phone: 1-866-664-2832 2. Liz Briere PT, DPT Director of PTA program Phone: (928)505-3347 E-mail: [email protected] 3. Tamra Coleman, PT, DPT, OCS, COMT ACCE, Resident Faculty Phone: 928-302-5323 E-mail: [email protected] 4. Jennine Ramirez: Program Secretary: Phone: (928)505-3351 E-mail: [email protected] Best wishes in you educational and career pursuits. Sincerely, Liz Briere PT, DPT, Director of Physical Therapist Assistant Program Application Process: Prior to applying to the program, please complete the admissions application process. See link below: https://jics.mohave.edu/ICS/Admissions_Apply_Online/Application_for_Admission.jnz MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 3 of 31 Mohave Community College Physical Therapist Assistant Program FREQUENTLY ASKED QUESTIONS: 1. WHAT CAN I DO TO GET READY NOW? Review the Essential Functions of a PTA found on page 25 to make sure you can perform those selected activities. Complete requirements to obtain your high school diploma or GED. HOBET exam is required and reviewed for consideration into the program. Contact Academic Advising to determine your need for any assessment tests in English and Math (COMPASS test). If needed, enroll in Transitional Math and/or English to be eligible for college level courses. NOTE: In order to apply to the PTA program, students must receive an appropriate score on the COMPASS exam, or successful completion of TRE 089 and TRM 091 (Prerequisite). By the spring semester, taking the following general education courses prior to applying for the PTA program will increase your points toward admission. o BIO 100 Biology Concepts (Prerequisite) o COM 121 Interpersonal Communications OR COM 151 Public Speaking o BIO 201 Human Anatomy & Physiology I o BIO 202 Human Anatomy & Physiology II o ENG 101 English Composition I o PSY 101 Introduction to Psychology o CIS 110 Introduction to Computer Information Systems Recommended but not required courses: o HES 113 Medical Terminology o MEA 100 Medical Law and Ethics *Be aware that some courses may have additional pre-requisites associated with them. The following students must take STU 101 prior to applying to the PTA program: o Cumulative High School or College GPA of less than 2.5 (4.0 scale); and/or o If you have not taken at least 12 credits in the last 3 years. Become certified in CPR at the Healthcare Provider level. 2. WHAT IS THE DIFFERENCE BETWEEN A PHYSICAL THERAPIST AND A PHYSICAL THERAPIST ASSISTANT? a. Physical Therapists (PTs) evaluate patients, determine the plan of care, and perform skilled treatments. b. Physical Therapist Assistants (PTAs) are supervised by the Physical Therapist. They help the Physical Therapist by performing selected treatment activities listed in the plan of care. 3. WHAT IS PHYSICAL THERAPY? a. Physical Therapy (PT) is the art and science of providing care to patients recovering from injury or disease which has resulted in a loss of function. Physical Therapy interventions, such as therapeutic exercises, gait training, electrical stimulation, functional training are utilized to restore function to the highest level. Patients may include infants, children, adults, and the elderly. 4. WHAT EDUCATION IS NECESSARY FOR A PTA LICENSE? a. Physical Therapist Assistants attend community or technical colleges that offer an associate’s degree. The program takes two years to complete. You must graduate from an accredited Commission on Accreditation in Physical Therapy Education program (CAPTE) in order to sit for the National Physical Therapy Examination for PTAs. (See question # 11) MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 4 of 31 Mohave Community College Physical Therapist Assistant Program 5. WHERE DO PTA’S WORK? a. PTA’s work in hospitals, rehabilitation centers, skilled nursing facilities, outpatient clinics and sports medicine centers. Work hours are generally during the daytime, Monday through Friday. Weekend work is generally available or required at hospitals and skilled nursing facilities. 6. HOW MUCH MONEY DO THEY MAKE? a. The new graduate PTA can expect to earn $31,070 - $68,820 per year for a full time position. 7. WHAT IS THE CURRENT JOB MARKET? a. The job market for PTA’s is projected to continue to grow for the next several years both locally in Arizona and throughout the country. The United States of Labor Statistics forecasts that through 2020 the demand for Physical Therapist Assistants will grow by 45%, much faster than the average for all occupations. Opportunities for individuals interested in becoming Physical Therapist Assistants are expected to be very good. 8. WHY SHOULD I CONSIDER A CAREER IN PHYSICAL THERAPY? a. A career in Physical Therapy is very rewarding. Each day Physical Therapist Assistants work closely with their patients to help them recover from injuries or illnesses that have temporarily or permanently changed their lives. PTA’s are important members of the rehabilitation team. Helping people to progress back towards optimal health is a wonderful experience. b. PTA’s are men and women who enjoy challenging work, communicating with people, and working in a team environment to assist patients to achieve their fullest rehabilitation potential. 9. CAN I APPLY IF I HAVE A CRIMINAL RECORD? a. Yes, you may apply to the PTA program if you have a criminal record. You must be able to achieve clearance through a background check upon admission. You will also be required to obtain a fingerprint clearance card prior to clinical education experience. b. Upon graduation from the PTA program you must apply to the Arizona State Board of Physical Therapy (ASBPT) for PTA certification. The ASBPT has the ultimate authority to grant PTA certification in the state of Arizona. They can make this determination after reviewing the PTA certification application, including examination of criminal history. c. Agreements with the healthcare facilities require that students receive a Fingerprint Clearance Card issued by the Arizona department of Public Safety. Additionally, a student must not be listed on the Federal Government’s Office of the Inspector General’s Exclusion List. Students that are unable to obtain either of these clearances will be prohibited from attending the Physical Therapists Assistant Program at Mohave Community College. 10. DO I NEED TO PASS AN EXAMINATION TO BE A PTA? a. To hold the title of Physical Therapist Assistant in Arizona, an individual must pass the National Physical Therapy Examination (NPTE) for the respective level of education and training. The examination is administered by the Federation of State Boards of Physical Therapy (FSBPT). Costs associated with applying for certification and taking the examination are approximately $500. 