EMT COURSE

APPLICATION PACKET

Dear Prospective EMT Student:

Thank you for your interest in the Labette Community College Emergency Medical Technician course. We have invested a tremendous amount of time and energy in developing the finest EMT training program in the region. We maintain high standards and select the very best students. I want to give you a clear understanding of what our training, and the world of Emergency Medicine will require of you. Working in the Emergency Medical Service is a challenging and rewarding endeavor. Professionals in this field demonstrate the highest attention to detail. Full consideration will be reserved for applications that have been completed in their entirety. The EMT course for which you are applying is both mentally and physically challenging. Because of the unique environment in which an EMT works, it is important to have a good understanding of these demands. An EMT’s primary responsibilities are responding to emergency calls, in all weather conditions, to provide efficient and immediate care to the critically ill and injured, and to administer lifesaving interventions while transporting their patient to a medical facility. Their jobs are necessarily physically and mentally strenuous. You will almost certainly witness suffering patients and life and death situations during this course, and it is likely that at least some of these patients will be known to you, you must be prepared for this. EMT’s serve as, and work with, Law Enforcement, Fire, and Emergency Medical Services personnel. As a student you will be studying and working with all of the above. The highest level of professional conduct and courtesy is expected of all students at all times. Successful candidates will possess high attention to detail, great listening and time management skills, ability to remain calm and gather, organize and convey information quickly and clearly during stressful situations. This course is designed to help you develop knowledge and confidence to take decisive actions in critical situations. EMT’s also have “grit” and a solid work ethic. They routinely work 24 hour shifts and are guaranteed to work several holidays each year. You will need to be prepared to handle the personal and professional demands that this line of work entails. The Labette Community College EMT course has a limited class size and we utilize a competitive enrollment process. Meeting the minimum requirements is one small step above inadequacy and in no way guarantees acceptance into the program. Test scores and previous academic performance will be evaluated. Active duty/volunteer Fire/LOE/EMS prospects will be given first consideration for admission. Please feel free to contact me if you have any questions.

Ryan Seme Director of Workforce Education, Career Training and Personal Enrichment * [email protected] * 620-820-1273

**Note on Vaccines** Immunizations can take some time to complete. I urge you to begin the process immediately. Immunizations need to be “in process” at the time of application and need to be completed BEFORE the first day of class. Depending on the time of the year for the class will determine the flu vaccine requirement. Please ask your pharmacist or health care provider of their recommendation. The vaccines usually come out in the fall for the upcoming year.

Minimum Course Admission Requirements: (completion of these minimum requirements does not ensure admission into the EMT Course)

1. A. If you have never taken classes at LCC, you need to Apply online to Labette Community College (see

2.

3. 4. 5.

checklist for instructions) B. If you have taken classes at LCC, you need to update your profile by calling Registrar Completion of Pre-enrollment Tests (Turn in results to Carol in the Workforce Education Office, Room M203/204) a. Reading (Compass minimum score 75/ACT minimum score 17) no charge; and b. Algebra (Compass minimum score 34/ACT minimum score 17) no charge Must be 17 years of age by end of the course and have in your possession a valid Driver’s License (include copy of your Driver’s License in documents to return with your application) High School Diploma, GED, or be a current high school senior enrolling with consent of Principal Completion of the application packet which includes the following documents that must be read, signed and returned to Workforce Education Office, Room M203/204, Labette Community College: a. The Student Health Record Form to be signed by a Primary Care Provider for verification of immunizations. (Need proof of following immunizations) i. Measles, Mumps, and Rubella (Must have proof of two MMR vaccines or documented titer); ii. Tetanus/Diphtheria (one within last 10 years); iii. Evidence of immunity to varicella (Chickenpox) in adults includes any of the following:  documentation of 2 doses of varicella vaccine at least 4 weeks apart;  US-born before 1980, except health care personnel and pregnant women;  history of varicella based on diagnosis or verification of varicella disease by a health care provider;  history of herpes zoster based on diagnosis or verification of varicella disease by a health care provider;  Laboratory evidence of immunity or laboratory confirmation of disease (titer). iv. Negative 2-step TB skin test (or chest X-ray) v. Hepatitis B immunization series (strongly recommended) or signed waiver vi. Optional Meningococcal vaccine b. Written Proof of Flu Vaccine to be turned in prior to first clinical or wear N95 respirator during flu season (see the Flu Vaccination Policy Form) c. Labette Community College Statement of Confidentiality/Social Media Conduct Form d. Understanding and Release for Exposure to Infectious and/or Human Fluids Form e. Waiver of Liability, Assumption of Risk and Indemnity –on/off campus activity Form f. Videotape/photograph Consent Form g. Health/Immunization/Safety sign off form h. LCC Criminal Background Check and Release for Health Science Student Form i. Labette Health Criminal Background Verification Form j. LCC Drug Testing Policy and Procedure and Signature Sheet (if under 18 will require an additional form to be signed by a parent/guardian. k. Shirt Order Form l. Grit Test

