dear prospective phlebotomy student - macc€¦ · dear prospective phlebotomy student: thank you...

Dear Prospective Phlebotomy Student:

Thank you for your interest in the Moberly Area Community College Phlebotomy class at the Advanced

Technology Center located in Mexico, Missouri. Enclosed you will find an application packet for the

fall/spring Phlebotomy class. Please review all documents carefully. All completed application

forms, immunization records, background checks and drug screen results are all required in our

office before enrollment in the class is allowed.

Please use the following checklist as a guide to help you through the application process:

Completed Form/Document

MACC Application

Phlebotomy Program Application

Record Review Permission Form

Release of Information Form

Fingerstick Release Form

Instructor Reference Form

Employer Reference Form

Other Reference Form

Essential Qualifications Form NOTARIZED

Immunization Records Form

Missouri State Highway Patrol Background Check ($13.00 Name Search) Form or

Hard Copy Results

Background Check Advantage Request Form ($2.75 check or money order Made payable to: MACC for OIG background check)

Caregiver Background Screening Form

Received Form/Document

Directions to Mid-Mo Drug Testing Collection Site

MLT 261 Advanced Phlebotomy Course Information

Immunizations

Proof of the following immunizations are required before enrolling into the Phlebotomy class:

Hepatitis B vaccine: There are three inoculations. Students must have at least begun the series;

Two MMR immunizations or positive titer;

Positive immune varicella titer or an immunization;

DPT inoculation series;

A 2-step TB test or documentation of having had two TB tests in two years or chest x-ray if a

positive reaction has been documented;

Some sites may require an influenza vaccine; please be advised this might be necessary too,

once your clinical site has been decided

Drug Screen

Proof of a negative 14 panel drug screen must be received before enrollment in the phlebotomy class

is allowed. A map to the collection site is included in this packet.

MSHP Criminal Background Check

Send the completed Missouri State Highway Patrol Criminal Background Check, with $13.00 payment,

directly to the Missouri State Highway Patrol (see address on the form). Send for the background check

early because it may take up to six weeks to be completed and arrive in our office. For an additional

$1.25 fee, a faster service option is available. The Missouri Automated Criminal History Site (MACHS)

may be accessed at www.machs.mshp.dps.mo.gov. If you select the online option, you will need to

print and include the results with your application packet.

Caregivers Background Check

Fax or mail the Caregivers Background Screening to the fax number or address on the back of the form.

Use “Option 4” in the bottom right hand corner as the correct fax number or mailing address. We can

fax this form for you if you do not have access to a fax machine.

Office of Inspector General Background Check

Complete the MHA “Background Check Advantage” OIG form and send it to our office with cash,

check or money order in the exact amount for $2.75; Made payable to: MACC for OIG background

check. We will process this background check ourselves.

Reference Forms

In addition, please be advised that all reference forms must be returned to our office in a sealed envelope

from the persons of your choosing. References should be from teachers, ministers or supervisors. No

friends or relatives please.

Course Enrollment Form

Once you have submitted your completed application packet, please contact the MLT Program

Coordinator or the Nursing Administration office to obtain your enrollment form for the course(s). You

may not enroll for this course without this enrollment form. The enrollment form must be signed by

MLT Program Coordinator before you can enroll.

MLT 261 Enrollment

You also have the option of enrolling in MLT 261, Advanced Phlebotomy. This course is recommended

if you have never had phlebotomy experience prior to MLT 260. You must complete both MLT 260

http://www.machs.mshp.dps.mo.gov/

& MLT 261 in order to take the certification exam to become a certified phlebotomist. If you wish to

enroll for this course as well, please notify the MLT Program Coordinator or the Nursing

Administration office so that we can add this course to your enrollment form. The enrollment form

must be signed by MLT Program Coordinator before you can enroll.

I look forward to working with you and the rest of your class. If you have further questions, do not

hesitate to contact me via email or phone at the number listed below.

