Cedar Valley College Continuing/Workforce Education PHLEBOTOMY

Cedar Valley College Continuing/Workforce Education PHLEBOTOMY PHLEBOTOMY Refresher and Clinical Application Student Checklist Name Date: Email 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. Class Information: Reminder: CLEAR COPIES of documentation only. Do not submit original documentations. PHLEBOTOMY Application WorkKeys Test Score Report for: Applied Mathematics, Reading for Information, Locating Information High School Diploma or GED (college transcript will not be accepted) A valid non-expired U.S or State Govt. Issued Identification A valid non-expired American Heart Association CPR for HealthCare Provider Card (If you do not have proof prior to Phlebotomy application, you can enroll at Cedar Valley College concurrently; you must complete and show proof prior to phlebotomy clinical. Please circle one. Proof of Personal Health Insurance (Copy of front and back of insurance card ) TB Skin Test FLU Shot Immunization Signature Form or Separate Documents for required Immunizations _Student Responsibility Form Solid Scrub Set (Hunter Green) Liability/Malpractice Insurance Cedar Valley College ID Badge

For Office Use Only: Reviewed by: Date: Comments: Semester/Term:

GENERAL COURSE INFORMATION What do phlebotomists do? Phlebotomists draw blood from individuals in clinical/hospital settings. What classes do I have to take? PLAB.1023 Phlebotomy Lecture (80 hours) PLAB.1060 Phlebotomy Clinical (80 hours). The clinical instructor will determine final clinical schedule EMSP1019 - CPR (for students who do not have an AHA CPR card) When is it offered/when does it start? The lecture/skills refresher class two days a week/evenings. Final schedule will be determined by instructor. Clinical will be one day a week (Vary) and 9am-4pm on Saturdays. The clinical instructor will determine final clinical schedule. See schedule for dates and times. Schedule may be viewed online at: How much does it cost? (Cost varies depending on what you are missing with immunizations) Certified Phlebotomy Refresher Lecture Tuition - $0 Certified Phlebotomy Clinical Tuition - $500 CPR course- $60 TB test - $5 / Chest x-ray (if skin test is positive)- $50 Immunizations - $0-139 (may vary by clinic) Measles, Mumps, Rubella (2 doses) Combination tetanus/diphtheria/pertussis (Tdap), Varicella (2 does) Influenza, Hepatitis B series (3 injections) Liability insurance Fall $13.00 / Spring $9 / Summer $5 Criminal Background Check - $45 Drug Screening - $39 Textbook $60 (new) WorkKeys - NCRC Initial Testing is free, $5.50 for each NCRC retest Will Financial Aid pay for my courses? Texas Public Education Grant (TPEG) pays for tuition only (if you qualify and are approved). Eligibility is based on financial need. You must complete the FAFSA www.fafsa.ed.gov and TPEG application. Financial aid will not pay for books, supplies and vendor fees. CVC s Federal School Code 004453 You will need a valid email address in order to accept your award through econnect. How much will I earn? $12-16 per hour, wages will increase with experience and national credentialing. Am I certified when I finish the courses? These courses will provide you with the knowledge and skills required by the American Society of Clinical Pathologists (ASCP) for certification as a Certified Phlebotomy Technician. To become certified requires passing the phlebotomy exam offered by the ASCP. You will be given information on the exam in class. Where are the classes held? The M Building at Cedar Valley College Clinical: various clinical site and times vary from semester to semester. Students are responsible for their own transportation arrangements to campus and to their assigned health care facilities for clinical experience. *Subject to change at the discretion of the Cedar Valley College, Continuing/Workforce Education division. 2

