Phlebotomy Technician Program – Fall 2014 Program Information:

Phlebotomy Technician Program – Fall 2014
Program Information:
Thank you for your interest in Certified Phlebotomy Technician Training at Tunxis Community
College! This 150 hour program has been approved by the National Health Career Association. This
program that includes classroom and a hand-on laboratory is limited to 15 students accepted on a first
come, first served basis. Course content includes: basic aspects of medical terminology, anatomy and
physiology, venipuncture, specimen collection procedures, safety and universal precautions, common
laboratory tests with clinical significance to body systems and disease processes, and laboratory
equipment. Upon successful completion, the student is eligible to sit for the National Certification
examination, to be administered at the college, and for a clinical externship.
Program Requirements:
You must be at least 18 years of age with a high school diploma or GED, and complete the following:
 Fill out the enclosed PT application cover sheet, Questionnaire, Physical Verification form and
Health form (original health form due by Oct. 10).
 Mail or bring the application and forms along with a non-refundable $35 administrative fee
(credit or debit card, check or money order payable to TCC – no cash please), to Continuing
Education, Tunxis Community College, 271 Scott Swamp Road, Farmington, CT 06032.
Your application will then be forwarded to the Allied Health Coordinator for consideration. Upon
acceptance, you will be notified in writing and given further instructions to complete your enrollment.
Once you are accepted, the tuition must be paid to the College within five business days of
notification. Refunds may be obtained ONLY if your written withdrawal is submitted to
Continuing Education three business days prior to the first class meeting.
Health Form:
Each student that applies to the program must submit a completed
health form. See Associated Cost Sheet for details. No one can be
permitted to participate in the lab portion of the program or externship
without this requirement. The original form must be submitted to the
Allied Health Coordinator and cannot be faxed (due Oct. 10).
Please be advised that if you have been convicted of a felony, you may not be
eligible for clinical experiences, internships, externships or certifications associated with certain Allied Health
courses or programs. Those with previous convictions may also find it difficult to secure employment within a
health care agency or institution.
Course Dates, Times and Location:
Day Program: Sept. 22 – Dec. 16 Mon & Tues 9am-2pm
Lab: Mondays, room 326 Lecture: Tuesdays, room 6-173
Evening Program: Sept. 22 – Dec. 17
Mon, Tues & Wed 5:30-8:45pm
Lecture: Mondays, room 313 Lab: Tuesdays & Wednesdays, rooms 313/326
**No Class Monday, Oct. 13**
For more information, please call the Continuing Education Office at (860) 255-3666.
COSTS ASSOCIATED WITH THE
TUNXIS PHLEBOTOMY PROGRAM
FALL 2014
Fees Due Directly to Tunxis Community College:
$35 non-refundable administrative fee
payable to TCC at the time of registration
$1,850 tuition
includes malpractice insurance (personal health insurance is recommended in case of injury or exposure)
Payment Plan Option: (includes a $25 installment fee)
$975 – due within five business days of acceptance
$925 – due Nov. 6
Payment Plans are initiated and completed at the Business Office. Please visit or notify the
Continuing Education office first.
Costs Associated With the Program but Not Payable to TCC:
$125 National Health Career Association Certification Examination fee
$200 (estimated) Textbook/Workbook/Review book and white lab coat
payable to Follett Bookstore at TCC
$100 (estimated) for uniform: light grey scrub top and pants
sneakers or nursing shoes (not open toed)
Health Form requirements:
Physical Exam within the last year
Verification of measles, mumps, rubella vaccinations or rubella and rubeola titers
Chickenpox – verbal history of disease, date(s) of vaccination, or blood titers
Tuberculosis testing – chest x-ray if positive results
Hepatitis B series (optional) or waiver signature
Tetanus shot within the last 10 years
NOTE: This form must be in place by the deadline date (listed on previous page) in order for a
student to be eligible for clinical and externship.
BANNER ID ____________________________________
FEE PAID ON ____________________________
CC ______________
CRN _____________________
TUNXIS COMMUNITY COLLEGE
PHLEBOTOMY TECHNICIAN PROGRAM 2014
Spring
Program Choice (check only one):
DAY
Summer
Fall
EVENING
Please Note: Evening program not
available during summer.