Mailing Instructions for Application Packet: Application packets are not accepted before Feb. 1, and must be postmarked on or before April 24 to be considered eligible for admission into the Labette Community College EMT Course (pending approval from the Kansas Board of EMS). The priority application deadline is April 3. Only complete application packets will be processed. Missing information or documents will result in processing delay or non-review of your application to the course. If an applicant is in the process of completing application minimum requirement they can still be in consideration, however it is contingent on them successfully fulfilling the requirements. Applicants that have fulfilled requirements will have precedence over those that are in the process. Submission of false material in this Application Packet will be grounds for non-admission, or if discovered after admission, grounds for expulsion. It is recommended that application packets be sent by certified mail, or hand delivered and date stamped on delivery. Hand deliver or mail the complete EMT Course Application Packet to: Labette Community College Carol Rabig, Room M203/204 Workforce Education, Career Training and Personal Enrichment 200 S. 14th Parsons, KS 67357

Additional Help: Please refer to the application Check-Off Sheet found on the last page of this packet and check-off as you complete each step to assist you with your application process. You may also call the LCC Workforce Office 620-820-1273 to have questions answered. Enrollment Procedure Once Acceptance into the EMT Course 1. 2. 3. 4. 5. 6.

Contact Carol Rabig at 620-820-1273 to confirm enrollment Come to the required orientation. Bring cash, check or money order for $350 Make payment arrangements to cover the tuition costs of the class with the business office Go to Admissions to get your student ID card. Review the EMT Handbook found online in the coursework area. For additional information, please contact the Workforce Education Department at 620-820-1273

EMT Course Expenses All students enrolled in the EMT Course are required to have basic health insurance for clinical/FI participation. Students must maintain current coverage throughout the duration of their clinical/FI experiences in the EMT course and understand that Labette Community College cannot assume any liability or financial obligation for students’ health care and students are responsible for the cost of their own illness or injury. It is the responsibility of the student to keep this policy active and up to date. Labette Community College does not provide Student Health Insurance Plans. Information regarding options for student health insurance can be found through the Labette Community College website: http://www.labette.edu/athletics/forms/LCCAthletic-Insurance.pdf. Students are to assume financial responsibility for course-related costs including, but not limited to transportation costs, registration fees, textbooks and supplies, and uniforms. See the table below. Costs are subject to change. Prior to Acceptance into the course Item(s) 2-step TB skin Test (on your own) Required immunizations Reading and Math Test

Expense $40 (Variable) paid to Provider (Variable) paid to Provider No cost at LCC

Prior to 1st Day of Class Once Accepted into Course Item(s) Tuition (in state) paid directly to Business Office (2nd floor Student Union) Required text and digital lab fee, 2 uniform shirts and cap, CPR card, liability insurance, criminal background check fee, and KBEMS Application fee Uniform: black shoes, black socks, EMS black slacks and black belt Photo ID

Expense Per credit hour = $49 Tuition/$43 fees = $92 per credit hour Total = $1104 Subject to Change Total $350 (check , money order, or cash to LCC and brought to orientation or Workforce Office Subject to Change (Variable) Free for 1st one

Approximately Week 4 of the EMT Course Psychomotor Testing Fee (Nonrefundable) –SKEMS/Region II Required for each examination.

$125 Payable to SKEMS (money order or cashier’s check only)

Registration for National Exam at end of course National Registry Application (Required for initial examination and each additional attempt of the written exam -Non Refundable)

$80 completed online-cannot be cash, check or money order.

Other Expenses Transportation Costs

(Variable)

Application Packet Check off Sheet CHECK-OFF LIST (Please check off all completed) Step 1: (Before Application Deadline of April 24)

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Item Check the Course Dates and Times to make sure you will be available to attend every class. (Included in this packet). Complete application to LCC (unless taken classes prior to this one). Go to www.labette.edu. Under Admissions tab click on Apply Online; click here to start filling out application Or Click on: http://redzone.labette.edu/ICS/Admissions/Admission_Information.jnz?portlet=Apply_Online_2.0&screen=Be gin//b79d05f0-81c7-471e-bfff-582b8409e7e2&screenType=next%27

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If you have taken classes at LCC before call the Registrar and update your profile. Call 620-820-1147 (Student Success Center) to schedule your reading and math test (free of charge). After your test is complete, obtain a copy of the test results and include those with this application packet or give to Carol in the Workforce Education office Room M203/204 to put on file. Download this application packet and print all forms that will need to be read, filled out, and signed. Contact your Primary Care Provider or Local Health Department to schedule a 2-step TB skin test. Please be aware the TB skin test is usually done on your inner arm. A small needle is used to put some testing material, called tuberculin, under your skin. In 48 to 72 hours after the test is “planted,” a healthcare professional will need to read the test by checking your arm to see if there is a reaction to the test. The two-step test means you need to repeat this process within one to three weeks – in other words you will be tested on both arms. You must receive “negative” results on both tests. Copies of the results should be brought to the campus with your application packet (room M203/204) or faxed to 620-421-4481, attn: Carol. A negative Chest x-ray for TB is also acceptable. -------In addition to the TB skin tests, schedule an appointment with your Primary Care Provider for the completion of your Health Record (required form in packet) to confirm all immunizations or proof of immunity to diseases (including a Tetanus/Diptheria in the last 10 years, 2 MMR’s, Chickenpox immunity or vaccine, Hepatitis B Series of 3) and no latex allergies. Your local health department may be of some help to provide information regarding these vaccines as well. Read, fill out and sign all forms that will need to be returned in the application packet. [ ] Student Health Record and supporting documentation if test or immunization is completed in an alternate setting [ ] TB skin Test (1) [ ] TB skin Test (2) [ ] MMR 1 [ ] MMR 2 [ ] Hepatitis B Series (1) [ ] Hepatitis B (2) [ ] Hepatitis B (3) or Waiver [ ] Varicella Immunity [ ] TDaP within last 10 years [ ] Documentation of Latex Allergy or No Latex Allergy [ ] Statement of Confidentiality/Social Media Conduct [ ] Statement of Understanding and Release for Exposure to Infectious and/or Human Fluids [ ] Waiver of Liability, assumption of Risk and Indemnity –On/Off Campus activity [ ] Videotape/Photograph Consent [ ] LCC Criminal Background Check and Release for Health Science Students [ ] Labette Health Policy and Procedure Background Verification (complete policy upon request). Please make sure to print your name on the verification form as well as signing your name [ ] Signature Sheet for the Drug Testing Policy and Procedure. [ ] Health/Immunization/Safety statement [ ] Shirt order form

