Bartow Medical and Fire Academy EKG Course 18 19 SY
18/19 SY
Electrocardiography Technician
Required Paperwork
Please return this packet to the instructor with all required signatures.
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Student Name (please print): ______
ITEMS ON THIS PAGE ARE FOR CLINICAL EDUCATION OFFICE USE ONLY
Item # 1 ______ Student Contact Information Form
Item # 2 ______ Free From Addiction and/or Disease or Defect Ability
Item # 3 ______ Compliance Agreement
Item # 4 ______ Copy of Government Issued I.D. / Health Insurance
Item # 5 ______ Physical Examination Form
Item # 6 ______ Immunization Schedule
Item # 7 ______ Affidavit of Good Moral Character
Item # 8 ______ Background / Drug Screen Notice
Item # 9.______Blanket Field Trip Form
Item # 10 ______Medical Treatment Authorization
Item # 11 ______Classroom/Clinical/Skills/High Fidelity Simulation Labs SOP
This will be entered by instructor when received after testing at the academy.
Item # 12. ______ Background Check Results received
Item # 13. ______ Drug Screen Results received
Item # 14. ______HOSA App.
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 1
Please print neatly!!!
Student
Last Name: ______First Name: ______
Street Address: ______
City: ______State: ______Zip Code: ______
Cell Phone: ______Home Phone: ______
Date of Birth: ______Gender (circle one): M / F Age: ______
E-Mail address: ______
EKG Program Instructor: ______Period: ______
Parent or Guardian
Last Name: ______First Name: ______
Street Address: ______
City: ______State: ______Zip Code: ______
Cell Phone: ______Home Phone: ______
Last Name: ______First Name: ______
Street Address: ______
City: ______State: ______Zip Code: ______
Cell Phone: ______Home Phone: ______
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 2
STATEMENT AFFIRMING FREEDOM FROM ADDICTION AND/OR DISEASE
I, ______, hereby attest that I am free from addiction to alcoholic
beverages and/or any controlled substances. Furthermore, I hereby attest that I am free from physical and/or mental defects or disease, which may impair my ability to perform as an EKG Program student.
______
Student Signature
______
Parent Signature
______
Date
______
Notary Signature
______
Date
Affix Notary Seal
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 3
COMPLIANCE AGREEMENT
This agreement is required so as to ensure that all students have been informed of certain rights that the student is entitled according to the standard college policy.
I, ______, have read the EKG Program policies manual, have obtained a current Student Handbook, and have read the sections entitled:
Students Rights and Responsibilities
Due Process
Health Services
Class Attendance and Absences
Student Conduct
Discipline and Due Process
I understand and agree to comply with the policies, rules, and regulations in both publications.
______
Applicant Signature Date
______
Parent Signature Date
______
Notary Signature
______
Date
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 4
VERIFICATION OF HEALTH INSURANCE AND I.D.:
Those currently covered by a health insurance plan; please attach a copy of your current health insurance card and initial the first selection below. Those who do NOT have any health insurance coverage at present; please initial the second selection below. Polk County School Board is not financially liable for any injuries that may occur while a participant of the EKG training program.
Also, please attach a copy of your Driver’s License, Florida ID or Passport to this sheet.
I, ______, understand that I shall be financially responsible for the treatment of any injury and/or illness that occurs while I am engaged in any type of program activity, whether on or off-campus.
PLEASE INITIAL ONE OF THE FOLLOWING:
_____ I have a current health insurance policy, which I agree to keep current throughout the duration of the EMS program. Said company’s name, policy number, and/or other claims related information, is listed on the card which I have provided a copy of.
_____ I DO NOT have a current health insurance policy. Thus, I understand that, Polk County School Board affords students minimal accidental injury coverage. Moreover, I understand and agree that I am liable for any remaining financial liability resulting from an accident, injury, illness and/or death incurred by me while partaking in any EKG program activity.
______
Applicant Signature
______
Parent Signature Date
______
Date
______
Notary Signature
______
Date
ATTACH A COPY OF YOUR HEALTH INSURANCE CARD AND I.D. BELOW
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 5
PRE-ENTRANCE PHYSICAL EXAMINATION
The medical examiner is required to make a careful physical examination. Impairments found after admission may lead to the rejection of the applicant due to the inability of the applicant to meet patient care responsibilities. According to Florida Law, General Authority Section 15; Chapter 73-125: An applicant must be free from any physical or mental defect or disease, which might impair the applicant’s ability to attend clinical.
