Fall 2021–Spring 2022 Registered Dental Assistant Program
Admission Process
Tarrant County College, Northeast Campus, 828 W Harwood Road Hurst TX 76054 Thank you for your interest in Tarrant County College’s The admission process is listed below.
Part I of the admission requirement is reviewing the admissions packet information packet and attending a mandatory
orientation session. The purpose of orientation is to help determine if this program is for you. In the admissions packet you will find information concerning the program (i.e., curriculum, costs, course information, student expectations, etc.). Enrollment is on a first come first serve basis once all admissions requirements are met for entrance into the program. The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are "eligible students."
Date Times Location:
June 29, 2021 1–3 p.m. MS Teams
June 30, 2021 8–10 a.m., 11 a.m.–1 p.m. MS Teams
July 1, 2021 10 a.m.–noon ,1–3 p.m., 4–6 p.m. MS Teams
July 6, 2021 4–6 p.m. MS Teams
July 7, 2021 8–10 p.m., 1–3 p.m. MS Teams
July 13, 2021 3:30–5:30 p.m. MS Teams
July 14, 2021 1–3 p.m. MS Teams
July 15, 2021 10 a.m.–noon,1–3 p.m., 4–6 p.m. MS Teams
Part II of the admissions requirement is to provide a copy of a high school diploma or GED equivalency and student must
be 18 years of age to attend the clinical portion of the program in the spring semester.
Part III of the admission requirement is to 1) complete the health and immunization requirements and submit a copy to
CastleBranch for the admissions review and 2) provide confirmation of current health insurance coverage and submit to CastleBranch for admissions review. In addition, view the US Dept of Labor Dental Assisting Occupational Outlook Summary information video and complete/submit the Summary Form. Also required is completion confirmation for an American Heart Association CPR Basic Life Support for Healthcare Providers course and certification.
Part IV of the admission requirement is to pass a national background check and drug screen through CastleBranch prior
to admissions and upload all Immunization and Health Record information into your CastleBranch Compliance Tracker account. Background checks ($40) and the Compliance Tracker ($25) will be completed online though Castlebranch Services. Drug-screening ($55) must be completed at Texas Health Breeze Urgent Care, Southlake TX and results will be sent to Castlebranch Services. Note: The background check/drug screen will be repeated 30 days prior to clinical site placement in the spring semester; date/time determined by Program Coordinator.
Student must submit all required forms on the FL 21-SP 22 Admissions Checklist to CastleBranch and Laurie Semple, via email or in person (NHSC 1136A -office) by August 13, 2021. For additional information, please contact NE Health
Services at 817.515.6435 or [email protected]
***For career advising questions, please contact Stacy Liebel CTE Student Support Specialist, at 817-515-6178 or [email protected]***
Revised 06/29/21
Registered Dental Assistant Program • Fall 2021–Spring 2022 • TCC Northeast
• Course Dates: Fall: August 23–December 16, 2021; Spring: January 18–March 25, 2022 • Clinical Dates: March 28–May 6, 2022• Course Schedule: Monday–Thursday; Times Arranged between 8 a.m.–6 p.m. • Clinical Days/Times: TBD by Assigned Clinical Site
Admission Requirements:
• Attend Orientation Session
• Pass Background Check and Drug Screen Test (Admissions and Clinical Placement) • Copy of high school diploma or GED equivalency
• Complete Health Record and Immunization Requirements
• Complete CPR certification for American Heart Association/Basic Life Support for Healthcare Providers • Complete US Dept of Labor Statistics Occupational Outlook Summary Form
• Provide confirmation of current health insurance
Salary Expectations:
The salary of a dental assistant varies depending upon the responsibilities associated with the specific position and the geographic location of employment. The median wage of a dental assistant in Texas is currently $19.08 per hour; national median wage is $19.80 per hour (U.S. Bureau of Labor Statistics/2020). There is evidence that dental assistants who have completed a formal training program or employed in states that require certification or registration receive higher salaries.