The following clinics may have low cost vaccines available. These are suggested clinics you may call to inquire about immunizations. Feel free to contact your doctor and/or search for other low cost immunizations in your community. Dallas County Health & Human Services 2377 N Stemmons Fwy Dallas, TX 75207 (214) 819-2000 *Flu shots for $10.00 Los Barrios Unidos Community Clinic 809 Singleton Blvd Dallas, TX 75212 (214) 651-8739 The Martin Luther King, Jr. Family Clinic 2922 Martin Luther King Jr Blvd Dallas, TX 75215 (214) 426-3645 City of Mesquite Health Clinic 972 329 8326. http://www.cityofmesquite.com/community_services/ Mission East Dallas 9706 La Prada Drive Dallas, TX 75228 (214)-393-6700 3

Application Packet Requirements 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. Application packets with incomplete materials will be disqualified. The PHLEBOTOMY application materials must be submitted in a 9 X 12 inch envelope and include the following documentation to be considered. What do I need to submit for application consideration? 1. PHLEBOTOMY Application (included in this packet, page 8) Information Sessions The health packet outlines application procedures and acceptance policies. Information sessions will be held for Questions and Answers. Please bring this information packet with you to the information session and be sure to read through the packet. Information sessions begin promptly; allow extra time for parking and locating the assigned room. No children allowed. Plan to stay for an hour and a half. No late entries will be allowed. A map of the Cedar Valley College campus and parking suggestions are available online at: http://www.cedarvalleycollege.edu/aboutcedarvalley/mapsanddirections/ 2. Pre-Test Results (Report) WorkKeys Assessment (NCRC) Applied Mathematics (a minimum score of 3 or above) Reading for Information (a minimum score of 4 or above) Locating Information (a minimum score of 4 or above) 3. High school diploma or GED (a college transcript will not be accepted) 4. Identification A Valid (non-expired) U.S. or state government-issued photo I.D. (i.e. passport, driver s license, state identification card) 5. CPR Certification American Heart Association CPR for Health Care Provider card. 6. Personal Health Insurance 7. 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 registration approval for Phlebotomy clinical). TB screening and proof of immunity from Measles, Mumps, Rubella. Combination tetanus/diphtheria/pertussis (Tdap),Varicella/Chickenpox, and Hepatitis B series. Detailed information on immunizations is included in this packet, page 9). 8. Student Responsibility Form (included in this packet) 9. Student Check List (included in this packet) Submit a complete packet to Cedar Valley College, Continuing Education, A105, 3030 N Dallas Ave, Lancaster, Texas 75134. Mail or deliver complete application packet. Applications by FAX or EMAIL will not be accepted. Students are advised to retain a photocopy of all materials submitted. There are no deadlines for submitting an application; students are approved on a first-come, first-served basis with complete packets. Once the class is full, the Continuing/Education office will not accept packets until the next available semester is open. How do I know if my application packet was approved? You will receive an email informing you on your approval and registration instructions and deadline. 4

Registration Approval If you are approved for registration, a valid email address is required. Once you have received registration approval, you will be responsible for the following items: TUITION - Tuition must be paid in full at the time of registration. LIABILITY INSURANCE Fall - $13.00 Spring - $9.00 Summer - $5.00 Liability insurance will appear as a separate fee on the fee receipt that you will receive when you register. No refunds are given for liability insurance. I.D. BADGE Free Once you have a paid fee receipt from the Cashiers Office indicating payment has been made for your classes, you can obtain an Cedar Valley College I.D. Badge from the Office of Student Life on the 2 nd floor of the B Building in room B270. Hours are: Monday-Thursday 8:30 am-6:00 pm Friday 8:30 am 4:30 pm The I.D. Badge is to be worn at all times on campus and at the clinical training site. TEXTBOOK TITLE: Phlebotomy Essentials AUTHOR: McCall PUBLISHER: Lippincott, Williams & Wilkins 5 th edition ISBN: 0781766443 I understand in order to be approved for clinical, I must pass the lecture class with a grade of C or better and provide the following information: PERSONAL HEALTH INSURANCE In order to meet clinical site requirements, you must provide proof of personal health insurance. If you do not currently have personal health insurance, please visit the link below for https://www1.dcccd.edu/catalog/ss/sd/insurance.cfm for available student insurance programs. This requirement is not met by the purchase of Liability Insurance. CRIMINAL BACKGROUND CHECK - $45 Do not submit any information or payment to Group One until you have been given a directive to do so by your instructor. Be prepared to complete and purchase the first week of class. DRUG SCREENING- $39 Drug Screenings are required for all students entering into the Phlebotomy Clinical. Urinalysis specimens will be collected by a representative of SurScan on-campus. SurScan representatives will accept cash and money orders (No personal checks). Drug screenings from other sources are not accepted. Your instructor will notify you of date and time. If you did not submit proof of 3rd hepatitis shot, you are responsible for proof of the 3 rd shot for clinical approval. 5