- STUDENT INFORMATION -
Name: ______DOB: ______Sex: M F
Past Medical History: ______
Medications: ______
Allergies: ______
- FINDINGS OF PHYSICAL EVALUATION –
Height: ______Weight: ______Blood Pressure: ______Pulse: ______
Vision: R 20/_____ L 20/_____ Corrected: Y / N Contacts: Y / N Glasses: Y / N
INDICATORS NORMAL? ABNORMAL FINDINGS / COMMENTS
General AppearanceYES
Head/Neck YES
Eyes/Sclera/Pupils YES
Ears: YES
Ear Drums YES
Gross Hearing YES
Nose/Mouth/Throat YES
Lymph Glands YES
Cardiovascular: YES
Heart RateYES
Rhythm YES
Murmur ABSENT
If murmur present Standing makes it: Louder Softer No change Squatting makes it: Louder Softer No change
Valsalva makes it: Louder Softer No change
Femoral Pulses YES
Lungs: Auscultation/Percussion YES
Chest ContourYES
Skin YES
Abdomen (liver, spleen, masses)YES
Neck/Back/Spine: YES
INDICATORS NORMAL? ABNORMAL FINDINGS / COMMENTS
Range of Motion YES
Scoliosis ABSENT
Upper Extremities: YES
Range of Motion YES
Strength YES
Stability YES
Lower Extremities: YES
Range of Motion YES
Strength YES
Stability YES
Neurological: YES
Balance YES
Coordination YES
Reflexes YES
Additional Observations:
______
______
______
Physician/ARNP Certification Statement
After a complete and thorough physical examination, it is my opinion that the person whose name is listed on the front of this form is in good health. In addition, this person is able to participate in any physical activity associated with any facet of Bartow Medical and Fire Academies Program without any restrictions.
Please print or stamp the facility or physician’s name and address below.
______
______
______X______
Physician/ARNP Signature Please sign and date
THE PHYSICAL ACTIVITY REFERENCED ON THE CERTIFICATION STATEMENT ABOVE INCLUDES, BUT IS NOT LIMITED TO; HEAVY LIFTING, TWISTING, BENDING, AND PROLONGED PERIODS OF PHYSICAL EXERTION. IN ADDITION, EKG PROGRAMS PARTICIPANTS HAVE AN ELEVATED RISK OF BEING EXPOSED TO COMMUNICABLE AND/OR INFECTIOUS DISEASES.
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 6
Please PRINT student’s name HERE: ______
Complete this form in its ENTIRETY. Include all NAMES, SIGNATURES, and ADDRESSES.
T-DAP within the last 10 years Name/Title of Agency (print or stamp)
Date administered ______
By: ______
Signature: ______
Measles, Mumps, and Rubella (MMR)Name/Title of Agency (print or stamp)
Date administered ______
By: ______
Signature: ______
Varicella (TITER is required)Name/Title of Agency (print or stamp)
Date drawn: ______
By: ______
Signature: ______
Report: Positive _____ Negative _____
All students MUST have the above blood test (TITER) drawn regardless of how many times you may have experienced the disease or who can attest to your medical history.
PPD (TB skin test within the last 3 months) Name/Title of Agency (print or stamp)
Date administered ______
By: ______
Signature: ______
Report: Positive _____ Negative _____
Positive results of PPD require a chest x-ray
Date of chest x-ray: ______
By: ______Assessed by: ______
Signature: ______Signature: ______
Report: Positive _____ Negative _____
Hepatitis C TITER (antibody testing within the last 6 months) Name / Title of Agency (print of stamp)
Date drawn: ______
By: ______
Signature: ______
Report: Positive _____ Negative _____
Heptovax Series
If the applicant chooses not to receive this immunization, the waiver at the bottom of this form must be signed.
Name / Title of Agency (print of stamp)
Date Administered ______
By: ______
Signature: ______
Name / Title of Agency (print of stamp)
Date Administered ______
By: ______
Signature: ______
Name / Title of Agency (print of stamp)
Date Administered ______
By: ______
Signature: ______
Rejection of Immunization
This will certify that I, the undersigned, understand the risk of exposure and possible complications that may occur because of contact with patients who have Hepatitis B. Should I contact Hepatitis B while on hospital or field affiliation as an EKG Program student, I will not hold Polk County Public Safety, the hospital, nursing home, or Polk County School Board responsible.