Required Courses for Level 1 Certificate of Completion:
Fall Courses /13 SCH-$832 Section Semester Hours Contact Hours Fee $64/SCH
Dental Science DNTA-1311 3 64 $192
Comm & Beh in the Dental Office DNTA-1202 2 48 $128
Preventive Dentistry DNTA-1245 2 48 $128
Chairside Assisting DNTA-1315 3 64 $192
Dental Radiology DNTA-1005 3 80 $192
Spring Courses/12 SCH-$768 Section Semester Hours Contact Hours Fee $64/SCH
Dental Materials DNTA-1301 3 80 $192
Dental Assisting Applications DNTA-1353 3 80 $192
Dental Office Management DNTA-1251 2 32 $128
RDA Course & Exam DNTA-1103 1 16 $64
Clinicals DNTA-1360 3 224 $192
Estimated Program Costs: $2495.00: Tuition - $1600; Additional Program Costs - $895.00
• Books: Approximately $300 (TCC Bookstore Bundle Package Available – see Required Textbook List) • Background Check: $40 x 2 (Admissions and Clinical Placement – CastleBranch)
• Drug Screen: $55 x 2 (Admissions and Clinical Placement-CastleBranch) • Compliance Tracker: $25 -CastleBranch
• CPR/American Heart Association/Basic Life Support for Healthcare Providers: $40 (TCC) • Health Screen & Immunizations: Determined by individual coverage
• Health Insurance: Determined by individual coverage
• Scrubs, T-shirts, Lab Jacket, Name Tag, Shoes, Socks, Watch: Approx. $250 • American Dental Assistants Association Student Membership (SADAA): $45 • OSHA/HIPPA Training: $45
Optional Non-Credit Certification Courses/Exams (Strongly Recommend to Complete Spring Semester) - $620.00
Tarrant County College - Registered Dental Assistant Program Admission Requirements Checklist – Fall 2021
Student Name: ____________________________________Student ID#:__________________ o Received Admissions Packet
o Attend Virtual Orientation (Date: ___/___/___)
o These 3 original forms must be completed/submitted to L. Semple to start admissions process:
Student Information Form
Background and Drug Screen Requirement Form Waiver of Liability Form
o Provide copy of high school diploma or GED equivalency (Submit to L. Semple)
o Purchase CastleBranch packages: TW58 (Background Check/Drug Screen /
Compliance Tracker)
o Complete / upload Immunization & Health Record Form (CastleBranch) o Complete / upload copy of all required information/immunizations
(CastleBranch)
Tetanus / Diphtheria / Pertussis MMR
Varicella
Complete hepatitis B series or Titer results confirming immunity Current (within 1 year) negative Tuberculosis Screening
Written verification of annual Influenza Vaccine on required form (CastleBranch) – Waived for FL 21 admissions—Due by 10/1/21
o Confirm Completed CastleBranch Compliance Tracker
o Copy of Current Health Insurance Card (Upload to CastleBranch)
o Copy of current Basic Life Support for Healthcare Providers CPR Card
(CastleBranch) Waived for Fall 21 admissions / Due between 9/1/21–12/1/21
o Student to review / complete U.S. Dept of Labor Dental Assisting Occupational Outlook Summary information / video and Summary Form (Submit to L. Semple)
o Complete CastleBranch Background Check
o Passed CastleBranch Background Check
o Complete CastleBranch Drug Screen (Texas Health Breeze Urgent Care)
o Passed CastleBranch Drug Screen
o Sent / Received Completed Admissions Paperwork Confirmation Email o Sent / Received Acceptance Letter and Course Registration Information o Confirm Registration / Payment for all 5 Fall 2021 courses
o Student Accessibility Resource accommodations if applicable Clinical Site Placement Requirement
Not required for program admissions – Due Spring 2022
o Repeat / Pass CastleBranch (TW58re) Drug Screening (Texas Health Breeze
Urgent Care) and Background Check– Date TBD by Program Coordinator
o Program Coordinator: LaurieSemple – [email protected], 817-515-6151 (office)
Tarrant
County College
tccd.castlebranch.com/
TT97
Texas Health Breeze Urgent Care
Registered Dental
Assistant Program
Drug Screen
DATE
June 29 – August 06, 2021
TIME
8:00 a.m. - 8:00 p.m.
