For consideration for admission to the HACC EMS Academy, the following must be received by the HACC EMS Education Unit by application deadline:

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1 Dear EMS Academy Candidate, Thank you for your interest in the HACC - Shumaker Public Safety Center EMS Academy. The 24 th HACC EMS Academy is scheduled to begin on August 27, 2018 and will conclude on November 30, The cost for the program is $3, Tuition must be paid in full or proof of funding source must be received before the start of the academy. The EMS Academy has been designed to ensure the highest level of training to potential Emergency Medical Service providers for successful entry into the field. It is a full time program, primarily scheduled Monday through Friday however, the commitment may include some evenings and weekends. This concentrated program requires over 550 hours of training. Attendance is mandatory and it is recommended that candidates do not hold employment while attending the academy. All candidates enrolled in the HACC EMS Academy are referred to as cadets and are expected to meet the academic, practical and physical development standards set forth within the Academy. The Academy is operated with strict guidelines established for cadet s behavior, attitude, and interaction. For training purposes the academy does have a command structure. Cadets will be required to assume in-class leadership roles during the academy. Cadets are exposed to daily and weekly academic testing and physical exercise and development. Although not a pre-requisite, preparatory physical exercise will greatly enhance a cadet s ability to meet the physical rigors of academy training. The application and qualification process includes several steps designed to assess your compatibility with the program and your interest in Emergency Medical Services. The information, which follows, is provided so you know what is reviewed in the qualification process. For consideration for admission to the HACC EMS Academy, the following must be received by the HACC EMS Education Unit by application deadline: 1. A completed HACC EMS Academy Application 2. Proof of minimum age of eighteen (18) at time of entry 3. Proof of a high school diploma or state recognized equivalent 4. A statement from a physician indicating that rigorous physical activity is not prohibited as well as a completed HACC Health Examination form.

2 5. 12 Panel Drug and Alcohol Screens results. All students must complete the drug and alcohol screen process through 6. 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: and select Department of Health. *HACC's Prohibitive Offense Policy will be provided upon request. 7. Three (3) letters of reference from non-relatives. The form is attached for distribution to your designated references. All forms and letters are be returned directly by the references to EMS Academy Admissions Board, HACC-SPSC, 1 HACC Drive, Harrisburg, PA Include at least one reference from a Healthcare Provider/Professional. 8. Current copy of complete 10 year driving record from the Pennsylvania Department of Transportation. Submission of an application DOES NOT guarantee admission or enrollment into the HACC EMS Academy. Once the HACC EMS Academy Application and all required documents are received, candidates will be scheduled for an oral interview. Following the interview, all applicants will be notified by mail of their final determination. Applications will not be accepted after July 20, Questions should be directed to the EMS Education Staff by calling Sincerely, Melissa Etzweiler, NRAEMT- HACC EMS Academy Coordinator

3 Senator John J. Shumaker Public Safety Center EMS Academy Application Applicant Information Full Name: Last First M.I. Street Address Apartment/Unit # Date: City State ZIP Code Phone: ( ) Social Security No. (Last 4 digits): Date of Birth: Emergency Contact: Relationship: Emergency Contact Number: High School: From: To: Did you graduate? Education YES NO Degree: College: From: To: Did you graduate? YES NO Degree: Other: From: To: Did you graduate? YES NO Degree: References Please list three professional references. Full Name: Relationship: Company: Phone: ( ) Full Name: Relationship: Company: Phone: ( ) Full Name: Relationship: Company: Phone: ( ) 12/16me

4 Employment Company: Phone: ( ) Supervisor: Job Title: From: To: Company: Phone: ( ) Supervisor: Job Title: From: To: Company: Phone: ( ) Supervisor: Job Title: From: To: Military Service Branch: From: To: Type of Rank at Discharge: Discharge: If other than honorable, explain: Disclaimer and Signature I certify that all of the information in this document is true, complete, and accurate to the best of my knowledge. I understand that withholding information or providing false information may make me ineligible for admission to the HACC-Central PA s Community College EMS Academy. Signature: Date:

5 Please provide brief responses to the following questions: Applicant s Name: 1). Why do you want to become an EMT? 2). What are some of your other skills and interests? 3). What are your career goals following completion or the EMS Academy? 4). Describe a situation in which you demonstrated an ability to assume responsibility and make a difficult decision. The situation may be taken from family, business, community, or military experience.

6 EMS Academy Applicant Reference Applicant s Name: The person above has applied for admission into the EMS Academy at Harrisburg Area Community College, Senator John J. Shumaker Public Safety Center and is requesting your reference. The information you provide will be held in strict confidence. Thank you in advance for your prompt reply. Please return to: EMS Academy Admissions Board, HACC-SPSC, 1 HACC Drive, Harrisburg, PA (5 = Excellent, 1 = Poor) Quality of work N/A Productivity N/A Cooperation N/A Dependability N/A Attitude N/A Ability to Follow Instructions N/A Academic Ability N/A Nature of your relationship to the applicant: How long have you known the applicant? Please provide the qualities that you feel would make this applicant a successful student and EMT. Attach additional pages if necessary. Name Signature Title Date

7 EMS Academy Applicant Reference Applicant s Name: The person above has applied for admission into the EMS Academy at Harrisburg Area Community College, Senator John J. Shumaker Public Safety Center and is requesting your reference. The information you provide will be held in strict confidence. Thank you in advance for your prompt reply. Please return to: EMS Academy Admissions Board, HACC-SPSC, 1 HACC Drive, Harrisburg, PA (5 = Excellent, 1 = Poor) Quality of work N/A Productivity N/A Cooperation N/A Dependability N/A Attitude N/A Ability to Follow Instructions N/A Academic Ability N/A Nature of your relationship to the applicant: How long have you known the applicant? Please provide the qualities that you feel would make this applicant a successful student and EMT. Attach additional pages if necessary. Name Signature Title Date

