EMT COURSE

APPLICATION PACKET

Dear Prospective EMT Student:

Thanks so much for choosing Labette Community College where it truly is all about you! We strive to

help you meet your goals in life and that starts with education. Our instructors and Workforce

Education staff have spent several hours and ample energy developing the best Emergency Medical

Technician (EMT) training program Southeast Kansas has to offer.

At LCC, we hold high standards and only select the very best students for the EMT program. This

career path is very challenging but even more, it is rewarding. Full consideration will be reserved for

applicants that have completed this application in its entirety.

The EMT program for which you are applying is both mentally and physically challenging. Please,

complete some basic research on what some of the responsibilities of an EMT are. This includes but is

not limited to: responding to emergency calls, provide efficient and immediate care to the critically ill

and injured, and to administer lifesaving interventions, as appropriate, when transporting a patient to

the nearest hospital. Being an EMT can be both physically and mentally strenuous at times. You must

be able to pay close attention to detail and have a good handle on time management. Most

importantly, you must learn to stay calm and organize and convey information quickly during

stressful situations as they occur. Most EMT’s work 24 hour shifts and are guaranteed to work some,

if not all, holidays each year depending on how the rotating schedule falls.

The LCC EMT Training Program has a limited class size. Please note, meeting the minimum

requirements is one small step above inadequacy and in no way guarantees acceptance into the

program. Test scores and previous academic performance will be evaluated on each applicant. If you

are an applicant that is currently serving in the military, a volunteer firefighter, LOE, or EMS

employee, you will be given first consideration for admission in to the EMT Training Program.

Vaccines: Immunizations can take some time to complete. I urge you to begin the process

immediately. Immunizations need to be “in process” at the time of application and need to be

completed BEFORE the first day of class. Depending on the time of year, the flu vaccine requirement

could vary. Most flu vaccines are held in the fall. Please, talk to your local pharmacist or health care

provider for their recommendation if you are unsure.

We look forward to receiving your application! Please, do not hesitate to call or email with any

questions! Good luck!

Trudy Hill, R.N.

Workforce Education and Career Training Assistant

620-820-1257

trudyhill@labette.edu

EMT Orientation First Night of Class

Tuesday, August 20, 2019

5:00 pm LCC Thiebaud Theater, Main Campus

Presenter: Travis Modesitt and Bob Huggard, Instructors

*All students that have been accepted into the EMT

Training Program will be mandatory to attend. Please,

mark your calendars if you are accepted into the program.

This is the first night of class.

Minimum Course Admission Requirements: (completion of these minimum requirements does not

ensure admission into the EMT Course)

1. A. If you have never taken classes at LCC, you need to Apply online to Labette Community

College (see checklist for instructions)

B. If you have taken classes at LCC, you need to update your profile by calling Registrar

2. Completion of Pre-enrollment Tests (Turn in results to Melissa in the Workforce Education

Office, Room M203/204)

a. Reading (Compass minimum score 75/ACT minimum score 17; Accuplacer-English

Sentence Skills Test 75; or Accuplacer Next Generation Writing 263) no charge; and

b. Algebra (Recommended Compass minimum score 34; ACT minimum score 17;

Accuplacer Test at 60; or Accuplacer Next Generation Quantitative Reasoning, Algebra

& Statistics 250) no charge

3. Must be 17 years of age by end of the course and have in your possession a valid Driver’s

License (include copy of your Driver’s License in documents to return with your application)

4. High School Diploma, GED, or be a current high school senior enrolling with consent of

Principal

5. Completion of the application packet which includes the following documents that must be

read, signed and returned to Workforce Education Office, Room M203/204, Labette

Community College:

a. The Student Health Record Form to be signed by a Primary Care Provider for

verification of immunizations. (Need proof of following immunizations)

i. Measles, Mumps, and Rubella (Must have proof of two MMR vaccines or

documented titer);

ii. Tetanus/Diphtheria (one within last 10 years);

iii. Evidence of immunity to varicella (Chickenpox) in adults includes any of the

following:

documentation of 2 doses of varicella vaccine at least 4 weeks apart;

US-born before 1980, except health care personnel and pregnant women;

history of varicella based on diagnosis or verification of varicella disease by a health care provider;

history of herpes zoster based on diagnosis or verification of varicella disease by a health care provider;

Laboratory evidence of immunity or laboratory confirmation of disease (titer).

iv. Negative 2-step TB skin test (or chest X-ray)

v. Hepatitis B immunization series (strongly recommended) or signed waiver

vi. Optional Meningococcal vaccine

b. Written Proof of Flu Vaccine to be turned in prior to first clinical or wear N95

respirator during flu season (see the Flu Vaccination Policy Form)

c. Labette Community College Statement of Confidentiality/Social Media Conduct Form

d. Understanding and Release for Exposure to Infectious and/or Human Fluids Form

e. Waiver of Liability, Assumption of Risk and Indemnity –on/off campus activity Form

f. Videotape/photograph Consent Form

g. Health/Immunization/Safety sign off form

h. LCC Criminal Background Check and Release for Health Science Student Form

(background check will be processed upon acceptance to course)

i. Labette Health Criminal Background Verification Form

j. LCC Drug Testing Policy and Procedure and Signature Sheet (if under 18 will require an

additional form to be signed by a parent/guardian.

k. Shirt Order Form

l. Grit Test

Mailing Instructions for Application Packet: Application packets are now being accepted, and must be postmarked on or before August 13, 2019

to be considered eligible for admission into the Labette Community College EMT Course (pending

approval from the Kansas Board of EMS). The priority application deadline is August 1, 2019. Only

complete application packets will be processed. Missing information or documents will result in

processing delay or non-review of your application to the course. If an applicant is in the process of

completing application minimum requirement they can still be in consideration, however it is

contingent on them successfully fulfilling the requirements. Applicants that have fulfilled

requirements will have precedence over those that are in the process. Submission of false material

in this Application Packet will be grounds for non-admission, or if discovered after admission, grounds

for expulsion. It is recommended that application packets be sent by certified mail, or hand delivered

and date stamped on delivery.