LOCATION
125 Davis Blvd
Southlake, TX 76092
Let us know when you're on your way or
simply walk-in.
Texas Health Breeze Urgent Care stands
ready to care for you.
Quick Information
breezeurgentcare.texashealth.org 682-212-9104
TARRANT COUNTY COLLEGE
Registered Dental Assistant Program
Student Information Form
PLEASE RETURN TO: Laurie Semple, CDA, RDA CDPMA, M.Ed. [email protected]
Health Sciences Bldg., NHSC 1136A
Name of Program: Registered Dental Assistant
Semester Fall Year 2021
Name_______________________________________ Date_________________ TCC Student ID ______________________________________________________
Phone number _______________________________________________________
Street Address _______________________________________________________
Tarrant County College
Registered Dental Assistant Program
Background & Drug Screen Requirement
Please initial each statement and sign at the bottom:
_________ Student must pass a background check through CastleBranch as a
requirement for admission into the Registered Dental Assistant Program. Please be
advised that a criminal background could prevent registration as a dental assistant by
the Texas State Board of Dental Examiners (TSBDE). Flagged background checks will
require the student to request a criminal history evaluation letter from the TSBDE, which
will determine your eligibility for program admission and clinical placement. Questions
about your background and state registration should be directed to Laurie Semple,
Program Coordinator.
________ Student must pass a drug screen as a requirement for admission into the
Registered Dental Assistant Program. The student must go to Texas Health Breeze
Urgent Care, Southlake TX for the drug screen and results will be sent to CastleBranch
for review. Failure to pass the required drug screen will disqualify the student to
continue in the admissions process.
________ Student must retake/pass a background check (CastleBranch) and drug
screen (Texas Health Breeze Urgent Care/Southlake TX) 30 days prior to starting the
assigned clinical site during the designated one-week time frame. This is the only time
the student may retake the background check and drug screen; date to be determined
by Program Coordinator.
_______ Student is aware that they must pass the retake background check/drug
screen to be placed in a clinical site. If the student doesn’t pass the background check
and/or drug screen the student will not be able to continue in the program or complete
and graduate from the Fall 2021-Spring 2022 Registered Dental Assistant Program.
________ If the student doesn’t pass the background check/drug screen they will not
receive a refund for any course which they have completed or partially completed within
the Registered Dental Assistant Program.
Student Name (Print): __________________________________________
Student Signature: _____________________________________________
Date: ________________________________________________________
Department of Safety & Emergency Management Division of Risk & Insurance Management
7.23.2020
RESPONSIBILITIES OF THE STUDENT / PARTICIPANT IN
ACTIVITY OR EVENT
1. Completion of Waiver Form
√Student / Participant agrees to read and complete the attached Release and Waiver of Liability Assumption of Risk and Indemnity Agreement (the “Waiver”), maintain a copy for his or her records and return it to the sponsoring faculty/staff prior to the activity set forth in the Waiver.
2. Transportation agreement
√Student / Participant understands that they have waived any claims against the Tarrant County College District (the “District”) in the event of accident, injury or death as a result of travel to or from the activity/event.
√Student / Participant agrees to meet the s pons or ing f acu lt y/ st af f at designated times and locations for the activity/event. Failure to do so may result in the group's departure without the Student / Participant.
√Student / Participant agrees to notify the s p o ns or in g f aculty/ st af f prior to the activity/event
if unable to attend.
√If a Student / Participant utilizes private transportation to attend an activity/event, that activity/event is deemed to commence upon arrival at the activity/event.