11. HOW MANY STUDENTS WILL BE ADMITTED TO THE PROGRAM? a. A new class of up to 20 students will be admitted each August to the traditional day program. The number of students admitted may change depending on employment market conditions MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 5 of 31 Mohave Community College Physical Therapist Assistant Program and the availability of clinical training sites. There is a selection process and a deadline to submit applications. In the event of a tie in rank, the space will go to the person who submits their application the earliest. 12. WHAT HAPPENS TO MY APPLICATION IF I AM NOT ONE OF THE FIRST 20 APPLICANTS? a. The application remains on file. If a student in the initial acceptance group is unable to take their space, the position is offered to the next ranked applicant. For reconsideration for the following year, a new application must be submitted. 13. HOW LONG DOES IT TAKE TO COMPLETE THE PROGRAM? a. The program at MCC is an integrated 2 year program and can be completed in 5 semesters. (Fall, Spring, Summer, Fall, Spring). b. The program at Mohave Community College is an integrated 2 year program and can be completed in 5 semesters. If all lecture laboratory, and clinical courses are completed satisfactorily students will be able to graduate within 2 years. Many students take a year prior to actually beginning the program courses to complete program prerequisites and general education courses that are required for the Associate in Applied Science (AAS) degree. c. Please be aware that a semester below 12 credits can affect a student’s financial aid. 14. IS THIS PROGRAM ACCREDITED? Physical Therapist Assistant Program at Mohave Community College is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, Virginia 22314; telephone: 703-706-3245; email: [email protected]; website: www.capteonline.org. 15. WHEN ARE CLASSES SCHEDULED? a. Lecture and lab courses may be scheduled Monday through Friday. Classes may begin as early as 8:00 am and end as late as 5:00 pm. Depending on the semester, students may be in class for 6-8 hours, 3-5 days per week. All of these classes are held on site at Mohave Community College, Lake Havasu Campus. b. Clinical education classes (PTA 206, PTA 280, and PTA 290) are Monday through Friday for 8 hours each day for 4-6 consecutive weeks. Extended hours and weekends are occasionally necessary during clinical experiences. These classes require attendance at clinical facilities that include hospitals, extended care facilities, and outpatient practices. There will be 3 clinical education courses. c. Due to the rural nature of our location and the limited clinical site availability in Mohave County, you will have to do at least one of your clinical education rotations outside of Mohave County. If you have friends or family in the outlying areas, who would allow you to bunk there for the defined weeks, the program will make the greatest attempt to place you in close proximity to that location. The program reserves the right to place a student in a facility that will best meet the student’s needs to fulfill the requirements of clinical education to become a competent Physical Therapist Assistant. 16. CAN I WORK AND GO TO SCHOOL? a. PTA program applicants are cautioned the PTA program is a rigorous course of study. The program faculty recommends that work hours be kept to a minimum but each student must make an individual decision about the number of work hours that he/she can handle while continuing to make acceptable academic progress in the program. The program recommends working no more than 20 hrs. Per week while enrolled in the PTA Program. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 6 of 31 Mohave Community College Physical Therapist Assistant Program The Clinical Education experience requires the student to be in the facility for a 40 hour work week. 17. WHAT IS THE COST OF THE PROGRAM? a. Students will pay the normal tuition plus a Program Fee of $1850 per semester. The program fee will include student uniforms, student lab materials and tools, initial drug testing fees and evaluation materials for clinical performance. Out of pocket costs include, but are not limited to CPR, vaccines, medical clearance, costs for transportation & housing for clinical rotations, health insurance, and additional tests required by individual facilities. 18. IS FINANCIAL AID AVAILABLE? a. Financial assistance is available to eligible students in the form of grants, scholarships, employment, or loans. Students may receive aid from one funding source or aid that may be in a package from offered multiple sources. Students may contact the financial aid office at (866)-664-2832 or visit the website at www.mohave.edu for additional information. 19. ARE THERE ANY SPECIAL SITUATIONS I NEED TO BE AWARE OF BEFORE I APPLY? a. Students are required to complete three clinical education courses during the program. This is a series of work experiences with patients in a variety of off-campus settings, under the supervision of practicing PTA’s and PT’s. This includes one four week and two six week, full time (40 hours per week) clinical experiences where the student must display sufficient skill and competence to enter the field as a practicing PTA. Students must be willing and able to organize their time, transportation, and other life responsibilities to complete and benefit fully from their clinical experiences. Working during the clinical education experience is an unrealistic expectation. b. Due to the limited amount of clinical sites and the rural nature of Mohave County, at least one of these rotations will require the student to travel out of Mohave County for 4 or 6 weeks. All students will complete a student rotation outside of Mohave County, whether you have children or not. 20. IS THERE A DRESS CODE? a. Professionalism includes your physical appearance. On campus: program shirts, long pants or shorts (appropriate length), appropriate footwear (no platform shoes). In clinic: You must follow the dress code of the clinic. Tattoos must be covered. In lab: shorts, halter tops, sports bras and athletic shoes for access to body parts and for ease of movement. 21. ARE THE PTA PROGRAM COURSES TRANSFERABLE TO COLLEGES OR UNIVERSITIES IF I DECIDE TO PURSUE A BACHELOR’S DEGREE? a. Mohave Community College has a partnership with many universities. Contact college advising for further information via the Call Center at 866-664-2832. Also, see www.nau.edu/extended for information about the Bachelor of Science in Health SciencesPhysical Therapist Assisting. 