I NEED MORE INFORMATION ON IMMUNIZATION REQUIREMENTS Immunizations for CE Health Careers Students In order to comply with the Texas Administrative Code (Title 25 Health Services, Rules 97.61-97.72) regarding immunization records for students enrolled in health-related courses, the following guidelines are now in force for students in Cedar Valley College Continuing Education Health Careers courses and programs. Health Careers students must present the following documentation with their application: I. Immunization Record Form An immunization record form is included with this information sheet. The completed form verified by a physician or nurse practitioner will document dates of all required immunizations and/or date of a positive titer result for each. NOTE: If immunization records have been recorded on separate documentation such as a hospital printout, health department card, office call invoice, etc., a clear photocopy of that documentation may be attached to the Physical Examination and Immunization Record form. A. Tuberculosis Screening An intradermal PPD (Mantoux) skin test is required for all applicants. The PPD must be current within (12) months of the applicant s anticipated entry into a Health Careers course. If the PPD indicates a positive reaction, documentation must indicate the induration of the test site and the applicant must also obtain a chest x-ray verifying the absence of active disease. The chest x-ray must be current within one (1) year of program entry. The chest x-ray will then be valid for two (2) years while the student is enrolled. Individuals who have received the BCG injection or who have a history of tuberculosis or a positive PPD result should obtain a chest x-ray rather than the PPD. B. Immunizations An applicant must have completed the following immunizations according to the indicated guidelines and schedules. Documentation of a titer (blood test) with specific lab values verifying immunity or seropositivity is also accepted for Measles, Mumps, Rubella, Varicella and Hepatitis B. 1. Measles Two (2) doses of measles ( rubeolla ) vaccine is required either in a separate injection or in combination with mumps and rubella ( MMR ). Both measles immunizations must have been received after January 1, 1968. Individuals who were born prior to 01/01/1957 are exempt from the measles immunization requirements. 2. Mumps One (1) dose of mumps vaccine is required either in a separate injection or in combination with measles and rubella ( MMR ). Individuals who were born prior to 01/01/1957 are exempt from the mumps immunization requirement. 3. Rubella One (1) dose of rubella vaccine is required either in a separate injection or in combination with measles and mumps ( MMR ). There is no exemption from the rubella immunization requirement for individuals who were born prior to 01/01/1957. 4. Tetanus/Diphtheria/Pertussis ( Tdap ) One (1) dose of Tdap is required within the past ten (10) years. The documentation must clearly indicate that a Tdap was received. NOTE: a standard Tetanus or Tetanus/Diphtheria (Td) is not accepted. 5. Varicella (chickenpox) Two (2) doses of varicella vaccine are required or documentation of a positive titer (blood test) with lab values report. NOTE: A statement from a physician or parent indicating the student s previous varicella disease history is no longer accepted. 6. Influenza One dose of a flu vaccine is required within twelve (12) months of anticipated entry to health program. 7. Hepatitis B series Three (3) doses of Hepatitis B vaccine are required per the timetable Initial dose 6