8 EMS Academy Applicant Reference Applicant s Name: The person above has applied for admission into the EMS Academy at Harrisburg Area Community College, Senator John J. Shumaker Public Safety Center and is requesting your reference. The information you provide will be held in strict confidence. Thank you in advance for your prompt reply. Please return to: EMS Academy Admissions Board, HACC-SPSC, 1 HACC Drive, Harrisburg, PA (5 = Excellent, 1 = Poor) Quality of work N/A Productivity N/A Cooperation N/A Dependability N/A Attitude N/A Ability to Follow Instructions N/A Academic Ability N/A Nature of your relationship to the applicant: How long have you known the applicant? Please provide the qualities that you feel would make this applicant a successful student and EMT. Attach additional pages if necessary. Name Signature Title Date

9 INCOMING HEALTH CAREER STUDENT HEALTH EXAMINATION PLEASE PRINT ALL INFMATION Name: HACC ID: Date: HAWKMAIL 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 (choose 1) MEASLES 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. BLOOD TEST TB T-SPOT (must be valid for the program year) Date: Results: positive negative borderline indeterminant If result is borderline or indeterminant, repeat assay. 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 POSITIVE RESULT F ANY OF THE 3 testing methods above: Date of 2 View Chest X-ray (completed within 1 year of date of admission): Result: positive or negative (circle one) If POSITIVE CHEST X-RAY: Isoniazid Prophylaxis Rx Start date: Estimated end date: G:\Health Careers\HC Focus Group\Approved Documents Policies\Health Forms\Health Form 0516.docx Rev 5/24/16 ALR/immunization committee/approved Health Careers Focus Group 9/17/14 Rubeola IgG Antibody titer Date: Result: Positive Negative 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: Result: Positive Negative 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: Result: Positive Negative If negative or equivocal to the above, an MMR with followup testing is required. MMR Administered: Date: Rubella IgG Antibody titer Date: Result: Positive Negative (Follow-up test 4 to 8 weeks post vaccine) Booster dose recommended for those vaccinated prior to Physician s Initials

10 Name: Date: VARICELLA (CHICKEN POX) STATUS Varicella IgG Antibody titer Date: Result: Positive Negative 2 Doses Varicella Vaccine given 1 month apart: Dates: 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: INFLUENZA STATUS All students are required to have the annual influenza vaccine if attending clinical between October and March. Date Administered: LOT # Manufacturer Normal VISION EXAM (Snellen Eye Chart or similar exam) Referred for Correction: 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 student clinical experience in health care agencies. Please refer to the attached Essential Qualifications required by the program specific course. 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: G:\Health Careers\HC Focus Group\Approved Documents Policies\Health Forms\Health Form 0516.docx Rev 5/24/16 ALR/immunization committee/approved Health Careers Focus Group 9/17/14 Physician s Initials

11 Name: Date: Recommended Vaccinations HEPATITIS B STATUS Hepatitis B surface antibody titer (anti-hbs 10 IU/mL). Date: Immune status: Positive *Negative Sign Non-Immunity Form (available on Castle Branch website or from Program Director) Previous Vaccinations (not required) Hepatitis A Vaccine Vaccination Dates: Dates: Pneumococcal Vaccine Vaccination Dates: Dates: Meningococcal Vaccine Vaccination Dates: Dates: Haemophilus Influenzae type B (Hib) Vaccination Dates: Dates: HPV Vaccine Vaccination Dates: Dates: Signature of Physician/ Nurse Practitioner/ Physician Assistant Date Printed Name Phone Number: G:\Health Careers\HC Focus Group\Approved Documents Policies\Health Forms\Health Form 0516.docx Rev 5/24/16 ALR/immunization committee/approved Health Careers Focus Group 9/17/14 Physician s Initials

12 EEOC POLICY 005: It is the policy of Harrisburg Area Community College, in full accordance with the law, not to discriminate in employment, student admissions, and student services on the basis of race, color, religion, age, political affiliation or belief, gender, national origin, ancestry, disability, place of birth, General Education Development Certification (GED), marital status, sexual orientation, gender identity or expression, veteran status, genetic history/information, or any legally protected classification. HACC recognizes its responsibility to promote the principles of equal opportunity for employment, student admissions, and student services taking active steps to recruit minorities and women. The Pennsylvania Human Relations Act ( PHRAct ) prohibits discrimination against prospective and current students because of race, color, sex, religious creed, ancestry, national origin, handicap or disability, record of a handicap or disability, perceived handicap or disability, relationship or association with an individual with a handicap or disability, use of a guide or support animal, and/or handling or training of support or guide animals. The Pennsylvania Fair Educational Opportunities Act ( PFEOAct ) prohibits discrimination against prospective and current students because of race, religion, color, ancestry, national origin, sex, handicap or disability, record of a handicap or disability, perceived handicap or disability, and a relationship or association with an individual with a handicap or disability. Information about these laws may be obtained by visiting the Pennsylvania Human Relations Commission website at If an accommodation is needed, please contact the disability coordinator for your campus: G:\Health Careers\HC Focus Group\Approved Documents Policies\Health Forms\Health Form 0516.docx Rev 8/14 ALVR/immunization committee Rev 5/6/13 ALV/HL/Rev 8/13/13 ALV/Rev 09/09/13 ALV Rev 4/8/14 ALV/HL

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