Sincerely,

Alese M. Thompson MS, MLS (ASCP)CM

MLT and Phlebotomy Program Coordinator

(573) 582-0817 ext. 13624

[email protected]

mailto:[email protected]

Date Received_________ Entered by_________ Letter Sent_________ Date Scanned_________ ID #_____________

Moberly Area Community College 101 College Avenue Moberly, MO 65270

(660) 263-4100 or 1-800-622-2070 Have you previously applied to MACC? □ Yes □ No Fax: (660) 263-2406 E-Mail address: [email protected] Please complete application in ink and return to MACC. No Admission Fee

General Information: Social Security Number: (Required if seeking Financial Aid) Legal Name: ________________________________________________________________________________________ Last First Middle Previous or Maiden

Permanent Legal Address: (Verification may be requested) Phone: (_____) ____________________ (MACC may contact you via text message)

__________________________________________________________ E-mail Address: ____________________ Street Box Apt. #

__________________________________________________________ _______________________________ City State Zip County Birth City, State, and Country

Date of Birth: _____/______/________ MM DD YYYY

IF you have lived at above address less than one year, please list previous address.

__________________________________________________________ Street Box Apt. #

__________________________________________________________ City State Zip County

Local Address (if different from above): _________________________________________________________________ Address City State Zip County Date to begin Classes: 20_____ □ Fall □ Spring □ Summer

Emergency Contact: ___________________________ Relationship: ______________ Phone: ___________

Address: __________________________________ City/State: ___________________________ Zip: _____________

Personal Information: Voluntary* Required

Gender: □ Male □ Female Race (select 1 or more) Citizenship: Are you Hispanic/Latino: □ Yes □No □ American Indian or Alaska Native □ U.S. Citizen Veteran: □ Yes □ No □ Child/Spouse □ Asian □ Non U.S. Citizen Marital Status: □ Black or African American □ Permanent Resident Alien □ Married □ Single □ Divorced □ Native Hawaii/Other Pacific Islander □ Political Asylum □ Widowed □ Separated □ Single Parent □ White First Generation College Student: □ Yes □ No *This information is requested for the purpose of reporting to Federal Compliance Agencies and will not be used in determining admission status. Your response to this information is strictly voluntary.

Continue on back

Application For Admission

mailto:[email protected]

Enrollment Status: (please check only one) □ Degree Seeking □ Non-degree Seeking □ Visitor □ High School Student (enrolled for dual-credit/dual enrolled) Current high school grade level is: □ Freshman □ Sophomore □ Junior □ Senior Educational Background: *An official copy of your high school transcript or of your HiSET (or G.E.D.) scores must be submitted

Last High School Attended: ___________________________________________________________________________ School Name City State

□ Graduated: Month _______ Year ________ □ Passed High School Equivalency Test: Month _______ Year ________ □ Attending high school and expect to graduate: Month _______ Year ________ □ Highest grade level completed: ________ Did you complete a two-year vocational program during high school? □ Yes □ No

Name of Vocational School: ______________________________________ Program: ____________________________

Colleges or Universities Attended: *Degree seeking students must submit official transcripts ____________________________________________________________________________________________________________ Name of College/University City/State Dates Attended Hours/Degree Earned

____________________________________________________________________________________________________________ Name of College/University City/State Dates Attended Hours/Degree Earned

__________________________________________________________________________________________________________________ Name of College/University City/State Dates Attended Hours/Degree Earned

Safe & Secure Environment: *You must check box below for completion of application Moberly Area Community College is committed to providing a safe and secure environment. As required by federal, state and local law and college policy, the annual security and fire safety compliance reports – published annually by October 1 – and sexual misconduct policy documents are available at www.macc.edu/index.php/crime-stats. Printed copies of the Annual Security Report containing the above information are available from the MACC Security Department, Andrew Komar Jr. Hall, Room 12, Moberly, MO 65270 or by calling (660)263-4100 x11247. The documentation contains information regarding campus security, personal safety, crime prevention, fire safety, security officers, crime reporting policies, disciplinary procedures, sexual misconduct policies and other matters of importance related to campus security and safety. It also contains information about crime statistics for the tree previous calendar years concerning reported crimes that occurred on our campuses and on public property within or immediately adjacent to and accessible from the campuses is also included.