2 nd dose one month after the initial dose 3 rd dose five months after the second dose If an applicant fails to adhere to the above schedule, the series may have to be repeated. II. Exceptions Exceptions from meeting certain immunizations requirements are allowed for such circumstances as medical conditions, religious beliefs, etc. Applicants must present documentation as indicated below. Requests for exceptions are reviewed on an individual basis. A. Medical Exceptions The applicant must present a statement signed by their physician with personal knowledge of the applicant s medical history. The statement must indicate in detail that a specific vaccine poses a significant health risk to the individual. If the statement requests exemption from the Hepatitis B series, the applicant must also complete a separate waiver form to accompany the physician s statement. Unless the statement specifies that a lifelong condition exists, the exemption is valid for one year only from the date of the signed statement. The signed statement must be submitted with an applicant s Physical Examination and Immunization Record form. B. Exceptions Based on Religious Belief/Reasons of Conscience The applicant must obtain an Exclusion Affidavit from the Texas Department of Health by submitting a written request and including the applicant s full name and date of birth. The written request must be mailed to the following agency: Texas Department of Health Bureau of Immunization and Pharmacy Support 1100 West 49 th Street Austin Texas 78756 The affidavit form will be mailed to the applicant who must complete and sign the form which must include the basis for the exception. The affidavit will be valid for a two-year period. The signed affidavit must be submitted with the applicant s Physical Examination and Immunization Record form. NOTE: These exemptions may not be recognized by all hospital affiliates at which health students are assigned for their clinical experiences. A student may be required to receive all screenings and immunizations for a health care facility. III. Cedar Valley College Health Center Services The Cedar Valley College Health Center does not offer immunizations, physical examinations, or chest x-rays; however they can provide a list of physicians and clinics which offers physical examination at a reasonable cost. Immunizations may be obtained at urgent care clinics, some pharmacies, and at the Dallas County Health and Human Services office at 2377 N. Stemmons Freeway in Dallas. 7

CRIMINAL BACKGROUND CHECK INFORMATION DO NOT START GROUP ONE'S BACKGROUND CHECK PROCESS UNTIL YOU ARE GIVEN A DIRECTIVE BY YOUR INSTRUCTOR TO DO SO Background checks are required for all students entering into a health careers program with a clinical component involving patients. Background checks from other sources are not accepted. The results of the background check are only released to the program coordinator. The results of the background check will not be released to students. Background check requests are now processed online. You must have access to a printer when you input your information in order to print a confirmation page as your receipt. The cost of the background check is $45.00. Payment is made via credit card or money order. Instructions for either payment method are found below. Information you will need to have at hand before you begin this process: Valid Mastercard or Visa credit card (no other credit cards or debit cards are accepted) FULL legal name (first, middle, last) Maiden names and/or former names Date of birth Home phone number Social Security Number Current address (complete address; not necessarily what is printed on your drivers license) Zip codes where you have lived during the past seven (7) years (There is a U.S. Postal Service zip code lookup link on GroupOne s homepage below to help you with this.) PROCEDURE IF PAYING BY CREDIT CARD Go to the following website: www.gp1.com/students and make the following sequenced menu selections: 1. Read the information on the main page, scroll down and click on the arrow by Continue. 2. On the pull-down menus, select the following: i. Texas ii. Cedar Valley College iii. On the Discipline pull-down menu, select your health careers program, course, or course sequence. 3. Click on Add then click Continue (click on the arrow). 4. The next page will indicate the charges for the background check. To accept the charges and continue to the payment procedure, click Continue. To exit the menu without paying, click Back. 5. Read the agreement information and make your selection at the bottom to agree or not agree to the terms. To continue, type your full name where indicated and Continue. 6. On the next page, fill out the information completely in the format indicated and Continue. 7. Fill out the next page (additional names/addresses) if applicable and Continue. 8. Verify that the information is correct (go Back to correct as necessary) and Continue. 9. On the next page, fill in your credit card information. (Ignore the Payment Code field.) 10. Sign your name electronically and after the credit card payment is confirmed, you will be prompted to print the page as your receipt. PROCEDURE IF PAYING BY MONEY ORDER Obtain a Money Order payable to GroupOne Services for $45.00. On a sheet of paper, provide the following information: FULL Legal Name (first, middle, last) Your Email address Telephone Number Mail the Money Order and the above information to the address below (You may also deliver the Money Order and information sheet to GroupOne offices in person): 8

