Emergency Medical Services Program Enrollment Requirements *NEW - Meningitis vaccination required for ALL NEW HCC students under 30 years-old (MUST OBTAIN MINIMUM 10 DAYS BEFORE CLASS START DATE - NO EXCEPTIONS!)

EMERGENCY MEDICAL SERVICES PROGRAM Summary Enrollment Requirements: HCCS Application for Admission – New Students: (www.hccs.edu) Attend Mandatory EMS Orientation Session High School Transcript / Diploma (GED Scores) Physician Statement of Health CPR Certification Medical Insurance / Waiver (obtain during registration) Immunization/Shot Records: o TB Skin Test - MMR - DPT - Varicella - Hepatitis B Series Urine Drug Screen Test (10 Panel) Background Check EMS Code of Conduct (Student agreement form) ALL STUDENTS MUST COMPLETE THE ABOVE REQUIRMENTS BEFORE ENROLLMENT APPROVAL. Upon obtaining ALL of the requirements the student MUST bring the documents to the EMS Office at either the NE-Codwell or Katy Campus EMS Office for approval (On-line registration is NOT an option).

HCCS EMS Program Office locations: HCCS-NE-Codwell Campus, Suite 111 o Office #: 713-718-7694 HCCS-Katy Campus, Suite 330 o Office#: 713-718- 5704

EMS Program Enrollment Requirements/Procedures: EMS Orientation Session - Mandatory for EMT-Basic Courses and ALL NEW EMS Students. The EMS Applicant MUST complete and submit an "HCCS Application for Admissions." (New Students) If no previous/recent enrollment or testing activity has taken place at HCCS, students MUST meet the PSI/EMS counselor first. High School Transcript - or -Copy of HS diploma - or -GED scores + passing TASP scores unless exempt. College level reading - ASSET; Compass; THEA or other comparable test -Meet with counselor about these. Physician Statement of Health -Physical Exam (may use form provided) CPR Certification -Obtain certification prior to enrollment (within the last 6 months) o NOTE: American Heart Association (AHA) or American Red Cross (ARC) ONLY cards accepted (ON-LINE CPR CERTIFICATIONS ARE NOT ACCEPTED). Immunization/Shot Records - Need Documentation associated with the following: TB skin test (not more than 6 months old) MMR (Measles, Mumps, Rubella) DPT (Diptheria, Pertussis, Tetanus) Tetanus within last 5 years Varicella (Chicken pox) - 2 shots unless,  Proof of Titer confirmation of immunity  Parent or physician verification Hepatitis B (3 shots): May / can obtain from Personal Physician or Personal Lab Services (www.plslabs.net) see attached Student Flyer o Shot 1 (prior to start of class)* o Shot 2 (1 month after 1st shot) o Shot 3 (6 months after 2nd shot) *Get started ASAP - Need to have the first (#1) shot on record before registration. Student Background Check o Healthcare Program Student Background Check (www.precheck.com). * •Select "StudentCheck," then select "Order Student Background Check." o MUST download/print COMPLETE REPORT and turn in with application packet during enrollment (Report takes 3-5 days). *Required by Hospitals associated with clinical rotations. Drug Screen o 10 – Panel Urine Drug Screen Test (ONLY 10-Panel ACCEPTED) EMS Code of Conduct – Student agreement form

Summary of Required Documents: HCCS Application for Admission – New Students EMS Orientation Session High School / GED / Degree Physician Statement of Health - Physical Examination Immunization Documents: Meningitis/MMR/DPT/Varicella vaccine or Hx of disease/TB Skin test/Hep B shots (min 1) Urine Drug Screen test (10 Panel) Background Check CPR Certification EMS Code of Conduct Student Agreement Form Proof of Medical Insurance or sign a Waiver (completed during registration process) Once students have completed ALL enrollment requirements they may bring the documents to one of the EMS Campuses for verification and approval to enroll into an EMS course (On-Line enrollment is not permitted). Additional EMS Program Information: EMS Program Uniform Requirement (select link): EMS Program Text Books;

Students MUST order the EMS program text books by option listed (EMS BOOKS NOT STOCKED IN HCC BOOKSTORES).

Publisher - Jones & Bartlett; Follow procedures listed below EMT-BASIC TEXT BOOKS: REQUIRED THE 1st DAY OF CLASS! o EMT Advantage Package, Print Edition / ISBN: 9781449695101 http://www.jblearning.com/cart/Default.aspx?bc=9510-1&coupon=HC1EP Optional Materials: o Navigate Test Prep: EMT / ISBN: 9780763795559 http://www.jblearning.com/cart/Default.aspx?bc=9555-9&coupon=HC1EP o EMT-Basic Review Manual for National Certification (ISBN-13: 9780763744663) (JB Publisher On-Line DISCOUNT Code = HC1EP)

AEMT - INTERMEDIATE / PARAMEDIC TEXT BOOKS: REQUIRED THE 1st DAY OF CLASS! o o

Mosby\'s Paramedic Textbook and Workbook Package, Fourth Edition / ISBN: 9780323072717 http://www.jblearning.com/cart/Default.aspx?bc=07271-7&coupon=HC1EP

Optional Materials: JB TestPrep: Paramedic Success / ISBN: 9780763757847 http://www.jblearning.com/cart/Default.aspx?bc=5784-7&coupon=HC1EP

EMERGENCY MEDICAL SERVICES PROGRAM 555 COMMUNITY COLLEGE DRIVE HOUSTON, TEXAS 77013

PHYSICIAN STATEMENT OF HEALTH FORM

Check appropriate box in which student is to be enrolled. [ [ [ [ [ [ [ [ [

] ] ] ] ] ] ] ] ]

Associate Degree Nursing Cardiovascular Technology Computed Tomography Dental Assisting Diagnostic Medical Sonography Emergency Medical Services Health Information Technology Histologic Technician Medical Assistant

[ [ [ [ [ [ [ [

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Medical Laboratory Technician Respiratory Therapist Nuclear Medicine Technology Nurse Aide Occupational Therapy Assistant Pharmacy Technician(Specify} Physical Therapist Assistant Radiography

[ ]Surgical Technology [ ] Vocational Nursing [ ] Other_____________________

1. NAME: _________________________________________________________________________ Last First Middle Initial 2. HOME ADDRESS__________________________________________________________________ 3. City______________________________ 4. State________________ 5. Zip Code_____________ 6. SOCIAL SECURITY (last 4 digits) __________ 7. HOME PHONE: ( ) _________________________ 8. DATE OF BIRTH:_____________________ 9. AGE:___________ 10. HEIGHT: _______________ 11. WEIGHT: ____________ 12. TEMPERATURE________________ 13. PAST HISTORY (Must be completed with dates of illnesses, operations, and injuries): _________________________________________________________________________________ _____ ___________________________________________________________________________ 14. EYES: Vision (R) ___________ (L)___________Glasses (R)__________, (L) ________________ 15. EARS: Condition(R) __________ (L)__________ Hearing (R)__________, (L)________________ 16. TEETH: _______________ 14. TONSILS: _______________ 15. NOSE _____________________ 17. SINUSES: _____________ 17. SKIN: ______________ 18. THYROID: _____________________ 18. POSTURE: ____________ 20. HEART: ______________ 21. ABDOMEN: ____________________ 19 VARICOSE VEINS: _______ 23. ORTHOPEDIC CONDITION: _______ 24. HERNIA______________ 20. BLOOD PRESSURE: S_____________ D_______________ 26. LUNGS: ____________________ 21. COLOR BLINDNESS: ______________ 28.FEET: (R) _____________ (L) ___________________ 22. TB SKIN TEST: (Mantoux or PPD): (Within last 6 months) NOTE: Students with a history of BCG vaccination or those with previous positive reactions should have a current chest x-ray verifying inactive disease.

DATE OF SKIN TEST: _______________________FINDINGS:________________________________ DATE OF CXR: ____________________________FINDINGS:________________________________

IMMUNIZATIONS

MONTH/DAY/YEAR

30. TETANUS (Td) 31. MEASLES, MUMPS

_____________ 1ST _____________ 2nd _____________

32. HEPATITIS B (HBV)

1ST _____________ 2nd _____________

33. CHICKENPOX HISTORY

3rd _____________ Titer____________ ________________

34. SUBSTANCE ABUSE PANEL (7-10) ________________ (Please attach original results.) Date

REQUIREMENTS A Booster within the last 10 years Students born on or after 1/1/57 must show proof of 2 doses. Students born before 1/1/57 must Have 1 dose and show proof of Immunity to measles, mumps, Rubella (physician validated Hx, or serologic confirmation. All students must receive a Complete series of Hepatitis B Vaccine or show serologic Confirmation of immunity to Hepatitis B virus Two doses of Varicella Zoster vaccine Must be administered to students not previously vaccinated who lack a reliable history of chickenpox. URINE DRUG ANALYSIS WITH CREATININE AND PH LEVELS

35. PHYSICIAN FINDINGS: ___________________________________________________________ _________________________________________________________________________________ 36. PHYSICIAN RECOMMENDATIONS: ___________________________________________________ _________________________________________________________________________________ 37. In your opinion, is this individual in suitable physical and mental condition for training in the above selected Health Science Program? ______________________________________________________ If not, why? _______________________________________________________________________ _________________________________________________________________________________

PLEASE RETURN THIS COMPLETED FORM TO THE PROGRAM DEPARTMENT CHAIR Signature of Examining Physician: ____________________________________ Printed Name: ___________________________________________________ ____________________________________________________________________________________ Address: ____________________________________________________________________________________ Street City State Zip Phone Number: (

) _________________________

Date: ___________________

*Physician signature verified by office stamp name and / or location.

Rev. 7/2012

EMS Application / Test Fee’s: Texas Department of State Health Services – Texas requirements for initial certification/licensure: o At least 18 years old Complete high school or GED certificate (Texas Education Agency approved or out-of-state equivalent) o Successful completion of a DSHS approved EMS training course o Submit EMS Personnel Certification Application and fee  DSHS (http://www.dshs.state.tx.us/emstraumasystems/certinfo.shtm) o Pass National Registry exam o To gain paramedic licensure status, you are required to follow the steps above and submit proof of either a two-year EMS degree or a four-year degree in any field. o Submit fingerprints through the Fingerprint Applicant Services of Texas (FAST) for Texas/FBI criminal history check. To schedule your fingerprinting, see L-1 Identity Solutions- Texas Locations. ($44.20) (http://www.l1enrollment.com/state/?st=tx) EMT-Basic : Application / Test Fee’s NREMT - $70.00 ( included in EMSP 1160 Clinical Course) TDSHS – $64.00 EMT-Intermediate: Application / Test Fee’s NREMT - $100 TDSHS - $96.00 EMT-Paramedic: Application / Test Fee’s NREMT – $ 110.00 TDSHS - $96.00 ** NREMT = National Registry of Emergency Medical Technicians **TDSHS = Texas Department of State Health Services