Emergency Medical Technician

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Emergency Medical Technician TRAINING PROGRAM APPLICATION PACKET SOUTH HOWELL COUNTY AMBULANCE 1951 EAST STATE ROUTE K WEST PLAINS, MO PHONE: FAX: Dear Applicant: Thank you for your interest in the Emergency Medical Technician Program offered by South Howell County Ambulance Education Department. The application process is structured in a manner to be fair, balanced, consistent, and allows us to assess your ability to perform well in the program. This packet describes the steps involved in the application process. South Howell County Ambulance Education Services does not discriminate on the basis of race, color, religion/creed, age, gender, disabling condition, handicap, or national origin. To be admitted to the EMT Program, students must first meet the basic entrance requirements of South Howell County Ambulance Education Services. The program to which you are applying is both mentally and physically challenging. Because of the unique environment in which EMS personnel function, it is important to have a good understanding of the demands of the profession. A copy of the Functional Job Description can be requested and sent to you upon request. If you believe you have a disability that will require accommodations during the application process or during your enrollment as a student, please contact the Education Department as soon as possible. While we assure that everyone is offered equal opportunity during application and instructional processes. You should be aware that you must complete ALL of the program s requirements either with or without reasonable expectations. This packet also includes a list of the program s pre-requisites and several records. Please complete the records carefully and provide any necessary attachments. You should consult the checklist at the bottom of the form to ensure your application is complete. Please be aware that the timeframe for immunizations is lengthy and you should plan accordingly. Students may incur some costs involved in the application process that are not included in the cost for the course. Again, thank you for your interest in our Emergency Medical Technician Program. Best regards, Richard R. Cotter Education Operations Manager Website: Page 2 EMT Training Program Curriculum Overview: The following is a general description of the Training Program: EMT Course o 184 Hours of didactic (classroom/laboratory) o 60 Hours of field clinical experience o 48 Hours of hospital clinical experience DIDACTIC EDUCATION: The didactic portion provides the theoretical foundation necessary for success as a student and a professional EMT. LABORATORY EDUCATION: Laboratory education allows students to develop hands on skills and apply concepts to clinical decision-making. HOSPITAL/FIELD CLINICAL EDUCATION: Hospital and Field Clinical education provides an opportunity for students to develop and apply theoretical knowledge and laboratory skills to the actual treatment of patients. Students will participate in various supervised clinical experiences within local hospitals and on EMS paramedic units (ambulances). SUMMATIVE FIELD EVALUATION: The summative field evaluation provides students with the opportunity to function as a team leader on actual 911 emergency calls, with EMS paramedics serving as mentors and preceptors, applying the knowledge and skills outlined above. CLINICAL SITES: Students will complete training in the following clinical areas: Emergency Department Urgent Care Labor and Delivery Units South Howell County Ambulance (Field Clinical Site) Other Sites deemed necessary Page 3 EMS EMT Training Program Application Process This handout details the application process for South Howell County Ambulance Districts EMS Emergency Medical Technician Training Applicant. There are 6 Phases to the application process. All phases must be completed before an application is eligible for entrance into the course. Completion does not guarantee that an applicant will be offered entrance into the course. Phase I Phase II Phase III Phase IV Phase V Phase VI Completion of Application &Submission of Documents Written Entrance Essay Physical Oral Interview Drug/Alcohol Screen Background Check submission Phase I COMPLETION OF APPLICATION & SUBMISSION OF DOCUMENTS The application must be completed in its entirety & submitted with all required documents. The application packet can be delivered via mailed, ed, faxed or in person at the station. Mail/Physical address: Attn Richard R. Cotter, 1951 E. State Route K, West Plains, MO Fax: Phase II WRITTEN ENTRANCE ESSAY This allows us to assess your knowledge of EMTs, judge your writing skills, gauge your understanding, measure you against your peers & challenge you to deepen your awareness. Phase III PHYSICAL Applicants must provide their/a physician with a copy of the Functional Job Description along with the physician verification of student health status record to access the applicants ability to meet job requirements. Phase IV Entrance exam and ORAL INTERVIEW Applicants will be interviewed by the Instructor and/or the Education Operations Manager. Those applicants meeting the selection criteria will be notified & offered a conditional acceptance into the course contingent on successful completion of Phases IV & V. Phase V Drug/Alcohol Screen Upon conditional acceptance into the course, applicants can be scheduled for a drug/alcohol screen. Page 4 Applicants must meet the following requirements: 1. Must be 17 years and 10 months of age in order to enter the program. 