Please Type or Clearly Print Date of Birth /_ /_. Home Address: Number & Street County City State Zip. Day Phone: Alternate Phone: Social Security No.

Transcription

1 Program Application Packet Semester Requested (Check one): Fall Spring Summer Year: Access to Lamar State College-Port Arthur s programs or activities shall not be limited on the basis of race, color, creed, national origin, religion, age, gender, sexual orientation, political affiliation, or physical disability. Applications accepted year round. Please Type or Clearly Print of Birth /_ /_ LSCPA Student ID: Leave blank if you do not have one address: is the preferred method of communication with you Last First Middle Home Address: Number & Street County City State Zip Day Phone: Alternate Phone: Social Security No. Sex: Male Female Ethnic Origin: Hispanic or Latino Origin Not Hispanic or Latino Origin Decline to Answer Race Group: White Black or African American Asian American Indian or Alaskan Native International Unknown Native Hawaiian or Other Pacific Islander Please read the entire Program Application Packet and addition linked information about the program. If you have any questions or concerns prior to submitting your application, please contact personnel in the Allied Health Department at OR Dean of Technical Programs/Workforce Training Office Additional information about the Certified Medication Aide is available at To begin the program, at a minimum, you must submit this page of the packet along with Immunization Part I, Part II and Criminal Background check. Also all applicants must satisfy all requirements to be eligible to complete the training. For students under 22, please review meningitis requirements Prior to receiving access to register for any skills lab/practicum/clinical course, students must: o Submit completed documentation of ALL clinical eligibility requirements prior to being able to register for class. o These clinical requirements can be found on the attached Immunization Part I and Part II & Criminal Background Check forms. o Please review these attachments carefully as they contain the necessary instructions for meeting these requirements. o Please note some of these requirements have time-sensitive deadlines.

2 Acceptance of an application does not guarantee a student a seat in the course. Classes may fill quickly, preventing you from registering even though you have completed the application process. Students must notify the Allied Health Department, Continuing Education and the Admission and Records Department of any change in applicant data. Failure to do so may result in the withdrawal of permission to register in the classes or the inactivation of the application. The tuition payment must be paid in full and all admission requirements satisfied by published deadlines or students will be dropped from the program. I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is cause for denial of admission or expulsion from the College. I understand that the faculty and staff of the Allied Health Department, Dean of Technical Programs/Workforce Training/Continuing Education and Admission and Records will read the information contained in this application. I have read and understand all information included as part of this application. Signature of Applicant It is the student s responsibility to: Return this application to the Admission & Records Office, Allied Health Department or Dean of Technical Programs/Workforce Training Office, Lamar State College-Port Arthur, P.O. Box 310, Port Arthur, Texas, For assistance, please call or For Workforce Training Office Use Only Application Received : Accepted Rejected Added/Verified to Banner : Reviewed By: Track: Print Name and Phone Extension : Cohort: Student Advised of Status : by by mail by phone by message in person

3 Immunizations Part I Program: SSN or LSCPA ID#: of Birth: Measles (Rubeola): A. Two doses of measles vaccine on or after their first birthday and at least 30 days apart OR #1 #2 B. Serologic test positive for measles antibody Result Combined MMR Vaccine is vaccine of choice if recipients are likely to be susceptible. Mumps: A. Two dose of mumps vaccine on or after their first birthday and at least 30 days apart OR #1 #2 B. Serologic test positive for mumps antibody Result If TB Skin Test (PPD) is also needed, if it is not administered on the same day as the required vaccines, the student must wait to have the PPD administered 30 days after receiving the vaccines. Rubella: A. One dose of Rubella vaccine on or after their first birthday OR B. Serologic test positive for Rubella antibody Result Tdap Vaccine required once only: Note: After Tdap, TD booster every 10 years. Indicate clearly this is TDap and not Dtap Flu Shot One dose required during flu season Hepatitis B. Must show proof of: A. The minimum interval between the first two doses is 4 weeks, and the minimum interval between the second and third doses is 8 weeks. However, the first and third doses should be separated by no less than 16 weeks. It is not necessary to start the series or add doses because of an extended interval between doses. OR #1 #2 #3 B. Serologic test positive for Hepatitis B antibody Result

4 Workforce Training Health Professions Institute Immunizations Part I Program: SSN or LSCPA ID#: of Birth: Varicella: Must show proof of: A. Two doses of Varicella vaccine administered 4-8 weeks apart OR #1 #2 B. Serologic test positive for Varicella antibody OR Results C. Physician documented history or diagnosis of Varicella. Documented history after September 1, 1991 must have a month, day and year Disease Occurred. Only one dose of Varicella vaccine is needed if the student received first dose before the age of thirteen (13). Measles, Mumps, Rubella (MMR)/Varicella vaccines if not given on the same day MUST be 30 days apart. IMPORTANT INFORMATION: Vaccines administered after September 1, 1991 shall include the MM/DD/YY each vaccine was given. Physician or Approved Licensed Health Professional Information: Printed Name Address Signature of Primary Care Provider (Signature and only validates vaccinations)

5 Workforce Training Health Professions Institute Immunization Part II & Criminal Background Check Required by State Law/Clinical Facilities Program: SSN or LSCPA ID#: of Birth: Criminal Background Check Please indicate the date you submitted your request to for PreCheck to conduct the background check. Select the program for which you applying, if program is not listed please select Health Professions CE Background Check Only Must be current within 3 months of your skills lab/practicum/clinical start date. **See excerpt from CDC website below from Latent Tuberculosis Infection Tuberculosis. Must show proof of: A. Documentation of negative (<10mm) two-step tuberculin skin test (TST) must be current within 3 months of your skills lab/practicum/clinical start date OR Given: #1 Positive Read by: Given: #2 Positive Read by: Negative (If negative, repeat in 1-3 weeks) : Negative : A. Negative blood assay (QFT, TSPOT) must be current within 3 months of your skills lab/practicum/clinical start date Results B. IF a prior positive reactor to TST, must show documentation of a negative blood assay within 90 days Results C. IF prior positive blood assay, present a negative chest x-ray within past 2 years, be free of productive cough, night sweats or unexplained loss of weight.(submit Disease Screening TB Questionnaire) : X-ray results: **This is required by our clinical agencies no exceptions. Some people infected with M. tuberculosis may have a negative reaction to the TST if many years have passed since they became infected. They may have a positive reaction to a subsequent TST because the initial test stimulates their ability to react to the test. This is commonly referred to as the booster effect and may incorrectly be interpreted as a skin test conversion (going from negative to positive). For this reason, the two-step method is recommended at the time of initial testing for individuals who may be tested periodically (e.g., health care workers). Physician or Approved Licensed Health Professional Information: Printed Name Address Signature and of Primary Care Provider (only validates Tuberculosis info above)

6 GENERAL REQUIREMENTS for the (CNA) Training: Must have an official high school diploma/transcript or GED or official transcripts of higher education Must have proof of completion of Cardiopulmonary Resuscitation (CPR) for the Healthcare Provider course. Must have Negative (clear) criminal background check Must have Completed physical examination Must have Proof of current immunization to include: Tetanus/Diphtheria, Polio, Measles, Mumps, Rubella, Hepatitis B, PPD, Varicella and Influenza. In addition to class meeting dates be advised that this program also requires that you be able to complete clinical training with times to be arranged at a later time. (for additional clarification, contact the Allied Health Department staff)