Hand deliver or mail the complete EMT Course Application Packet to:

Labette Community College

Trudy Hill, R.N. Z215

Workforce Education, Career Training and Personal Enrichment

200 S. 14th

Parsons, KS 67357

Additional Help: Please refer to the application Check-Off Sheet found on the last page of this packet

and check-off as you complete each step to assist you with your application process. You may also

call Trudy Hill, R.N. Workforce Assistant at 620-820-1257 or the LCC Workforce Office 620-820-1273

to have questions answered.

Enrollment Procedure Once Acceptance into the EMT Course

1. Contact Melissa Bruce at 620-820-1273 to confirm enrollment

2. Come to the required orientation.

3. Make payment arrangements to cover the tuition costs and material fees of $300 for the class

with the business office prior to 1st class. $300 material fees are due by 1st night of class. No

exceptions to receive uniform and online registration for online lab and e-book

4. Go to Admissions to get your student ID card.

5. Review the EMT Handbook found online in the coursework area.

6. For additional information, please contact Trudy Hill, 620-820-1257 or the Workforce

Education Department at 620-820-1273

EMT Course Expenses

All students enrolled in the EMT Course are required to have basic health insurance for clinical/FI

participation. Students must maintain current coverage throughout the duration of their clinical/FI

experiences in the EMT course and understand that Labette Community College cannot assume any

liability or financial obligation for students’ health care and students are responsible for the cost of

their own illness or injury. It is the responsibility of the student to keep this policy active and up to

date. Labette Community College does not provide Student Health Insurance Plans. Information

regarding options for student health insurance can be found through the Labette Community College

website: Student Health Insurance Option Information.

Students are to assume financial responsibility for course-related costs including, but not limited to

transportation costs, registration fees, textbooks and supplies, and uniforms. See the table below.

Costs are subject to change.

Prior to Acceptance into the course [Item(s) and Expense]

2-step TB skin Test or T-spot if 2-step is not available (on your own)-$40 (variable) paid to

Provider

Required immunizations and completion of Health Record Form - (Variable) paid to Provider

Reading and Math Test - No cost at LCC

Prior to 1st Day of Class Once Accepted into Course [Item(s) and Expense]

Tuition (in state) paid directly to Business Office (2nd Floor Student Union): Per credit hour =

$54 Tuition/$51 fees = $105 per credit hour (Kansas Residents) = Total $1260. Subject to

Change

Required text and digital lab fee, 2 uniform shirts and cap, CPR card, liability insurance,

criminal background check fee: Total $300 (check , money order, or cash to LCC and brought

to orientation or Workforce Office. Subject to Change NON-REFUNDABLE

Uniform: black shoes, black socks, EMS black slacks and black belt (variable)

Photo ID: Free for 1st one.

Week 1 of the EMT Course

KSBEMS Application Fee (Completed online by each applicant) :$50

Approximately Week 4 of the EMT Course

Psychomotor Testing Fee (Non-refundable) –SKEMS/Region II. Required for each

examination: $125 Payable to SKEMS (money order or cashier’s check only)

Registration for National Exam at end of course

National Registry Application (Required for initial examination and each additional attempt of

the written exam -Non Refundable): $80 completed online-cannot be cash, check or money

order.

Other Expenses

Transportation Costs: (Variable)

Application Packet Check off Sheet CHECK-OFF LIST (Please check off all completed)

Step 1: (Before Application Deadline of August 13th) Check the Course Dates and Times to make sure you will be available to attend every class.

(Included in this packet).

Complete the Admissions Application (unless taken classes prior to this one). If you have

taken classes at LCC before call the Registrar and update your profile.

Call 620-820-1147 (Student Success Center) to schedule your reading and math test (free of

charge). After your test is complete, obtain a copy of the test results and include those with

this application packet or give to Trudy Hill in the Zetmeir Building Room Z215 to put on file.

Download this application packet and print all forms that will need to be read, filled out, and

signed. Contact your Primary Care Provider or Local Health Department to schedule a 2-step

TB skin test or T-spot. Please be aware the 2-step TB skin test is usually done on your inner

arm. A small needle is used to put some testing material, called tuberculin, under your skin. In

48 to 72 hours after the test is “planted,” a healthcare professional will need to read the test

by checking your arm to see if there is a reaction to the test. The two-step test means you

need to repeat this process within one to three weeks – in other words you will be tested on

both arms. You must receive “negative” results on both tests. The t-spot is a blood test. Copies

of the results should be brought to the campus with your application packet (room Z215 in

Zetmeir Building) or faxed to 620-421-4481, attention: Trudy Hill. A negative Chest x-ray for

TB is also acceptable.

In addition to the TB skin tests, schedule an appointment with your Primary Care Provider for

the completion of your Health Record (required form in packet) to confirm all immunizations

or proof of immunity to diseases (including a Tetanus/Diphtheria in the last 10 years, 2

MMR’s, Chickenpox immunity or vaccine, Hepatitis B Series of 3) and no latex allergies. Your

local health department may be of some help to provide information regarding these vaccines

as well.

Read, fill out and sign all forms that will need to be returned in the application packet.

Student Health Record and supporting documentation if test or immunization is

completed by a Health Care Provider in an alternate setting

o TB skin Test (1) [ ] TB skin Test (2) or T-spot

o MMR 1 [ ] MMR 2

o Hepatitis B Series (1) [ ] Hepatitis B (2) [ ] Hepatitis B (3) or Waiver

o Varicella Immunity

o TDaP within last 10 years

o Documentation of Latex Allergy or No Latex Allergy

Statement of Confidentiality/Social Media Conduct

Statement of Understanding and Release for Exposure to Infectious and/or Human Fluids

Waiver of Liability, assumption of Risk and Indemnity –On/Off Campus activity

Videotape/Photograph Consent

LCC Criminal Background Check and Release for Health Science Students

Labette Health Policy and Procedure Background Verification (complete policy upon

request). Please make sure to print your name on the verification form as well as signing

your name

Signature Sheet for the Drug Testing Policy and Procedure.

