PROGRAM
APPENDICES
Medical Assistant Program Information
The Medical Assistant Program is a ten month (1080 hours), full-time day program, beginning each fall semester. The program educates qualified individuals to assist the physician in the care of patients within the medical assisting scope of practice. Students are required to attend classroom hours Monday through Friday from 7:40 a.m. until 2:10 p.m. Each of the two semesters encompasses theory, administrative, computer applications (Medisoft, Electronic Health Record, Microsoft Office Works), laboratory, and career development. At the end of the spring semester students participate in an externship rotation. Externship hours are assigned according to affiliating offices, clinics or walk-in/urgent care centers.
Mission Statement
The mission statement of the Connecticut Technical High School System is to provide a unique and rigorous post-secondary learning environment that: ensures both student academic success, and career technical education (CTE) mastery and instills a zest for lifelong learning; prepares students for career advancement, apprenticeships, and immediate productive employment; responds to employers’ and industries’ current and emerging and changing global workforce needs and expectations through business/school partnerships.
Transfer Policy
The post-secondary Medical Assistant Program at Platt Technical High School is the only adult education program at the institution and within the system. Students from other institutions will be responsible for commencing the program from the start with no transfer of coursework or credits.
A. WELCOME
Welcome to a year of growth in Medical Assistant clinical/administrative skills and knowledge. Our faculty is committed to providing fundamental medical/clinical/administrative knowledge along with hands-on competency skills which will enable the medical assistant student to become a proficient, responsible professional member of the medical team.
B. HISTORY
The Adult Medical Assistant Program offered at Platt Technical School is the first in the Vocational Technical School System. The first class began in September 1986.
C. PURPOSE
The Medical Assistant Program educates qualified individuals enabling them to assist the healthcare provider in the care of patients within the scope and limitations of practice, as recommended by the American Medical Technologists. The qualified Medical Assistant has the unique position of being a liaison between the healthcare provider and the patient, as well as with other health care professionals. D. PHILOSOPHY
The Medical Assistant Program is committed to the mission of vocational education which meets the needs of ourever-evolving technological society. A Medical Assistant must be educated to meet the various demands within the health care community in order to provide quality patient care.
The Medical Assistant endeavors to become proficient in both the clinical and administrative components of the profession as well as becoming responsive to the emotional and psychological needs of the patient.
Tuition is charged for all Adult Day Programs. The first semester tuition is due on or before the opening day of school. Tuition for the second semester must be paid by the first day of the spring semester, which is after winter breakin January.
F. OBJECTIVES
Upon completion of this program, the Medical Assistant will be able to:
communicate effectively with patients, families and team members; perform all clinical and administrative techniques in a competent manner; seek employment in a variety of medical settings;
perform all assigned responsibilities competently;
understand the ethical, legal, and professional principles of the vocation; and engage in life-long learning activities.
G. CONTACT INFORMATION Platt Technical High School 600 Orange Avenue
Milford, CT 06461
Attn: Mrs. Karen Canty RN
Medical Assistant Department
H. ADMISSION REQUIREMENTS
1. Official high school transcript or copy of GED. Proof must be submitted. 2. Successful personal interview.
3. Short essay at time of interview.
4. Good health, as evidenced by a physical examination, including immunization requirements. Students will not be permitted to attend externship if all health requirements are not completed and up-to-date.
5. Complete Medical Assistant Program application for admission. Send to Platt Technical School 600 Orange Ave. Milford, CT, 06460, Attn: Medical Assistant Program.
6. Basic computer skills.
7. A non-refundable application fee of $50 in cash, certified bank check or money order (payable to Treasurer, State of CT) will need to be submitted upon acceptance. 8. Background check will be required of each student. Cost is paid by the student. More
details will be given during the interview. I. COURSE TITLES/PROGRAM CONTENT
1. Administrative Medical Office Procedures 2. Anatomy and Physiology
3. Applied Communications including Career Development 4. Clinical Procedures of Medical Assisting
5. Computer Applications (Electronic Health Record, Medisoft, Microsoft Office Works)
6. Medical Law and Ethics 7. Medical Terminology 8. Pharmacology
9. Therapeutic Communications
10. CPR Certification (through the American Heart Association)and First Aid Certification (through the National Safety Council) will be completed during the spring semester
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11. Externship 160 hours
12. Medical Assistant Review to prepare for National Certification Exam.
J. ATTENDANCE
*Regular attendance is essential. If you must be absent or tardy, notify the Dept. Head, by 7:50 a.m. by calling (203) 783-5331.