□ I understand I have been made aware of MACC’s Safe & Secure Environment Policy.

All students enrolled in college credit classes must provide or have on file proof of high school graduation or HISET (formally GED), or equivalent by the completion of the first ten days of class in a 16-week semester or the equivalent in a shorter session. High school students enrolled through dual-credit or dual-enrollment programs and persons with proof of an associate or higher degree are excluded from this requirement. Admission to Moberly Area Community College does not guarantee acceptance into selected admission M-2 programs. A separate application process is required in all Allied Health programs and the Law Enforcement Training Center. All transcripts become the property of MACC and will not be returned. I hereby certify that to the best of my knowledge the information on this application is true and complete without evasion or misrepresentation. I understand that if found to be otherwise, it is sufficient cause for rejection or dismissal with forfeiture of all my fees and/or deposits. Further, I agree to accept and abide by all rules, regulations and policies established by the Board of Trustees of MACC.

Date:______________________ Signature: _________________________________________________________________________________________ (legal name) APPLICATION MUST BE SIGNED

Moberly Area Community College is committed to a policy of non-discrimination on the basis of race, color, national origin, gender, sexual orientation, disability, age, marital or parental status, religion, genetics, ancestry, or veteran status, in admissions, educational programs, activities, and employment. All inquiries concerning nondiscrimination, including equal opportunity and Title IX, should be directed to the Title IX Coordinator: Jackie Fischer, Ph.D. Dean of Academic Affairs, 101 College Avenue, Moberly, MO 65270 660-263-4100 ext. 11236. Inquiries concerning Section 504 of the Rehabilitation Act of 1973, which guarantees access to education regardless of disability, should be directed to: Amy Evans, Director, Office of Access and ADA Services, Moberly Area Community College, Columbia Higher Education Center, Room 119, 601 Business Loop 70 West, Columbia, MO 65203 573-234-1067, ext. 12120 9/29/2016 Form SS201A

http://www.macc.edu/index.php/crime-stats

10/17/2016

Tuberculosis (TB) Screening

Missouri law, MO SB 197 (RS 199.290), requires all Missouri institutions of higher education to perform a tuberculosis screening process for all students enrolling in college. Answer to the following questions are required.

Are any of the following statements true? □ Yes □ No

1. Have you had contact with a person known to have active tuberculosis (TB)? 2. Were you born in or have you lived for more than two months in Asia, Africa, Central or South

America, or Eastern Europe? 3. Have you worked or volunteered in a high-risk congregate setting (e.g., a correctional facility, a

long-term care facility, a homeless shelter, hospital, etc.)? 4. Have you ever been sick with tuberculosis?

If you answered No to the above questions, no further action is required.

If you answered Yes to any of the above questions, you must provide required documentation of medical test.

a. Contact your health care provider or local Health Department for a TB skin test, OR; b. Provide documentation of TB screening results completed in the United States within the

past 12 months, OR; c. Provide documentation of prior treatment for active TB or latent TB infection.

Documentation must be provided to the Dean of Student Affairs for review. Your documentation can be submitted at any of the MACC campus Student Affairs office. Applicants with positive TB test results or unsatisfactory prior treatment will not be allowed to enroll. Contact Student Affairs with any questions.

Signature: _____________________________________ Date: ___________ ID #: __________

Frequently Asked Question’s

1. If I am in any of the allied health programs (PN, ADN, MLT, OTA) does this apply to me? Yes, but this screening is included in the admission packet for each of those programs

2. If I took classes with MACC previously (more than a semester) does this apply to me? Yes, if you answered YES to any of the TB-related questions, it applies to you.

3. If I have negative results from a TB test from the past 12 months, will that suffice? Yes, as long as appropriate documentation is provided.