GroupOne Services 250 Decker Drive Irving, TX 75062 Within 2-4 business days after money order payment has been processed, you will receive an email from GroupOne with a payment code to use when you enter your data on-line. Follow the instructions below to proceed. Go to the following website: www.gp1.com/students and make the following sequenced menu selections: 1. Read the information on the main page, scroll down and click on the arrow by Continue. 2. On the pull-down menus, select the following: i. Texas ii. Cedar Valley College iii. On the Discipline pull-down menu, select your CE health careers program, course, or course sequence. 3. Click on Add then click Continue (click on the arrow). 4. The next page will indicate the charges for the background check. To accept the charges and continue to the payment procedure, click Continue. To exit the menu without paying, click Back. 5. Read the agreement information and make your selection at the bottom to agree or not agree to the terms. To continue, type your full name where indicated and Continue. 6. On the next page, fill out the information completely in the format indicated and Continue. 7. Fill out the next page (additional names/addresses) if applicable and Continue. 8. Verify that the information is correct (go Back to correct as necessary) and Continue. 9. On the next page, fill in the Payment Code field with the information emailed to you from GroupOne. and click on the Continue arrow. Do not fill in any other information. 10. You will be prompted to print the page as your receipt. GROUP ONE SERVICES www.gp1.com 250 Decker Dr. Irving, TX 75062 Telephone: 972-719-4208 FAX: 469-648-5088 All background check and drug screening results become the property of the Health/Legal Studies/Continuing/Workforce Division and will not be released to the student or any other third party. 9

Application Form Applicants to Continuing Education health courses are responsible for retaining a photocopy of all documentation submitted for their personal records. Once this documentation has been submitted to Continuing Education the documentation becomes the sole property of Continuing Education and will not be returned nor photocopied for the applicant, their instructors or any other party. Continuing Education Health Careers DCCCD STUDENT ID NO. / / DATE NAME ADDRESS BIRTHDATE Last First Middle I. Month/Day/Ye ar Street City and State ZIP TELEPHONE ( ) ( ) Home Business/Mobile EMAIL HEALTH QUESTIONNAIRE - (To be completed by the applicant) Do you have any physical limitations which would affect your ability to lift, turn, or transfer patients? Yes No Do you have any limitations in use of your senses, such as in sight or hearing, which would limit your ability to practice a health profession? Yes No Do you have any other condition which might interfere with your ability to practice a health profession? Yes No If you have answered "yes" to any of the above, please explain your limitations in detail below: I certify that the information provided by me is complete and accurate. I give Continuing/Workforce Education permission to submit my personal information, this includes criminal background and drug screening results and immunization and TB documentation, to any of the facilities in which I will be doing clinical practicum while I am a student at Cedar Valley College. Applicant s Signature Date 10

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 01/01/1957 2. Mumps 1 dose if born on or after 01/01/57; or positive Titer ; Exempt if born on or before 01/01/1957 3. 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 12 months DOES NOT APPLY *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 clinical approval. TUBERCULOSIS SCREENING Documentation requires a physician's signature or verification from the Health Center. Intradermal PPD (Mantoux) - within six (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 11