*Clinical Days—Notify externship of absence or tardiness prior to starting time, in addition to calling Dept. Head at Platt.
*Clinical absences must be made up by the student on her/his own time. *All early dismissals must be approved by Department Head.
*Absenteeism, which jeopardizes the student's standing in the program, will be evaluated by faculty and administration.
Excused absences require documentation upon the first day of return to school. Excused absences are: medical reasons which are verified by ahealth care provider (M.D. P.A. or A.P.R.N.); death in the immediate family, as verified by an obituary/death notice;
court appearances verified by official notification; and, religious holidays.
*Tardiness is defined as entering class after attendance has been taken.
*Students shall inform the Department Head of pregnancy so that medical clearance for externship activity may be procured (i.e., x-ray exposure).
*The student should not be absent more than five days per semester. Credit denial will occur after the tenth unexcused absence. Appeal may be made to the Educational Consultant for the program. *It is not the school’s policy to have students arrive tardy or leave before the end of the school day. If
you need to leave early you must get permission from the department head and sign an early dismissal form.
** Attendance is utilized for inquiries for potential employers.
**Any change made to your clinical schedule by the facility must be communicated to the Department Head as soon as possible (Staff training, office closing early healthcare provider is away).
** While on externship you must submit a clinical time sheet with your arrival time and departure time. This must be signed by the office manager or your supervising M.A. and submitted weekly to the Department Head.
K. CERTIFICATION EXAM
At the conclusion of the program the students will be awarded a certificate of completion at graduation. Subsequently, they will be eligible to apply to the American Medical Technologists to take a national certification examination. The students are responsible for the cost of the optional exam.
L. CLASS SCHEDULE/PROGRAM LENGTH
1. This is a full-time day program lasting one school year. Classes meet Monday through Friday from 7:40 a.m. to 2:10 p.m.
2. Clinical Days: Hours will differ from those of the normal school day. Hours will be agreed upon according to the facility.
3. Closings: School closings and delays will be announced over local radio and TV stations. We follow Milford Public Schools decisions for snow cancellations, delays, and early dismissals. M. EMERGENCIES
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If a student must be contacted for any emergency, please call the school at (203) 783-5331. Cell phones will not be allowed to disrupt the educational process. The cell phone policy will be discussed in more detail during orientation. Policy must be followed or it may be grounds for termination from the program.
N. EXPENSES (STUDENT)
1. Tuition—To be determined by State Department of Education.
2. Textbooks—Student is required to purchase textbooks on her/his own. 3. Uniforms—See dress code.
4. Computer access—Students should have access to a functioning computer and printer outside of school.
5. Transportation—Student is responsible for own transportation throughout the program. 6. Background check cost is paid by the student.
7. CPR certification will be completed during the spring semester. Student is responsible for cost.
8. Graduation pin.
9. Supplies—See welcome letter.
O. GRADING/METHOD OF EVALUATING STUDENTS
1. To be eligible for graduation, the student must attain a passing grade of 70% in each course. 2. Any student in danger of failing a course will be placed on probation.
3. Failure to achieve satisfactory grades may result in termination. If a student has cheated to obtain a grade, the grade will be entered as a zero. Cheating or plagiarism may be grounds for termination from the program.
4. Grading System: A = 90 - 100 B = 80 - 89 C = 70 - 79 D = 60 - 69 F = Below 60
5. Students must be passing with a 70% in each course, including demonstrating competency in clinical skills before participating in externship. If a student is not passing with a 70% in each course this may be grounds for dismissal.
6. A 160 hour externship and competent performance must be completed prior to graduation. Failure in the externship rotation will result in termination from the program.
7. Practical exams and oral/written reports will be graded. These are equal to one test grade each. Standard medical assisting skills must be passed to competency before advancing to externship.
8. A year-end final transcript will be issued. The final transcript will be kept on file at the school.
9. Student must exhibit appropriate professional behaviors in both classroom and clinical settings, as defined in the Adult Post-Graduate student handbook.