4. Do I have to satisfy this issue if I only take online classes? Yes, online students may have to visit campus to take proctored exams, or may decide to take in-seat classes.

5. If I was previously treated for TB infection or disease, is that satisfactory? Yes, as long as appropriate documentation is provided.

6. If I have a negative chest x-ray, is that satisfactory? A chest x-ray does NOT substitute for a skin test. Chest x-rays are generally required for a person who has had a positive skin test.

7. Some of my friends applied at the same time as me and they got enrolled. Why have I been singled out? Students are identified for TB screening according to their answers to the questions about possible TB exposure.

MOBERLY AREA COMMUNITY COLLEGE

PHLEBOTOMY PROGRAM

APPLICATION

Legal Name_____________________________________________________________________

Last First Middle

Previous Names: _________________________________________________________________

Address_________________________________________________________________________

Street City State Zip

Phone Number (_____) _______________Email Address: _________________________________

Emergency Contact: ________________________________________ (_____) _______________

Last First Phone Number

PREVIOUS EDUCATION

Schools

Attended Name and Location Dates

Certificate, Diploma, or

Degree Awarded Year

High School

College or

Universities

MLT Schools

Other

Moberly Area Community College does not discriminate on the basis of race, color, national origin, sex, disability, age,

and marital or parental status in admissions, programs and activities, and employment.

Inquiries concerning Section 504 of the Rehabilitation Act of 1973, which guarantees access to education regardless of

disability, should be directed to: Angela Duvall, Office of Student Services, 101 College Avenue, Moberly, MO 65270,

660-263-4110 ext. 278. All other inquiries concerning nondiscrimination, including equal opportunity and Title IX,

should be directed to one of the following people: Dr. Jeff Lashley, Office of Academic Affairs, 101 College Avenue,

Moberly, MO 65270, 660-263-4110 ext. 216 or

Pat Twaddle, Career and Placement Services, 101 College Avenue, Moberly, MO 65270, 660-263-4110 ext. 232.

Students with documentable disabilities as addressed by the Americans with Disabilities Act may register proper

documentation with the Office of Student Services. The Student Services Office will then notify appropriate instructors

of suggested official accommodations. Students may also wish to personally inform their instructors of their particular

disabilities.


PHLEBOTOMY PROGRAM

RECORD REVIEW PERMISSION FORM

Have the following documents sent to the address listed below:

Moberly Area Community College

Attn: Alese Thompson

Medical Laboratory Technician Program

2900 Doreli Lane, Mexico, MO 65265

1. A completed, acceptable Criminal Background check (Complete the form, enclose a $13.00 check

or money order made out to the “State of Missouri, Criminal Record System”, and send to the

address on the form. The State Police will send the background check to the Program

Coordinator).

2. Three letters of reference on the designated forms.

3. Submit to a drug screen through Mid-Mo Drug Testing (Once completed, the drug testing facility

will send the results to the Program Coordinator).

4. Submit inoculation records for the following to the Program Coordinator:

a. All 3 doses of Hepatitis B vaccine or documentation of having begun the series;

b. MMR vaccine series;

c. Positive immune varicella titer or an immunization;

d. DPT inoculation series within 10 years;

e. 2-step TB test or 2 TB tests within 2 years or chest x-ray if a positive reaction has been

documented.

f. Influenza vaccine

5. A completed Caregiver Registry background check (to include the Employee Disqualification List

background check) form sent to the Program Coordinator.

6. A completed, acceptable Background Check Advantage form that includes OIG

Medicare/Medicaid Fraud and Abuse background check (Complete the form, attach a check or

money order for $2.75 and send to the Program Coordinator for faxing).

7. Complete form to allow release of background information.

8. Signed and notarized Essential Qualifications form.

I understand that all information received from references as well as shot records and background

check, will be reviewed by the Program Coordinator or by an admissions committee, and I hereby

grant permission to have my records reviewed.

