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Health & Public Safety Suncoast Technical College 4748 Beneva Road, Sarasota, FL (941) FAX (941)

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Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

(941) 924-1365 FAX (941) 361-6886

Health Science & Public Service Application Steps

Step 1: Attend an information session. This is presented by the Student Services department. At this session you will be given the specific application procedures for all of our programs and the application packet which you must complete. Please be sure you are aware of the “application windows” for each program as applications are accepted only during specified time periods.

Step 2: Application. The application form must be completed in black ink and include a “2X2” passport type photo. Please be sure you complete every line and answer all questions. No blanks.

Step 3: Physical Packet. The physical packet consists of the Physical Assessment form (to be filled out by the applicant), the Physical Exam form, the Immunizations form, the Tuberculosis Screening (PPD) form and the Flu form. When you begin your program, you will also be completing a form for Hepatitis B. Please read all directions on the forms carefully, and be sure that all lines have been filled out and each page signed, dated and stamped properly. No blanks.

Please note: it is required that you be vaccinated for, or have a positive titer test for Varicella. Our clinical sites do not accept having your doctor state that you had Varicella as this does not always provide sufficient immunity.

Also please note: the Physical Exam and TB (PPD) tests are only valid for one year and must be repeated if they expire during your class enrollment.

Step 4: Official High School Transcript. With the exception of the Nursing Assistant program, all applicants for Health Science/EMS programs must obtain an official, sealed copy of their high school transcript proving graduation, or an official copy of a GED certificate. Please do not have your high school send the transcript to the Health Science office. Bring the sealed transcript with you when you turn in your application.

Step 5: Background Checks. All applicants for Health Science/EMS programs must complete a comprehensive background check before being accepted into program. Students participating in the Practical Nursing, Paramedic, and Surgical Technology programs will undergo another background check six months into their programs to comply with the

requirements of our clinical affiliates. Initial background checks will be presented as part of your application package and paid for at Student Services.

Step 6: Turning in your Application package. During the appropriate “open window” period for your program, present your completed packet to the Health Science office. The application packet includes:

(1) Application (2) Physical Packet

(3) Official, sealed High School transcript/GED diploma certificate (except Nursing Assistant program) (4) Background Check Packet

(5) Driver's License/State ID (to copy for file) (6) Original Social Security Card (to copy for file)

All paperwork needs to be presented to the Health Science office at the same time. The administrative assistant will check your packet for missing information and will return to you any forms that are incomplete or need clarification. Later, a review committee will check all complete files.

Step 7: For Paramedic- You must enroll in Anatomy & Physiology which is a co-requisite for the program. You must also present your current Florida EMT license and current BLS card.

The Sarasota School Board prohibits discrimination in its educational programs, services or activities, or employment conditions or practices on the basis of race, color, religion, gender, sexual orientation, age, ethnic or national origin, genetic information, marital status, qualified disability defined under the ADAAA, or on the basis of the use of a language other than English, except as provided by law. The Sarasota School Board also ensures equal access to school facilities for the Boy Scouts of America and other patriotic youth groups.

Any person who believes he or she has experienced any such prohibited discrimination may file a complaint with the district Equity Coordinator Al Harayda by calling (941) 927-9000, ext. 31217, or writing him at 1960 Landings Blvd., Sarasota, Florida 34231

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Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

(941) 924-1365 FAX (941) 361-6886

Program you are applying for:

Personal Information: Social Security Number: - - __ _ __ Full Legal

Name:

(Last) (First) (Middle) (Maiden)

Home Address: City: State: Zip Email Address: Education:

You must be a high school graduate or possess a GED to apply for most Health Science programs. (Transcript or GED is not required for the Nursing Assistant program)

A. High School Graduate __ Yes _______ No (Year Graduated: ) Name & Address of High School:

If Yes: request an official transcript from your former high school and provide it with your application.