22. PHYSICAL EXAMINATION, IMMUNIZATION AND TB TESTING REQUIREMENTS: a. A physical examination, proof of immunization and TB testing will be required. Please see attached (or below whatever works) form. Please be aware that immunization and testing may vary depending on the clinical site that you may attend during the clinical rotation. Therefore, additional expenses may occur. 23. BACKGROUND CHECK REQUIREMENTS: a. Background checks are required for incoming students to insure the safety of the patients treated by the students in the clinical education program. You will be required to order MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 7 of 31 Mohave Community College Physical Therapist Assistant Program your background check in sufficient time for it to be reviewed by the program coordinator. A Public Safety Fingerprint Clearance Card (FCC Card) is also required. Students bear the responsibility for the cost of the Background Check and the FCC Card. b. For additional information please go to www.mystudentcheck.com, and select Mohave Community College District from the drop down menu. In the next drop down menu you will select Physical Therapist Assistant. If you have been advised of being denied entry into the program due to information on the report, you can contact Pre-Check’s Adverse Action Hotline at 800-203-1654. This is the procedure by the Fair Credit Reporting Act that allows you to see the report and to dispute the information. You can also contact [email protected] for further assistance. 24. DRUG SCREENING a. Each student must go through a preclinical drug screen prior to beginning the first clinical rotation. The urine drug screen will test for alcohol; illegal drugs, or drugs that may impair judgment while working with patients at the clinical site. If the drug test is positive for the illegal drugs, or drugs that may impair judgment or motor function the student may not be able to continue in the program. Readmission is at the discretion of the college and the program director. Some clinical sites also require screening for nicotine. Students who test positive for nicotine may not be able to be placed at some clinical sites, but are not excluded from the program. 25. MEDICAL INSURANCE a. It is a requirement for Mohave Community College PTA students to have medical insurance while enrolled in this program. Please contact a local insurance provider. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 8 of 31 Mohave Community College Physical Therapist Assistant Program PROGRAM OF STUDY – PROGRAM REQUIREMENTS: YEAR ONE *NOTE: Students selected for PTA program must complete BIO 100 BIOLOGY CONCEPTS (4 CREDITS) or equivalent prior to the start of the fall semester. A grade of C or better must be achieved in all general education classes to count toward PTA program. FALL – YEAR ONE SEMESTER ONE COURSE CODE BIO 201 ENG 101 PTA 101 PTA 103 PTA 200 COURSE NAME HUMAN ANATOMY & PHYSIOLOGY I ENGLISH COMPOSITION SURVEY OF PHYSICAL THERAPY KINESIOLOGY PATENT MOBILITY TECHNIQUES TOTAL CREDITS – YEAR ONE – FALL CREDIT S 4 3 3 4 4 18 SPRING – YEAR ONE SEMESTER TWO COURSE CODE BIO 202 PTA 202 PTA 203 PTA 205 PTA 214 PTA 215 COURSE NAME HUMAN ANATOMY & PHYSIOLOGY II PHYSICAL THERAPY MODALITIES CLINICAL PATHOLOGY COMMUNICATION IN PHYSICAL THERAPY ELECTROMODALITIES WOUND CARE TOTAL CREDITS – YEAR ONE – SPRING CREDIT S 4 5 3 2 3 1 18 SUMMER – YEAR ONE SEMESTER THREE COURSE CODE PTA 206 PTA 217 CIS 110 COURSE NAME CLINICAL PRACTICUM I CLINICAL NEUROLOGY INTRODUCTION TO COMPUTER INFORMATION SYSTEMS TOTAL CREDITS – YEAR ONE – FALL CREDIT S 4 2 3 9 MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 9 of 31 Mohave Community College Physical Therapist Assistant Program PROGRAM OF STUDY – PROGRAM REQUIREMENTS: YEAR TWO FALL – YEAR TWO SEMESTER ONE COURSE CODE COM 121 (OR) COM 151 PSY 101 PTA 208 PTA 210 PTA 230 COURSE NAME CREDIT S INTERPERSONAL COMMUNICATION (OR) PUBLIC SPEAKING 3 INTRODUCTION TO PSYCHOLOGY REHABILITATION OF SPECIAL POPULATIONS ORTHOPEDIC PHYSICAL THERAPY PHYSICAL THERAPY SEMINAR TOTAL CREDITS – YEAR TWO – FALL 3 5 4 3 18 SPRING – YEAR TWO SEMESTER TWO COURSE CODE PTA 280 PTA 290 COURSE NAME CLINICAL PRACTICUM II CLINICAL PRACTICUM III TOTAL CREDITS – YEAR TWO – SPRING CREDIT S 6 6 12 PTA PROGRAM TOTAL CREDIT HOURS – 75 MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 10 of 31 Mohave Community College Physical Therapist Assistant Program PROGRAM COSTS PTA ESTIMATED PROGRAM COST: IN- STATE COSTS: Registration Name Cost Per Credit/Fee Total Credits/Fee In – State Cost Tuition Fee $ 80.00 75 $ 6,000.00 Technology Fee $ 6.00 75 $ 450.00 Student Life Fee $ 1.00 75 $ 75.00 Program Fee $ 7,405.00 1 $ 7,405.00 Books Estimate $ 2,100.00 1 $ 2,100.00 Estimated Total Cost Of Program (Based On Estimated $2,100 Book Fee) $ 16,030.00 OUT- OF - STATE COSTS: Registration Name Cost Per Credit Total Credits/Fee Out – Of – State Cost Tuition Fee $ 280.00 75 $ 21,000.00 Technology Fee $ 6.00 75 $ 450.00 Student Life Fee $ 1.00 75 $ 75.00 Program Fee $ 7,405.00 1 $ 7,405.00 Books $ 2,100.00 1 $ 2,100.00 Estimated Total Cost Of Program (Based On Estimated $2,100 Book Fee) $ 31,030.00 MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 11 of 31 Mohave Community College Physical Therapist Assistant Program PROGRAM COSTS PTA ESTIMATED PROGRAM COST PER SEMESTER: FALL – YEAR ONE SEMESTER ONE Registration Name Cost Per Credit In-State Tuition Fee Technology Fee Student Life Fee Program Fee Books $ $ $ $ $ Cost Per Credit Out-Of-State Total Credits 80.00 $ 280.00 18 6.00 $ 6.00 18 1.00 $ 1.00 18 1,480.00 $ 1,480.00 1 500.00 $ 500.00 1 Estimated Total Cost Of Program For Semester In-State Costs $1,440.00 $ 108.00 $ 18.00 $1,480.00 $ 500.00 $3,546.00 Out-Of-State Costs $ $ $ $ $ $ 5,040.00 108.00 18.00 1,480.00 500.00 7,146.00 SPRING – YEAR ONE SEMESTER TWO Registration Name Tuition Fee Technology Fee Student Life Fee Program Fee Books Cost Per Credit InState $ $ $ $ $ 80.00 6.00 1.00 1,880.00 500.00 Cost Per Credit Out-Of-State $ $ $ $ $ 280.00 6.00 1.00 1,880.00 500.00 Total Credits 18 18 18 1 1 Estimated Total Cost Of Program For Semester In-State Costs Out-Of-State Costs $1,440.00 $ 108.00 $ 18.00 $1,880.00 $ 500.00 $ $ $ $ $ 5,040.00 108.00 18.00 1,880.00 500.00 $3,946.00 $ 7,546.00 SUMMER – YEAR ONE SEMESTER THREE Registration Name Tuition Fee Technology Fee Student Life Fee Program Fee Books Cost Per Credit InState $ $ $ $ $ 80.00 6.00 1.00 810.00 500.00 Cost Per Credit Out-Of-State $ $ $ $ $ 280.00 6.00 1.00 810.00 500.00 Total Credits In-State Costs Out-Of-State Costs 9 9 9 1 1 $ 720.00 $ 54.00 $ 9.00 $ 810.00 $ 500.00 $ $ $ $ $ 2,520.00 54.00 9.00 810.00 500.00 $2,093.00 $ 3,893.00 Estimated Total Cost Of Program