___________________________________________________ _________________

Signature Date

MACC

PHLEBOTOMY PROGRAM

RELEASE OF INFORMATION FORM

Full Name:____________________________________________________________________

Maiden/Alias Name(s):__________________________________________________________

Address:______________________________________________________________________

City:________________________________ State:____________________ Zip:___________

Social Security Number:_________________________________________________________

Date of Birth:__________________________________________________________________

Place of Birth:__________________________________________________________________

I authorize Moberly Area Community College to request and obtain a copy of my criminal

background as provided in Section RSMo. 610.120 and make an inquiry to the Department of

Social Services regarding the “Employee Disqualification List” as provided in Section RSMo.

660.315. I also authorize Moberly Area Community College to request and obtain a copy of my

drug screen results, immunization records, a Division of Family Services background check

regarding child abuse or neglect, and a background check with the Office of Inspector General. I

also realize I must provide a criminal background check for each state in which I have lived within

the past ten (10) years.

I further authorize Moberly Area Community College to provide the necessary documentation of

all the above stated information to individual clinical affiliates, to verify my eligibility to

participate in the clinical experience.

___________________________________________________ _________________

Signature Date

___________________________________________________ _________________

Witness Date


PHLEBOTOMY PROGRAM

FINGERSTICK RELEASE FORM

I, _______________________________________________release Moberly Area Community

College, the Allied Health Division, the instructor, and the student performing the venipuncture

and/or fingerstick blood collection from any responsibility. My signature constitutes that I have been

informed of potential complications and voluntarily agree to participate.

___________________________________________________ _________________

Signature Date

___________________________________________________ _________________

Witness Signature Date


Advanced Technology Center 2900 Doreli Lane Mexico, MO 65265

PHLEBOTOMY COURSE

*INSTRUCTOR REFERENCE

Please return this form to the Medical Laboratory Technician Program Coordinator, Alese Thompson,

at the Advanced Technology Center in Mexico as soon as possible. Thank you for your assistance.

__________________________is a candidate for admission into the Phlebotomy program at MACC.

Please note: I hereby authorize parties who receive requests to give full and complete information

as may be requested by Moberly Area Community College. I further agree that the information will

not be disclosed to me and I thereby waive any right to review this reference form.

____________________________________ ________________

Student Signature Date

Please Check:

APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4)

Reliability/

Accountability

Oral and Written

Communication Skills

Good Moral Character

Integrity

Ability to Work

With Others

Ability to Cope With

Stress/Crisis

Initiative

Please indicate whether or not you endorse the applicant:

Endorse with Enthusiasm______ Endorse_______ Do not Endorse_______

Number of courses taken with you_______*

How long have you known applicant? _____________________________

Name and Address: _________________________________________________________________

Position: __________________________________ Phone Number: (_____) __________________

Signature: ___________________________________________ Date: ______________________ *If the potential phlebotomy student does not have a prior instructor to receive an evaluation from, due to an acceptable

reason verified by the Program Coordinator, please use this form for an additional reference from a non-teacher.



PHLEBOTOMY COURSE

EMPLOYER REFERENCE




Please note: I hereby authorize parties who receive requests to give full and complete information as

may be requested by Moberly Area Community College. I further agree that the information will not

be disclosed to me and I thereby waive any right to review this reference form.

____________________________________ ________________


Please Check:

APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4)

Reliability/

Accountability

Oral and Written



Integrity

Ability to Work

With Others


Stress/Crisis

Initiative


Endorse with enthusiasm______ Endorse_______ Do not endorse_______

Number of years employed with you: ________

How long have you known applicant? _________________________________________________

Name and Address: _________________________________________________________________

Position: ______________________________________ Phone Number: (_____) _______________

Signature: _____________________________________________ Date: ______________________



PHLEBOTOMY COURSE

REFERENCE




Please note: I hereby authorize parties who receive requests to give full and complete information

as may be requested by Moberly Area Community College. I further agree that the information will

not be disclosed to me and I thereby waive any right to review this reference form.

