Medical Assistant Program - Tunxis Community College

Transcription

Medical Assistant Program
Spring 2016
February 8, 2016 – December 8, 2016
Program Information:
Thank you for your interest in the Medical Assistant Program at Tunxis Community
College. This 720 hour, 10 month program has been approved by the American
Medical Technologists and is limited to 14 students who are accepted on a first come,
first served basis. Upon successful completion, students are eligible to sit for the
American Medical Technologists’ National Examination. Classroom instruction and
lab groups are held at the college. Clinical internships are held at physicians’ offices
and clinics within our college service area.
Program Requirements:
You must be at least 18 years old and complete the following:
 Fill out the enclosed MA application, Physical Verification form,
Questionnaire, and Policies form
 Submit a copy of your high school diploma or GED
 Mail or bring the application and forms along with the non-refundable $35
administrative fee (credit/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.
It is the applicant’s responsibility to make sure all materials have been received.
Only completed applications will be reviewed.
Your application will be forwarded to the Allied Health Coordinator for
consideration. If accepted, you will be notified in writing and given further
instructions to complete your enrollment.
Required Uniform:
 Ceil blue scrub top and pants
 White lab coat
 Black sneakers, shoes or Crocs (cannot be open-toed)
 A watch with a second hand
Tuition Payment:
Once you are accepted, tuition must be paid to the College within five business days
of notification. Refunds may be obtained only if your written withdrawal is received
by the Continuing Education Office five (5) business days prior to the Mandatory
Orientation Session.
Your tuition includes the cost of malpractice insurance.
Additional costs include textbooks, uniforms, and National Examination fee
(see “Associated Costs” sheet).
Health Requirements:
Each student accepted into the program must have a health examination along with required
immunizations and bloodwork. See “MA Program Checklist” sheet for details. No student
can be permitted to participate without these requirements. The original health form is
due in its entirety by March 8th (no faxes).
Online Requirements:
This program contains an on-site and an online portion. An Internet access point, like the
Tunxis Library or your home service provider, is required for successful completion.
Online classes are listed in the schedule portion of this packet.
For a complete view of the schedule, please go online to
tunxis.edu/cehealth.
Students who successfully complete the MA program are eligible to receive college credit
through the Connecticut Credit Assessment Program administered by Charter Oak State
College. Students should request a copy of their program transcript from the Continuing
Education Office to be sent to Charter Oak. Credits may be used at Charter Oak State
College or transferred to another school by setting up a credit registry with Charter Oak
(any transfer credit is at the discretion of the institution).
http://www.charteroak.edu/current/programs/creditregistry.cfm
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.
COSTS ASSOCIATED WITH THE
TUNXIS MA PROGRAM – SPRING 2016
Fees Due Directly to Tunxis Community College:
$35 non-refundable administrative fee
(paid at the time of registration)
$5,524 tuition (due within five business days of acceptance)
$476 out of pocket student expense for Ed2Go classes
Total tuition: $6000 (includes malpractice insurance)
Payment Plan Option: (includes a $25 installment fee)
$2,349 – due within five business days of acceptance
$2,200 – due 5/12/16
$1,000 – due 7/14/16
Please note: online courses are not included in the payment plan.
Payment plans are initiated and completed at the Business Office. Please go to the Continuing Education
Office first.
Costs Associated With the Program but Not Payable to TCC:
$476 Four Ed2Go Online classes ($119 each) – the first three classes must be paid in
full at the Mandatory session
$120 American Medical Technologists National Examination Fee
$105 National Healthcareer Association Phlebotomy Certification Exam (optional)
$250 (estimated) for uniform and lab coat (lab coat may be purchased at the Follett Bookstore at Tunxis)
$975 (estimated) textbooks (payable to the Follett Bookstore at Tunxis)
$30 (estimated) 16GB flash drive (payable to the Follett Bookstore at Tunxis)
$75-100 (estimated) background check fee for UCONN Externship
**Workforce Innovation and Opportunity Act (WIOA) approved programs
are funded through the CT Dept. of Labor. To see if you qualify call New
Britain CT Works at 860.223.0889. This program is not eligible for federal
financial aid.**
TUNXISCOMMUNITYCOLLEGEMEDICALASSISTANTPROGRAM
CHECKLIST
Application Deadline is January 27; program begins Monday, February 8, 2016.