______
Program Participant’s Signature Date
______
Parent Signature Date
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 7
Exhibit “A”
Affidavit of Good Moral Character
I hereby attest that I am of good moral character, that I have not been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:
1. Section 415.111 relating to adult abuse, neglect, or exploitation of aged persons or disabled adults
2. Section 782.04 relating to murder
3. Section 782.07 relating to manslaughter
4. Section 782.071 related to vehicle homicide
5. Section 782.09 relating to killing an unborn child by injury to the mother
6. Section 784.011 relating to assault, if the victim of the offense was a minor
7. Section 784.021 relating to aggravated assault
8. Section 784.03 relating to battery, if the victim of the offense was a minor
9. Section 784.045 relating to aggravated battery
10. Section 787.01 relating to kidnapping
11. Section 787.02 relating to false imprisonment
12. Section 794.011 relating to sexual battery
13. Chapter 796 relating to prostitution
14. Section 798.02 relating to lewd and lascivious behavior
15. Chapter 800 relating to lewdness and indecent exposure
16. Section 806.01 relating to arson
17. Chapter 812 relating to theft, robbery, and relating crimes if the offense is a felony
(See 812.014, 812.016, 812.019, 812.081, 812.13, 812.133, 812.135, 812.14, and 812.16)
18. Section 817.563 relating to fraudulent sale of controlled substances, only if the offense was a felony
19. Section 826.04 relating to incest
20. Section 827.03 relating to aggravated child abuse
21. Section 827.04 relating to child abuse
22. Section 827.05 relating to negligent treatment of children
23. Section 827.071 relating to sexual performance by a child
24. Chapter 847 relating to obscene literature
25. Chapter 893 relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.
I further attest that I have not been judicially determined to have committed abuse or neglect against a child as defined in s.3901 (2) and (36), Florida Statutes; nor do I have a confirmed report of abuse, neglect, or exploitation as defined in s.415.102, or abuse or neglect as defined in s.415.503 (3), which has been uncontested or upheld under s.415.103 or s.415.504, Florida Statues; nor have I committed an act which constitutes domestic violence as defined in s.741.28, Florida Statutes.
BEFORE ME this day personally appeared, ______, who, being duly sworn, deposes and says: Under the penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.
______
Applicant
______
Parent Signature Date
OR
To the best of my knowledge and belief, my record may contain one of the foregoing disqualifying acts or offenses.
______
Applicant
______
Parent Signature Date
SWORN TO AND SUBSCRIBED before me this ______day of ______, 20___, by
______, who is personally known to me or has produced
______, as identification, and who did take an oath.
______
Signature of Notary Public – State of Florida
______
Notary Seal
Bartow Medical and Fire Academy EKG Program
Required Paperwork
Item # 8
Background Check / Drug Screen Notice
All students enrolled in the course listed above are hereby advised; continued enrollment in this course is contingent upon a satisfactory result on a seven-year criminal background history check and negative results on a ten-panel drug screen. Failure to comply with one or both of these requirements will result in your immediate dismissal from EKG without any refund of uniform, dues and/or lab fees.
For a sample list of criminal and/or felony offenses, which will yield an unsatisfactory result on the seven-year criminal background history, refer to Item # 8; which is the previous page. However, anyone who has been convicted, or plead guilty, or nolo contendre to a felony violation, regardless of adjudication, is strongly urged to consult with a Program Director – EKG prior to the start of classes.
The ten-panel drug screen will check for the presence of:
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Bartow Medical and Fire Academy EKG Course 18 19 SY
Amphetamines
Cannabinoids
Cocaine
Phencyclidine
Methaqualone
Opiates
Barbiturates
Benzodiazepines
Methamphetamine
Propoxyphene
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Bartow Medical and Fire Academy EKG Course 18 19 SY
A positive result for any of the above substances will disqualify a student from participation in the Electrocardiography Tech. Program. Thus, dismissal from Bartow Medical and Fire Academy will ensue without any refund of uniform, dues and/or lab fees.
I understand that my continued enrolment in Bartow Medical and Fire Academy is contingent upon meeting the above requirement. As such, I agree to be dismissed from the program if I should fail to meet the minimum accepted standards as outlined. Furthermore, I agree to be bound by the terms listed above, specifically those parts, which state no refund will be issued if I am dismissed from the course.
The Medical and Fire Academy has made arrangements to have this testing done on campus for a $120 fee. This is a onetime only deal. If you do not get the testing done at this time it will be up to you to have the testing done by the deadline given. Students are not allowed to go to clinical without this testing. Students need to bring this paper signed by a parent or guardian and a driver’s license, Florida ID card or Passport when testing in the Nursing Lab.
I am giving the Polk County School Board permission to test my student.
Parent Name:______
Parent Signature:______
Please declare if you are taking any prescribed or over the counter Medications:______
______
______
Student Signature Date
______
Printed Student NameStudent Identification Number
Item # 09
Form No. TRNS 0082 Appendix A
THE SCHOOL BOARD OF POLK COUNTY, FLORIDA
BLANKET FIELD TRIP PERMISSION FORM
TO WHOM IT MAY CONCERN:
___________has my permission to participate in all
Name of student
field trips to be taken by __Bartow Senior Medical & Fire Academy/ HOSA/FPSA____
Name of organization/group
during the __2018 - 2019__ school year. As parent/guardian I acknowledge the following:
1.School officials are authorized to obtain emergency medical treatment for this student as necessary.
2.The School Board has made available to this student the opportunity to purchase student accident insurance.
3.During this field trip, that the School Board will not be liable for injury to this student as result of the negligence, errors, and omissions of others (i.e., charter bus owners and drivers, or amusement park owners or workers), their agents, heirs, employees or assigns either through their action or inaction.
4.If your child takes personal belongings on this field trip, he or she will be responsible for them. The School Board accepts no responsibility for personal items, such as watches, purses, money, cameras, and wallets, etc. If a student stores personal items in a locker at an amusement park, that entity may be responsible for any loss or damage.
______
Signature of parent/guardian Date
NOTES:
1. THIS BLANKET FORM MAY BE USED FOR TRIPS OF A SIMILAR NATURE, WHICH ARE REPEATED DURING THE SCHOOL YEAR.
2. FOR ALL OUT-OF-COUNTY TRIPS, A NOTARIZED MEDICAL TREATMENT AUTHORIZATION FORM MUST ALSO BE AVAILABLE. THE MEDICAL FORM MUST BE COMPLETED PRIOR TO THE STUDENT'S FIRST OUT-OF-COUNTY TRIP AND SHOULD BE RETAINED FOR USE DURING THE REMAINDER OF THE SCHOOL YEAR.
All students must provide transportation to and from all functions. Students are required to stay for the entire function and are not permitted to leave unless the instructor in charge of the function has been notified and the parent has given permission for the student to leave. Please sign below if you will allow your student to drive to and from all functions and leave only when the function is over.
______Parent Signature
Item # 10Form No. TRNS 00797 Appendix D
THE SCHOOL BOARD OF POLK COUNTY, FLORIDA
MEDICAL TREATMENT AUTHORIZATION FORM
TO WHOM IT MAY CONCERN:
I the undersigned parent/guardian of ______hereby authorize any necessary medical treatment for this student while participating in field trips conducted under the sponsorship of Bartow Medical & Fire Academy ALL HOSA/FPSA Events_ during the 2018-2019_school year and guarantee payment of all charges incurred as a result of this medical treatment.
INFORMATION: Please Print
ALLERGIES TO FOOD, MEDICATION, ETC. (If none, so state.) ______
SPECIAL MEDICAL CONDITIONS (If none, so state.)______
FAMILY PHYSICIAN ______
OFFICE ADDRESS ______PHONE NO______
PARENT/GUARDIAN NAME______
PARENT/GUARDIAN HOME ADDRESS______
HOME PHONE______WORK PHONE______
______
Insurance Company Policy No. or Group No.
______
PARENT/GUARDIAN SIGNATURE DATE
STATE OF FLORIDA, COUNTY OF ______
I hereby certify that the foregoing was executed before me this ______day of______,
by______, who is personally known to me or who has produced ______as identification and who did (did not) take an oath.
______
Notary Public, State of Florida
THIS FORM IS TO BE USED FOR ALL OUT-OF-COUNTY FIELD TRIPS EXCEPT ATHLETIC ACTIVITIES. THE FORM SHOULD BE COMPLETED PRIOR TO THE STUDENT’S FIRST OUT-OF-COUNTY TRIP AND RETAINED ON FILE FOR THE REMAINDER OF THE SCHOOL YEAR.English Version 8/00
Item 11.Throughout the remainder of this syllabus: Print your initials on the blank lines to the left to acknowledge that you have read, reviewed, comprehend, and agree to be bound by the statements on the right.
Classroom/Clinical/Skills/High Fidelity Simulation Labs SOP
2-0.1 ______Uniforms identify you as an EKG-Intern and are to be worn while attending all program functions; unless you are otherwise informed. The uniform policy will be strictly enforced. Failure to adhere to the uniform policy will result in a reprimand, which is the first in a series of steps to dismiss said student from class. Nothing will excuse a student from adhering to this policy.