Name_________________________________________________ Date of Birth_______________________
last
first
middle
Home Address____________________________________________________________________________
street
city
state
zip
E-mail Address____________________________________________________________________________
Phone___________________ Work / Cell Phone____________________ SSN#_______________________
Gender:
Male
Female
Ethnic/Racial (optional):
White
Primary Language__________________________________
Black
Hispanic
Asian
Native American
Other
Emergency Contact Name________________________________________ Phone #___________________
Are you a U.S. Citizen?
Yes
No If no, are you an alien who has the legal right to work?
Have you ever been convicted of a felony or misdemeanor?
No
Yes
No
Yes—briefly explain below.
*An arrest record could affect your ability to obtain employment as a CPT.
EDUCATIONAL INFORMATION
High School or GED Certification______________________________________________________________
U
(school attended and year graduated or certified)
College or University _______________________________________________________________________
(school attended, degree and year graduated)
Are you competent in reading comprehension and able to do math computation?
Yes
No
If no, please explain.
List employment history below.
Tuition Payment Source
Self
Agency (Agency Name, Caseworker and phone # Required below):
________________________________________________________________________________________
Application Fee Paid By: Check Number
Money Order
MasterCard/Visa/Discover:
Agency
Exp. Date
I understand the refund policy means I must contact the CE office three business days prior to the start of class
and that no refunds will be issued after that time under any circumstances.
The information provided on this CPT registration form is complete and accurate.
Signed____________________________________________________
Date______________________
TUNXIS COMMUNITY COLLEGE
CERTIFIED PHLEBOTOMY TECHNICIAN PROGRAM
Name: _________________________________________________________________
Do you have transportation?
Yes
No
Tell us about yourself.
List five qualities you possess that would make you a good candidate for the program.
Do you know what being a Phlebotomist entails? Briefly describe.
Why do you want to take this course?
How can Tunxis be assured that you will be committed to the program?
Do you have any physical limitations? If yes, please explain.
Have you ever been arrested? If yes, please explain.
What are your career goals?
How did you hear about this course?
Student Signature: ______________________________________Date: ____________
Name: ___________________________________________ Date: ________________
Check if you Agree, Disagree, or ‘N/A’ if it doesn’t apply.
1. I have trouble knowing what to study for a test.
Agree
Disagree
2. I need a friend with whom to discuss important things.
3. I am swamped by details and facts when I study.
Agree
Agree
Disagree
Disagree
4. I have recently endured the death of a family member or pet.
Agree
7. I usually work best against a tight deadline.
8. I seem never to have enough leisure time.
9. It is not easy for me to make friends.
10. I need more time for my family.
Agree
Agree
Agree
Disagree
11. I rarely have enough money to meet expenses.
N/A
N/A
Disagree
Agree
Agree
N/A
N/A
Agree
12. I have recently gained a new family member.
13. I have had a change in my financial state.
Disagree
Disagree
Disagree
N/A
Disagree
Agree
Disagree
Agree
Disagree
N/A
N/A
Agree
5. There has recently been a change of health for a family member.
6. I am overburdened with responsibility.
N/A
N/A
Disagree
Disagree
N/A
N/A
14. Money is going to be very tight for me this year.
Agree
Disagree
N/A
15. I am experiencing a great deal of family friction.
Agree
Disagree
N/A
16. I have to do jobs I can’t cope with.
Agree
17. I am experiencing a change in living conditions.
18. Most health care personnel are overworked.
Disagree
Agree
Agree
N/A
Disagree
Disagree
N/A
N/A
N/A
N/A
Tunxis Community College
271 Scott Swamp Road
Farmington, Connecticut 06032
CERTIFIED PHLEBOTOMY TECHNICIAN PROGRAM
PHYSICAL VERIFICATION FORM
Name of Student__________________________________________________________________________________
Address_________________________________________________________________________________________
City___________________________________________ State___________ Zip Code_______________________
Check the appropriate answer.
Please answer as honestly as possible. If yes is checked, please provide an explanation.
Allergies?
Yes
No
Pregnant?
Yes
No
On Medication?
Yes
No
Please list any medications here:
Mental Health Concerns?
Yes
No
_______________________________________
Hearing Problems?
Yes
No
_______________________________________
Back Problems?
Yes
No
_______________________________________
Knee Problems?
Yes
No
Recent Surgeries?
Yes
No
Lifting Restrictions?
Yes
No
Yes
No
(i.e. arthritis, injury, surgeries, etc.)
Latex Allergy?
If you are pregnant, have any back problems/lifting restrictions, or a medical condition that is being monitored by
a physician, a form will be provided by the College that must be completed by your physician along with your
signature.
Please list any other conditions that you feel may present a risk for you or that your Instructor should be aware of to
protect your well-being and safety.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Student Signature _____________________________________________ Date:__________________________
For Office Use Only
BANNER ID @_________________
Certified Nurse Aide
Phlebotomy Technician
HEALTH FORM
Name_______________________________________________________________________________________________
Address______________________________________________________________________________________________
Date of Birth_________________________ Telephone #_______________________________________________________
__________________________________________ was examined and found to be in good health on
(Name)
__________________________.
(Date of Examination)
He/she is in good health, free of any communicable disease and has no known deficits that would interfere with the ability to
participate in the lab/clinical setting. A pregnant student requires OB/GYN assessment.
__________________________________________________________
Healthcare Provider Signature
______________________________
Healthcare Provider Phone #
__________________________________________________________
Address
______________________________
Date
Immunization
CT state laws require that any student/instructor born on or after January 1, 1957 be protected against measles and rubella
(MMR). Please complete your immunization history.
**The Department of Public Health requires 2 doses of the measles vaccine, with at least one dose being given after 1980.
Proof of one dose of the rubella (German measles) vaccine administered after the student’s first birthday must also be
provided to the college.
#1_________________ #2__________________
Date
Date
If you have no MMR vaccine, then you must report your rubeola and rubella titers:
MMR
___________________________ ________________ _________________________________ ___________
Rubeola titer
Date
Rubella titer
Date
History of Disease: Yes: ___
Date ____________________________
No: ___
If no, Titer must be reported
Varicella Titer _____________________________________________
Results
Date
Date(s) of Immunization:_____________________________________
VARICELLA (Chicken Pox)
Tetanus Booster - Date: ______________________ (**Must be done within last 10 years)
Flu vaccine – Date:_______________________ (Fall and Spring Applicants only)
TUBERCULOSIS
PPD:
NEG ___________________
POS _____________________
Date–within past 9 mos
Date
Done by: __________________________________
Signature - Title
Date
If positive, results of chest x-ray (within past 6 months) _______________________________________________
**A copy of the X-ray report must be submitted with this form**
Results
Date
HEPATITIS B
Hepatitis vaccination is recommended but not required. You should discuss the option with your
physician and either begin vaccination or sign waiver. Employers may provide opportunity upon hire.
#1 ___________________________ #2 ___________________________ #3 ___________________________
Date
Date
Date
I waive Hepatitis B vaccination at this time: Signature___________________________________ Date:____________
For Office Use Only
BANNER ID @_________________
HEPATITIS B RISK FORM
I understand that due to my potential exposure to blood, body fluids and other potential infectious
materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. Because I have not completed
the Hepatitis B vaccination series or waived having the series, I understand that I continue to be at risk
of acquiring Hepatitis B, a serious disease.
I understand that if I experience an exposure to blood, body fluids or other infectious materials, I must
notify my preceptor and/or instructor immediately. I will be directed to the Emergency Department
where I will be offered the Hepatitis B virus immune globulin (HBIG), an injection(s). This injection
provides temporary passive immunity from Hepatitis B. I will need to continue or start the Hepatitis B
vaccination series.
By my signature below I acknowledge understanding that I (the student) am solely responsible for
payment of all services, injections, vaccinations and other costs associated with my exposure to blood,
bodily fluids or other infectious materials while in the Program even though I have not completed the
Hepatitis B vaccination series. I further understand that the College, its employees and clinical sites, will
not be responsible for any services, injections, vaccinations or other costs associated with my exposure
to blood, bodily fluids or other infectious materials while in the Program even though I have not
completed or waived the Hepatitis B vaccination series.
I have received information about Hepatitis B and the risks of exposure to blood, body fluids and other
potential infectious materials and my responsibility in reporting any incident of possible exposure.
I waive Hepatitis B vaccination at this time.
_________________________________________
Student’s name – please print
_________________________________________
Student’s Signature
________________
Date