Health/Immunization/Safety statement

Shirt order form

Grit test (2 pages)

Reading Test results

Math Test results

Copy of your Driver’s License

Other:

If you decline the Hepatitis B vaccines you will need the waiver signed and returned

Flu vaccine form returned after immunization is available and prior to 1st clinical

Once the forms are complete, mail the completed packet to Labette Community College, Trudy

Hill, Workforce Education, Career Training and Personal Enrichment, 200 S. 14th, Parsons, KS

67357. If you are waiting for spacing of certain immunizations (such as Hepatitis B and the second

MMR) please go ahead and return the packet prior to completion of those immunizations. The TB

skin test results with the Health Record form need to accompany the application.

Step 2 (After Acceptance into the Course and before class begins) Call Melissa Bruce at (620)820-1273 to confirm enrollment

Obtain EMT slacks, belt, and shoes. You must have these the first day of class.

Bring $300 cash, money order, or check to LCC

Go to Business office or contact Business Office to make arrangements for payment of

tuition/fees (620) 820-1231

Go to Admission Office (2nd floor Student Union) to get your student ID card

Read EMT Handbook and Course Syllabus found online in your course shell

Mandatory Orientation on first night of class for prospective students (First class at Thiebaud

Theatre LCC)

Step 3 (Once classes begin) Orientation to online course material/lab

Review Labette Health HIPAA policy and sign off and any other forms for continuation in class.

Schedule for Clinical and FI dates

Flu vaccine form signed and returned prior to 1st clinical and upon availability of vaccine-

usually available around Sept – October (Flu vaccine for current year – for classes beginning in

late spring or summer will be based upon recommendation and hospital requirements)

Approximately week 1 pay $50 for KSBEMS application online

Approximately week 4 Pay $125 SKEMS/Region II Psychomotor Testing Fees (money order or

cashier’s check only) (Required for each examination)

Psychomotor testing Date: TBA

Register online to take National Registry exam with $80 credit card (no checks, money orders,

or cash) by Date: TBA

Recognition Night/Awards Date: TBA

Labette Community College-EMT Course Application

Please Print or Type All Information

FULL LEGAL NAME___________________________________________________________

DATE OF BIRTH _____________________STUDENT ID NUMBER ______________________

ADDRESS_____________________________CITY ________________ STATE ____________

TELEPHONE (HOME) _________________ (Cell) ________________ (OTHER) ___________

E-MAIL ADDRESS ___________________________________________________________

Please check the following questions that apply to you, choosing the best answers that describes your

current circumstances.

I do not hold any EMT certifications

I am a state of Kansas certified EMR

I am EMT certified in a state other than Kansas. Level of certification ______ State ______

I am a Registered Nurse or Licensed Practical Nurse

I do not hold any other health care licenses

I hold another healthcare professional license: _______________

I am a Member/Veteran of the U.S. Military/Branch _________________

Are you now or have you ever been enrolled at LCC (YES)_____ (NO)_____

I am a municipal employee at __________________________ Telephone #

________________

I am a volunteer Fire Fighter for ________________________

Emergency Contact Information

Name: ________________________________ Relationship:________________________________

Home Phone: ______________________ Street Address: __________________________________

Work Phone: ___________________________ City: ______________ State:_________________

Completion of this form and minimum course requirements does not constitute admission to the

course. Applicants will be notified by letter when they are accepted into the course.

"I certify that the information provided on this application is complete and accurate in every respect. I understand that falsifying any of this application may result in cancellation of admission." Signature of Applicant (Do Not Print): _____________________________________________

Date Application Received by Workforce Education (to be filled out by LCC employee)

Course Dates and Times

Course Dates and Times:

Tuesday, August 20 5:30-9:45PM

Thursday, August 22 5:30-9:45PM

Tuesday, August 27 5:30-9:45PM

Thursday, August 29 5:30-9:45PM

Tuesday, Sept 3 5:30-9:45PM

Thursday, Sept 5 5:30-9:45PM

Tuesday, Sept 10 5:30-9:45PM

Thursday, Sept 12 5:30-9:45PM

Tuesday, Sept 17 5:30-9:45PM

Thursday, Sept 19 5:30-9:45PM

Tuesday, Sept 24 5:30-9:45PM

Thursday, Sept 26 5:30-9:45PM

Tuesday, Oct 1 5:30-9:45PM

Thursday, Oct 3 5:30-9:45PM

Tuesday, Oct 8 5:30-9:45PM

Thursday, Oct 10 5:30-9:45PM

Tuesday, Oct 15 5:30-9:45PM

Thursday, Oct 17 5:30-9:45PM

Tuesday, Oct 22 5:30-9:45PM

Thursday, Oct 24 5:30-9:45PM

Tuesday, Oct 29 5:30-9:45PM

Thursday, Oct 31 NO CLASS

Saturday, Nov 2 8AM-4:30PM

Tuesday, Nov 5 5:30-9:45PM

Thursday, Nov 7 5:30-9:45PM

Tuesday, Nov 12 5:30-9:45PM

Thursday, Nov 14 5:30-9:45PM

Tuesday, Nov 19 5:30-9:45PM

Thursday, Nov 21 5:30-9:45PM

Saturday, Nov 23 8AM-4:30PM

Tuesday, Nov 26 NO CLASS

Thursday, Nov 28 NO CLASS

Tuesday, Dec 3 5:30-9:45PM

Thursday, Dec 5 5:30-9:45PM

Saturday, Dec 7 8AM-4:30PM

Tuesday, Dec 10 5:30-9:45PM

Thursday, Dec 12 5:30-9:45PM

STATEMENT OF CONFIDENTIALITY/SOCIAL MEDIA CONDUCT

As a student in a Labette Community College Allied Health course (Nurse Aide: Geriatric/C.N.A.,

Medication Aide/C.M.A., Emergency Medical Technician/E.M.T. or Home Health Aide/H.H.A.) I

understand that some of my education will involve access to resident/patient care, information and

records that are considered confidential and protected under HIPPA Guidelines.

I acknowledge my responsibility to respect the confidentiality of resident/patient records and guard

the privacy of any resident/patient by not revealing any information regarding that resident/patient

to anyone, and to act in a professional manner in the classroom, the clinical/FI setting, and in the

community.

I further understand that if I am found to be indiscreet with confidential material or fail to protect the

privacy of a resident/patient or others through my actions, I will be dismissed from the course. I

understand this action to be necessary in order to maintain the high professional standards of the

Allied Health care courses and integrity of Labette Community College.

To uphold the privacy of such information, I agree not to post or discuss any theory or clinical/FI

experience or information regarding my experience with the college or clinical/FI agency, its staff, or

its clients/patients on my internet social media (Facebook, Twitter, emails, MySpace, and any others

not mentioned). In addition, cell phones with camera capabilities are prohibited in patient care areas.

Statement of Understanding

I further understand if I violate the rules of the clinical facility, am involved in resident/patient abuse,

violence toward another individual, academic dishonesty, violation of confidentiality or any other

inappropriate behavior I will be removed immediately from the course.

I understand that while participating in clinical activities as part of LCC’s C.N.A., C.M.A., E.M.T. or

H.H.A. course, I will be subject to the rules and regulations of the clinical facility and could be subject

to drug testing at my own expense. If found positive in such drug testing, I will be subject to

discipline by the college under general rules of student conduct as outlined in the LCC Catalog.

Name:___________________________________________ (please print)

Signature: ______________________________________ Date: ________________

STATEMENT OF UNDERSTANDING AND RELEASE FOR EXPOSURE TO INFECTIOUS AND/OR HUMAN FLUIDS

I, _____________________________________ (Print Name), am a student at Labette Community

College (LCC) and am enrolled in the EMT Course. I acknowledge that I have been informed of the

following and that I understand the following:

1. That the health science program have enrolled in may involve exposure to human body fluids

and cell and tissue cultures that may carry infections such as HIV (Human Immunodeficiency

Virus) and Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)

2. That exposure to infectious blood and other body fluids and cultures by contact through eye,

mouth, blood, non-intact skin, or other method may put me at risk of contracting a blood

borne infection.

3. That to protect myself from exposure to blood and other body fluid and cultures, I will wear

protective apparel according to OSHA (Occupational Safety and Health Administration)

standards and comply with applicable policies of the College and any hospital or clinical

affiliate that I am attending.

4. That if I should become exposed by eye, mouth, blood, non-intact skin, or other method to

blood or other human fluids or cultures, I will immediately report such incident to the I/C or

Clinical/FI affiliate supervisor.

5. That if such exposure should occur, I hereby authorize the College or the Clinical/FI affiliate to

administer such immediate first aid as is deemed appropriate until medical help can be

obtained.

6. That I hereby release and hold harmless Labette Community College (LCC), its employees,

officers, agents, and representatives, including all hospital and clinical/FI affiliates, from any

liability for any and all injury, illness, disability, or death, including all costs for medical care,

resulting from my exposure to infectious blood or other human fluids or cultures or the

administration of emergency first aid after such exposure, during the course of my

participation in the health science program, whether caused by the negligence of the College

or otherwise, except that which is the result of gross negligence or wanton misconduct by the

College

Student Signature: _______________________________________

Printed Name: __________________________________________

Instructor Signature: _____________________________________

WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY – ON/OFF CAMPUS ACTIVITY

I, the undersigned participant, represent and warrant that I am an adult of 18 years of age or older

(parent signature included if under age 18), and have the legal capacity to enter into this Waiver of

Liability, Assumption of Risk and Indemnity Agreement (“Agreement”).

Waiver: In consideration of being permitted to participate in the Labette Community College EMT

course/activity to the extent permitted by law, I, for myself, my heirs, personal representatives or

assigns, do hereby release, waive, discharge, covenant not to sue, and agree to indemnify and hold

harmless Labette Community College, its officers, employees and agents (collectively the

“Indemnified Parties”) from any and all liability, loss, claim demands and possible causes of action

(including all costs and attorney’s fees incurred by the Indemnified Parties in enforcing this release

and indemnification agreement), that may otherwise accrue from any loss, damage or injury

(including death) to my person or property, in anyway resulting from, or arising in connection with, or

related to my participation in the Labette Community College EMT course/activity, whether or not

such injury or death is caused by negligence or from any other cause.

Assumption of Risk: Participation in Labette Community College EMT course/activity carries with it

certain risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks

vary from one activity to another, but the risks may include, but are not limited to: 1) minor injuries

such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss of sight, joint or

back injuries, heart attacks, and concussions; and 3) catastrophic injuries including paralysis and

death. I have read the previous paragraphs and I know, understand, and appreciate these and other

risks that are inherent. I hereby assert that my participation is voluntary and I knowingly assume all

such risks.

Governing Law and Severability: The construction, interpretation and enforcement of this

agreement shall be governed by the laws of the State of Kansas. The courts of the State of Kansas

shall have jurisdiction over this Agreement and the parties. The undersigned further expressly agrees

that this Agreement is intended to be as broad and inclusive as is permitted by the laws of the State

of Kansas and that if any portion thereof is held invalid, it is agreed that the balance shall,

notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk and

indemnity agreement, fully understand its terms, and understand that I am giving up my rights,

including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and

intend by my signature to be a complete and unconditional release to the greatest extent allowed by

law.

Signature: _______________________________________ Date: ________________________

Printed Name: ___________________________________

VIDEOTAPE/PHOTOGRAPH CONSENT

Videotape/photograph consent student signature page to be complete before course entry.

I, ______________________________________ give Labette Community College (LCC) EMT Course

consent to videotape/photograph/audiotape me during classroom, lab or off campus education

experiences for education purposes and for use in the promotion of future classes.

Student Signature: _____________________________________________Date: ______________

Printed Name: ________________________________________________

CRIMINAL BACKGROUND CHECK AND RELEASE FOR HEALTH SCIENCE STUDENTS Permission and Release Form

I authorize Labette Community College to release the results of any criminal background check to any site where I will be placed for any legitimate educational purpose and I waive my privacy rights under the Family Educational Rights and Privacy Act (FERPA) and consent to a background check for this limited purpose.

I hereby release Labette Community College from any liability in the event:

I am not cleared for placement by the clinical sites and therefore, cannot continue in the course.

I am unable to obtain the necessary credits to continue in the course due to a criminal charge or conviction that occurred after being accepted into the course.

I am unable to obtain licensure/certification in my field of study due to adverse results on a criminal background check.

I understand that I cannot be guaranteed placement at a clinical/FI site and if I cannot complete the clinical/FI requirements, I will not be able to complete the course.

Print Name: _______________________________________

Signature: ________________________________________ Date: _______________

Please submit this signed form as part of your application to the LCC EMT Course.

Procedure for Drug Testing

DRUG TESTING POLICY

FOR HEALTHCARE STUDENTS

Introduction It is the policy of Labette Community College that students who enroll in healthcare programs or

allied health courses including, but not limited to, Nursing, Respiratory Care, Radiologic Technology,

Physical Therapist Assistant, Diagnostic Medical Sonography, Dental Assisting Programs and Certified

Nurse Aide, Certified Medication Aide, and Pharmacy Technician Preparation for Exam courses

submit to drug and/or alcohol testing when required by a clinical facility, a specific healthcare

program policy, or as directed by a reasonable cause event.

Purpose Students in LCC Healthcare Programs and Allied Health Courses must adhere to the standards of conduct

required of healthcare professionals. No student will be allowed in the classroom or clinical area while under

the influence of drugs or alcohol. This policy is consistent with the “Student Code of Conduct Policy” in the LCC

Catalog-- http://www.labette.edu/catalog/conduct.html. Healthcare students found to be involved in any of

these activities are subject to disciplinary action up to and including dismissal from their respective healthcare

programs.

Labette Community College Healthcare Programs strive to ensure the health and safety of students and

patients are not compromised. Education of healthcare students at Labette Community College requires

collaboration between the college and clinical facilities and cannot be complete without a quality clinical

education component, generally referred to as a clinical rotation. Clinical facilities are increasingly required by

their accrediting agencies, including The Joint Commission (TJC), to provide a drug screen for security purposes

on individuals who supervise, care, render treatment, and provide services within the facility, therefore,

clinical facilities may require a negative drug screen on each student prior to that student arriving for his/her

clinical rotation.

PROCEDURE FOR DRUG TESTING

HEALTHCARE STUDENTS

Consent to drug testing The student must provide written consent to provide specimens for the purpose of analysis. If the

student is under eighteen (18) years of age, the student’s parent or legal guardian must sign the drug

testing consent form in addition to the student.

Refusal to be tested The program director shall be notified of any refusal to be tested. In the case of a pre-clinical test or

if there is reasonable suspicion of impairment in a clinical situation, refusal to submit to drug testing

will result in ineligibility to complete the required clinical rotation and the student will receive a grade

of “F” for that clinical rotation. Refusal to submit to any drug screening (classroom, pre-clinical or

clinical) will result in disciplinary action up to and including termination from the program.

Pre-Clinical Testing Students assigned to a site requiring drug screening must submit to testing. Pre-clinical drug testing

will be done at Labette Health in Parsons, KS. Labette Health is accredited by HFAP (Health Facility

Accreditation Program). Students must complete an “Authorization for Testing and Release of

Records” form available in their respective program offices. Before the clinical rotation begins, a

copy of the signed consent form must be returned to the program director or clinical coordinator to

be maintained in the student’s program file. To be tested, Labette Health requires student

identification with current photograph and a copy of the completed form.

The drug screen vendor will perform a specimen validity check, testing, and reporting in accordance

with their policies and the policies of Labette Community College Healthcare Programs. This policy is

available for student review in each LCC healthcare program student handbook.

*Based on individual program policies, the cost of the pre-clinical drug tests will be paid by the

student as part of the course materials fee, or the student may be required to make payment as

services are rendered. Only drug tests conducted by labs approved by the program director will be

accepted.

Reasonable Cause Testing Students may be asked to submit to a drug and/or alcohol test based on a reasonable suspicion that

their ability to perform work safely or effectively may be impaired. Factors that individually or in

combination could result in reasonable suspicion drug testing include, but are not limited to, the

following:

Direct observation of an individual engaged in drug- and/or alcohol-related activity;

Unusual, irrational or erratic behavior or a pattern of abnormal conduct;

Unexplained, increased or excessive absenteeism or tardiness;

Sudden changes in work or academic performance;

Repeated failure to follow instructions or operating procedures;

Violation of LCC or clinical facility safety policies or failure to follow safe work practices;

Unexplained or excessive negligence or carelessness;

Discovery or presence of drugs in a student’s possession or near a student’s work area;

Odor or residual odor peculiar to some drugs;

Involvement in an accident that results in injury to the student or another person while on campus or

at a clinical site;

Secured drug supply disappearance; or

Information provided either by reliable or credible sources or independently corroborated.

The student is responsible for the cost of any “reasonable suspicion” drug and/or alcohol test and

must make arrangements for payment with the provider prior to testing.

Verified evidence that a student has tampered with any drug and/or alcohol test will result in

disciplinary action up to and including termination from the program.

PROCEDURE FOR DRUG TESTING

HEALTHCARE STUDENTS

If a student is suspected of being impaired by drugs or alcohol in the clinical area:

The clinical instructor from the facility will attempt to notify the program director immediately.

The clinical instructor and one other professional staff person will complete written

documentation describing the impaired behavior observed.

The student cannot leave the site until a drug screening consistent with the policy of that site has

been completed and a program representative, family member, or friend arrives to transport the

student.

Once dismissed, a student cannot return to the clinical site until the results of the drug screen

have been verified as “negative” by the program director.

Results of the drug test will be sent through secure channels to the program director and he/she

will inform the student. If the result of the drug screen is negative, the student may continue in

the program. If the results are positive, the student will be terminated from the program.

In the event a student is suspected of being impaired while attending clinicals at a facility that does

not provide drug testing, the program director will determine the lab, and the clinical instructor (or a

designated program representative) will transport the student.

If a student is suspected of being impaired by drugs or alcohol in the classroom:

The classroom instructor will attempt to notify the program director immediately. The classroom instructor and one other professional staff person will complete written

documentation describing the impaired behavior observed.

The student must complete an “Authorization for Testing and Release of Records” form available in the respective program office. A copy of the signed consent form must be returned to the program director or clinical coordinator to be maintained in the student’s program file.

The student will be transported to Labette Health by a program representative. Labette Health requires student identification with current photograph and a copy of the completed form.

The student cannot leave Labette Health until the drug screen is completed and the program representative, a family member, or friend must transport the student.

The student may not return to the classroom until the results of the drug screen have been verified as “negative” by the program director.

Results of the drug test will be sent through secure channels to the program director and he/she will inform the student. If the result of the drug screen is negative, the student may continue in the program. If the results are positive, the student will be terminated from the program.

In the event a student is suspected of being impaired while attending class at the Cherokee Center,

the student will be transported to Via Christi Medical Center in Pittsburg, KS for testing by the

classroom instructor or a designated program representative.

Cost of the drug and/or alcohol test for reasonable suspicion is the responsibility of the student. Payment

must be made to LCC in the program office prior to testing at Labette Health or before services are rendered at

Via Christi Medical Center.

Failure to pay for a reasonable suspicion drug test is considered a refusal to test and will result in

termination from the program.

PROCEDURE FOR DRUG TESTING

HEALTHCARE STUDENTS

**Medical review of positive drug test results Specimens are screened by immunoassay. Positive results are confirmed by gas chromatography

with mass spectrometry (GC/MS) or liquid chromatography with tandem mass spectrometry

(LC/MS/MS). All specimens identified as positive on the initial test shall be confirmed by the testing

laboratory at no additional charge to the student. Any positive test result will be reviewed by the

vendor’s Medical Review Officer (MRO). A Medical Review Officer, who shall be a licensed physician

with knowledge of substance abuse disorders, shall review and interpret positive test results.

The MRO shall: Examine alternate medical explanations for any positive test results. This action may include

conducting a medical interview and review of the student’s medical history or review of any other

relevant biomedical factors.

Review all medical records made available by the tested student when a confirmed positive test

could have resulted from legally prescribed medication. Prior to making a final decision on the

results of the confirmed positive test, the MRO shall give the student an opportunity to discuss

the results. The MRO may contact the student directly to discuss the results of the test. The

student will be given the opportunity to discuss any prescription medications he/she is currently

taking, and written documentation from the prescribing physician will be required to support this

statement.

Some facilities may require the student to complete a form listing all legally prescribed

medications they are taking prior to testing.

Reporting of drug test results Notification of drug screening results can only be delivered in a manner that insures the integrity,

accuracy and confidentiality of the information. Written notification indicating either a “NEGATIVE”

drug screen or “CONFIRMED POSITIVE” shall be provided by the drug screen vendor to the

appropriate program director at Labette Community College as soon as possible following initial

testing and a copy will be placed in the student’s secured file. Results of student drug screens will be

reported to the student as soon as possible after they are received. Test results will not be released

to any individual who has not been authorized to receive such results. Students shall not be allowed

to hand deliver any test results to college representatives. They may be provided to a contracted

clinical facility upon request. Results of any student’s drug screen will be shared only on a need to

know basis with the exception of legal, disciplinary or appeal actions which require access to the

results.

PROCEDURE FOR DRUG TESTING

HEALTHCARE STUDENTS

Readmission Substance abuse is a recognized illness for which prompt treatment should be undertaken. Information

regarding available resources can be found in the LCC Alcohol/Drug-Free Campus Policy—

Any student, who fails or refuses to submit to a drug test, or admits to the use, possession, or sale of

illegal substances, will be immediately dismissed from the respective program, and the dismissal will

be considered a clinical failure. If the student is a licensed practitioner, admission of use, possession,

or sale of illegal substances and/or a positive drug screen will be reported to the licensing agency, as

required by law. Conviction of any criminal drug statute while enrolled in a healthcare program or

allied health course at Labette Community College will be grounds for immediate dismissal from the

program or course. The student will not be eligible for readmission.

A student may contest disciplinary action based on a drug test result or refusal to submit to a drug

test by following the procedure set forth in the Student Grievance Procedure in the LCC Catalog—

For confidential information regarding treatment for drug abuse contact:

Tammy Fuentez

Vice-President of Student Affairs

tammyf@labette.edu or 620-820-1264

(Office--Student Union Building, SU220)

*COST OF TESTING AT LABETTE HEALTH--basic drug test required by most clinical sites--$22; 10-panel

screen that includes tricyclic antidepressants--$56; breath alcohol test--$27.

**DRUG CATEGORIES TO BE TESTED—amphetamines, barbiturates, benzodiazepines, cocaine

metabolites, phencyclidine, propoxyphene, marijuana metabolites, methadone, opiates, oxycodone,

and creatinine—urinary. This list of tested drugs is subject to change. Testing for additional

substances may occur based on clinical affiliation agreement requirements

Signature Sheet

I have received a copy of and have been given the opportunity to ask questions about the Labette

Community College Policy and Procedure for Drug Testing Health Science Students. As a Health

Science Course or Allied Health Course student I understand and agree that I am subject to drug and

alcohol testing at any time and understand the consequences of a positive drug or alcohol test.

Printed Student Name: ____________________________________

Student Signature: ________________________________________

Date: ______________________________

Course/Course Witness: ____________________________________

Date: ______________________________

HEALTH/IMMUNIZATIONS/SAFETY

The I/C, Lab Instructor(s), and/ or preceptor(s) will oversee all student performance, in both the

classroom and clinical setting. Each student will address any problem or concern that s/he may have

regarding his/her safety immediately to the individual directly involved with the training at hand.

All students will perform with normal regard for personal safety as well as the safety of patients and

others involved with the patient care. At NO TIME will the student perform any action that s/he or

the preceptor deems unsafe or that the student/preceptor feels inappropriate action for the student

to take.

Any student that has an infectious disease (common cold, flu, hepatitis, AIDS, etc.) will not be allowed

to participate in practical skill stations. These students will be expected to attend class and observe

others in the practical stations. In the event there is enough equipment such student may be given a

set of their own to work with. The student will make up practical time at the discretion of the

I/C. The student will be held responsible for the instruction.

Any disease that requires the student to miss two or more classes will be required to have a medical

release by a physician before being allowed to return to class. This will also apply to injuries that

preclude the student from taking practical examinations.

Any student with a history of chronic health problems, pregnancy, recent surgery, or back injury, will

be required to present a medical release by a physician. The I/C has the option at all times to request

such a release at his or her discretion.

Any time the student suffers an injury while functioning as an EMT student, the student will

immediately report the occurrence to the preceptor who will in turn make a report to the I/C. A

written incident report of the occurrence must be made within 48 hours.

All students must exercise prudent physical exertion in the classroom, during labs and during clinical

rotations. All equipment will be properly cleaned with disinfectant after each student’s use. Due to

the nature of the training, it is imperative that all students maintain proper personal hygiene habits.

Students will take pride in the equipment provided for their use. Equipment and supplies are

expensive and at times difficult to obtain. The equipment is of no use if it has been abused or

damaged. Any student that intentionally misuses equipment shall be disciplined appropriately. If any

equipment is accidentally broken or is found inoperative, the student shall report the incident to the

instructor immediately.

It is the responsibility of all class participants, instructors, and assistants to insure that equipment is

cleaned and put away in a neat and orderly manner after each class.

At NO TIME will a student, while participating in clinicals, be allowed to drive any ambulance

The clinical/Field experience for students may require prolonged standing and walking; frequent

heavy lifting, pushing, pulling, carrying, occasional climbing, stooping, balancing, kneeling, constant

need for good vision and hearing; ability to tolerate stressful situations; and occasional exposure to

hazardous material. Students should be able to lift 125 lbs. (250 with assistance). All students must

exercise prudent physical exertion in the classroom lab sessions and in the clinical/FI setting using

techniques taught in this class for lifting and moving patients.

Additional safety policies and procedures are included in the EMT student handbook.

I have read the above requirements and understand that my inability to comply with these may result

in my failure to complete the EMT course.

Student Name (Printed):______________________________________

Student Signature: __________________________________________

Date: ___________________________

Flu Vaccination Policy

In cooperation with Labette Health, the EMT course will require EMT students to either accept the flu

vaccine or sign a waiver of refusal and accept responsibility to wear an appropriate mask during all

patient contact for the designated flu season.

At the beginning of flu season the forms will be made available. If the student chooses to accept the

flu vaccine, it will be the student responsibility. In the event that the flu clinics do not offer

paperwork to verify that you have received the vaccine, a form will be provided from LCC Workforce

Education department to have signed by the person administering the vaccine. If the decision is made

to decline the flu vaccination there will be a waiver that you will complete and sign. Understand that

by completing this waiver you assume responsibility to ensure safety of patients and infection

control. You will be required to wear the appropriate mask while in all patient contact, regardless of if

you have any symptoms; as required by the clinical facility. The “flu season” will be determined by

the CDC guidelines. Either the completed vaccine form, or the refusal waiver will be required during

the designated times to be eligible for clinical clearance. The form should be submitted to the lead

instructor.

Revision 4.1.12; 10/8/12

Flu Vaccination Form

I verify that _______________________________, EMT Student has received the influenza vaccine.

Date: _____________________

Person Administering Vaccine: ___________________________________

Facility Providing the Vaccine: ____________________________________

Thank you for your assistance in tracking the student’s vaccination status. This vaccination is a

requirement for LCC EMT students to ensure the safety of our patients during flu season.

Flu Vaccination Waiver

I, ______________________________ verify that I have chosen to refuse the influenza vaccine that is

required for LCC EMT students to ensure safety for our patients during flu season. I understand that

by completing this form I understand that it is my responsibility to provide an equal level of safety

and protection for the patients. I will be responsible for wearing an appropriate mask while in all

patient care areas, regardless of if I have any physical symptoms of the flu. I will be required to do

this through the dates of “flu season” as set by the Centers for Disease Control. Refusing to wear the

appropriate mask while in patient care areas during clinical would result in an unsatisfactory grade in

clinical for each day.

Signed:______________________________________

Date:_______________________________________

WAIVER OF HEPATITIS B IMMUNIZATION

Hepatitis B – is a major cause of viral infection; it results in swelling, soreness, and loss of normal liver

function. Signs and symptoms include flu like symptoms such as fatigue, weakness, nausea,

abdominal pain, headache, fever, and possibly jaundice. Hepatitis B virus can survive for at least one

week in dried blood or on contaminated surface and may be transmitted through contact with these

surfaces. Caution must be taken to avoid contact with any blood or other fluid that potentially

contains a blood-borne pathogen.