10. Warnings: If a student is in jeopardy of failing in either academic grades or clinical grades, a warning will be issued. The instructor and student will conference to establish a plan with a timeline. A signed copy of the warning will be placed in the student’s file. Continued academic or clinical failure may result in termination from the program. The appeal may include a record of the warnings.
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Also, with regard to progressive discipline, students are responsible for monitoring their own behavior in class and externship settings. If a student’s behavior is inappropriate or unacceptable, a progressive discipline plan will be initiated. The instructor will arrange a meeting with the student to discuss what specific behaviors are inappropriate or unacceptable and a plan will be established. A signed copy of the progressive discipline form will be placed in the student’s file. Continued failure to meet behavioral objectives may result in termination from the program.
P. GRADUATION
1. Graduation exercises will be held upon completion of the program.
2. A certificate of completion will be awarded to graduates by the school principal or his/her designee.
3. Graduation pins will be ordered near the end of the school year. They will be paid for by the student.
Q. REFERENCE BOOKS
There are books and periodicals in the Medical Assistant Department for your use. Reference books and magazines may be taken out. Books must be signed out. Additional resources are available in the school media center.
R. LOCKERS
Each student will be assigned a locker. Lockers are located in the hall adjacent to the Medical Assisting Program. Each is equipped with a combination lock. The school reserves the right to inspect lockers for health, discipline and safety reasons and to deny use of lockers to students who abuse the privilege.
S. SMOKING, ALCOHOL AND DRUGS
Smoking is not permitted in any area of school property during school hours. The use of alcohol or drugs is subject to discipline, it will not be tolerated and any incident relative to their use will be reported to the police.
T. ON-SITE FACILITIES
The lunch period is twenty (25) minutes—scheduled times will be announced.
All students will leave the classroom during lunchtime. A cafeteria is located on-site for student use. A Library Media Center is open during day time hours and there is a school nurse on the premises.
U. PARKING
Persons operating vehicles on school grounds and using the parking facilities must observe the following regulations (see student handbook):
1. Students are required to register their vehicle(s) and receive a parking permit. (no charge for one car). 2. Parking permits should be affixed to the car in such a way as to be visible from the front of the vehicle
and not in violation of the Department of Motor Vehicles (DMV) regulations (see student handbook). 3. Student parking is restricted to the student parking area. Only one space per vehicle is permitted.
4. Students will observe the school speed limit and the rules of courtesy and DMV laws while operating a motor vehicle.
5. DO NOT PARK IN THE FIRE LANEwhich is the first row of parking spaces in the student parking area.
V. MAKE-UP WORK
1. It is the student's sole responsibility to complete all work and assignments missed because of absence or tardiness.
2. Upon return to school, the student must contact the appropriate faculty member and a fellow student to elicit material covered during absence. Any work assigned prior to absence is due upon return.
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3. Any student who is absent at the scheduled test time will be expected to complete the test on the first day of return to school if no new information was given while the student was absent. An extra day will be given if a medical note is provided.
4. It is the student’s responsibility to arrange time for make-up work on the first day upon return to school.
5. Any previously assigned tests are to be made up after school or during lunch on the day of return to class, unless special arrangements are made.
6. If the test is not taken on the designated date, a meeting between the student and faculty will be held. Make-up tests and quizzes will be subject to a five point penalty per day. Failure to make up work within an allotted time will receive a zero for that test, lab or assignment.
W. TUTORIAL ASSISTANCE
1. Tutorial assistance is available in all courses.
2. Laboratory check-off after school hours will be done by appointment.
3. Laboratory and computer areas are available after school hours for student use. Faculty guidance is available.
X. MEDICAL ASSISTANT PROGRAM DRESS CODE
UNIFORMS: A professional dress code is followed each day during class time and externship. APPAREL: SAME FOR BOTH GENDERS
1. Professional uniform. No sweat pants style.
2. Top: short sleeve scrub tops only, any print or color. A plain long or short T-Shirt underneath your scrub top is acceptable.
3. No hats or hooded sweatshirts will be allowed to be worn.
4. Sweater: button down style either white, beige, navy blue, or black. Lab jacket is an option.
SHOES:
1. White nursing shoes. ALL WHITE or all black sneakers are acceptable. 2. Shoe polish--shoes and laces must be clean at all times.
STOCKINGS/SOCKS: Whiteor black. JEWELRY:
1. Watch with a second hand. 2. Simple, short necklaces.
3. Small, unobtrusive post-type pierced earrings. No hoop earrings.
4. Rings can be worn that do not interfere with patient care or maintaining medical asepsis. MAKE-UP:
1. In moderation.
NAILS:
1. Short, trimmed and neat.
2. Nail polish should be a natural color. NAME PIN:
1. Worn on side of uniform. Pin may state first name only or first and last name. Pin must indicate that you are a medical assisting student. Information on pins is included in the welcome letter mailed to you. This will be discussed during orientation.
HAIR:
1.Clean, neat and off the face.
2. Long hair, tied back and off the collar whenever student is involved with a clinical skill or
in the clinical area or you will not be allowed to participate. Y. POLICY ON DISCIPLINE
Policy follows the Full-Time Adult Student Handbook.
Z. COLLEGE CREDIT – see department head for details. This will be discussed at orientation.
All dismissals from this program are subject to an appeal process. All appeals must be made in writing to Central Office through the subject area consultant. Appeals will be referred to the Assistant Superintendent for Adult Education.
MEDICAL ASSISTANT PROGRAM
I have read and understand the attendance policy and recognize the consequences for failing to comply with it.
Print Name________________________________Signature_____________________________Date_______
NOTE:
The forms in this section must be completed and
returned to the Department Head or Instructor.
CONNECTICUT TECHNICAL HIGH SCHOOL SYSTEM
FULL-TIME ADULT STUDENT INFORMATION/FINANCIAL OBLIGATION
Program Resident/
Non-Resident
Tuition Registration Fees
(nonrefundable)
Payment Due Dates
New August 2015
Class Licensed Practical Nurse
In-State Resident Total of $11,550
payable over three semesters ($3,850 per semester)
$50.00 Per program
Based on selected payment plan
New August 2015
Class Licensed Practical Nurse
Non-State Resident Total of $23,772
payable over three semesters ($7,924 per semester)
$50.00 per program
Based on selected payment plan
Returning Aviation Resident Total of $6,576
payable over two years ($2,192 per installment) $50.00 per program August 2015 February 2016 New Aviation (December 2015) Resident Total of $6,576
payable over two years ($2,192 per installment) $50.00 Per program December 2015 **March 2016 **3rd Installment 2016-2017
Certified Nurse Assistant Not applicable $1,400
Per ten-week cohort
$50.00 per academic year
Date of first scheduled class
Dental Assistant Not applicable $3,710 payable over
two semesters ($1,855 per semester)
$50.00 per academic year
Date of first scheduled class Medical Assistant and Surgical Technology Not applicable $3,710 payable over two semesters ($1,855 per semester) $50.00 per academic year
Date of first scheduled class
Bristol T.E.C. Programs
Automotive Technology; Culinary Arts; Electronics Technology; Heating, Ventilation and Air Conditioning; Manufacturing
Technology; Welding and Metal Fabrication; HVAC/R (2years)
Not applicable $3,710 payable over
two semesters ($1,855 per semester) $7,420 payable over four semesters ($1,855 per semester) $50.00 per academic year
$50.00
Date of first scheduled class
Date of first scheduled class each
semester
Tuition and Fees:
The tuition and fee schedule for 2015-2016 academic year as approved by the Connecticut State Board of Education are as follows:
Acceptable Methods of Payment:
Bank check or money order made payable to Treasurer, State of Connecticut for the exact amount due;
Cash will be accepted in the school business office only during regular business hours (8:30 a.m. to 4:30 p.m.).
Unacceptable Methods of Payment:
Personal checks;
Debit and credit cards;
Cash (except during normal business hours).
Other Financing Options (it is the responsibility of the student to initiate and follow-up on the methods listed below):
The CTHSS offers financing options including:
Tuition Waivers are available for veterans, students age 62 and over (subject to seat availability), and ONLY to students enrolled in the Certified Nurse Assistant program that are experiencing financial hardship;
Financial Aid: Students enrolled in a full-time program may apply for a federal Pell grant;
Outside Agencies: Funding from other state agencies (i.e. Dept. of Labor, Office of the State Comptroller);
G. I. Bill Veteran Education Benefits
** Any student failing to pay or be approved for an alternative financing option by the payment due date will be immediately dismissed from their program of study. As regular attendance is a critical aspect of the educational process, students with attendance problems may be dismissed from the program. **
Applying for a Tuition Waiver:
Eligible students wishing to apply for a tuition waiver must complete a Tuition Waiver Request form (available at http://www.cttech.org/AdultED/index.htm) no later than four weeks prior to the first class session.
