Lone Star College – North Harris EMS Professions

Submission Information

Completed applications should be submitted to Madeleine Denison, Health and Human Services Academic Advisor, located in Winship 174G. Before meeting with Madeleine Denison, students must meet with Kellie Jones, clinical scheduler, by making an appointment to review completed immunization records, background check, and health care records. Kellie can be reached at 281-618-5764 or at Kellie.R.Jones@lonestar.edu. The last day to meet with Kellie is Tuesday June 25

th for application submission by July 1st.

Completed applications should be submitted to Madeleine no later than July 1

st proceeding the Fall semester

for which admission is desired. An appointment is not necessary when dropping off the program application. Please note, applications will NOT be accepted if students have not met with the clinical scheduler. Completed applications will be accepted after the deadline based on program availability.

Program Contact Information Lone Star College-North Harris EMS Professions 2700 W. W. Thorne Drive Houston, Texas 77073 281-618-5781 http://www.lonestar.edu/ems-dept-northharris.htm

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Lone Star College – North Harris EMS Professions

Application for Admission to the Advanced EMS Professions Program

APPLICATION COVERSHEET (Do not complete this application for EMT-Basic courses)

APPLICANT INFORMATION

Last Name First Middle

Date of Birth Social Security No. Student ID No.

APPLICANT CHECKLIST

I have reviewed the EMS Professions admissions requirements.

I have applied and gained admission to the Lone Star College System.

I have consulted with a college counselor or academic advisor and meet the TSI (reading, writing, and math prerequisites) requirements of the program, if required.

I have reviewed the Texas Department of State Health Services Functional Job Description (included in this application packet)

HAVE YOU ATTACHED THE FOLLOWING DOCUMENTS?

Even if you have provided the below information to the college upon admission, the EMS Professions program still needs a copy for your official EMS student file. All transcripts for the EMS Professions student file can be simple photocopies and UNOFFICIAL in nature.

Documentation of high school diploma or GED

Copies of all relevant academic transcripts: high school, college or university, military service schools, and other (proprietary schools)

A resume or curriculum vitae showing work history with emphasis on EMS or other health care experience

Documentation of EMT or EMT-Intermediate certification or NREMT Registration (Students who currently are enrolled in an EMT course or who have completed EMT course work and are engaged in the credentialing process should complete the form included in this application packet)

Completed LSCS Immunization Form included in this application packet—Reviewed by Clinical Scheduler

Completed LSCS Health History and Physical Forms included in this packet—Reviewed by Clinical Scheduler

Copy of the background check results from CertifiedBackground.com (Directions included in this application packet)---Reviewed by Clinical Scheduler

Copy of Texas Driver’s License or official state ID

Prepay for drug screen from an approved vendor and proof of payment (Directions included included

Proof of successful completion if the American Heart Association’s Basic Life Support for Health Care Providers within the previous year.

Completed and notarized EMS Professions FERPA form included in application packet

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Lone Star College – North Harris EMS Professions

Application for Admission to the Advanced EMS Professions Program

APPLICATION FOR ADMISSION

Date of Application

Program Goal Associate of Applied Science Paramedic Certificate Intermediate Certificate

APPLICANT INFORMATION

Last Name First Middle

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

Date of Birth Social Security No. Student ID No.

Do you hold TDSHS or NREMT EMT credentials?

YES NO If no, have you successfully completed an initial EMT-Basic course?

YES NO

Have you previously attended Intermediate or Paramedic training?

YES NO If yes, when and where?

Have you ever been convicted of a felony, Class A, or Class B misdemeanor?

YES NO If yes, list all convictions and dates.

Have you ever had a professional license or certification revoked, suspended, or subjected to other disciplinary proceedings?

YES NO If yes, list all actions and dates.

EMERGENCY CONTACT INFORMATION

Last Name First Relationship

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

EDUCATION

CPR Agency Exp. Date Course Director

EMT-Basic TEXAS Exp. Date Course Director

NREMT NREMT Exp. Date Course Director

EMT-Intermediate/AEMT TEXAS Exp. Date Course Director

NREMT-Intermediate/AEMT NREMT Exp. Date Course Director

OTHER____________ Agency Exp. Date Course Director

OTHER____________ Agency Exp. Date Course Director

EDUCATION

High School or GED

Address

From To Did you graduate? YES NO Degree

College Address

From To Did you graduate? YES NO Degree

College Address

From To Did you graduate? YES NO Degree

Trade or Professional Address

From To Did you graduate? YES NO Degree

RELEVANT EMS/MEDICAL EMPLOYMENT OR VOLUNTEER HISTORY

Company Phone ( )

Street Address Supervisor

City State ZIP

Job Title From to Hours per week

Responsibilities

Company Phone ( )

Street Address Supervisor

City State ZIP

Job Title From to Hours per week

Responsibilities

DISCLAIMER—INITIALS AND SIGNATURE

___Criminal History: Applicants who wish to become certified or licensed with the Texas Department of State Health Services and/or the National Registry of EMTs need to be aware that any criminal history may prevent them from such action. The Lone Star College System’s EMS Professions programs are not able to, or responsible for, advising a student with criminal history on whether they are eligible for certification or licensure. All questions regarding eligibility should be directed to both the Texas Department of State Health Services and the National Registry of EMTs. ___ Clinical Requirements: Texas mandates required immunizations for all EMS Professions students. Criminal background checks utilizing an LSCS approved vendor are required of all students who attend a clinical rotation. Standards for the background check are established by our clinical affiliates. Clinical affiliates require completion of satisfactory drug screenings. Additionally, clinical affiliates may require personal medical insurance, and additional immunizations. ___College Admission: This application is intended for program purposes ONLY and does not constitute application to the college or college system. To be admitted to the EMS Professions program, applicants must first meet all entrance requirements for and be properly admitted to Lone Star College. Successful admission to Lone Star College does not constitute automatic admission or enrollment in the EMS Professions program. ___I certify that I have read and understand the admission requirements for the EMS Professions program. Additionally, I certify that the information given in this application packet is complete and correct. Falsification or omission may subject me to admission disqualification or immediate dismissal from the EMS Professions program and/or LSCS.

Signature Date

Have you now, or ever had:

Yes

No

Varicose Veins

Kidney/Bladder Trouble

Menstrual Trouble

Foot Trouble

Sprained/Strained Back/Ruptured Disc

Arthritis/Painful/Swollen Joints

Back Trouble/Injury/Unable to lift 50 lbs

Epilepsy/Fits/Seizures

Frequent Dizziness/Fainting

Nervous Breakdown/Memory Loss

Eating Disorder/Bulimia/Anorexia

High/Low Blood Sugar/Diabetes

Take any Prescribed Medication Regularly

*Allergies/Reactions to Medications/Drugs

HEALTH HISTORY (This Page To Be Completed By Student)

Name: Date:

Address: Age:

City/State/Zip:

Sex:

DOB:

Telephone: Program Applying For: (circle one)

Physician: Rad Tech Pharm Tech OTA/PTA

Hospital of Choice: EMS Nursing Surg Tech

Should any condition change during enrollment, it is your responsibility to notify the department. Answer each of the following questions truthfully. Falsification of information will result in dismissal.

Have you now, or ever had:

Yes

No

Frequent Headaches/Migraines Eye, Ear, Nose, Throat Trouble Difficulty in Hearing Wear Contacts/Glasses Sinus Trouble/Frequent Colds Asthma/Difficulty Breathing Lung Trouble/Pneumonia Chest Pains Rheumatic Fever Heart Disease/ Murmur Hepatitis/Jaundice Hernia/Rupture Excessive Bleeding from Cuts Thyroid Disease

List All Medications Taken Regularly:

*Please Specify Any Drug Allergies: Do you have any serious illness/injury not listed above, or do you have any present concern pertaining to your health which may interfere with activities of the health care program to which you are applying? Yes (If yes, please explain)

No

In Case of Emergency, Please Notify: Home Phone:

Work Phone:

Name Relationship

I certify that all of the above information is true and correct to the best of my knowledge. Date: Signature:

Lone Star College System Physical Examination

Name Age Date

C O

M P

L E

T E

P H

Y S

I C

A L

Height Weight B/P / Pulse

Vision R 20/ L 20/ Corrected: Yes No Pupils

Normal Abnormal Findings Initials

Cardiopulmonary

Pulses

Heart

Lungs

Skin

Abdominal

Genitalia

Musculoskeletal

Neck

Shoulders

Elbow

Wrist

Hand

Back

Knee

Ankle

Foot

Other

Clearance: A. Cleared

B. Cleared after completing evaluation/rehabilitation for:

C. Not cleared for:

Lifting / Transferring 50 lbs / Carrying 25 lbs. Reaching / Stretching / Bending

Pushing 100 lbs Standing / Walking for 8-12 hours

Due to:

Recommendation: I certify that I have examined this individual and have found no condition(s) that would appear to

prevent him/her from participating in all activities of the Program. Further, I have found no condition, which might represent a potential hazard to the health of other students or to that of

clients/employees in clinical facilities.

Date Phone # Physician Signature

PRINT NAME OF PHYSICAN and ADDRESS

Lone Star College System

Emergency Medical Services Professions

DOCUMENTATION OF REQUIRED IMMUNIZATIONS

Name: __________________________________________________________________________ (Last) (First) (MI)

Date of Birth: ____________________ SS#: _XXX-XX-___________ Enrollment Date: _________ All students enrolled in health related courses that have or will have any direct patient contact must show proof of the following immunizations prior to starting the clinical component of their course.

MEASLES MUMPS RUBELLA: Healthcare provider signature verifying record of date of illness or two (2) DOSES on or after first birthday or a laboratory report of a positive titer.

Date of Illness Date of MMR #1 Date of MMR #2 Date of TITER Healthcare Provider Signature

ATTACH LAB REPORT

TB TEST: Negative PPD or Quantiferon-TB Gold Test is required upon admission and yearly thereafter. Students with a history of a positive PPD test should obtain a chest X-ray or a negative Quantiferon-TB Gold Test.

Test Date Results of Test Date of Chest X-ray Results of X-ray Healthcare Provider Signature

PPD or GOLD

ATTACH REPORT

DIPHTHERIA-TETANUS-PERTUSIS: All students must submit proof of a booster shot within the past three years or TDaP if taking now.

Type of Vaccine Date of Booster Vaccine Healthcare Provider Signature

TD or TDaP

CHICKEN POX: Two varicella injections or titer (attached). Date of Varicella #1 Date of Varicella #2 Date of TITER Healthcare Provider Signature

ATTACH LAB REPORT

SEASONAL INFLUENZA: Required for Fall/Spring.

Date of Vaccine Healthcare Provider Signature

HEPATITIS B: All students must submit proof of series or serum antibody titer. Date of Vaccine Healthcare Provider Signature

Hepatitis B Vaccination #1

Hepatitis B Vaccination #2

Hepatitis B Vaccination #3

Date of TITER

ATTACH LAB REPORT

22 February 2011

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STUDENT INSTRUCTIONS FOR LONE STAR COLLEGE

NORTH HARRIS – EMS PROFESSIONS

About CertifiedProfile

CertifiedProfile is a secure platform that allows you to order your background check online. Once you have placed your order, you

may use your login to access additional features of CertifiedProfile, including document storage, portfolio builders and reference

tools. CertifiedProfile also allows you to upload any additional documents required by your school.

Order Summary

Required Personal Information

In addition to entering your full name and date of birth, you will be asked for your Social Security Number, current

address, phone number and e-mail address.

Payment Information

During the online order process you will be prompted to enter your Personal Identification Number (PIN).

Place Your Order

Go to: www.CertifiedBackground.com and enter package code: LD69

You will then be directed to set up your CertifiedProfile account.

View Your Results

Your results will be posted directly to your CertifiedProfile account. You will be notified if there is any missing information needed in

order to process your order. Although 95% of background check results are completed within 3-5 business days, some results may take

longer. Your order will show as “In Process” until it has been completed in its entirety. Your school's administrator can also securely

view your results online with their unique username and password.

If you have any additional questions, please contact Student Support at 888-914-7279

or email studentservices@certifiedprofile.com.

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Welcome to the Drug Screening Registration

site for LSC - North Harris College

The following webpage will guide you through the quick and easy process of fulfilling your drug test

requirement. As part of the admission process, all students are required to complete this specific drug test.

This is done in order to obtain access to clinical rotation. SurScan has been chosen to provide this service for

all incoming students.

http://www.surscan.com/nhc2030.html

The process is simple:

1. You will enter the requested personal and payment information (we accept most credit cards).

2. After you have submitted your registration (step 1), you will receive an e-mail that is your "Auto-

Receipt". Be sure to keep this for your records.

3. Once you have registered on-line you have completed everything you need to do for your drug test.

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http://www.dshs.state.tx.us

1100 West 49th Street Austin, Texas 78756-3199

512/458-7111

FUNCTIONAL POSITION DESCRIPTION

ECA EMT EMT-I EMT-P

Introduction We are providing the following position description for ECA/EMT/EMT-I/EMT-P. This should guide you when giving advice to anyone who is interested in understanding what qualifications, competencies and tasks are required of the ECA/EMT/EMT-I/EMT-P. Qualifications: Successfully complete a department approved course. Verification of skills proficiency and achievement of a passing score on the written certification examination. Must be at least 18 years of age. Generally, the knowledge and skills required show the need for a high school education or equivalent. Ability to communicate verbally; via telephone and radio equipment; ability to lift, carry, and balance up to 125 pounds (250 with assistance); ability to interpret written, oral and diagnostic form instructions; ability to use good judgment and remain calm in high-stress situations; ability to be unaffected by loud noises and flashing lights; ability to function efficiently throughout an entire work shift without interruption; ability to calculate weight and volume ratios and read small print, both under life threatening time constraints; ability to read English language manuals and road maps; accurately discern street signs and address numbers; ability to interview patient, family members, and bystanders; ability to document, in writing, all relevant information in prescribed format in light of legal ramifications of such; ability to converse in English with coworkers and hospital staff as to status of patient. Good manual dexterity, with ability to perform all tasks related to highest quality patient care. Ability to bend, stoop, and crawl on uneven terrain; and the ability to withstand varied environmental conditions such as extreme heat, cold, and moisture. Ability to work in low light and confined spaces.

An Equal Employment Opportunity Employer

COMPETENCY AREAS ECA Emergency Care Attendant

Must demonstrate competency handling emergencies utilizing all Basic Life Support equipment and skills in accordance with all behavioral objectives in the DOT/First Responder Training Course and the FEMA document entitled "Recognizing and Identifying Hazardous Materials", and to include curricula on aids to resuscitation, blood pressure by palpation and auscultation, oral suctioning, spinal immobilization, patient assessment, and adult, child, and infant cardiopulmonary resuscitation. The automated external defibrillator curriculum is optional. EMT – Emergency Medical Technician Must demonstrate competency handling emergencies utilizing all Basic Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic curriculum and the FEMA document entitled "Recognizing and Identifying Hazardous Materials". EMT 1994 curriculum includes objectives pertaining to the use of the pneumatic antishock garment, automated external defibrillator, epinephrine auto-injector and inhaler bronchodilators. EMT-I Intermediate

Must demonstrate competency handling emergencies utilizing all Basic and Advanced Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic and EMT-I curriculum. The curriculum will include objectives pertaining to endotracheal intubation. EMT-P Paramedic

Must demonstrate competency handling emergencies utilizing all Basic and Advanced Life Support equipment and skills in accordance with all behavioral objectives in the DOT/EMT Basic, EMT-I curriculum, and the Paramedic curriculum. The Paramedic has reached the highest level of pre-hospital certification.

An Equal Employment Opportunity Employer

Description of Tasks

Receives call from dispatcher, responds verbally to emergency calls, reads maps, may drive ambulance to emergency site, uses most expeditious route, and observes traffic ordinances and regulations. Determines nature and extent of illness or injury, takes pulse, blood pressure, visually observes changes in skin color, makes determination regarding patient status, establishes priority for emergency care, renders appropriate emergency care (based on competency level); may administer intravenous drugs or fluid replacement as directed by physician. May use equipment (based on competency level) such as but not limited to, defibrillator, electrocardiograph, performs endotracheal intubation to open airways and ventilate patient, inflates pneumatic anti-shock garment to improve patient's blood circulation. Assists in lifting, carrying, and transporting patient to ambulance and on to a medical facility. Reassures patients and bystanders, avoids mishandling patient and undue haste, searches for medical identification emblem to aid in care. Extricates patient from entrapment, assesses extent of injury, uses prescribed techniques and appliances, radios dispatcher for additional assistance or services, provides light rescue service if required, provides additional emergency care following established protocols. Complies with regulations in handling deceased, notifies authorities, arranges for protection of property and evidence at scene. Determines appropriate facility to which patient will be transported, reports nature and extent of injuries or illness to that facility, asks for direction from hospital physician or emergency department. Observes patient en route and administers care as directed by physician or emergency department or according to published protocol. Identifies diagnostic signs that require communication with facility. Assists in removing patient from ambulance and into emergency facility. Reports verbally and in writing observations about and care of patient at the scene and in-route to facility, provides assistance to emergency staff as required. Replaces supplies, sends used supplies for sterilization, checks all equipment for future readiness, maintains ambulance in operable condition, ensures ambulances cleanliness and orderliness of equipment and supplies, decontaminates vehicle interior, determines vehicle readiness by checking oil, gas, water in battery and radiator, and tire pressure, maintains familiarity with all specialized equipment.

An Equal Employment Opportunity Employer