[ [ [ [

] Grit test (2 pages) ] Reading Test results ] Math Test results ] Copy of your Driver’s License

Other: [ ] If you decline the Hepatitis B vaccines you will need the waiver signed and returned [ ] Flu vaccine form returned after immunization is available and prior to 1st clinical Once the forms are complete, mail the completed packet to Labette Community College, Carol Rabig, Room M204, Workforce Education, Career Training and Personal Enrichment, 200 S. 14th, Parsons, KS 67357. If you are waiting for spacing of certain immunizations (such as Hepatitis B and the second MMR) please go ahead and return the packet prior to completion of those immunizations. The TB skin test results with the Health Record form need to accompany the application. Step 2 (After Acceptance into the Course and before class begins) Call Carol Rabig at (620)820-1273 or 1-888-522-3883 to confirm enrollment Obtain EMT slacks, belt, and shoes. You must have these the first day of class. Attend Orientation: Date: TBA Bring $350 cash, money order, or check to LCC Go to Business office or contact Business Office to make arrangements for payment of tuition/fees (620) Go to Admission Office (2nd floor Student Union) to get your student ID card Read EMT Handbook and Course Syllabus found online in your course shell Step 3 (Once classes begin) Orientation to online course material/lab Review Labette Health HIPAA policy and sign off and any other forms for continuation in class Schedule for Clinical and FI dates Flu vaccine form signed and returned prior to 1st clinical and upon availability of vaccine- usually available around Sept – October (Flu vaccine for current year – for classes beginning in summer will be based upon recommendation and hospital requirements) Approximately week 4 Pay $125 SKEMS/Region II Psychomotor Testing Fees (money order or cashier’s check only) (Required for each examination) Psychomotor testing Date: Register online to take National Registry exam with $80 credit card (no checks, money orders, or cash) by Date: Recognition Night/Awards Date:

Labette Community College EMT Course Application Please Print or Type All Information FULL LEGAL NAME DATE OF BIRTH

STUDENT ID NUMBER

ADDRESS

CITY

TELEPHONE (HOME)

STATE

(Cell)

(OTHER)

E-MAIL ADDRESS Please check the following questions that apply to you, choosing the best answers that describes your current circumstances.          

I do not hold any EMT certifications I am a state of Kansas certified EMR I am EMT certified in a state other than Kansas. Level of certification ______ State ______ I am a Registered Nurse or Licensed Practical Nurse I do not hold any other health care licenses I hold another healthcare professional license: _______________ I am a Member/Veteran of the U.S. Military Branch _________________ Are you now or have you ever been enrolled at LCC (YES)_____ (NO)_____ I am a municipal employee at __________________________ Telephone # ________________ I am a volunteer Fire Fighter for ________________________

Emergency Contact Information Name:

Relationship:

Home Phone:

Street Address:

Work Phone:

City:

State:

Completion of this form and minimum program requirements does not constitute admission to the program. Applicants will be notified by letter when they are accepted into the program.

"I certify that the information provided on this application is complete and accurate in every respect. I understand that falsifying any of this application may result in cancellation of admission." Signature of Applicant (Do Not Print):

Date Application Received by Workforce Education (to be filled out by LCC employee)