For Semester MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 12 of 31 Mohave Community College Physical Therapist Assistant Program PROGRAM COSTS PTA ESTIMATED PROGRAM COST PER SEMESTER: FALL – YEAR TWO SEMESTER ONE Registration Name Cost Per Credit InState Cost Per Credit Out-Of-State Total Credits In-State Costs Out-Of-State Costs Tuition Fee $80.00 $280.00 18 $1,440.00 $5,040.00 Technology Fee $6.00 $6.00 18 $108.00 $108.00 Student Life Fee $1.00 $1.00 18 $18.00 $18.00 $1,615.00 1 $1,615.00 $1,615.00 $500.00 1 $500.00 $500.00 $3,681.00 $7,281.00 Program Fee $1,615.00 Books $500.00 Estimated Total Cost Of Program For Semester SPRING – YEAR TWO SEMESTER TWO Registration Name Tuition Fee Technology Fee Student Life Fee Program Fee Books Cost Per Credit InState $ $ $ $ $ 80.00 6.00 1.00 1,620.00 100.00 Cost Per Credit Out-Of-State $ $ $ $ $ 280.00 6.00 1.00 1,620.00 100.00 Total Credits 12 12 12 1 1 Estimated Total Cost Of Program For Semester In-State Costs Out-Of-State Costs $ 960.00 $ 72.00 $ 12.00 $1,620.00 $ 100.00 $ $ $ $ $ 3,360.00 72.00 12.00 1,620.00 100.00 $2,764.00 $ 5,164.00 PTA PROGRAM TOTAL CREDIT HOURS – 75 MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 13 of 31 Mohave Community College Physical Therapist Assistant Program CLINICAL NEEDS CHECK LIST This is only a checklist, please do not have the physician sign or stamp this form. It is the student’s responsibility to provide proof of the following to the program secretary before the end of the first semester for clinical practicum placement. Updates must be provided 30 days prior to starting each clinical practicum throughout the PTA Program. Individual clinical needs documents will not be accepted until check list is complete. Please turn in a completed packet of clinical needs documents from the checklist when completed. STUDENT ID # AGE FIRST NAME MALE MIDDLE INITIAL FINGERPRINT CLEARANCE CARD – AZ Department of Public Safety. Fingerprint card is good for 6 years. Date: ___________________________________ HEALTH INSURANCE – Student’s personal health care insurance. You must provide your own health insurance. Date: ___________________________________ PHYSICAL – Student’s healthcare provider. Physical is good for the duration of the program. Date: ___________________________________ DRUG SCREENING – PTA DEPARTMENT WILL PAY FOR YOUR SCREENING. Do not make an appointment for this. Sonora Quest Laboratories form 30 days prior to clinical placement. Date: ___________________________________ ANNUAL TB TEST – If you have never had a TB Test you will need the 2-Step TB. Annual TB test is good for 1 year. If you have had a chest x-ray that is good for two years. LAST NAME Process for 2-Step TB – The 1st step is an injection from your health care provider followed up with a reading 2-3 days after the injection. The 2nd step repeats the process 1-3 weeks after the 1st reading. 2-step TB is not complete until the second test is read. 2-StepTB test is good for 2 years. Date: _____________________________ BACKGROUND CHECK – Pre-check form. Background check is good for the duration of the program. Date: ___________________________________ HEALTH CARE PROVIDER CPR – Must be obtained through either the American Red Cross or the American Heart Association, classes offered through Community Outreach program at MCC. CPR is good for 2 years. Date: ___________________________________ FEMALE HEP B OR TITER – (optional but highly recommended - if titer is low or no immunity you will need the HEP B vaccine or you must sign a declination form) Hepatitis B is contracted from blood borne pathogens. HEP B is good for 7 - 10 years. Booster recommended after 10 years. Three immunization series – 1. 1st injection of vaccine Date: ___________________________________ 2. 2nd injection is administered 30 days after 1st injection. Date: ___________________________________ 3. 3rd injection administered at the end of the 5th month. Date: ___________________________________ All 3 vaccinations must be completed in order to obtain full immunity. VARICELLA (chicken pox) OR TITER – (if titer is low or no immunity you will need the Varicella vaccine) this vaccine is good for 10 years. Date: ___________________________________ MMR (Measles, Mumps, and Rubella) OR TITER – (if titer is low or no immunity you will need the MMR vaccine) this vaccine is good for 10 years. Date: ___________________________________ MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 14 of 31 Mohave Community College Physical Therapist Assistant Program PHYSICAL EXAMINATION FORM Student Name: “STUDENT USE ONLY” (Student must complete this side) Social Security#: / / Address: City: Home Phone: State: Zip: Cell Phone: Physical Therapist Assistant (PTA) Student Qualifications A physical therapist assistant student MUST be able to perform the following functions: 1. Stand and walk continuously for up to eight hours. 2. Visual acuity and depth perception to read physical therapist orders. 3. Hearing acuity and to hear machine alarms, announcements on PA systems, normal conversations, and through stethoscopes. 4. Safely handle blood and other body excretions and secretions. 5. Perform basic resuscitation and emergency procedures according to CPR protocols. 6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care. 7. Ability to lift 50 pounds. 8. Lift, move, and operate equipment used in the care of patients. 9. Assist with or administer treatments and therapies using potentially hazardous equipment (i.e. needles, caustic drugs, X-rays). 10. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders. 11. Psychological stability to perform effectively under stress. 12. Ability to exercise critical thinking reasoning and judgment in a client care situation. Understanding of Requirements As a physical therapist assistant student of MCC, I understand I must be able to meet the above physical requirements. I have read and understand the requirements, and I am able to perform all the above listed functions. As a physical therapist assistant student of MCC, I understand that I must provide the following requirements: 1) Proof of current vaccinations or verification of immunity through positive titer’s a. MMR b. Varicella c. Hepatitis B Series 2) Negative TB (2-step) or Chest X-ray 3) Current CPR certification (Heartsaver, Adult or Community CPR is not acceptable) 4) Negative Drug screen (positive results must be followed up with verifiable proof of prescriptions) 5) Current Physical Examination provided by a physician found on the back of this form As a physical therapist assistant student of MCC, I understand that failure to provide CURRENT documentation will result in dismissal from