Statement of Student s Responsibility Review and initial each section as verification that you have read and understand this information: I acknowledge that this information packet contains policies, regulations, and procedures in existence at the time this publication went to press. I also acknowledge that the District Colleges including Cedar Valley College reserve the right to make changes at any time to reflect current Board policies, administrative regulations and procedures, and applicable State and Federal regulations. Furthermore, I understand that this packet is for information purposes only and does not constitute a contract, expressed or implied, between any applicant, student or faculty member and the Dallas County Community College District. I accept full responsibility for submitting a complete application packet and understand incomplete materials including missing or incomplete forms, immunizations records, and CPR certification will disqualify my application. I also accept the responsibility of informing Continuing Education Office of any change in my status, address, telephone number, or other information that would affect my application status. I understand that if accepted to Continuing/Workforce Education health program, all forms, immunization records, etc. submitted with my packet becomes the property of Continuing/Workforce Education and will not be returned nor photocopied for me. Therefore, I am responsible for keeping my own photocopies of these documents before I submit them with program application packet materials. I also authorize the release of these records to any of my clinical sites which may require them. I acknowledge that if admitted to PHLEBOTOMY, I may be assigned to clinical rotations at area healthcare facilities which may require additional proof of immunity or additional inoculations/immunizations. I also acknowledge that I am required to have health care coverage through the duration of my courses. I acknowledge that a criminal background check and mandatory drug screening are required before I am allowed to attend clinical. I understand that the results of these screenings become the property of Continuing/Workforce Education and will not be released to me or any other third party. I also understand that the outcome of these screenings may results in my dismissal from Cedar Valley College, Continuing/Workforce Education, and PHLEBOTOMY. I acknowledge that I must comply with class and clinical requirements, if I am absent from clinical for physical or mental illness, surgery or pregnancy reasons, I must present a written release from a physician before being allowed to return to the clinical setting. Applicant s Signature Date 12 Educational opportunities are offered by the Dallas County Community College District without regard to race, color, age, li i ti l i i di bilit l i t ti Continuing/Workforce Education, A105 2015May

FREQUENTLY ASKED QUESTIONS 1. What is considered acceptable vaccination records? Documents submitted from any private clinic, Dallas County Health Clinic or Hospital. All records must include a date of vaccine and doses for Hep B series. Your vaccination documentation must include a physician/nurse/p.a signature or official stamp for verification. Phlebotomy students can submit an official high school transcript that may include most vaccination verification on back of transcript. 2. Where can I obtain my shot records? Dallas County Health & Human Services if you lived in Dallas and were immunized in Dallas County, http://www.dallascounty.org/department/hhs/immunizations.html 3. Do I still need the varicella vaccine if I had chickenpox as a child? Yes, a statement from a physician or parent indicating previous varicella disease history is no longer accepted. 4. I have a CPR card but it is not with American Heart Association, will this be accepted? No, you must have a healthcare provider card by American Heart Association. 5. Do I have to have my CPR card before entering PHLEBOTOMY class? If you do not have your CPR card prior to applying for Phlebotomy lecture, you can submit your application and enroll in a CPR class at Cedar Valley College concurrently. You must have completed and proof for clinical approval. 6. What if I do not have personal health insurance? Students must provide proof of personal health insurance. If you do not currently have personal health insurance, please visit https://www1.dcccd.edu/catalog/ss/sd/insurance.cfm for available programs. 7. What is the difference between the liability insurance and personal health insurance? Liability insurance protects the company or individual from 3 rd party claims or great loss if confirmed responsible for damage or injuries, personal health insurance provides health coverage to the student during clinical experience. 8. When do I complete the criminal background check? If approved for registration, you instructor will let you know when to complete the criminal background check, be prepared to complete and pay for screening upon instructor s request. 9. Why are background checks required and can I turn one in from my work? Background checks are required for all students entering into a health careers program with a clinical component involving patients. Background checks from other sources are not accepted. 10. What if I have an offense on my background record? You will not qualify for clinical if you have a felony offense. 11. When should I start financial aid paperwork? As soon as possible, all students are responsible for financial obligations if approved for registration and upon registration. It is the student s responsibility to follow up with financial aid to ensure timely 13 Educational opportunities are offered by the Dallas County Community College District without regard to race, color, age, li i ti l i i di bilit l i t ti Continuing/Workforce Education, A105 (Revised 2015 May)