Course Dates and Times

TBA

LABETTE COMMUNITY COLLEGE STATEMENT OF CONFIDENTIALITY/SOCIAL MEDIA CONDUCT As a student in a Labette Community College Allied Health course (Nurse Aide: Geriatric/C.N.A., Medication Aide/C.M.A., Emergency Medical Technician/E.M.T. or Home Health Aide/H.H.A.) I understand that some of my education will involve access to resident/patient care, information and records that are considered confidential and protected under HIPPA Guidelines. I acknowledge my responsibility to respect the confidentiality of resident/patient records and guard the privacy of any resident/patient by not revealing any information regarding that resident/patient to anyone, and to act in a professional manner in the classroom, the clinical/FI setting, and in the community. I further understand that if I am found to be indiscreet with confidential material or fail to protect the privacy of a resident/patient or others through my actions, I will be dismissed from the course. I understand this action to be necessary in order to maintain the high professional standards of the Allied Health care courses and integrity of Labette Community College. To uphold the privacy of such information, I agree not to post or discuss any theory or clinical/FI experience or information regarding my experience with the college or clinical/FI agency, its staff, or its clients/patients on my internet social media (Facebook, Twitter, emails, MySpace, and any others not mentioned). In addition, cell phones with camera capabilities are prohibited in patient care areas. STATEMENT OF UNDERSTANDING I further understand if I violate the rules of the clinical facility, am involved in resident/patient abuse, violence toward another individual, academic dishonesty, violation of confidentiality or any other inappropriate behavior I will be removed immediately from the course. I understand that while participating in clinical activities as part of LCC’s C.N.A., C.M.A., E.M.T. or H.H.A. course, I will be subject to the rules and regulations of the clinical facility and could be subject to drug testing at my own expense. If found positive in such drug testing, I will be subject to discipline by the college under general rules of student conduct as outlined in the LCC Catalog.

Name (Please Print)

Signature

Date

STATEMENT OF UNDERSTANDING AND RELEASE FOR EXPOSURE TO INFECTIOUS AND/OR HUMAN FLUIDS Labette Community College EMT Course I, _____________________________________ (Print Name), am a student at Labette Community College (LCC) and am enrolled in the EMT Course. I acknowledge that I have been informed of the following and that I understand the following: 1. That the health science program have enrolled in may involve exposure to human body fluids and cell and tissue cultures that may carry infections such as HIV (Human Immunodeficiency Virus) and Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) 2.

That exposure to infectious blood and other body fluids and cultures by contact through eye, mouth, blood, non-intact skin, or other method may put me at risk of contracting a blood borne infection.

3.

That to protect myself from exposure to blood and other body fluid and cultures, I will wear protective apparel according to OSHA (Occupational Safety and Health Administration) standards and comply with applicable policies of the College and any hospital or clinical affiliate that I am attending.

4.

That if I should become exposed by eye, mouth, blood, non-intact skin, or other method to blood or other human fluids or cultures, I will immediately report such incident to the I/C or Clinical/FI affiliate supervisor.

5.

That if such exposure should occur, I hereby authorize the College or the Clinical/FI affiliate to administer such immediate first aid as is deemed appropriate until medical help can be obtained.

6.

That I hereby release and hold harmless Labette Community College (LCC), its employees, officers, agents, and representatives, including all hospital and clinical/FI affiliates, from any liability for any and all injury, illness, disability, or death, including all costs for medical care, resulting from my exposure to infectious blood or other human fluids or cultures or the administration of emergency first aid after such exposure, during the course of my participation in the health science program, whether caused by the negligence of the College or otherwise, except that which is the result of gross negligence or wanton misconduct by the College

Student Signature

Date

Printed Name

Instructor Signature

Date

WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY – ON/OFF CAMPUS ACTIVITY LABETTE COMMUNITY COLLEGE/EMT I, the undersigned participant, represent and warrant that I am an adult of 18 years of age or older (parent signature included if under age 18), and have the legal capacity to enter into this Waiver of Liability, Assumption of Risk and Indemnity Agreement (“Agreement”). Waiver: In consideration of being permitted to participate in the Labette Community College EMT course/activity to the extent permitted by law, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, covenant not to sue, and agree to indemnify and hold harmless Labette Community College, its officers, employees and agents (collectively the “Indemnified Parties”) from any and all liability, loss, claim demands and possible causes of action (including all costs and attorney’s fees incurred by the Indemnified Parties in enforcing this release and indemnification agreement), that may otherwise accrue from any loss, damage or injury (including death) to my person or property, in anyway resulting from, or arising in connection with, or related to my participation in the Labette Community College EMT course/activity, whether or not such injury or death is caused by negligence or from any other cause Assumption of Risk: Participation in Labette Community College EMT course/activity carries with it certain risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks may include, but are not limited to: 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; and 3) catastrophic injuries including paralysis and death. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent. I hereby assert that my participation is voluntary and I knowingly assume all such risks. Governing Law and Severability: The construction, interpretation and enforcement of this agreement shall be governed by the laws of the State of Kansas. The courts of the State of Kansas shall have jurisdiction over this Agreement and the parties. The undersigned further expressly agrees that this Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Kansas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk and indemnity agreement, fully understand its terms, and understand that I am giving up my rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release to the greatest extent allowed by law.

Student Signature

Date

Printed Name

VIDEOTAPE/PHOTOGRAPH CONSENT LABETTE COMMUNITY COLLEGE EMT Course Videotape/photograph consent student signature page to be complete before course entry.

I, ______________________________________ give Labette Community College (LCC) EMT Course consent to videotape/photograph/audiotape me during classroom, lab or off campus education experiences for education purposes and for use in the promotion of future classes.