the physical therapist assistant program. COMMENTS: Student Name (please print): Date: Student Signature: MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 15 of 31 Mohave Community College Physical Therapist Assistant Program “PHYSICIAN USE ONLY” (Physician must complete this side) STUDENT NAME: HEENT: Lungs: Vital Signs: VISION: Heart: Extremities/Joints: (R) (L) Abdomen: Neurological/Mental: CORRECTED: (R) (L) Please list all prescription medications being used by the student and the reason: Please list all chronic conditions or medical problems the client has: Record of Immunizations: (PROOF is required for all Immunizations or Titers) Clinical sites utilized for MCC physical therapist assistant student Clinical Experiences require proof of all of the following Immunizations or tests. Students will only be allowed an exception based on a medical condition and a physician’s note is required. MMR Varicella Date: Date: Date: Influenza (or) Positive (or) Positive Titers (Required for NUR (Annual) Titer Titer Date: Titers Date: III ONLY) Hepatitis B Series (or) status of Immunity With a Titer Date: Date: #3. Date: Titers Date: #1. TB Skin Test Negative (2-Step) (or) Negative X-Ray #2. Date: Date: X-Ray Date: #1. #2. Physical Therapist Assistant Student Qualifications A physical therapist assistant student must be able to perform the following functions: 1. Stand and walk continuously for up to eight hours. 2. Visual acuity and depth perception to read doctor’s orders and medical dosages on syringes and vials. 3. Hearing acuity to hear machine alarms, announcements on PA systems, normal conversations, and through stethoscopes. 4. Safely handle blood and other body excretions and secretions. 5. Perform basic resuscitation and emergency procedures according to CPR protocols. 6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care. 7. Ability to lift 50 pounds. 8. Lift, move, and operate equipment used in the care of patients. 9. Assist with or administer treatments and therapies using potentially hazardous equipment (i.e. needles, caustic drugs, Xrays.) 10. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders. 11. Psychological stability to perform effectively under stress. 12. Ability to exercise thinking, reasoning and judgment in a client care situation. Physicians Signature of Authorization Based on this physical examination, do you find this person capable of performing ALL of these functions without ANY reservations? YES: (If No, Please Explain): Physician Name (please print): Date: Physician Signature: Address: NO: Telephone: City: State: Zip: MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 16 of 31 Mohave Community College Physical Therapist Assistant Program MOHAVE COUNTY DEPARTMENT OF PUBLIC HEALTH Health Department 2001 College Drive Lake Havasu City, AZ 86403 Phone: 928-453-0703 Fax: 928-453-0740 ADULT IMMUNIZATIONS: 2014 PRICING TD (TETANUS/DIPHTHERIA HEPATITIS A HEPATITIS B MMR VARICELLA MENACTRA (MENINGOCOCCAL VACCINE) MENOMUNE (MENINGOCOCCAL VACCINE) TWINRIX (HEPATITIS A AND B COMBINED) RABIES (IMOVAX) ADACEL (ADULT PERTUSSIS) T DAP INFLUENZA PNEUMONIA HEP B TITER VARICELLA TITER MEASLES - RUBELLA TITER RABIES TITER HPV SHINGLES $52.00 $64.00 $72.00 $93.00 $131.00 $155.00 $154.00 $92.00 $272.00 $70.00 $37.00 $98.00 $81.00 $87.00 $158.00 $118.00 $178.00 $211.00 These services offered on sliding fee scale based upon patient income If you are 18 years old and have no insurance coverage for vaccines you can be seen for free on kid’s day (Tuesday’s). 2014 Current Mohave County/Public Health pricing for adult services MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 17 of 31 Mohave Community College Physical Therapist Assistant Program APPLICATION PACKET Application Period: January 5th, 2015 – April 24th, 2015 (Application Deadline is April 24th, 2015) 2014-15 Academic Year MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 18 of 31 Mohave Community College Physical Therapist Assistant Program APPLICATION CHECKLIST Please follow these steps in the order they are presented: BECOME AN MCC STUDENTComplete the online admissions application at: https://jics.mohave.edu/ICS/Admissions_Apply_Online/Home.jnz TRANSCRIPTS – 1. Hard copy of your COMPASS test results (if taken). 2. ALL OFFICIAL transcripts from colleges/universities AND high school transcript (OR GED scores) to be sent to: Liz Briere, PT, DPT Mohave Community College Director, PTA Program 1977 W Acoma Blvd Lake Havasu City, AZ 86403 IMPORTANT NOTE: Transcripts must be sent from previous institutions directly to MCC to be considered official. Please allow 2 weeks for receipt of transcripts. The program can retrieve your MCC transcripts, it is not necessary to request MCC transcripts. OBSERVATION HOURS – Include observation hour’s form after completing observation hours. It is required that you complete 12 hours in-patient and 12 hours out-patient. Some physical therapy sites do not allow you to observe until you have spoken to the Program Director. PRE-CHECK CRIMINAL BACKGROUND CHECK – Obtain Pre-Check Criminal Background Check (www.mystudentcheck.com). After the Pre-Check Criminal Background check has been cleared, select school – Mohave Community College district, PTA. Complete remaining application online. HOBET TEST – HOBET Entrance Examination can be taken at any MCC campus in the testing center. You can schedule this test inside student services. You will need to print out a copy of the exam results and include it with the application. (http://www.mohave.edu/resources/testing) HEALTHCARE PROVIDER CPR CERTIFICATION – Proof of healthcare provider CPR certification. You can sign up from a list of courses offered at anyone one of MCC’s four campuses through community education program. (http://www.mohave.edu/community/communityeducation) OPEN HOUSE – Attend PTA Applicant Open House. This is mandatory and by invitation only to those individuals qualified to continue in the application process. Once your application has been reviewed and the program director determines you are eligible to move to the next step, you will be sent an invitation to the open house. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 19 of 31 Mohave Community College Physical Therapist Assistant Program Application Period: January 5th, 2015 – April 24th, 2015 (Application Deadline is April 24th, 2015) ADMISSION REQUIREMENTS AND SELECTION CRITERIA: APPLICATION REQUIREMENTS CHECKLIST MCC’s Online Admissions Application PTA Program Application Admissions Application Disclaimer Signature Page Drug Screening and Criminal Background Self-Disclosure Signature Page Essential Functions and Understanding of requirements Signature Page Proof of college level reading and math skills via the Compass Test or Transcripts High School Transcripts OR GED scores. All Official College Transcripts (if any) – Official transcripts are sent from Institution to Institution. Transcripts mailed to the student are considered unofficial. Demonstrate an overall GPA of 2.7 Demonstrate a minimum GPA of 2.7 in BIO 100 PreCheck Criminal Background Check Proof of CPR Certification – Healthcare Provider level 24 Observation Hours HOBET Entrance Examination SELECTION CRITERIA – POINTS WILL BE GIVEN FOR THE FOLLOWING CRITERIA: COURSES A B C Points PREREQUISITES GENERAL EDUCATION BIO 100 BIO 201 BIO 202 PSY 101 COM 121 or 151 ENG 101 CIS 110 HEALTH OCCUPATIONS BASIC ENTRANCE TEST (HOBET V) 3 3 3 3 2 2 2 2 1 1 1 1 3 2 1 3 2 3 2 5 points 50% to 60% RESIDENCY County Resident Arizona Resident WORK EXPERIENCE PT Related Healthcare Related ADDITIONAL COURSE COMPLETION POINTS Completion of 5 to 6 of the above prerequisites & general education Completion of 3 to 4 of the above prerequisites & general education Completion of 1 to 2 of the above prerequisites & general education 1 1 10 points 61% to 100% Points 2 2 Points 7 5 Points Points Points Points 10 6 2 TOTAL POINTS: _______________ *NOTE: in the case of a tie, the application admitted the earliest would receive a place in the program. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 20 of 31 Mohave Community College Physical Therapist Assistant Program APPLICATION If you have any physical or mental impairment contact: Disability Services: (928) 680–5946 PLEASE PRINT OR TYPE Name: ____________________________________________________________________________________ Former name(s) which may appear on transcripts: ________________________________________________ Are you currently enrolled at MCC? YES or NO (Please Circle Yes or No) Student ID # or Last 4 of Social Security Number: __________________ Home Address: _____________________________________________________________________________ City: _________________________________________________ State: _________ Zip __________________ Home Phone: ___________________________ Work/Cell Phone: ___________________________________ Email: __________________________________________________________________ WORK EXPERIENCE: (LAST 5 YEARS, BEGINNING WITH MOST RECENT) EMPLOYER POSITION DATES PHONE REASON FOR LEAVING From: To: From: To: From: To: From: To: From: To: NOTE: It is the applicant’s responsibility to assure that the information on this application remains current. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 21 of 31 Mohave Community College Physical Therapist Assistant Program ADMISSION APPLICATION DISCLAIMER Your admission to the Mohave Community College Physical Therapist Assistant Program does not guarantee you will receive an Associate in Applied Science Degree from the College. Further, completion of the Physical Therapist Assistant Program is not the sole criterion for obtaining a license/certificate to practice. Licensing/certification requirements are the exclusive responsibility of the individual State Boards of Physical Therapy or similar agencies, and you must satisfy those requirements independently of MCC. CERTIFICATION: I hereby certify that the facts set forth in this student application are true and complete to the best of my knowledge. I understand that if accepted, any falsified statements on this application shall be considered sufficient cause for suspension or dismissal. CLINICAL EXPERIENCE: MCC Physical Therapist Assistant students will be required to travel outside of Mohave County for a portion of their clinical experience. I understand that if accepted into the Physical Therapist Assistant Program, I will be required to travel for these clinical experiences and that I will be responsible for my own housing, transportation and meals. I understand that if accepted, I will be required to meet the health requirements of the Physical Therapist Assistant Program. __________________________________________________ Applicant’s Name (PRINT) __________________________________________________ Applicant’s Signature _______________________________________ Date SUBMIT TO: Mohave Community College Liz Briere, PT, DPT Director, PTA Program 1977 W Acoma Blvd Lake Havasu City, AZ 86403 Phone: 928-505-3347 [email protected] MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 22 of 31 Mohave Community College Physical Therapist Assistant Program DRUG SCREENING Drug Screening - Each student must go through a preclinical drug screen prior to beginning the first clinical rotation. The urine drug screen will test for alcohol; illegal drugs, or drugs that may impair judgment while working with patients at the clinical site. If the drug test is positive for the illegal drugs, or drugs that may impair judgment or motor function the student may not be able to continue in the program. Readmission is at the discretion of the college and the program director. Some clinical sites also require screening for nicotine. Students who test positive for nicotine may not be able to be placed at some clinical sites, but are not excluded from the program. CRIMINAL BACKGROUND SELF-DISCLOSURE Criminal Background Self-Disclosure -- Prior conviction of a felony or certain misdemeanors, other than minor traffic offenses, may make a student ineligible to participate in various clinical experiences and possibly make it impossible for a student to complete the scheduled program of study. Prior conviction of a felony or misdemeanor may make the individual ineligible for professional licensure, professional certification, or professional registration, dependent on specific regulations of individual state of practice. Please Note: Convictions or charges resulting in any of the following must be reported: plea of guilty, plea of nolo contendere (no contest), withheld or deferred adjudication, suspended or stay of sentence, and/or military court martial. HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR A FELONY? Misdemeanor charges or convictions that occurred while a juvenile and that were processed through the juvenile court system are not required to be reported. Misdemeanor speeding convictions are not required to be reported unless they are related to alcohol or drug use. 1. Have You Ever Been Convicted of a Misdemeanor or a Felony? Circle One: Yes No 2. If response is YES, list all offenses, dates, locations of courts, and outcomes. Official court documentation may be required by the licensing agency. My statement regarding my criminal background is accurate to the best of my knowledge. I understand the falsification or omission of information may result in disqualification or dismissal of this application for admission to Mohave Community College Physical Therapist Assistant Program. I hereby certify that the statements on this application are correct to the best of my knowledge and I understand that falsification or omission of information may result in disqualification or dismissal of this application for admission to Mohave Community College Physical Therapist Assistant Program. I authorize official representatives of Mohave Community College Physical Therapist Assistant Program to verify information provided in this application. Application materials submitted as part of the application process, become the property of Mohave Community College Physical Therapist Assistant Program. Materials will not be returned, and copies will not be provided. I agree to abide by the policies and regulations of Mohave Community College Physical Therapist Assistant Program. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 23 of 31 Mohave Community College Physical Therapist Assistant Program DRUG SCREENING Note 1: Please keep a copy for your records. Note 2: Drug screening will be required of students as a condition of eligibility to participate in clinical practicum. Be advised that a positive result on a drug test will result in consequences that will vary depending on the level of severity and the need for additional treatment. At the very least the student will be unable to attend a clinical or field site until cleared to do so. Other potential consequences may include suspension or expulsion. ____________________________________ Applicant’s Name (PRINT) ______________________________________ Applicant’s Signature _____________________________ Date SUBMIT TO: Mohave Community College Liz Briere, PT, DPT Director, PTA Program 1977 W Acoma Blvd Lake Havasu City, AZ 86403 Phone: 928-505-3347 [email protected] MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 24 of 31 Mohave Community College Physical Therapist Assistant Program MOHAVE COMMUNITY COLLEGE PHYSICAL THERAPIST ASSISTANT ESSENTIAL FUNCTIONS THE FOLLOWING IS A LIST OF PHYSICAL AND MENTAL JOB EXPECTATIONS FOR A PHYSICAL THERAPIST ASSISTANT: A physical therapist assistant student MUST be able to perform the following functions: 1. Demonstrate visual acuity and auditory ability to assess the condition of a patient and administer effective patient care. 2. Demonstrate manual dexterity, eye-hand coordination, fine and gross motor skills, and tactile abilities to perform functions as directed by the physical therapist and in accordance with the Evaluative Criteria for the Accreditation of Physical Therapist Assistant Education Programs (http://www.apta.org/CCIP/). 3. Demonstrate critical thinking and problem solving skills for effective patient management and implementation of selected treatment interventions. 4. Maneuver equipment in a patient’s room or in the physical therapy department. 5. Work in stressful situations that require quick thinking and the simultaneous coordination of a variety of activities. 6. Demonstrate physical agility to respond to patient and family needs, including unexpected changes in the patient’s status. 7. Demonstrate the physical ability to assist patients in ambulating, positioning in bed, and transferring from the bed/mat, wheelchair or car. 8. Demonstrate proper body mechanics for lifting. 9. Lift objects in excess of 100 pounds with assistance with frequent lifting and/or carrying objects weighing 50 pounds or more. 10. Tolerate prolonged standing, stooping, squatting, bending, pushing, and pulling. 11. Demonstrate ability to read, write, understand and speak English. 12. Demonstrate effective verbal and non-verbal communication skills with internal and external customers. Graduates who are unable to perform these functions, with or without reasonable accommodations, may be unsafe and unsuccessful as a provider of physical therapy services. EQUAL OPPORTUNITY POLICY STATEMENT Mohave Community College does not discriminate on the basis of sex, color, race, religious preference, age, disability, national origin, Veteran status or any other legally protected class in any of its policies, practices, and procedures, and it is an affirmative action and equal opportunity employer. For more information, call the Human Resources Office at 928.757.0835, 1971 Jagerson Ave., Kingman, AZ 86409. Grievance procedures are available at the Mohave Community College libraries in Bullhead City, Colorado City, Kingman and Lake Havasu City. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 25 of 31 Mohave Community College Physical Therapist Assistant Program UNDERSTANDING OF REQUIREMENTS As a physical therapist assistant student of MCC, I understand I must be able to meet the above physical requirements. I have read and understand the requirements, and I am able to perform all the above listed functions. As a physical therapist assistant student of MCC, I understand that I must provide the following requirements: 6) Proof of current vaccinations or verification of immunity through positive titer’s 7) MMR, Varicella, Hepatitis B Series, Negative TB (2-step) or Chest X-ray 8) Current CPR certification (Heart Saver, Adult or Community CPR is not acceptable) 9) Negative Drug screen (positive results must be followed up with verifiable proof of prescriptions) 10)Current Physical Examination provided by a physician found on the next form As a physical therapist assistant student of MCC, I understand that failure to provide CURRENT documentation will result in dismissal from the physical therapist assistant program. _____________________________________________________ Applicant’s Name (PRINT) _____________________________________________________ Applicant’s Signature ____________________________________________ Date MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 26 of 31 Mohave Community College Physical Therapist Assistant Program OBSERVATION HOURS Twenty Four (24) hours of observation are required prior to application for admission into the Physical Therapist Assistant (PTA) Program at Mohave Community College. The requirement assures that the applicant has done career exploration in the field. Additionally, the program wants to be reasonably certain that students entering the program are committed to this career goal. The applicant should expect that the majority of facilities allow volunteers “observation only” of physical therapy practice. “Hands on” experience is not allowed in most facilities. It is the responsibility of the student to arrange for observation hours and/or to certify work experience gained in the field. Facilities may have a waiting list for