North Lake College Workforce Business & Technology Division PHLEBOTOMY PROGRAM

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1 North Lake College Workforce Business & Technology Division Cover Sheet The 96 hour Phlebotomy Technician Certification Program prepares professionals to collect blood specimens from clients for laboratory analysis. Students will become familiar with all aspects of blood collection and develop comprehensive skills to preform venipunctures competently and safely. Classroom work includes terminology, anatomy, physiology, blood collection procedures, specimen hands on practice. The program also includes lab exercises. Students will work with a training arm and other exercises intended to prepare them to function as entry level phlebotomy technicians. The curriculum is designed to provide the educational information and competencies required by both National Center for Competency Testing, NCCT, and National Healthcareer Association, NHA as a Phlebotomy Technician. Your registration packet includes the following: 1. Phlebotomy Technician Certification Program, Cover Sheet 2. Phlebotomy Technician Certification Program Requirement Sheet 3. Phlebotomy Technician Certification Student Checklist 4. North Lake College Continuing Education Immunization Form 5. Dallas County Community College District, Workforce and Continuing Education Registration Form 1

2 North Lake College Workforce/Continuing Education NLC Phlebotomy Application Packet Requirements Phlebotomy Technician Certification PLAB hours Provider CPR ESMP hours* Total 104 hours * EMSP 1019 is a program prerequisite and must be completed prior to registration. This information packet contains specific application guidelines and requirements. By submitting an application packet, an individual verifies that they have (1) read the packet thoroughly, (2) obtained all necessary documents, and (3) understood the policies and procedures for application and acceptance to PHLEBOTOMY. Upon successful completion of this program, the student is eligible to take the National Center for Competency Testing, NCCT, or National Healthcareer Association, NHA exam for Phlebotomy Technician. The PHLEBOTOMY application materials must be submitted in a 9 X 12 inch envelope and include the following documentation to be considered. Application packets with incomplete materials will be disqualified. Phlebotomy Technician Certification Program Prerequisites/Requirements 1. Copy of High School Diploma or equivalent 2. Copy of Basic Cardiac Life Support, BCLS, for Healthcare Providers 3. A copy of valid US or Texas Government Photo ID (e.g. driver s license) 4. Immunizations (Phlebotomy students are required to have the 1 st and 2 nd shots of the 3-shot hepatitis B series before submitting an application packet for Phlebotomy. The 3 rd shot of the 3-shot series is required for most employment. TB screening and proof of immunity from Measles, Mumps, Rubella. Combination tetanus/diphtheria/pertussis (Tdap),Varicella/Chickenpox, and Hepatitis B series. 5. Student Check List (included in this packet) 6. DCCCD Registration Form Submit a complete packet to North Lake College, Continuing Education, ATTN: Rose Chivers T121, 5001 N MacArthur Blvd, Irving, Texas Mail or deliver complete application packet. Applications by FAX or will not be accepted. Students are advised to retain a photocopy of all materials submitted. The following are NOT INCLUDED IN THE COST of the phlebotomy Technician Certification Program and are the responsibility of the student. Textbooks NCCT or NHA certification exam for Phlebotomy Technician Liability insurance ( Must be paid at the time of registration) Uniform scrub set (any color and style) 2

3 Student Checklist North Lake College Workforce/Continuing Education All forms in this packet must be completed and approved prior to registration. Name Date: Phone: I am submitting a complete application packet for the next available class. I used the checklist to double check my packet and have signed all necessary forms. Submit in 9x12 envelope Class Information: Reminder: CLEAR COPIES of documentation only. Do not submit original documentations. Copy of High School Diploma or equivalent TB Skin Test results (Current within 12 months unless previously positive) Immunization Signature Form or Separate Documents for required Immunizations A valid non-expired American Heart Association CPR for HealthCare Provider Card A copy of valid US or Texas Government Photo ID (e.g. driver s license) DCCCD Registration Form For Office Use Only: Reviewed by: Date: Comments: Semester/Term: 3

4 NLC Phlebotomy IMMUNIZATION FORM Two ways to submit immunizations: (1) Use this form, each line requires a doctor s signature or verification from your health center and date of immunization or dates of lab results indicating positive titer (seropositivity) required. You must include the lab results. (2) Or immunization records recorded on a separate document such as a hospital printout/health department card. 1. Measles 2 doses since 01/01/68 or positive Titer; Exempt if born on or before 01/01/ Mumps 1 dose if born on or after 01/01/57; or positive Titer ; Exempt if born on or before 01/01/ Rubella 1 dose or positive Titer 4. Tetanus/diphtheria/pertussis (Tdap) 1 dose within past 10 yrs. Date of Immunization #1 #2 If Seropositive, Date of Positive Titer (Attach Lab Results) DOES NOT APPLY Doctor s Signature or Health Center Signature valid only if injection was given 5. Varicella (chickenpox) - 2 doses or positive Titer #1 #2 6. Hepatitis B series 1 st initial dose 2 nd dose after 1 month *3 rd dose after 5 months Or Positive Titer 7. Influenza- 1 dose within past DOES NOT APPLY 12 months *Phlebotomy students can submit proof of 1 st and 2 nd shot of Hepatitis B 3-shot series and submit 3 rd shot prior to completion of course. TUBERCULOSIS SCREENING Documentation requires a physician's signature or verification from the Health Center. Intradermal PPD (Mantoux) - within TWELVE (12) months unless previously positive Date Results Physician's Signature Chest x-ray - within one (1) year if PPD positive (Must also include positive PPD verification above.) Date Results Physician's Signature 4

5 CONTINUING EDUCATION REGISTRATION PLEASE CHECK THE COLLEGE YOU PLAN TO ATTEND Brookhaven College Cedar Valley College Eastfield College El Centro College Mountain View College North Lake College Richland College Dallas Colleges Online HOW DID YOU HEAR ABOUT US Website Friend/Family Social Media Magazine Catalog Student/Employee Advertisement Other Student Information For new students, additional information may be required. New Student Existing Student Gender: Male Female DCCCD Student I.D. Number: Ethnicity information is used to meet Texas State reporting requirements and providing this information is voluntary on your part. White, Non-Hispanic Black, Non-Hispanic International/Non-Immigrant No Response Hispanic Asian/Pacific Islander American Indian/Alaskan Native Other Last Name First Name MI Address City State Zip Primary Phone Address Date of Birth I verify that the above information is accurate. Course Information Signature Date TERM COURSE TITLE RUBRIC COURSE # SECTION # FEE Fall 2017 Microsoft Excel I TSW $150 PAYMENT INFORMATION Payment will be made at the college business office. Cash, Check, and Credit/Debit Cards are accepted. REFUND POLICY A refund of 100% will be made if requested prior to the first scheduled meeting day. Your request for a refund must be made during business hours prior to the first day to qualify for a 100% refund. A refund of 80% is allowed before the close of business on the day of the second class meeting. No refund is allowed after the second class meeting. Should the college cancel the class a 100% refund will be issued. Refunds may take up to four weeks to process. The Colleges of the Dallas Community College District reserve the right to make changes that may include, but are not limited to, the days and times courses are offered, classroom location, instructors who teach the course, and cancellation of courses. If you have questions regarding refund policy, refer to Certain Continuing Education courses have entrance requirements that the student must meet prior to registration. Consult College for details.