Student Signature

Printed Name

Date

CRIMINAL BACKGROUND CHECK AND RELEASE FOR HEALTH SCIENCE STUDENTS Permission and Release Form I authorize Labette Community College to release the results of any criminal background check to any site where I will be placed for any legitimate educational purpose and I waive my privacy rights under the Family Educational Rights and Privacy Act (FERPA) and consent to a background check for this limited purpose. I hereby release Labette Community College from any liability in the event:   

I am not cleared for placement by the clinical sites and therefore, cannot continue in the course. I am unable to obtain the necessary credits to continue in the course due to a criminal charge or conviction that occurred after being accepted into the course. I am unable to obtain licensure/certification in my field of study due to adverse results on a criminal background check.

I understand that I cannot be guaranteed placement at a clinical/FI site and if I cannot complete the clinical/FI requirements, I will not be able to complete the course. Print Name: _______________________________________ Signature: ________________________________________

Date: _______________

Please submit this signed form as part of your application to the LCC EMT Course.

Procedure for Drug Testing

DRUG TESTING POLICY FOR HEALTHCARE STUDENTS

Introduction It is the policy of Labette Community College that students who enroll in healthcare programs or allied health courses including, but not limited to, Nursing, Respiratory Care, Radiologic Technology, Physical Therapist Assistant, Diagnostic Medical Sonography, Dental Assisting Programs and Certified Nurse Aide, Certified Medication Aide, and Pharmacy Technician Preparation for Exam courses submit to drug and/or alcohol testing when required by a clinical facility, a specific healthcare program policy, or as directed by a reasonable cause event. Purpose Students in LCC Healthcare Programs and Allied Health Courses must adhere to the standards of conduct required of healthcare professionals. No student will be allowed in the classroom or clinical area while under the influence of drugs or alcohol. This policy is consistent with the “Student Code of Conduct Policy” in the LCC Catalog-- http://www.labette.edu/catalog/conduct.html. Healthcare students found to be involved in any of these activities are subject to disciplinary action up to and including dismissal from their respective healthcare programs. Labette Community College Healthcare Programs strive to ensure the health and safety of students and patients are not compromised. Education of healthcare students at Labette Community College requires collaboration between the college and clinical facilities and cannot be complete without a quality clinical education component, generally referred to as a clinical rotation. Clinical facilities are increasingly required by their accrediting agencies, including The Joint Commission (TJC), to provide a drug screen for security purposes on individuals who supervise, care, render treatment, and provide services within the facility, therefore, clinical facilities may require a negative drug screen on each student prior to that student arriving for his/her clinical rotation.

PROCEDURE FOR DRUG TESTING HEALTHCARE STUDENTS Consent to drug testing The student must provide written consent to provide specimens for the purpose of analysis. If the student is under eighteen (18) years of age, the student’s parent or legal guardian must sign the drug testing consent form in addition to the student. Refusal to be tested The program director shall be notified of any refusal to be tested. In the case of a pre-clinical test or if there is reasonable suspicion of impairment in a clinical situation, refusal to submit to drug testing will result in ineligibility to complete the required clinical rotation and the student will receive a grade of “F” for that clinical rotation. Refusal to submit to any drug screening (classroom, pre-clinical or clinical) will result in disciplinary action up to and including termination from the program. Pre-Clinical Testing Students assigned to a site requiring drug screening must submit to testing. Pre-clinical drug testing will be done at Labette Health in Parsons, KS. Labette Health is accredited by HFAP (Health Facility Accreditation Program). Students must complete an “Authorization for Testing and Release of Records” form available in their respective program offices. Before the clinical rotation begins, a copy of the signed consent form must be returned to the program director or clinical coordinator to be maintained in the student’s program file. To be tested, Labette Health requires student identification with current photograph and a copy of the completed form. The drug screen vendor will perform a specimen validity check, testing, and reporting in accordance with their policies and the policies of Labette Community College Healthcare Programs. This policy is available for student review in each LCC healthcare program student handbook. *Based on individual program policies, the cost of the pre-clinical drug tests will be paid by the student as part of the course materials fee, or the student may be required to make payment as services are rendered. Only drug tests conducted by labs approved by the program director will be accepted. Reasonable Cause Testing Students may be asked to submit to a drug and/or alcohol test based on a reasonable suspicion that their ability to perform work safely or effectively may be impaired. Factors that individually or in combination could result in reasonable suspicion drug testing include, but are not limited to, the following:            

Direct observation of an individual engaged in drug- and/or alcohol-related activity; Unusual, irrational or erratic behavior or a pattern of abnormal conduct; Unexplained, increased or excessive absenteeism or tardiness; Sudden changes in work or academic performance; Repeated failure to follow instructions or operating procedures; Violation of LCC or clinical facility safety policies or failure to follow safe work practices; Unexplained or excessive negligence or carelessness; Discovery or presence of drugs in a student’s possession or near a student’s work area; Odor or residual odor peculiar to some drugs; Involvement in an accident that results in injury to the student or another person while on campus or at a clinical site; Secured drug supply disappearance; or Information provided either by reliable or credible sources or independently corroborated.

The student is responsible for the cost of any “reasonable suspicion” drug and/or alcohol test and must make arrangements for payment with the provider prior to testing.

Verified evidence that a student has tampered with any drug and/or alcohol test will result in disciplinary action up to and including termination from the program.