2. Must be a U.S. Citizen 3. High School Diploma or a G.E.D. 4. Valid Driver s license 5. Pass the following medical examinations: a. Alcohol & Drug Screen 6. Physically able to perform the duties of EMT 7. Current immunizations status : a. Verification of immunization against tetanus/diphtheria/mumps/measles/rubella/varicella b. Negative results from a tuberculosis skin test or chest x-ray performed within the last 12 months 8. Must submit a criminal background check 9. Must successfully clear interview process If you wish to have the Hepatitis B Vaccination completed prior to beginning clinicals; it is suggested that you have the 1 st Hepatitis B vaccination (1 of 3) either before starting the course or within the first couple weeks of the course beginning. Evaluation of Applicants The number of students in the program is limited by spaces available for clinical experience in affiliated hospitals and EMS provider organizations. Competitive selection of students may be necessary if the number of applicants exceeds the number of seats available. In this event, the Medical Director and Education Operations Manager will review applicants. Factors that may be considered if competitive selection becomes necessary include: 1. Previous academic coursework and performance 2. Prior work experience 3. Interview results Page 5 CRIMINAL BACKGROUND AFFIDAVIT 1. Have you ever received a DUI/DWI violation? YES NO 2. Are there any criminal charges currently pending against you? YES NO a. If Yes please explain: 3. Are you currently on probation or parole? YES NO 4. Have you had any voluntary surrender, disciplinary action, consent order or settlement imposed, or is any disciplinary action pending on your license/certificate in any state or jurisdiction? YES NO 5. Have you had other than an honorable discharge from the military? YES NO 6. Have you been named in a civil/malpractice case relating to your employment as a health care worker? YES NO 7. Have you had clinical privileges suspended, revoked, or limited? YES NO 8. Have you had or have a physical, mental, or emotional condition that might affect you ability to practice safely as a certified EMT? YES NO 9. Have you ever been arrested, charged with, convicted of, or pled guilty or no contest to, or been sentenced for any criminal offense, including all misdemeanors or felonies in Missouri or any state? YES NO NOTE: Even though an arrest or conviction has been pardoned, expunged, dismissed, or deferred, and your civil rights have been restored, you must answer Yes and attach certified copies of the bill of information or clerk of court records regarding any offenses. I authorize the South Howell County Ambulance District to conduct a Criminal History check on me at anytime through the course. And by signing this I affirm all questions to be accurate and correct. (Signature) (Date) Page 6 The applicant must submit a Criminal Background check that can be acquired from the following website: You will click on the Missouri Firefighters and EMT s section and follow the instructions to complete. It can be printed and attached or submitted by directly to SHCA Education Department by attaching the following address to the other recipients: Page 7 STUDENT APPLICATION LAST FIRST MIDDLE Current Employer Name and address: Job Title: Job Functions: Employed : From Previous Employer Name and address: to Reason for Leaving: Job Title: Job Functions: Employed : From to How do you learn best reading, doing, seeing or hearing? Reason for Leaving: Do you have any health problems that might interfere with your abilities to perform the standards of being an EMT NO YES If yes, Please state: CURRENT EMS CERTIFICATION(S) AND CERTIFYING AGENCY(S) WHERE DID YOU COMPLETE YOUR PREVIOUS EMS EDUCATION? CERTIFICATION LEVEL SCHOOL MONTH/YEAR DID YOU RECEIVE COLLEGE CREDIT? HIGHEST LEVEL OF EDUCATION COMPLETED, INCLUDING DEGREE AND INSTITUTION Accomplishments that have given you great satisfaction: Your reasons for selecting this program as a career: Your plans and future aspirations: Hobbies and sports: include your interests, hobbies, recreational activities, involvement in civic organizations, and other community service. Include Service awards: Page 8 MILITARY SERVICE 1. Were you ever in any branch of the UA Armed Forces? YES NO Branch: (If NO skip this section) 2. Selective Service Number: (If unknown, call or visit to obtain) You must provide a DD Form 214 (Discharge) for each period of Non-continuous service. 