Decline the Hepatitis B Vaccine

I understand that due to my occupation exposure to blood or other potential infectious material, I

may be at risk of acquiring hepatitis B virus (HBV) infection. I have read the informed statement on

the potential risk and consequences with contraction of hepatitis B. However, I decline to get the

hepatitis B vaccination at this time. I understand that by declining this vaccine, 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 want to be vaccinated with hepatitis B vaccine, I

may do so at my cost.

Student Name: _____________________________________________

Student Signature: __________________________________________

Date: _________________________________

Shirt Order (Due with application)

Name: _____________________________Telephone Number: _______________________

Size of Polo:

[ ] Small [ ] Medium [ ] Large [ ]X-Large [ ] XXL [ ] 3XL

Size of T-Shirt:

[ ] Small [ ] Medium [ ] Large [ ]X-Large [ ] XXL [ ] 3XL

Optional Extra Shirts (Must be paid at the time of order)

Please order ____________extra polo shirts @ $35 ea. Size _____ (XX-large add $2.00 each)

Please order ____________ extra T-shirts @ $17 ea. Size ______ (XX-large add $2.00 each)

Total paid for extra t-shirt/polo =________________Paid to: ____________________________

Labette Health EMS/LCC Jan 2017

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13- Item Grit Scale

Name _____________________________________________________

Are you a first responder/ municipal employee? Yes No

Directions for taking the Grit Scale: Please respond to the following 13 items. Be honest – there are no right or wrong answers!

1. I have overcome setbacks to conquer an important challenge. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 2. New ideas and projects sometimes distract me from previous ones. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 3. My interests change from year to year. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 4. Setbacks don’t discourage me. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all

Labette Health EMS/LCC Jan 2017

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5. I have been obsessed with a certain idea or project for a short time but later lost interest. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 6. I am a hard worker. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all

7. I often set a goal but later choose to pursue a different one.

Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 8. I have difficulty maintaining my focus on projects that take more than a few months to complete. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 9. I finish whatever I begin. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all

Labette Health EMS/LCC Jan 2017

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10. I have achieved a goal that took years of work. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 11. I become interested in new pursuits every few months. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 12. I am diligent. Very much like me

Mostly like me

Somewhat like me

Not much like me

Not like me at all 13. What color do you like the best? Blue

Black

Red

Purple

Green

Labette Health EMS/LCC Jan 2017

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Labette Community College Student Health Records

Student Health Record must be completed by one of the following: MD, DO, APRN, or PA

Please collect your immunization records and bring them to your physical examination with your Primary Care Provider. They must sign this form below, and will verify you have the requested

tests, immunizations, or titers.

PROCEDURE/VACCINATION RESULTS COMMENTS

1. TB SKIN TEST: 2-Step Required

Results documented cannot be “negative”,

must be documented in “0 mm”.

Or

T-Spot or TB Gold Blood Test

If TB Skin test cannot be performed, you may

do a T-Spot or TB Gold blood test.

1st Step TB 2nd Step TB If Positive

Negative:

mm Negative: mm Date of Chest X-Ray:

Positive: mm Positive: mm Chest X-Ray Result:

Date Read: Date Read:

If you have received a TB skin test within the last year a 1-

Step TB may be all that is required with verification of the 1st

one. Please contact the Program Assistant for details.

Negative TB will be documented yearly.

Initials: Initials:

Negative: Date Read:

Positive: Initials:

2. MMR:

Two doses of MMR vaccine required or

EVIDENCE OF TITERS (Mumps, Rubeola,

and Rubella):

Titers: results must be documented as

“immune” or “not immune.”

Mumps 1st: Date: Initials:

If you cannot show proof of 2 doses of MMR vaccine, positive

Rubeola & Rubella, or titer you are required to get a MMR

Booster.

Mumps 2nd: Date: Initials:

Rubeola & Rubella: Date: Initials:

MMR Booster Date: Initials:

3.

HEPATITIS B SERIES

(or signed waiver):

Titers: results must be documented as

“immune” or “not immune.”

Hepatitis B

1st Date:

Initials:

If your series of 3 Hep B vaccinations will not be completed

prior to starting the program in which you have been selected

you must sign the waiver.

2nd Date:

Initials:

3rd Date:

Initials:

Titer: Date

Initials:

4.

VARICELLA (Chicken Pox)

Two doses of Varicella or Titer.

Titers: results must be documented as

“immune” or “not immune.”

Varicella 1st Date

Initials:

Titer may be used to show immunity for Varicella. Results

must be recorded as “immune” or “not immune” If immunity

cannot be proven, then the vaccination must be taken.

2nd Date: Initials:

Titer: Date: Initials:

5. TETANUS SHOT (TDaP):

Tetanus Shot must have been given within last ten (10) years

Date last tetanus shot given:

____________________________Latex Allergy Yes ____ No______

Student must read the following statement, sign, and date below: To the best of my knowledge, the information above is correct and accurate, and I do not currently have a communicable disease that would

put clients or patients at risk. I hereby grant permission to the Labette Community College Healthcare Program in which I am enrolling in to release this information to agencies at which I have practicum or

clinical experiences.

Student

Student Date:

Signature Print

Primary Care Provider must read the following statement, sign, and date below.

I have reviewed the available records and agree that there is no evidence that the student currently has any of the above communicable diseases that would put clients or patients at risk.

Healthcare

Provider

Healthcare

Provider Date:

Signature Print

(MD, DO, APRN, PA only) 05:24:10; Rev’d 08:05:10; 11:01:10; 11:30:10; 04:18:18; 5:9:18

Labette Health EMS/LCC January 2017 Application Packet