If No: 1. GED number State of Issue: ____ (provide a copy with your application) 2. Not Required

B. College:

Name and Address of College:

Years Complete: 1 2 3 4 4+ Graduate: Yes No Degree:

C. Within the past 5 years, have you enrolled/completed any job preparation course at STC? ____ Yes No If Yes: Name of Program: Dates enrolled/completed:

D. Have you taken any online classes at STC? Yes No

If Yes: Currently enrolled or Completed (Date of Completion) Name of Class (es):

Applicant: Please staple

2x2 color photo here

Please complete all portions of this form. Use the letters N/A to fill out any area that does not apply to you.

Cell Phone: ( )

Home Phone: (____) ____

Work Phone: ( )

If you wish to have health related college courses considered for credit please provide an official transcript and syllabus to the Health Science Office

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Employment Reference Information

(Include all employers within the last 5 years. Use extra sheet attached if necessary)

Current Employer:

Company Name: _ ______________________________ ________________ ________ __ _ Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ ______ ___ ________

Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

(Month/Year) (Month/Year)

Previous Company Name: ____ ________ ___________________________________________

Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ ________ __ ____ Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

(Month/Year) (Month/Year)

Previous Company Name: _ _________ _____ ____________ ______ _________________ __

Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ ___ ____ ________

Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

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NAME: ______________________________________________ SSN: ____ __ -__ __ -____

Previous Company Name: _ ___ __ _____ ______________ _________________ _____

Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ ________ _ ________

Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

(Month/Year) (Month/Year)

Previous Company Name: _ ___________ ____________ ____________ _______

Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ _________ ______

Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

(Month/Year) (Month/Year)

Previous Company Name: _ _________________________ _____ _ ___________________

Company Address:

(Street) (City) (State) (Zip)

Contact/Supervisor: ________________________________________ Title: _ __________ _______

Phone No. ______________________________

Dates Employed: ________________ to __________________Your position: __

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Periods of Unemployment:

(Include time as a full or part-time student) From: to: (Month/Year) (Month/Year) Reason: From: to: (Month/Year) (Month/Year) Reason: From: to: (Month/Year) (Month/Year) Reason: From: to: (Month/Year) (Month/Year) Reason: From: to: (Month/Year) (Month/Year) Reason: From: to: (Month/Year) (Month/Year) Reason:

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In completing the forms, which are part of this application packet, I understand that my answers and statements must be complete and accurate. I hereby give permission for STC to verify any and all statements made by me in this application packet. Incomplete, false, or misleading answers or statements may result in being denied admission to a Health Science program or in being withdrawn from a Health Science program in which I am enrolled.

Print your name: ___________________________________________________________________ Signature: ___________________________________________ Date: ________________________

Sarasota County School Board complies with State Statutes on Veterans’ Preference and Federal Statutes on non-discrimination on basis of religion, race, national origin, marital status, sex, age, or handicap.

We are always interested in knowing how our students became aware of our programs. Please assist us by identifying how you found out about our program.

_____Newspaper Former or Current Student Friend/Family ____ Internet _____Career Fair Television Employer Radio

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Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

(941) 924-1365 FAX (941) 361-6886

PHYSICAL ASSESSMENT- To be completed by the Applicant

Full Name: _____________________________ _________ Program applying for: ______________________ Please Note:

1.) Students in Health Science/Public Service programs must be free from weightlifting restrictions. 2.) Complete this section carefully; omissions or misrepresentations may disqualify you from enrollment in program or result in withdrawal from any program in which you are enrolled.

3.) If you are pregnant, please discuss with your physician the possible harm to the health of the fetus from exposure to ill patients or certain medical equipment (e.g. X-ray) during required clinical rotations.