3. Are you currently on active duty? YES NO (If yes, provide the information below) Branch: Date Entered: Length of Commitment: Actual or Estimated Date of Separation: Grade/Rank: Current M.O.S.: Supervisor: Unit Mailing Address: 4. List all military service. (Attach additional pages if necessary) Dates of Service: Branch of Service: Complete Unit Address: M.O.S.: Highest Rank: Type of Discharge: Reason for Discharge: Disciplinary Action: Page 9 APPLICANTS NAME EMERGENCY CONTACT INFORMATION First Middle Last Preferred First Name: Address City State Zip County Date of Birth: Age: SS # Place of Birth: City State Country Address: Home # Cell # Alternate # Employed by Employers # In case of Emergency, Illness, accident; SHCA is authorized to proceed as indicated below: (Please number Each below in the order of desired action) Contact: Relationship Phone #(s) Contact Physician Doctors name: Phone # Take to Emergency Room Take to a licensed Physician Other desired procedures: List any other name(s) that you have used or by which you have been known. Explain full Why, Where and When it was used. Include nicknames, aliases, maiden name, and previous married name(s). Attach additional pages if needed. Page 10 PHYSICIAN S VERIFICATION OF STUDENT HEALTH STATUS I have reviewed the health status of: and the attached Functional Position Description defining the technical standards of the EMT Program offered by South Howell County Ambulance Education Services. Based on these reviews I have determined that: This student will be able to meet all of the Program s technical standards without accommodations. This student will be able to meet all of the Program s technical standards if reasonable accommodations are provided. I have attached a signed, dated statement on my office letterhead describing the student s functional limitations relative to the Program s technical standards and appropriate accommodations to these limitations. This student will NOT be able to meet the Program s technical standards, even with reasonable accommodations. I have attached a signed, dated statement on my office letterhead describing the reasons for this determination. Physician s Signature Date Printed Name License Number Office Telephone Number Page 11 ADMISSION DRUG & ALCOHOL TESTING Acceptance of students to the EMS Education Program is contingent upon satisfactory compliance of physical examination and testing for illegal drugs. The initial drug screen will determine if any drugs are present. You will be asked to list all prescription and over-the-counter drugs you are taking, and the name and telephone number of the doctor who prescribed them. The cost for this test is included in your application and testing fee. If the initial test is positive, a confirmation test to identify the drug will be done. The testing is a condition of final acceptance as a student into the program. Applicants (students) who test positive for illegal drug will be refused admission to the program. An applicant who refuses to comply with this policy will not be accepted into the program. The applicant (student) will be responsible for the drug confirmatory testing, with payment made to South Howell County Ambulance District in the form of cash or money order. The in-house test will consist of a saliva swab test for drugs and a disposable chemical activated breathalyzer for alcohol. To protect all of our patients and employees, the sample must be taken under monitoring conditions. Failure to cooperate fully in this process will result in immediate withdrawal of the conditional offer of admission. As an applicant (student), I give permission for the drug test results to be released to South Howell County Ambulance District Education Services. I agree to comply with the enrollment process, as indicated above. Applicant Signature Date I do not agree to comply with the enrollment process as indicated above. Applicant Signature Date Page 12 HEPATITIS B VIRUS VACCINE I,, understand that due to my occupational exposure to blood and other potentially infectious materials while I am a student with South Howell County Ambulance Education Services, I may be at risk of acquiring Hepatitis B Virus (HBV infection). I have been informed that it is the policy of South Howell County Ambulance Education Services faculty to strongly encourage students to be vaccinated with Hepatitis B vaccine, and that the vaccine is available through a private physician. The cost of the vaccine is the student s personal expense and is approximately $ for the 3-series of injections I understand, by declining the Hepatitis B vaccine, I continue to at risk of acquiring Hepatitis B a seriously and potentially fatal disease. I understand that as a student with South Howell County Ambulance Education Services, I am expected to abide by the protective precautions as outlined in the Districts policy regarding transmission of blood borne pathogen disease. (AIDS and Hepatitis) I,, decline