Veterans requesting a tuition waiver must attach a copy of their Certificate of Release or Discharge (DD Form 214) (90 days of honorable active duty service in addition to that spent in active duty training and in attendance at military service academies for any war period after August 2, 1990 or engaged in combat or in combat support role in specific conflicts prior to August 2, 1990);
Senior Citizens: Students age 62 and over requesting a waiver must attach a copy of their proof of age;
Students receiving educational assistance benefits under the G. I. Bill from the Veterans Administration must submit enrollment verification or training agreement. The student
should provide the school Certification Officer, VA Form 22-1999 for submission to the Veterans Administration to receive the education benefits payment from VA;
If a student is denied tuition waiver, all tuition and fees are due by the next class session.
Applying for a Pell Grant:
Admitted students must complete the Free Application for Federal Student Aid (FAFSA). It is recommended that the student completes the FAFSA after completion and submission of the 2014 IRS Tax Return in order to avoid delay and having to go back to change information or making corrections. The completion and submission of 2014 IRS tax return will allow the student and/or parent(s) to use the IRS data retrieval tool when prompted during the FAFSA completion and will provide accurate financial information and therefore expedite the award process.
Admitted students must submit a valid Student Aid Report (SAR) and complete a CTHSS Financial Aid Application Packet available from the school’s Adult Education clerk;
The CTHSS deadline for applying for a Pell grant for the 2015-2016 academic year is as follows:
o LPN – July 22, 2015;
o All other full-time programs – August 3, 2015;
o New Aviation starting December 2015 – after official acceptance into the program by October 30, 2015;
*Applicants applying and accepted for a program after the specified deadlines can still apply for a Pell grant; however students will need to initiate tuition payments until determined eligible and Pell grant has been awarded.*
If a student is deemed ineligible for financial aid, outstanding tuition is due five days following receipt of the denial notification;
If a student is notified that their financial aid award will not cover the entire semester tuition cost, all tuition and fees are due five days following receipt of the award notice or by the regular tuition deadline, whichever is later;
The federal government randomly selects Pell grant applications for verification. If your application is selected for verification, you will be notified by the Financial Aid Administration and additional supporting documentation must be submitted by the specified deadline.
Procedures for Withdrawal:
In order to officially withdraw form an adult education program in the CTHSS and be considered for a tuition refund, candidates must complete and submit to the school’s Guidance Office, the following two documents available from the district’s Adult Education webpage www.cttech.org/AdultED:
9. Student Withdrawal Form
Upon approval of the Student Withdrawal Form by a school administrator (principal or assistant principal), students may be eligible for a tuition refund.
Eligibility for Tuition Refunds:
Except for withdrawal due to military action or serious illness, if the Student Withdrawal Form is received from the student prior to the first scheduled class session, the student is eligible for a 100% tuition refund;
Except for withdrawal due to military action or serious illness. If the Student Withdrawal Form is received from the student after the first scheduled class session, but prior to the fourteenth (14th) calendar day from the first scheduled class session, the student is eligible for a 60% tuition refund;
Except for withdrawal due to military action or serious illness, if a Student Withdrawal Form is received after the fourteenth (14th) calendar day from the first scheduled class session, the student is not eligible for a tuition refund;
All requests for tuition refunds due to military action and supported by written documentation from the military are eligible for 100% tuition reimbursement;
All requests for tuition refunds due to serious illness and supported by written documentation from a medical professional are also eligible for 100% tuition reimbursement;
Except for military action or serious illness, no refunds will be provided to students who are dismissed from their program of study due to issues with attendance, unsatisfactory educational performance or violation of the district’s discipline policy as detailed in the 2015-2016 Full-time Adult Student Handbook.
Processing of Tuition Refunds (only for students tuition who had paid out-of-pocket. Pell Grant recipients will be processed through the Post-Withdrawal calculation to determine earned funds and refundable funds to the federal government):
If the student meets the eligibility requirements for a tuition refund, the Request for Tuition Refund Form (Appendix IX) completed by the student will be forwarded from the school administrator to the school’s business office and then to the State Department of Education’s (DOE) Payments Unit. The SDE Payments Unit will then issue a state invoice utilizing the State of Connecticut’s official accounting system (CORE-CT) and transmits the invoice to the State Comptroller for issuance of a refund check payable to the student within the state’s payment timelines (currently net 45 days).
I have read and understand the above:
_____________________________________ _________________________________ _______
CONNECTICUT STATE DEPARTMENT OF EDUCATION
Technical High School System
ADULT EDUCATION
Student Withdrawal Form
Last Name: _________________________ First Name: __________________ M. I. _________
Street Address: ___________________________ Apt. No. ________ P. O. Box _____________
Town: ______________________________________ State: ________ Zip Code: _________
School Name:__________________________ Shop: __________________________________
Reason for withdrawal:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Student signature: ______________________________________________ Date:_________
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TO BE COMPLETED BY GUIDANCE STAFF
Official withdrawal code: _________________
Official withdrawal date: __________________
Guidance staff signature: ______________________________________ Date: ______________
Official grade at time of withdrawal: ___________________
Copies of the completed form must be sent to a School Administrator and to Central Office,
Attn: Financial Aid Administrator.
Student Acknowledgement/Agreement
FULL-TIME ADULT STUDENT HANDBOOKThis form must be completed, detached from the handbook and submitted to your instructor to be filed in the student’s permanent record file.
Student Name (printed) _______________________________ Program Area ___________________ I HAVE READ, UNDERSTAND and WILL COMPLY WITH THE RULES AND REGULATIONS AS STATED IN THIS HANDBOOK:
STUDENT SIGNATURE ______________________________ ___ DATE ______________________ Discipline Policy and Substance Abuse Policy
I understand the responsibilities outlined in the Discipline Policy and Substance Abuse policy. I also understand that should I violate either policy I shall be subject to disciplinary action, up to or including expulsion from school and/or referral to law enforcement officials, for violation of the law.
Attendance Policy
I understand that regular attendance is the responsibility of the student and is a critical aspect of the educational process. I also understand the credit denial policy. I further understand that I may make a written request for review within three school days following receipt of notification of denial of credit. Education Records
Regarding education records, I understand that certain personally identifiable information is considered directory information and does not require a signed release for disclosure. I understand that unless I deny the release of any or all of this information within 10 school days of the date this student handbook was issued, directory information may be released. I also understand that I have a right to inspect and review all of my student records.
I acknowledge that I have reviewed the above.
________________________ _________________
Student Signature Date
Permission to Publish My Photographic or Video Image
I do hereby certify, acknowledge, authorize and give consent to the Connecticut Technical High School System (CTHSS) to publish my photographic or video image, at its discretion, in school newsletters, newspapers, in TV or video coverage or in any related printed, electronic and/or video publications. It is my understanding that my photographic or video image shall only be used for informational and publicity activities conducted by the CTHSS and shall not be used for any commercial purposes.
_________________________ __________________
Student Signature Date
Please sign below ONLY IF you DO NOT grant permission.
I do not grant permission for the release of directory information without my prior consent.
_____________________________ ____________
Student Signature Date
I do not grant permission for the use of photographic or video images of me to be used by the Connecticut Technical High School System.
_____________________________ _____________
Progressive Discipline Form
1st Offense “Cite Handbook” ________________________________________________________________________ Student Name ______________________________________________________________________________________ Student’s statement of incident (includes date, place)
______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Instructor’s statement of incident
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Interventions _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Student Signature______________________________________ Instructor Signature __________________________________
****************************************************************************************** 2st Offense “Cite Handbook” ________________________________________________________________________________
Student Name ____________________________________ Date ______________ Referring Instructor ____________________
Student’s statement of incident (includes date, place)
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Instructor’s statement of incident
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Interventions _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Student Signature__________________________________________ DH Signature ____________________________________
****************************************************************************************** 3st Offense “Cite Handbook” ________________________________________________________________________________
Student Name ______________________________________ Date ______________ DH __________________________________
Student’s statement of incident (includes date, place)
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Instructor’s statement of incident
_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Interventions _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
Student Signature_______________________________________ DH Signature ________________________________________
AP Signature ____________________________________________Outcome ___________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________