A.) Are you being treated for or have you ever been treated for the following:

Yes No

___ ___ Alcohol or other Drug Abuse ___ ___ Allergy (Drugs/Food/Inhalants) ___ ___ Arteriosclerosis-High Cholesterol ___ ___ Arthritis or Joint Problems ___ ___ Asthma or Breathing Problems ___ ___ Back or Neck Trouble/Injury ___ ___ Birth Disorders

___ ___ Bone/Bone Marrow Problems ___ ___ Circulation Problems/Varicose Veins ___ ___ Depression, Emotional or other ___ ___ Mental Health Problems ___ ___ Endocrine Disorders Yes No ___ ___ Fainting Spells ___ ___ Headache/Migraine ___ ___ Hearing Impairment ___ ___ Heart Trouble/Disease/Angina ___ ___ Hemophilia or Clotting Disorder ___ ___ Hernia/Rupture ___ ___ High Blood Pressure (Hypertension)

___ ___ Kidney or Liver Problems ___ ___ Low Blood Pressure ___ ___ Hypoglycemia ___ ___ Diabetes Yes No ___ ___ Nerve/Muscle Disorders ___ ___ Operations/Surgery Within past 5 years ___ ___ Seizures/Convulsions ___ ___ Skin Disorders ___ ___ Stomach/Digestive/ Intestinal Problems ___ ___ Stroke ___ ___ Vision Impairment (Other than glasses/ contacts)

B.) For each ‘Yes’ Checked: Please give details as to time, duration, treatment and names and addresses of treating physicians. (Use the back of this sheet if necessary.)

_______________________________________________________________________________________________ ______________________________________________________________________________________ ___ C.) List all medications or treatments you are presently taking: ____

__ ____

D.) List any conditions which may affect your ability to perform the tasks required by the Health Science/Public Service Program for which you are applying (e.g. heavy lifting, bending, standing or sitting for long periods of time, dealing with emotional or stressful situations, etc.):

________________ ____________________

Please read the following statement and sign below:

I certify that the above statements are true and complete to the best of my knowledge. I give my permission to the Health Science & Public Service Department of Suncoast Technical College for disclosure of all of the health

information contained within the pages of my program application.

Signature of Applicant: ________________________ ____________________________ Date: _________________ (and Parent if High School Student or under 18 yrs. of age)

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Suncoast Technical College

Health & Public Safety Department

Physical Examination

Height________ Weight_________ B/P____________ PREGNANT ______Yes _____No

Is this the first time you have seen this patient? ___Yes ____No (If no, how long have you known them________)

Please make a notation on all lines 1-14 below even if “Not Observed”

Normal Abnormal Comments or Observations

1. Appearance 2. Skin 3. Head/Scalp 4. Eyes/Ears/Nose 5. Mouth/Teeth/Throat 6. Chest/Lungs 7. Heart 8. Abdomen 9. Musculoskeletal 10. Neurological 11. Emotional/Mental/Behavior Problems 12. Physical Impairment/Other (Specify) 13. Evidence of Abuse(Physical/Substance) 14. Restricted Activities (Please be specific)

Do you know of/observe any condition that would restrict this applicant’s ability to enroll in a Health Science & Public Service program and/or function normally in a health care profession (e.g., patient care: lifting/turning/moving)? ___Yes _ __No. If yes, please describe__________

______________________

Does this applicant have any weight lifting restrictions? __ _YES _ __NO (If yes, please describe):

Comments, Impressions, or Recommendations______________________________________________________

Note to Healthcare Professional performing physical examination:

-This form must be completed, signed and stamped by a licensed MD/DO/PA/ARNP only.

-Health Science programs require clinical rotations/externships that include close patient contact, moving and lifting patients. Applicants must be free from lifting restrictions.

-Physical exams are valid for 1 year from date of exam. Physician/Medical Office Address/Official Stamp _________________________________________________ ____________________

MD, DO, PA, ARNP Signature (Please circle credentials) Date of exam

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Name of Applicant/Student _______________________________________ Program _______________

Tuberculosis Screening

Directions: Participation in a Health Science/Public Service program requires a negative PPD screen

(Tuberculosis) or a negative chest x-ray/assessment. All TB tests are valid for one year. TB tests and Assessment Forms expiring during your enrollment must be repeated. Students with expired TB tests /Assessments will be unable to attend class or clinical rotations.

If the result of the PPD is positive, for the first time, you must have a Chest x-ray/Assessment performed. If there is a history of positive PPD, you must have a yearly TB Symptom Assessment Form completed.

Date PPD administered _________________/ ____________/ ____________ Month Day Year

Date PPD read ___________/ _________/ _________ Result: Negative _______ Positive ________ Month Day Year mm # ________ mm # __ OR

Date of Chest x-ray __________/ ___________/ __________ Result: _______________________ Month Day Year

OR

Date of Assessment __________/ ___________/ __________ Result: _______________________ Month Day Year

Note to Healthcare Professional performing physical exam:

-This form must be completed, signed and stamped by a licensed MD/DO/PA/ARNP/RN or LPN only.

-Physical exams and TB screenings are valid for one year

from date of exam.

Physician/Medical Office Address/Official Stamp

_________________________________ _______________ ______ _____

MD, DO, PA, ARNP, RN, LPN Signature (Please circle credentials) Date

Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

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Tuberculosis Symptom Assessment

Student Name: __________________________________________ DOB: _____________ Date: ___ ___ Documented PPD History: Date of test: ____________ Results: __________mm

If recent PPD, Chest X-ray date: ______________ Results: ______________________________ ___________________________________________________________________________ History of treatment for active TB disease or treatment for latent Tuberculosis:

Treatment (LTBI)?

____ Yes, ____ No. If yes, when? ____________ Where? __________________________ Number of months taken __________________ DOT: _____ self- administered: _________ Medication(s) taken: __________________________________________________________ - - - Date of Assessment: ______________

Do you currently have a productive cough? ____Yes ____No

If yes. How long have you had it? ____ Days ____Weeks ____Months If yes, what color is the mucus? ________________________________ If yes, are you coughing up blood? _______________________________ Do you have “night sweats”? ____ Yes ____ No

Do you have a low-grade fever? ____ Yes ____ No

Have you had weight loss without dieting? ____ Yes ____No If yes, how many pounds have you lost? ____________ Have you had unusual tiredness or fatigue? ____ Yes ____No

If yes, how long? ____Days ____ Weeks ____ Months Do you have chest pain?

If yes, how long? ____ Days ____Weeks ____ Months Do you have shortness of breath?

If yes, how long? ____ Days ____ Weeks ____Months

Do you know someone who has or has had these symptoms? ____ Yes ____ No

Comments/ Referrals: __________________________________________________________ ____________________________________________________________________________

Student Signature: ___________________________________ ___ ______ Date: _________ _

Physician/Medical Office Address/Official Stamp

Physician, Physician Assistant, ARNP, RN, LPN Signature Date

(Please circle credentials)

Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

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Name of Applicant/Student: ________________ ________________Program: _____________________

Measles, Mumps, Rubella, Varicella and Tdap Immunizations

Directions: Participation in a Health Science/Public Service program requires proof of immunization against Tetanus, Diphtheria, Pertussis, Measles (Rubeola), Mumps, Rubella and Chicken Pox (Varicella). It is not

acceptable to state that a person “had the disease” for any of these diseases because a mild case may not impart full immunity. Either a vaccination or a positive titer is required.

If you cannot produce proof of immunization you will need positive titers for Diphtheria, Tetanus, Pertussis, Measles, Mumps, Rubella and Varicella. If a titer is negative, you will need to be vaccinated.

Date of immunizations: Measles _______/ ________/________ Month Day Year Mumps _______/________/_________

Month Day Year Rubella ______/________/___________

Month Day Year Varicella _______ / ________/ ________

Month Day Year Tdap _______ / ________/ ________

Month Day Year OR

Date of titer(s): Measles _________ / _______/ ________ Result: Positive: ________ OR Negative: ________ Month Day Year

Mumps _________/________/_________ Result: Positive: ________ OR Negative: ________ Month Day Year

Rubella _________/________/_________ Result: Positive: ________ OR Negative: ________ Month Day Year

Varicella _______ / _______ / _________ Result: Positive _________ OR Negative _________ Month Day Year

PLEASE ATTACH COPY OF ALL TITER RESULTS.

Note to Healthcare Professional performing physical examination:

-This form must be completed, signed and stamped by a licensed MD/DO/PA/ARNP/RN or LPN only.

Physician/Medical Office Address/Official Stamp

____________________________________________________ ___ _________________

MD, DO, PA, ARNP, RN, LPN Signature (Please circle credentials) Date

Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

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Rev. 06/2019

Influenza Vaccination Certification

Name ________ ______________________________________ Program ______________

I hereby certify that I have received a vaccination for Influenza using the latest formulation approved by the

Centers for Disease Control as of the date on which it was administered.

Date Administered: Month____________ Day__________ Year 20______

Facility at which vaccination was administered:

___________________________________________________________________________

___________________________________________________________________________

Signature and credential of person administering vaccination

___________________________________________________________________________

Student Signature Date

___________________________________________________________________________

Parent Signature if under 18 years of age Date

PLEASE NOTE: This is required and is mandatory for all clinical sites. Failure to comply will result in our

inability to get you to a clinical site rotation and you will not be eligible to complete program. If you have

any questions or concerns, you must meet with your program coordinator.

Note: You may be required to get more than one vaccination during the duration of your class if a new

formulation is released.

APPENDIX B

VERIFICATION OF HEPATITIS B VACCINATION OR DECLINATION FORM

Health & Public Safety

Suncoast Technical College 4748 Beneva Road, Sarasota, FL 34233

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APPENDIX B

VERIFICATION OF HEPATITIS B VACCINATION OR DECLINATION FORM

Verification of Hepatitis B Vaccination

1. I hereby confirm that I have been vaccinated against Hepatitis B or have begun the vaccination series. My vaccination series was completed on ___________________________________. Date

____________________________________________ __________________ Print and / Signature of Student Date

OR

2. I hereby confirm that I have initiated the Hepatitis B series of vaccinations beginning _____________________.

Date

_____________________________________________ __________________ Print and / Signature of Student Date

Declination of Hepatitis B Vaccination

3. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given

information concerning the risks of exposure to hepatitis B in the health care setting. I do not wish to be vaccinated by my physician at this time. I understand that by declining vaccination, I continue to be at

risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure

to blood or other potentially infectious materials and I decide to be vaccinated with Hepatitis B vaccine by my physician, I will document the immunization in my Health Science files.

_______________________________________________________________________________

Student Signature Date

________________________________________________ Print Name

If the student is under the age of 18 years, the parent or legal guardian of the student must sign the

consent.

Relationship to student______________________________________________________

Parent/Guardian signature Date

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4748 Beneva Road, Sarasota, FL 34233 Office 941-924-1365 Ext. 62379 Fax 941-361-6886

“MEDICAL CLEARANCE”

This medical clearance form must be signed by your healthcare practitioner and returned to the Health Science Office prior to returning to class and/or clinical.

Student must be able to perform the following tasks without restriction:

All cognitive, affective, and psychomotor requirements listed in Addendum C without academic adjustments and/or auxiliary aids and services i.e must be able to lift, push, pull at least 25 pounds, stand for long periods of time. (Please refer to pages 48-55 in the Health Sciences Student handbook for complete list)

is able to return and participate in all class

(Student Name)

and clinical activities without any restrictions.

Physician/Medical Office Address / Official Stamp

Healthcare Practitioner - MD, DO, PA, ARNP Date Signature (please circle credentials)

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AMENDMENT TO MEDICATIONS

STUDENT MUST PRESENT PRESCRIPTION OR CONTAINER TO BE COPIED

PRINT STUDENT NAME _____________________________________________________________ PROGRAM: _______________________________________________ DATE: __________________

LIST NEW MEDICATION(S):

NAME OF MEDICATION REASON PRESCRIBED PRESCRIPTION OR

OVER THE COUNTER (OTC)

1. 1. Prescription_______OTC ______ 2. 2. Prescription_______OTC________ 3. 3. Prescription_______OTC________ 4. 4. Prescription______OTC________ 5. 5. Prescription______OTC________ COMMENTS: ____________________________________________________________________ _ ___________________________________________________________________________________ STUDENT SIGNATURE___________________________________________________________

REVIEWED BY PROGRAM COORDINATOR/MANAGER

________________________________________________________ _______________ Reviewer’s Signature Date

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