3. Obtaining permission to leave
√Student / Participant agrees to obtain permission from the s po n s o r i n g f a c ul t y/ s t af f in order to leave the activity/event or to embark on a personal side trip that is not activity related.
4. Unauthorized participants, visitors or guests
√Student / Participant is not permitted to invite unauthorized participants, visitors or guests to this activity/event.
5. Student conduct
√Student / Participant agrees to follow the directions/instructions of the sp ons or in g f acu lt y/s t af f while attending the activity/event. Failure to do so may result in the Student/Participant being required to leave the activity/event at his or her own cost.
√Student / Participant agrees to comply with the District’s Student Handbook while attending this activity/event. Disciplinary action may be taken against any student who engages in behavior defined as misconduct.
√Student / Participant agrees not to possess or consume alcoholic beverages or
illegal substances during this activity (even if age 21 or over) or carry firearms to or during this activity (even if the Student / Participant holds a valid permit to do so).
6. Personal possessions
√Student / Participant agrees to be responsible for any personal items brought on or to the activity/event (it is not recommended to bring "valuables").
7. Notification of Adviser regarding problems
The Department of Safety and Emergency Management The Division of Risk and Insurance Management
Informed Consent and Assumption of Risk Form
This form needs to be signed by all participants, students, guests, and other non-employees participating in act i vi t i es o r even t s . Students/ Participants under the age of 18 are required to obtain a signature from a parent or legal guardian.
(INSERT NAME OF ACTIVITY OR EVENT)
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
I, ("Participant"), hereby acknowledge that I have voluntarily elected to participate in the following activity or event __________
(the "Activity"), to be held in and around the following location
,on _________.
In consideration for being permitted by Tarrant County College District (the "DISTRICT") to participate in the Activity, I hereby acknowledge and agree to the following:
RULES AND REQUIREMENTS: I agree to conduct myself in accordance with DISTRICT policies
and procedures. I further agree to abide by all the rules and requirements of the Activity. I acknowledge that DISTRICT has the right to terminate my participation in the Activity if it is determined that my conduct is detrimental to the best interests of the group, my conduct violates any rule of the Activity, or for any other reason in the DISTRICT's discretion. Failing to follow rules of the Activity, staff directors, or the Student Handbook may result in disciplinary action. If I am told to leave the Activity as a result of my failure to follow the rules and requirements of the Activity or the directions of the staff directors, transportation from the Activity will be at my expense.
INFORMED CONSENT: I have been informed of and I understand the various aspects of the
Activity, including the dangers, hazards, and risks inherent in the Activity, including but not limited to transportation to and from the Activity and/or the DISTRICT via private vehicle and/or common carrier, participation in the Activity, overnight accommodations, weather conditions, conditions of equipment, facility conditions, negligent first aid operations or procedures, and in any independent research or activities I undertake as an adjunct to the Activity. I understand that as a participant in the Activity I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only DISTRICT's actions or inactions, but also the actions, inactions,
negligence or fault of others and despite safe precautions, DISTRICT cannot guarantee safety thereof and all risks cannot be prevented.
RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives,
heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE,DISCHARGE, AND COVENANT NOT TO SUE DISTRICT, its governing board, directors, officers, employees,
Registered Dental Assistant Program
March 28-May 6, 2022 TBD by Program Coordinator
March 28-May 6, 2022
The Department of Safety and Emergency Management The Division of Risk and Insurance Management
faculty, agents, volunteers and any participants or students (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Activity, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON,UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY,OCCURS OR IS BEING CONDUCTED. I
further agree that the Releasees are not in any way responsible for any injury or damage that Isustain as a result of my own negligent acts.
ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation
in the Activity, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage, or even death. I understand that there are potential risks as a consequence of, but not limited to: participation in this Activity, travel to and from DISTRICT via private vehicle or common carrier, weather conditions, overnight accommodations, facility conditions, equipment conditions, first aid operations or procedures of Releasees, and other risks that are unknown at this time. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OR OMISSIONS OF THE RELEASEES and
assume full responsibility for my participation in the Activity.
INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators,
agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all cost, expense or liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage, or death that I may suffer as a result of my participation in the Activity.
FERPA: I consent to the release of my records that are protected by the requirements of the federal Family Educational Rights and Privacy Act (20 U.S.C. Sec. 1232g, 34 CFR Par.99), but only in conjunction with the Activity, and I release the Releasees from any and all damage and liability, including any and all claims, demands, causes of action (known or unknown), suits or judgments of any and every kind (including attorney’s fees) arising from any damage, cost or expense I may suffer or incur as a result of the release of such records.
PERSONAL MEDICAL INSURANCE: I further acknowledge that I am responsible for the cost of any
and all medical and health services I may require as a result of participating in the Activity.
CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I am physically and mentally fit to
participate in the Activity and that I do not have any medical record of history that could be aggravated by my participation in this particular Activity. If I require any reasonable
accommodation(s) in order to participate in the Activity, I have notified the sponsor in writing of the nature of the accommodation(s) needed prior to the Activity.
MEDICAL CONSENT: I understand and agree DISTRICT is not responsible for my health and
safety. Recognizing this, however, I wish to, and hereby do, grant DISTRICT full authority to take, or not to take, in its sole discretion, whatever actions it may consider warranted under the
circumstances for my health and safety during my participation in the foregoing event, and I hereby release it from any liability for any such decisions or actions as may be taken in connection therewith. The authority granted in the preceding sentence shall include the right (in the sole discretion of DISTRICT) to place me, at my own expense, and without any further consent, in a hospital, for medical services and treatment, or if no hospital is readily accessible, to place me in the hands of a local medical doctor for treatment. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.
CHOICE OF LAW: I hereby agree that this Agreement shall be construed in accordance with the
laws of the State of Texas.
The Department of Safety and Emergency Management The Division of Risk and Insurance Management
conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby.
I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND IHAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT IAM AT LEAST EIGHTEEN YEARS OF AGE OR, IF NOT, THAT IHAVE SECURED BELOW THE
SIGNATURE OF MY PARENT OR GUARDIAN AS WELL AS MY OWN.
Name of Participant Student ID Number
Signature of Participant Date
Signature of Parent/Guardian for Participants under eighteen (18) years of age:
I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with Participant in
granting a release to Releasees as set forth in detail above.
Signature of Parent or Guardian Date
EMERGENCY CONTACT:
Name: Relationship: Phone Number:
*Please include all three (3) pages of this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
TCC Health Form - NE RDA 6.21.wpd
Make a COPY for Your Records
NE Health Sciences Tarrant County College - Northeast CampusHealth Sciences - Registered Dental Assistant Program
Immunization and Health Record
COMPLETED FORMS are DUE prior to acceptance into the Registered Dental
Assistant Program.
Forms which are incomplete or not submitted will delay the admissions
process.
Part I
- To be completed by Student Please Print All InformationHealth Science Program in which you are enrolled: Name: Age: Sex: (Last) (First) (Middle)
Address: City: State: Zip: Phone:
Part II
- To be completed by Healthcare ProviderTo the Medical Practitioner:
Students enrolled in health related programs are required by the Texas Administrative Code* to have specific immunizations or show proof of immunity before beginning clinical semesters. This is a TEXAS LAW and cannot be
waived by the student or medical practitioner. In addition, the DFW Hospital Council also places requirements on
students to assure the safety of both the student and the patients they encounter. The following table outlines the requirements for immunization that must be competed in their entirety in order for the student to enter health science programs.
*Vaccine requirements applicable to institutions of higher education, incorporated in Title 25, Health Services Chapter 97, '97.61-'97.77 of the Texas Administrative Code.
GENERAL HEALTH STATUS (Please note physical assessment below)
An essential component of this physical exam is to determine that this student is medically capable of pursuing the academic and clinical activities for their selected field (noted above).