PROCEDURE FOR DRUG TESTING HEALTHCARE STUDENTS If a student is suspected of being impaired by drugs or alcohol in the clinical area, the following procedure will be implemented:     

The clinical instructor from the facility will attempt to notify the program director immediately. The clinical instructor and one other professional staff person will complete written documentation describing the impaired behavior observed. The student cannot leave the site until a drug screening consistent with the policy of that site has been completed and a program representative, family member, or friend arrives to transport the student. Once dismissed, a student cannot return to the clinical site until the results of the drug screen have been verified as “negative” by the program director. Results of the drug test will be sent through secure channels to the program director and he/she will inform the student. If the result of the drug screen is negative, the student may continue in the program. If the results are positive, the student will be terminated from the program.

In the event a student is suspected of being impaired while attending clinicals at a facility that does not provide drug testing, the program director will determine the lab, and the clinical instructor (or a designated program representative) will transport the student. If a student is suspected of being impaired by drugs or alcohol in the classroom, the following procedure will be implemented:       

The classroom instructor will attempt to notify the program director immediately. The classroom instructor and one other professional staff person will complete written documentation describing the impaired behavior observed. The student must complete an “Authorization for Testing and Release of Records” form available in the respective program office. A copy of the signed consent form must be returned to the program director or clinical coordinator to be maintained in the student’s program file. The student will be transported to Labette Health by a program representative. Labette Health requires student identification with current photograph and a copy of the completed form. The student cannot leave Labette Health until the drug screen is completed and the program representative, a family member, or friend must transport the student. The student may not return to the classroom until the results of the drug screen have been verified as “negative” by the program director. Results of the drug test will be sent through secure channels to the program director and he/she will inform the student. If the result of the drug screen is negative, the student may continue in the program. If the results are positive, the student will be terminated from the program.

In the event a student is suspected of being impaired while attending class at the Cherokee Center, the student will be transported to Via Christi Medical Center in Pittsburg, KS for testing by the classroom instructor or a designated program representative. Cost of the drug and/or alcohol test for reasonable suspicion is the responsibility of the student. Payment must be made to LCC in the program office prior to testing at Labette Health or before services are rendered at Via Christi Medical Center. Failure to pay for a reasonable suspicion drug test is considered a refusal to test and will result in termination from the program.

PROCEDURE FOR DRUG TESTING HEALTHCARE STUDENTS **Medical review of positive drug test results Specimens are screened by immunoassay. Positive results are confirmed by gas chromatography with mass spectrometry (GC/MS) or liquid chromatography with tandem mass spectrometry (LC/MS/MS). All specimens identified as positive on the initial test shall be confirmed by the testing laboratory at no additional charge to the student. Any positive test result will be reviewed by the vendor’s Medical Review Officer (MRO). A Medical Review Officer, who shall be a licensed physician with knowledge of substance abuse disorders, shall review and interpret positive test results. The MRO shall: Examine alternate medical explanations for any positive test results. This action may include conducting a medical interview and review of the student’s medical history or review of any other relevant biomedical factors. Review all medical records made available by the tested student when a confirmed positive test could have resulted from legally prescribed medication. Prior to making a final decision on the results of the confirmed positive test, the MRO shall give the student an opportunity to discuss the results. The MRO may contact the student directly to discuss the results of the test. The student will be given the opportunity to discuss any prescription medications he/she is currently taking, and written documentation from the prescribing physician will be required to support this statement.

Some facilities may require the student to complete a form listing all legally prescribed medications they are taking prior to testing.

Reporting of drug test results Notification of drug screening results can only be delivered in a manner that insures the integrity, accuracy and confidentiality of the information. Written notification indicating either a “NEGATIVE” drug screen or “CONFIRMED POSITIVE” shall be provided by the drug screen vendor to the appropriate program director at Labette Community College as soon as possible following initial testing and a copy will be placed in the student’s secured file. Results of student drug screens will be reported to the student as soon as possible after they are received. Test results will not be released to any individual who has not been authorized to receive such results. Students shall not be allowed to hand deliver any test results to college representatives. They may be provided to a contracted clinical facility upon request. Results of any student’s drug screen will be shared only on a need to know basis with the exception of legal, disciplinary or appeal actions which require access to the results.

PROCEDURE FOR DRUG TESTING HEALTHCARE STUDENTS

Readmission Substance abuse is a recognized illness for which prompt treatment should be undertaken. Information regarding available resources can be found in the LCC Alcohol/Drug-Free Campus Policy— http://www.labette.edu/catalog/

Any student, who fails or refuses to submit to a drug test, or admits to the use, possession, or sale of illegal substances, will be immediately dismissed from the respective program, and the dismissal will be considered a clinical failure. If the student is a licensed practitioner, admission of use, possession, or sale of illegal substances and/or a positive drug screen will be reported to the licensing agency, as required by law. Conviction of any criminal drug statute while enrolled in a healthcare program or allied health course at Labette Community College will be grounds for immediate dismissal from the program or course. The student will not be eligible for readmission. A student may contest disciplinary action based on a drug test result or refusal to submit to a drug test by following the procedure set forth in the Student Grievance Procedure in the LCC Catalog— http://www.labette.edu/catalog/Student_Information.pdf

For confidential information regarding treatment for drug abuse contact:

Tammy Fuentez Vice-President of Student Affairs [email protected] or 620-820-1264 (Office--Student Union Building, SU220) *COST OF TESTING AT LABETTE HEALTH--basic drug test required by most clinical sites--$22; 10-panel screen that includes tricyclic antidepressants--$56; breath alcohol test--$27. **DRUG CATEGORIES TO BE TESTED—amphetamines, barbiturates, benzodiazepines, cocaine metabolites, phencyclidine, propoxyphene, marijuana metabolites, methadone, opiates, oxycodone, and creatinine—urinary. This list of tested drugs is subject to change. Testing for additional substances may occur based on clinical affiliation agreement requirements

Signature Sheet

I have received a copy of and have been given the opportunity to ask questions about the Labette Community College Policy and Procedure for Drug Testing Health Science Students. As a Health Science Course or Allied Health Course student I understand and agree that I am subject to drug and alcohol testing at any time and understand the consequences of a positive drug or alcohol test.

______________________________

_________________

Printed Student Name ______________________________

Date _________________

Student Signature

Date

______________________________

_________________

Course/Course Witness

Date

HEALTH/IMMUNIZATIONS/SAFETY The I/C, Lab Instructor(s), and/ or preceptor(s) will oversee all student performance, in both the classroom and clinical setting. Each student will address any problem or concern that s/he may have regarding his/her safety immediately to the individual directly involved with the training at hand. All students will perform with normal regard for personal safety as well as the safety of patients and others involved with the patient care. At NO TIME will the student perform any action that s/he or the preceptor deems unsafe or that the student/preceptor feels inappropriate action for the student to take. Any student that has an infectious disease (common cold, flu, hepatitis, AIDS, etc.) will not be allowed to participate in practical skill stations. These students will be expected to attend class and observe others in the practical stations. In the event there is enough equipment such student may given a set of their own to work with. The student will make up practical time at the discretion of the I/C. The student will be held responsible for the instruction. Any disease that requires the student to miss two or more classes will be required to have a medical release by a physician before being allowed to return to class. This will also apply to injuries that preclude the student from taking practical examinations. Any student with a history of chronic health problems, pregnancy, recent surgery, or back injury, will be required to present a medical release by a physician. The I/C has the option at all times to request such a release at his or her discretion. Any time the student suffers an injury while functioning as an EMT student, the student will immediately report the occurrence to the preceptor who will in turn make a report to the I/C. A written incident report of the occurrence must be made within 48 hours. All students must exercise prudent physical exertion in the classroom, during labs and during clinical rotations. All equipment will be properly cleaned with disinfectant after each student’s use. Due to the nature of the training, it is imperative that all students maintain proper personal hygiene habits. Students will take pride in the equipment provided for their use. Equipment and supplies are expensive and at times difficult to obtain. The equipment is of no use if it has been abused or damaged. Any student that intentionally misuses equipment shall be disciplined appropriately. If any equipment is accidentally broken or is found inoperative, the student shall report the incident to the instructor immediately. It is the responsibility of all class participants, instructors, and assistants to insure that equipment is cleaned and put away in a neat and orderly manner after each class. At NO TIME will a student, while participating in clinicals, be allowed to drive any ambulance The clinical/Field experience for students may require prolonged standing and walking; frequent heavy lifting, pushing, pulling, carrying, occasional climbing, stooping, balancing, kneeling, constant need for good vision and hearing; ability to tolerate stressful situations; and occasional exposure to hazardous material. Students should be able to lift 125 lbs. (250 with assistance). All students must exercise prudent physical exertion in the classroom lab sessions and in the clinical/FI setting using techniques taught in this class for lifting and moving patients. Additional safety policies and procedures are included in the EMT student handbook.

I have read the above requirements and understand that my inability to comply with these may result in my failure to complete the EMT course. Student Name (Printed): Student Signature:

Date:

Flu Vaccination Policy In cooperation with Labette Health, the EMT course will require EMT students to either accept the flu vaccine or sign a waiver of refusal and accept responsibility to wear an appropriate mask during all patient contact for the designated flu season. At the beginning of flu season the forms will be made available. If the student chooses to accept the flu vaccine, it will be the student responsibility. In the event that the flu clinics do not offer paperwork to verify that you have received the vaccine, a form will be provided from LCC Workforce Education department to have signed by the person administering the vaccine. If the decision is made to decline the flu vaccination there will be a waiver that you will complete and sign. Understand that by completing this waiver you assume responsibility to ensure safety of patients and infection control. You will be required to wear the appropriate mask while in all patient contact, regardless of if you have any symptoms; as required by the clinical facility. The “flu season” will be determined by the CDC guidelines. Either the completed vaccine form, or the refusal waiver will be required during the designated times to be eligible for clinical clearance. The form should be submitted to the lead instructor. Revision 4.1.12; 10/8/12

Flu Vaccination Form I verify that _______________________________, EMT Student has received the influenza vaccine. Date:______________________ Person Administering Vaccine:____________________________________ Facility Providing the Vaccine:_____________________________________ Thank you for your assistance in tracking the student’s vaccination status. This vaccination is a requirement for LCC EMT students to ensure the safety of our patients during flu season.

Flu Vaccination Waiver I, ______________________________ verify that I have chosen to refuse the influenza vaccine that is required for LCC EMT students to ensure safety for our patients during flu season. I understand that by completing this form I understand that it is my responsibility to provide an equal level of safety and protection for the patients. I will be responsible for wearing an appropriate mask while in all patient care areas, regardless of if I have any physical symptoms of the flu. I will be required to do this through the dates of “flu season” as set by the Centers for Disease Control. Refusing to wear the appropriate mask while in patient care areas during clinical would result in an unsatisfactory grade in clinical for each day. Signed:______________________________________ Date:_______________________________________

WAIVER OF HEPATITIS B IMMUNIZATION Hepatitis B – is a major cause of viral infection; it results in swelling, soreness, and loss of normal liver function. Signs and symptoms include flu like symptoms such as fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice. Hepatitis B virus can survive for at least one week in dried blood or on contaminated surface and may be transmitted through contact with these surfaces. Caution must be taken to avoid contact with any blood or other fluid that potentially contains a bloodborne pathogen.

Decline the Hepatitis B Vaccine I understand that due to my occupation exposure to blood or other potential infectious material, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have read the informed statement on the potential risk and consequences with contraction of hepatitis B. However, I decline to get the hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I may do so at my cost.

Student Name (Print)

Student Signature

Date

Shirt Order (Due with application)

Name:

Telephone Number:

Size of Polo:

Size of T-Shirt:

______(Small)

______(Small)

______(Medium)

______(Medium)

____ (Large)

____ (Large)

______(X-Large)

______(X-Large)

Optional Extra Shirts (Must be paid at the time of order) Please order

extra polo shirts @ $35 ea. Size

(XX-large add $2.00 each)

Please order

extra T-shirts @ $17 ea.

(XX-large add $2.00 each)

Total paid for extra t-shirt/polo =

Size

Paid to:

Name __________________________________________ Are you a first responder/ municipal employee?

13- Item Grit Scale Yes

No

Directions for taking the Grit Scale: Please respond to the following 13 items. Be honest – there are no right or wrong answers! 1. I have overcome setbacks to conquer an important challenge. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 2. New ideas and projects sometimes distract me from previous ones. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 3. My interests change from year to year. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 4. Setbacks don’t discourage me. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 5. I have been obsessed with a certain idea or project for a short time but later lost interest. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 6. I am a hard worker. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all

Labette Health EMS/LCC May 2015

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7. I often set a goal but later choose to pursue a different one. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 8. I have difficulty maintaining my focus on projects that take more than a few months to complete. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 9. I finish whatever I begin. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 10. I have achieved a goal that took years of work. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 11. I become interested in new pursuits every few months. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 12. I am diligent. Very much like me Mostly like me Somewhat like me Not much like me Not like me at all 13. What color do you like the best? Blue Black Red Purple Green

Labette Health EMS/LCC May 2015

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Labette Community College Student Health Records Check which Healthcare Program you have been selected to attend: Nursing Education Program Respiratory Program Radiography Program Physical Therapy Assistant

PROCEDURE/VACCINATION 1)

2)

3)

4)

Please provide this form or documentation of the information below to the program accepted to.

EMT Course

RESULTS

TB SKIN TEST: Need 2 step Must be complete prior to the start of the program. (Thereafter, annually with documentation provided.)

COMMENTS

1st Step TB Negative :

mm

Negative :

mm

Positive :

mm

Positive :

mm

Date Read:

Date Read:

Initials :

Initials :

MMR: Two doses of MMR vaccine required or EVIDENCE OF TITERS (Mumps, Rubeola, Rubella):

MMR #1

Date:

Initials:

MMR #2

Date:

Initials:

Titer

Date:

Initials:

MMR Booster

Date:

Initials:

Dates:

VARICELLA (Chicken Pox) Screened for immunity or evidence of Titer:

1st

Initials

2nd

Initials

3rd

Initials

Titer

Initials

Immune:

5)

LATEX ALLERGY:

6)

TETANUS SHOT (TDaP): Tetanus Shot must have been given within last ten (10) years.

Yes

Primary Care Provider:

Titer:

Chest X-Ray Result: If you have received a TB skin test within the last year a 1 Step TB may be all that is required with verification of the 1st one. Please contact the Program Assistant for details.

Results of reactions documented as “negative” cannot be accepted. Must be documented in “mm”.

HEPATITIS B SERIES (or signed waiver):

If Positive Date of Chest X-Ray:

2nd Step TB

If you cannot show proof of 2 doses of MMR vaccine, positive Rubeola & Rubella, or titer you are required to get a MMR Booster.

If your series of 3 Hep B vaccinations will not be completed prior to starting the program in which you have been selected you must sign the waiver.

Date:

Initials:

No If yes, provide documentation

Date last tetanus shot given: Primary Care Provider:

Signature

Date: Print

Student must read the following statement and sign and date below: To the best of my knowledge the information above is correct and accurate, and I do not currently have a communicable disease that would put clients or patients at risk. I hereby grant permission to the Labette Community College Healthcare Program in which I am enrolling in to release this information to agencies at which I have practicum or clinical experiences. Student:

Student: Signature

Labette Health EMS/LCC May 2015

Date: Print

28

Labette Health EMS/LCC

January 2017

Application Packet