volunteers and may have limited hours in which volunteers can be accommodated Allow several weeks to find a facility or facilities when you plan to complete the observation hours. A list of local facilities has been included in the packet for your convenience. OBSERVATION HOURS VERIFICATION FORM INSTRUCTIONS TO THE APPLICANT The observation form is located in the application packet. Only DIRECT observation in PHYSICAL THERAPY will satisfy the prerequisite requirement. Observation must have occurred within the past two years. Make additional copies of this form if your observation hours have been performed in more than one facility. A separate form should be provided to each facility. Appropriate dress is recommended. Closed toed shoes, slacks (nice khakis are acceptable), polo-type or similar shirt. Please do not wear sandals, halters, shorts, jeans, capris or any tight fitting clothing. Undergarments should not be seen. Long hair should be pulled back, minimal jewelry, and nails must be clean and fingertip length. Perfume, cologne and visible tattoos should be minimal. The facility has the right to turn you away for inappropriate appearance. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 27 of 31 Mohave Community College Physical Therapist Assistant Program OBSERVATION HOURS (REQUIRED) Please call ahead. Each facility has different requirements for job shadowing. Ask for either the volunteer office or the physical therapy department to schedule job shadowing. Be aware it does take extra time to arrange hours at some facilities. Immunization may be required prior to observation at some sites. This list is not conclusive of all rehab facilities in the tri-state area. ARIZONA Havasu Regional Medical Center LHC IP/OP Lakeside Physical Therapy & Rehab. LHC Outpatient PRO Therapy LHC Outpatient TruRehab LHC Outpatient Valley View Medical Center Ft. Mohave IP/OP Palo Verde Physical Therapy Willmore Wellness Bullhead City Bullhead City Western Arizona Regional Medical Center River Gardens Bullhead City Bullhead City 928-453-0411 928-855-4248 928-854-4776 928-453-0501 928-788-3604 Outpatient 928-758-0029 Outpatient 928-763-0807 IP/OP 928-763-0252 Inpatient 928-763-8700 Deering Physical & Occupational Therapy Kingman Outpatient Kingman Regional Medical Center Kingman IP/OP Physiotherapy Associates Kingman Outpatient Gardens Care Center Kingman Inpatient 928-753-4263 928-692-4635 928-757-1211 928-718-0718 IP/OP = Facility has inpatient and outpatient available MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 28 of 31 Mohave Community College Physical Therapist Assistant Program OBSERVATION HOURS VERIFICATION STUDENT NAME _____________________________ Note to Supervisor: The above named student is performing this task in anticipation of enrolling in the PTA program at Mohave Community College. Thank you for your support. The physical therapy volunteer/observation certified on this form can best be described as occurring in the following setting: *NOTE: A total of twenty four (24) hours is required from both inpatient (12 hours) and outpatient settings (12 hours). A (*) denotes site is acceptable as an inpatient setting. If several types of experiences were provided at one facility, please specify the number of hours spent in each type of experience. HOURS NAME OF FACILITY SIGNATURE/LICENSE # _______ Acute Care Hospital* ______________ __________________ _______ Rehab Unit (Hospital Based)* ______________ __________________ _______ Rehab Unit (Free Standing)* ______________ __________________ _______ Outpatient Services (Hospital Based) ______________ __________________ _______Private Practice ______________ __________________ _______ Sports Medicine ______________ __________________ _______ Extended Care Facility (NH/SNF)* ______________ __________________ _______ Industrial Injury Rehabilitation Clinic ______________ __________________ _______ Home care ______________ __________________ _______ Pediatric Care ______________ __________________ _______School Based Physical Therapy ______________ __________________ _______ Cardiac Rehabilitation ______________ __________________ _______ Other (Please specify) ______________ __________________ INSTRUCTIONS TO SUPERVISOR: Please sign on the line for the setting where you supervised the student’s hours. Please contact the PTA Program Director at Mohave Community College, with any questions or concerns about this experience (928-505-3347). INSTRUCTIONS TO STUDENT: Please submit this form with your application paperwork. A background check may be required by the facility prior to completion of the observation hours. MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 29 of 31 Mohave Community College Physical Therapist Assistant Program BACKGROUND CHECKS I understand that a positive result on the background check could preclude me from clinical affiliations at certain facilities since each clinical site has their own criteria. I also understand that this could affect my ability to graduate from the program. In addition, I understand that a positive background check will need to be addressed with the state board of physical therapy and that it may preclude me from obtaining a state license to practice as a Physical Therapist Assistant. ___________________________________ SIGNATURE _________________________ DATE _________________________________________ PRINTED NAME FINGERPRINT CARDS I, ______________________________, understand that I must present a valid AZ DPS fingerprint card in order to participate in all clinical education experiences. I must report any incident to the program within 7 days that may affect my status. If I am on a clinical experience, I have 24 hours to report the incident to the program. I acknowledge failure to maintain a valid Fingerprint Card may also be cause for dismissal from the program. ______________________________________ _________________________ SIGNATURE DATE _________________________________________ PRINTED NAME (Please sign and return with completed application) MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 30 of 31 Mohave Community College Physical Therapist Assistant Program STUDENT DEMOGRAPHIC INFORMATION DATE: __________________________________________ GENDER: MALE FEMALE AGE: ___________ ETHNIC ORIGIN: (PLEASE CHECK ONE) AFRICAN-AMERICAN/BLACK (NON-HISPANIC) AMERICAN INDIAN/ALASKAN NATIVE ASIAN/PACIFIC ISLANDER HISPANIC/LATINO WHITE (NOT OF HISPANIC ORIGIN) OTHER: CHECK PRIOR DEGREE/S EARNED: ASSOCIATES BACHELORS MASTERS DOCTORAL NONE MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT MCC Form EDU 0032 (Revised 7/1/2014) Page 31 of 31
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