Description of health status (including health problems):
Does this student have any emotional or psychological limitations that would restrict participation in the Dental Professions?
No
Yes, if AYes@ please explain restrictions:Does this student have any physical limitations that would restrict participation in the Dental Professions?
No
Yes, if AYes@ please explain restrictions:
TUBERCULOSIS SCREENING
Test must be administered within the year preceding the start of the program and repeated annually while enrolled.
SKIN TEST:
Intradermal (Mantoux) QFT (IGRA blood test)
TEST RESULTS:
Date of TEST: Date READ: READ by:
CHEST X-RAY RESULTS (if applicable):
Negative
Positive (if positive chest x-ray, has treatment been COMPLETED? Yes No
Required treatment must be complete to participate in Health Science programs.
Negative
TCC Health Form - NE RDA 6.21.wpd
Make a COPY for Your Records
NE Health SciencesContinued on back . . .
To be Completed by Healthcare Provider
ONLY
REQUIRED IMMUNIZATIONS - If the student will require an immunization containing a live virus, please perform the
TB test first and give the immunization when the student returns to have the TB test read.
Under State law, ALL IMMUNIZATIONS/TITERS must recorded ON THIS FORM and
completed prior to acceptance into the program and the first day of class. There are NO
grace periods or EXTENSIONS permitted. Copies of immunizations or shot records will not
be accepted.
Date of
1st dose 2Date of nd Dose 3Date of rd Dose Titer Date Not Immune Immune /
TETANUS / DIPHTHERIA / PERTUSSIS**
One dose as adult within the past ten years.
If previously given TD within last ten years, must have TDaP booster.
MMR
Two doses administered since January 1, 1957, at least 28 days apart.
MEASLES (RUBEOLA)*H
MUMPS *H
RUBELLAH
VARICELLAH
One dose before age 13; or receipt of 2 doses (administered at least 28 days apart) after age 13 years; or serologic evidence
of immunity. Previous disease no longer considered proof of immunity.
HEPATITIS B
Students must receive a complete series (3 injections: initial, at one month, and at six months) of hepatitis B vaccine prior to the start of the semester that incorporates direct patient care;
or show serologic confirmation of immunity to hepatitis B virus. Accelerated schedules are not acceptable.
SEASONAL INFLUENZA IMMUNIZATION
Required annually during flu season usually from August through April. The DFW Hospital Council requires this information be documented on a separate form.
MCV4 VACCINATION
All enrolling college students must show evidence of immunization against meningococcal meningitis (as required under Senate bill 1107 of the 82nd Texas Legislature).
Proof of meningococcal meningitis immunization is collected and monitored by the College Registrar and should not be
documented on this form. Contact the College Registrar for additional information and verification forms.
* Persons born before January 1, 1957 are considered naturally immune and vaccination is not necessary for measles (rubeola), mumps, or rubella.
H Should not be received during pregnancy.
I Exclusions for medical or religious conflict must be presented in the form of a written affidavit obtained from the State.
** Required by DFW Hospital Council in addition to State law.
If exempt, state Date of Birth
HEALTH CARE PROVIDER (Physician, Physician Assistant, and/or Nurse Practitioner only signature accepted)
NAME: ADDRESS:
PHONE:
The information on this form is accurate and correct.
Signature of Date Health Care Provider
TCC Northeast Health Sciences
Registered Dental Assistant Program
Validation of Seasonal Influenza Immunization
This requirement waived for Fall 2021 admissions
Due between September 1–December 1, 2021
Tarrant County College requires seasonal influenza vaccination as a patient safety initiative as per hospital/clinical setting requirements for clinical rotations. You must have this form completed where you received your vaccine. Upload to your CastleBranch Compliance Tracker by the specified due date.
Name Print: _____________________________ ID #: _________________________ Signature: _____________________________ Date: _________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Provider Information
Flu Vaccine Brand Name: ______________________Lot #: _____________________ Manufacturer: ________________________Expiration Date: ____________________ ProviderName/Location: