Phlebotomy Technician Program

Medical Arts & Technology Building

719-549-3198

PHLEBOTOMY TECHNICIAN PROGRAM APPLICATION

Application Dates

  • Fall Semester – Available May 1; due date for admission July 15
  • Spring Semester – Available November 1; due date for admission to January 5

What do I need to do to apply?

☐1.Successful completion of college level English course.

☐2.Or Accuplacer score for Sentence Skills – 95+ and Reading Comprehension – 62+.

Applicant Check List

The following items must be completed before submitting application. Check each box indicating your compliance with each step.

☐1.Completed Pueblo Community College admission application

☐2.Completed and signed Phlebotomy Technician application

☐3.Unofficial transcript or assessment scores are attached to application. (Required to be considered for Phlebotomy Technician program)

☐4.Academic Requirements (prerequisites) completed or in progress.

Note:Students that have all of the prerequisites completed will be considered for priority admissions. Students who are in progress with prerequisites will be considered for admissions if openings are available upon completion of the courses and updated transcripts are submitted.

Return Completed Application to:

Pueblo Community College

Health and Public Safety Division

MT 176 or MT 172

900 W. Orman Ave.

Pueblo, Colorado 81004

FOR OFFICE USE

Application received by onat

Phlebotomy Technician Application

Completion of this form does not constitute admission to the program.Students will be notified by phone and/or letter if they are accepted, placed on alternate list or denied for the program.

Applicant’s Name

Last Name: First Name: MI:

Date: Student Number:

Personal Email Address:

Student Email Address:

Cell/Home Phone Number:

Emergency Phone Number:

Mailing Address

Street Address: City: State: Zip

If there is a change in address or phone numbers, please give written notice by emailing the Program Coordinator or Administrative Assistant at .

If you have questions about the completion of this application, requirements, or qualifications please contact Bonnie Housh at719-549-3198

Essential Functions for Phlebotomy Technicians

Essential Function I: Observation

  • Distinguish red, yellow, and blue colors, distinguish clear from cloudy.

Essential Function II: Communication

  • Communicate effectively and sensitively with patients, their families, and members of the health team.
  • Communicate effectively with patients from different social and cultural backgrounds, as well as develop effective professional rapport with patients and co-workers.
  • See clearly enough to read hand-written and computer-generated communications

Essential Function III: Motor

  • Maneuver in the laboratory, around instruments, in confined spaces, and in patient rooms. Movement includes utilizing shoulders, arms, and neck; bending; twisting the body; standing; reaching and grasping overhead, in front of the body, and down.
  • Manipulate small objects and control adaptive devices with gloved hands.
  • Work standing on your for the majority of the day.
  • Help patients in and out of phlebotomy chairs.
  • Lift a minimum of 25 pounds

Essential Function IV: Intellectual-Conceptual, Integrative and Quantitative Abilities

  • Demonstrate through a variety of modalities including, but not limited to, classroom instruction; small group, team and collaborative activities; individual study; preparation and presentation of reports; and use of computer technology.
  • Interpret instructions furnished in oral, written, diagrammatic, or schedule form.
  • Apply safety and infection control standards learned in the program to maintain a safe and clean environment for patients and self.

Essential Function V: Behavioral and Social Attributes

  • Function effectively under stress and to adapt to an environment that may change rapidly, without warning, and/or in unpredictable ways. They must accept responsibility for learning, exercising good judgment.
  • Work effectively, respectfully and professionally as part of the healthcare team, and to interact with patients, their families, and health care personnel in a courteous, professional, and respectful manner.
  • Contribute to collaborative, constructive learning environments; accept constructive feedback from others; and take personal responsibility for making appropriate positive changes.
  • Interact with individuals and / or groups from a range of social, cultural, emotional, and intellectual backgrounds.
  • Comprehend and follow instructions; perform simple and repetitive tasks; maintain a work pace appropriate to a given work load; perform varied tasks; and present a professional appearance.

Essential Function VI: Ethical and Legal Standards

  • Comprehend and comply the basis and content of both general and medical ethics.
  • Possess attributes that include compassion, empathy, integrity, responsibility, and tolerance.
  • Recognize limitations in their knowledge, skills and abilities.
  • Seek appropriate assistance when confronted with limitations.

Other Essential Function:

  • Sufficient olfactory (smell) sense to maintain patients’ and environment safety.
  • Ability to work indoors, be around moving machinery; fumes, gases, odors, irritating particles, possibly be exposed to blood and body fluids, noise, vibration; work in confined spaces, use a computer monitor; work alone, with others, and/or around others.
  • Ability to wear safety glasses, face mask/shield, protective clothing, and protective gloves in the laboratory.

☐I have read the above and understand the performance standards specific to the occupation of Phlebotomy Technician.

☐I have the ability to meet the Physical Performance Standards as specified.

Signature:Date:

Program Requirements

Applicant please read the following statements. Please check box provided to indicate that you have read and understand each of the following statements:

☐1.It is the applicant’s responsibility to assure that their phone number and address are current. If the program coordinator is unable to contact the student by phone and/or student does not respond within 7 business days of conditional acceptance, the next applicant will be contacted.

☐2.I understand that the 11 credit (3 courses) Phlebotomy Technician Certificate Program does not qualifyfor Financial Aid. (CTE grant is available for eligible applicants)

☐3.I understand an internship course is required for this program and that I am required to complete a minimum of 100 hrs. at a clinic site outside of regular class time. Clinical rotations are scheduled during daytime hours with the possibility of one hour travel time to a clinic site and are scheduled by the course instructor.

☐4. I understand that after I am conditionally accepted I must pass a background check and drug screen which includes marijuana. The program coordinator will register you in program courses.

☐5.Qualified applicants will be conditionally accepted for enrollment, up to the class limit (20).

☐6.If you receive a letter of CONDITIONAL ACCEPTANCE, you will also receive information regarding specific dates/times to complete the background check, drug screen, immunizations, HealthCare Provider CPR, online payment agreement and liability insurance.

  • The program coordinator will be collecting this information in MT 172 and will enroll students in the appropriate classes after you have successfully passed background check and drug screen. (You cannot enroll yourself).
  • If you have questions about the completion of these requirements, contact the Bonnie Housh @ 549-3198.

☐7.I understand that my immunization information must be transferred to the PCC health form. This must be completed by the PCC Health Clinic in room MT 118 (719-549-3318). The form will be sent out with the conditional acceptance letter.

☐8.I understand I will be required to wear scrubs to class and clinic sites.

☐9.I have read and signed Phlebotomy Essential Functions form on page 3.

☐10.I understand I am required to attend a MANDATORY ORIENTATION. Applicants will be notified of date, time and place in letter of conditionally acceptance.

☐11.To the best of my knowledge and belief, the information I have given on this form is correct and can be verified. I have not withheld information that would affect my acceptance to the Phlebotomy Technician Program. I understand the process for admissions into the Phlebotomy Technician Program.

☐12.I have read and understood the application instructions, requirements, and qualifications for this program. I understand that only completed applicationswill be accepted, which includes full completion of this application, attached copies of all unofficial transcripts and/or placement scores.

Print Name:

Signature: Date:

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