Checklist:
 Step 1: All applicants must complete and submit an application packet along with a $35 nonrefundable administrative fee and a copy of your high school diploma or GED. Completed applications
should be submitted to the Continuing Education office.
 Step 2: Attend the required interview. Interviews are scheduled individually. Please call Shaina
Hamel, LPN 860.773.1454 or Cheryl Conaty, RN 860.773.1453 to set up a date and time.
 Step 3: Once you receive your acceptance packet, you must pay the full tuition or the first payment
plan installment within five business days of acceptance.
 Step 4: Bring the health form (included in this application packet) to your physician and have it
completed and signed. Completed forms cannot be submitted by fax; only original completed forms
will be accepted. Completed forms may be dropped off in the Continuing Education office prior to the
course start date or at the Mandatory Session on Monday, February 8, 2016.
Health Form requirements:
Page 1 Personal History – Please provide explanations for any “yes” answers.
Page 2 Immunization History – To be completed by health care provider.
Please attach documentation for all areas. Incomplete forms will be returned to the student.
Verification of measles, mumps, rubella, and polio vaccinations or titers
Chickenpox – date(s) of vaccination or varicella titer
Tuberculosis testing – chest x-ray if positive results or Quantiferon Gold titer
Provide dates only:
Hepatitis B series (optional) or waiver signature and risk form
Tetanus shot – must be done within the past 10 years
Flu shot – Spring and Fall applicants only
Page 2 Physical Exam – Must be within the last year. All areas must be completed by your health care
provider. Heart rate, blood pressure, hematocrit or hemoglobin must be documented in numbers.
Continuing Education Office Hours
Monday, Tuesday, Wednesday, Friday
9:00AM-4:30PM
Thursday
9AM-7PM
860.773.1450
ed2go.com/tunxis
How to Register for an Online Education2Go Course
1. In your internet browser, type ed2go.com/tunxis
2. In the upper right, type in the full name of the course (see course list and start dates on reverse)
under “Search for Courses” (see photo below).
3. If multiple courses appear, click on the correct course name.
4. Once you are on the course homepage, click on the “Enroll Now” button located on the top right of
the webpage (see photo below).
5. A new screen will appear. Choose the desired start date (see below). Classes run for six weeks.
6. Complete the steps on the screen to finish enrollment:
a. For the first log in, enter your email address and click on “Create Account” under the
New Student section on the right side of the screen. You will use this same email
address and password for all online courses.
b. For a returning student log in, enter your email address and a case sensitive password in
the fields on the left (see photo below).
7. You will then follow the online payment option (credit card required). Continue to the Orientation
page. You will have access to the classroom portion the first day of class.
COURSES MUST BE TAKEN IN ORDER




Computer Skills for the Workplace
Human Anatomy and Physiology I
Medical Terminology: A Word Association Approach
Human Anatomy and Physiology II
See the schedule for course start and end dates.
Note: WIA students do not
need to create an account;
one has been created with the
email provided on you
application. Students must
complete enrollment (create a
password) and choose
classes by clicking on the
registration email they
received.
Medical Assistant Schedule Spring 2016
Mandatory Orientation:
Monday, February 8, 2016
5:30 – 8:30PM
Location: Room 306
All courses below are located in Room 306 unless noted otherwise.
Lab 1: Clinical Office Procedures
February 9 – February 18 (TU/TH)
5:30-9:30PM
February 23– April 7 (TU/TH)
5:30-9:00PM
EKG and Pulse Oximetry Skills
June 15 – July 6 (W) July 8 (F) 5-9PM
Law, Liability & Ethics
February 10 – 24 (W) 5:30–9:30PM
March 2 – April 20 (W) 5:30-9:00PM
Medical Office Procedures
July 11 – September 19 (M/W)
6-8:30PM (no class Mon, Sept. 5)
Location: 205
Ed2Go.com/Tunxis online courses
Computer Skills for the Workplace
February 10 – April 1
Human Anatomy & Physiology I
March 16 – May 6
NO CLASSES WEEK of JULY 25th
Lab 3: Surgical Procedures and
Sterilization
August 2 – September 15 (T/TH)
5:30-9:30PM
September 20 (T) 6-8PM
Therapeutic Communication
April 12 & 14 (TU/TH) 5:30PM-9PM
April 19 – May 5 (TU/TH)
5:30-8:30PM
CPR/AED/BLS
September 16 (F) 4-8PM
Location: TBA
Ed2Go.com/Tunxis online course
Medical Terminology
April 13 – June 3
Laboratory Review
September 21, 22, 27, 28 (TU/W/TH)
5:15-9:30PM
September 29 (TH) 5:30-9:30PM
Seeking Employment
April 27 - May 11 (W) 6-9PM
Lab 2: Phlebotomy & Pharmacology
May 10 – 19 (TU/TH) 5:15PM-9:30PM
May 24 – July 19 (TU/TH) 5:30-9:30PM
Ed2Go.com/Tunxis online course
Human Anatomy & Physiology II
May 18 – July 1
Getting to Know Your
CPT & ICD-10 Manuals
May 18 – June 8 (W) 5:30-9PM
Internship
Dates/Times to be Scheduled Individually
All courses must be completed with a passing grade
of at least 70 in order for students to be eligible for
internship.