to receive the Hepatitis B vaccine. I have read and understand the above stated comments of the District. I,, agree to receive the Hepatitis B vaccine. I have already or will during first block of the program, receive the Hepatitis B vaccine. I have read and understand the above stated comments of the District. I,, already have received the Hepatitis B vaccine and have attached my immunization record. I have read and understand the above stated comments of the District. Witness Signature Date Page 13 APPLICATION ESSAY Please answer the following question: What are the traits and personal characteristics that all great EMT s share? Your answer should be at least 250 words in length. Respond in the space below, in your own handwriting, or you may attach a typed word document (Margins are 1 top and bottom; each paragraph has ½ indent; double spaced; two pages.) Page 14 APPLICANT AGREEMENT RECORD I,, the undersigned applicant for the (print name) EMT training course, at South Howell County Ambulance (SHCA) hereby agree to the following: 1. I understand my completed application must be received by SHCA, on or before the stated deadline by the Education Department. 2. Type or print an answer to every question. If a question does not apply, indicate with N/A. If you are not sure if a question applies, contact SHCA. 3. I further understand that all of the requested information in the application will be provided by me, all statements are true and correct to the best of my knowledge, and that withholding pertinent information of providing inaccurate information may nullify my application. 4. Incomplete forms in any part of the application will not be processed and further consideration may not be given to the application. 5. I understand that I will be required to comply in a specified time period with any written of oral request communicated to me by any individual representing SHCA as it applies to my application. 6. I understand that this application process is part of the student select process only and is not to be considered an indication or obligation by SHCA in making an appointment for acceptance. 7. Failure to acknowledge or comply with any of the statements above may result in my disqualification as a candidate and delay of reapplication until the next EMT course. NOW THEREFORE, I hereby acknowledge that I have read and fully understand each of the statements contained herein above, and further, that I had the opportunity to ask for clarification of each of the statements, and that my signature was not placed hereon until I fully understood each statement. Signature: Date: Page 15 Admission Process 1. If you believe you have a disability that will require accommodations during the application process or during your enrollment as a student, please contact the Education Office as soon as possible. Disabilities include but are not limited to: reading, ability to take tests, ADHD, Dyslexia, Vision (blurred/color blind etc.,), hearing loss 2. Complete and sign all the Application records: a. Emergency Contact Record b. Admission Drug & Alcohol Testing Record c. Student Applicant Record d. Hepatitis B Virus Vaccine Record e. Physicians Verification of Student Health Status Record must be completed by your physician and returned to the Education Office as a means of verifying that your health will permit you to meet the technical requirements defined by the functional position description, either with or without reasonable accommodations. *at applicants expense f. Applicant agreement Record g. Military Service Record h. Criminal Background Affidavit & Check. Attach or copy. *at applicants expense 3. Complete the Application Essay. 4. Obtain and attach the following documents: a. High school diploma/ged b. Verification of immunization against tetanus, diphtheria, mumps, measles, rubella, and Varicella, Negative results from a tuberculosis skin test or chest x-ray performed in the last 12 months. If applicant does not already have will be *at applicants expense. c. Copy of your current drivers license d. Copy of your social security card e. Copy of your negative 2-Step TB Skin test/negative chest x-ray *at applicants expense You are able to obtain this from the Howell County Health Department. f. Copy of your current CPR license *optional g. Copy of your hepatitis B vaccinations *optional 5. Submit your completed application with the accompanying documents to the Education Department. 6. After we receive your application and verify it is complete, we will contact you to schedule a time for a personal interview. 7. When you receive your acceptance letter, you re ready for class! Created By: Richard R. Cotter Page 16 SHCAD Revised by: Desiree Margerum Created date: Revised date: FUNCTIONAL JOB DESCRIPTION- EMERGENCY MEDICAL TECHNICIAN Career Requirements: Responds to emergency calls to provide efficient and immediate care to the critically ill and injured, and transports the patient to a med
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