Exam Review
December 5 (M) 4:30-9:30PM
Graduation
Wednesday, December 7, 2016
Time: TBA
Location: TBA
BANNER ID ____________________________________
FEE PAID ON ____________________________
CC ______________
CRN _____________________
TUNXIS COMMUNITY COLLEGE
REGISTERED MEDICAL ASSISTANT PROGRAM
Spring
2016
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 RMA.
EDUCATIONAL INFORMATION
High School or GED Certification______________________________________________________________
(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 RMA registration form is complete and accurate.
Signed____________________________________________________
Date______________________
TUNXIS COMMUNITY COLLEGE
Name:_____________________________________________________________
Do you have transportation?
Yes
No
Tell us about yourself.
Five qualities you possess that would make you a good candidate for the program:
Do you know what being a R.M.A. entails? Briefly describe.
Why do you want to take this program?
How can Tunxis be assured that you will be committed to the program?
Do you have any physical limitations? If yes, please describe.
Have you ever been arrested? If yes, please explain.
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.
Agree
1. I have trouble knowing what to study for a test.
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
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
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
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:_________________________
Name (please print): ____________________________________ TUNXISCOMMUNITYCOLLEGE
REGISTEREDMEDICALASSISTANTPROGRAM
IMMUNIZATIONS
I understand that I am required to have certain immunizations at the time of acceptance into
Tunxis Community College Registered Medical Assistant program.
CLINICALSITES
I understand that clinical learning experiences are planned as an integral part of the medical
assisting courses and are held at a variety of health care settings, such as hospitals, clinics,
private doctors’ offices and selected community health care centers. Students are responsible
for arranging their own transportation to and from assigned clinical sites. Internships are
assigned during daytime, between the hours of 8AM and 5PM. Assignment of clinical sites is at
the discretion of the Tunxis Medical Assisting faculty. All scheduled courses must be completed
with a passing grade of at least 70% before the student is allowed to participate in internship.
CRIMINALBACKGROUNDCHECKS
I understand that some clinical learning sites require students to undergo a background check
for felony convictions. Students who do not pass the background check may be excluded from
the clinical and may not be able to meet the competencies required for the program.
FELONYCONVICTION
I understand that if I have been convicted of a felony, I may not be eligible for clinical
experiences, internships, or certifications associated with certain Allied Health courses or
programs. I also understand that a previous conviction may make it difficult for me to secure
employment within a health care agency or institution. OTHERREQUIREMENTS
As a health care professional/student, I understand that I am at an increased risk for contracting
blood borne infectious diseases. The Medical Assisting Program at Tunxis Community College
is not responsible for any medical cost associated with my contracting any communicable
disease during or prior to my education and/or participation in Tunxis Community College
Medical Assisting Program sponsored functions. If I contract a blood borne infectious disease
before or during my enrollment, appropriate health experts must be consulted to determine my
ability to assist with patient care.
I have read and understand the above information.
________________________________________________
Sign Date
_________________
SPECIALREQUIREMENTS
The following additional Essential Functions are also expected of all students with or without
academic adjustments. Students must be able to fulfill the essential functions of the job without
endangering patients or other healthcare workers. Students with disabilities may be eligible for
academic adjustments.
Students must have the following abilities:
o
Proficiency in the use of the English language and must possess effective oral and
written skills in order to accurately transmit appropriate information to patients/clients,
faculty, colleagues, and other healthcare workers
o
Gross and fine motor skills sufficient to lift, position, and operate equipment
o
Interpersonal skills such that they are capable of interacting with individuals, families and
groups from a variety of social, economic and ethnic backgrounds
o
The ability to present a professional appearance, maintain personal health and be
emotionally stable
TRANSCRIPTAUTHORIZATION
Please note that upon successful completion of the program, an official copy of your transcripts
will be sent to: American Medical Technologists, 10700 W. Higgins Rd, Suite 150, Rosemont, IL
60018. By signing and dating at the bottom of the page, you are consenting to your transcripts
being mailed to the AMT.
If you do NOT want transcripts to be sent automatically upon completion, please check the box
and initial.
I do not want transcripts sent to the AMT: _________
initial
I have read, understand and discussed the information provided in this packet with the program
coordinator.
_______________________________________
Sign _________________
Date
POLICIESandPROCEDURES:
In order to complete the recommended number of hours, a student cannot miss any time from the
Medical Assisting Program. Students MUST call the Allied Health Coordinator, Cheryl Conaty, at
860.773-1453 to let her know of any absence/lateness from clinic and/or lectures and/or class.
Please note: these are UNEXCUSED circumstances.
Students must achieve a 70% or higher in all courses to progress in the program and participate in
the internship experience and to take the registry examination. For additional assistance, students
having difficulty with course material should contact the Allied Health Coordinator.
Students are responsible for paying the entire program tuition even if they fail a course.
Opportunities to make-up courses are at the Allied Health Coordinator’s discretion.
Students must complete all of the quizzes for the Ed2Go classes before taking the Final
Examination. Any student who fails to do so will have to take the next available class and pay the
course tuition again. If a student fails an Ed2Go class, they must take the next available class and
pay the course tuition again.
Students must make up all missed time. If the lecture/clinical/lab is not made up, the student is
withdrawn from the program per the Coordinator’s discretion. The student is still responsible for full
tuition. A student may apply to the next available program, once again, paying full tuition.
If a student has an emergency and cannot make it to lecture/clinical/lab, he/she must contact the
Coordinator so arrangements can be made within the same week to make up lost time. An
emergency situation is determined by the Coordinator. This policy also applies to any student who
has missed any portion of the lecture/lab/clinical experience, including lateness and unexcused time.
This is a zero tolerance policy. Our goal is to train competent and qualified Medical Assistants. In
order to achieve this standard, NO lecture/clinical/lab days can be missed. Students must meet all
hourly requirements in order to graduate.
Computers in the RMA Program are only to be used for educational purposes, even during breaks or
down time. All computer stations are monitored by the college. Any student observed “surfing” the
internet, on Facebook or other social networking sites, or checking personal emails will be asked to
leave the class. The student will receive a zero (0) for the day. If it happens a second time, the
student will be withdrawn from the program. Tuition is non-refundable.
I have read and understand the above information.
_______________________________________
Sign _________________
Date
STUDENT HEALTH FORM
Banner ID:
Board of Regents for Higher Education
CMAA
TUNXIS COMMUNITY COLLEGE, Attention: Cheryl Conaty, R.N.
271 Scott Swamp Road • Farmington, Connecticut 06032-3187
CNA
RMA
PHLEBOTOMY
APPLICANT: Please print. Complete this side.
EXAMINING PHYSICIAN: Please print. Complete reverse side ASAP and return to address above.
Name (last, first, middle)
Social Security #
Permanent Home Address (number & street, city or town, state, zip code)
Telephone # (include area code)
Sex
Date of Birth (month, day, year)
APPLICANT
Marital Status
Male
Female
Single
Married
Widowed
Divorced
Name (last, first, middle)
IN CASE OF
EMERGENCY
Relationship
Address (number & street, city or town, state, zip code)
Telephone # (include area code)
Has any family member ever had the following:
FAMILY
HISTORY
CANCER
TUBERCULOSIS
HEART DISEASE
DIABETES
ALLERGY OR ASTHMA
NERVOUS OR MENTAL ILLNESS
Have you ever had:
YES
NO
ITEMS 6-15
1. MEASLES
2. MUMPS
3. CHICKEN POX
4. GERMAN MEASLES
5. WHOOPING COUGH
MIGRAINE HEADACHES
Have you ever had:
·
All “Yes”
answers must
be explained
below.
EPILEPSY OR CONVULSIONS
YES
NO
STROKE
HIGH BLOOD PRESSURE
Have you ever had:
YES
6. RHEUMATIC FEVER
11. CONVULSIONS
7. HEART DISEASE
12. HIGH BLOOD PRESSURE
8. HEART MURMUR
13. ALLERGIES
9. DIABETES
14. FAINTING SPELLS
10. TUBERCULOSIS
15. HEPATITIS
NO
PERSONAL
HISTORY
QUESTION
YES
NO
If “YES,” please explain:
1. Have you ever had any operations and/or
signiﬁcant injuries?
2. Do you have any physical impairment?
(eg., paralysis, loss of hearing, vision)
3. Have you had any emotional problems
requiring treatment?
4. Do you take any medications regularly?
5. Have you reacted unfavorably to any
medication? (eg., penicillin, aspirin)
6. Has your physical activity ever been limited?
SIGNATURE(S)
PERMISSION
TO TREAT
MINOR INJURY
OR ILLNESS
PAGE 1 0F 2
Date
Student’s Signature (if under the age of 18, parent or guardian must also sign)
I hereby grant permission to the medical staff of the college to render or secure proper treatment for my daughter, son or ward (named above).
It is my understanding that I will be notified in case of any illness or injury of major proportion. In addition, I grant permission to the college
physician to hospitalize this student in case of a surgical emergency requiring the administration of anaesthesia provided that the physician is
unable to communicate with me and that, in his/her judgement, delay might endanger the life of the student.
Date
Parent’s or Guardian’s Signature
StudentHealthForm: rev. 1/2014
IMMUNIZATION HISTORY
ALL students are required to provide proof of either immunization or laboratory results of immunity. TITERS chosen for
proof of immunization MUST BE POSITIVE and the LABORATORY REPORT MUST ACCOMPANY THIS FORM.
MEASLES 1st dose:
date/given on or after 1st birthday & after Jan. l, 1969
or Titer ›
Immune?  YES  NO
Laboratory report must be attached to form.
or Titer ›
MEASLES 2nd dose:
date/given after Jan. 1, 1980
THIS SIDE TO BE COMPLETED BY EXAMINING PHYSICIAN ONLY
MUMPS:
date/given on or after 1st birthday
RUBELLA:
or Titer ›
date/given on or after 1st birthday
POLIO:
or Titer ›
date(s) of immunization
VARICELLA (Chicken Pox):
or Titer ›
date(s) of immunization
Td (TETANUS booster):
date/must have been given within the last 10 years
FLU VACCINE (spring and fall applicants only)
HEPATITIS B SERIES:
date/1st dose
date/2nd dose
date/3rd dose
Risk Form
intial
*TUBERCULIN TEST/PPD (Mantoux or QFT-G):
date given
date read
results
* Date no earlier than March 1 of the year of admission to the program. A student with a positive PPD or previous inoculation with BCG must
provide a chest x-ray report with appropriate medical follow-up.
PHYSICAL EXAMINATION
HEIGHT
WEIGHT
VISION (R)
EYES
COMMENTS and RECOMMENDATIONS
(L)
CORRECTION (R)
DRUMS
EARS
NASOPHARYNX
HEARING (R)
SEPTUM
NECK
CHEST
SKELETAL
CARIES
GINGIVITIS
CERVICAL NODES
THYROID
BREASTS
LUNGS
HEART (Rate)
ABDOMEN
(L)
TONSILS
OCCLUSION
TEETH
(L)
(Rhythm)
(Murmurs)
(Blood Pressure)
LIVER
SPLEEN
HERNIA
SPINE
JOINTS
FEET
REFLEXES
CNS
LABORATORY
URINALYSIS
HEMATOCRIT OR HEMOGLOBIN
I believe this student is able to participate in a full academic and clinical program (unless otherwise noted above).
DATE
EXAMINING PHYSICIAN’S SIGNATURE
ADDRESS
TELEPHONE
M.D.
PAGE 2 OF 2
StudentHealthForm(3): rev. 10/14
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. I understand that because I have either waived or not completed the Hepatitis B vaccination series, 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 waived or not completed 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. _________________________________________ Student’s name – please print _________________________________________ ________________ Student’s signature Date rev. 4/29/15

Medical Assistant Program - Tunxis Community College

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