____________________________________ ________________


Please Check:

APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4)

Reliability/

Accountability

Oral and Written



Integrity

Ability to Work

With Others


Stress/Crisis

Initiative


Endorse with enthusiasm______ Endorse_______ Do not endorse_______

How do you know the applicant? ________________________________

How long have you known applicant? _______________________________________________

Name and Address: _________________________________________________________________

Position: ______________________________________ Phone Number: (_____) _______________

Signature: _____________________________________________ Date: ______________________


MEDICAL LABORATORY TECHNICIAN AND PHLEBOTOMY PROGRAM

ESSENTIAL REQUIREMENTS

Introduction A graduate with an Associate of Applied Science degree from the Moberly Area Community College

(MACC) Medical Laboratory Technician program is educated to enter the practice of laboratory

medicine and qualified to take the accrediting exam from the American Society of Clinical Pathologists

(ASCP). Education in laboratory medicine involves assimilation of knowledge, acquisition of skills,

and development of judgment through handling patient specimens, manipulation of instrumentation,

and working with patients, doctors, nurses, and other health care professionals. Medical laboratory

technicians must be able to work independently and as a part of a team. They must be able to make

appropriate decisions regarding patient results.

The Medical Laboratory Technician program’s curriculum requires students to engage in diverse

complex and specific experiences primarily in the laboratory but also with patients. Unique

combinations of cognitive, affective, psychomotor, physical, and social abilities are required to perform

these functions successfully. These abilities are necessary to ensure the health and safety of patients,

fellow students, laboratory personnel, faculty, and other healthcare providers.

Policy MACC has a vested interest in the welfare of patients served by graduates of the Medical Laboratory

Technician program. The College also has a responsibility to its clinical affiliates, future employers,

program instructors, and students enrolled in the program. Therefore, not only have academic standards

been established but also non-academic essential requirements. These requirements, as distinguished

from academic standards, refer to cognitive, physical, and behavioral abilities that students must have

to acquire the knowledge and skills of the curriculum successfully. The standards must be met, with or

without reasonable accommodation, in order for students to participate in the program. Discrimination

is prohibited based on race, color, sex, national origin, age, disability, marital status, religion, or veteran

status in compliance with the Americans With Disabilities Act (PL 101-336).

The essential abilities necessary to acquire or demonstrate competence in laboratory medicine and

necessary for successful admission and continuance in the Medical Laboratory Technician Program

include but are not limited to the following:

Motor Skills and Mobility Dexterity and fine motor skills to perform laboratory testing and specimen manipulation

Physical ability to maneuver within the laboratory area to perform testing and the patient

treatment area to collect specimens

Sufficient touch discrimination to distinguish veins when performing venipunctures

Candidates should have sufficient motor function to move about the laboratory and the dexterity to

manipulate equipment, laboratory supplies, biohazards, chemical hazards, and patient specimens. They

must have the ability to operate instrumentation safely to avoid harm to self or others. Laboratory

workers interpret data from computer screens and perform data input. The candidate must be able to

perform phlebotomy; that is, moving from room to room or patient to patient, stooping or bending, to

draw blood safely. The candidate must be able to lift, carry, push, and pull. The candidate must be

able to move quickly and/or continuously as well as tolerate long periods of standing or sitting

(laboratory workers spend approximately 75% of each day standing or walking). The candidate must

be able to travel to clinical laboratory sites for practical experience.

Candidates must be willing to work with blood, infectious organisms, and chemical reagents.

Sensory/Observation Visual ability to perform and interpret test results, and to read charts, graphs, instrument

displays, and the printed word on paper or a computer monitor

Visual ability to distinguish gradients of colors Note: Color blindness does not necessarily

preclude admission to the program

Tactile ability to perform laboratory tests using assorted devices

A candidate must be able to acquire the information presented in demonstrations and experiences in

basic laboratory science. He or she must be able to discriminate subtle structure and consistency

differences in specimens and cultures both macroscopically and microscopically. Additionally, he or

she must be able to evaluate patient/client responses correctly; accurately read results or measurements

on patient-related equipment; and hear monitor alarms, emergency signals, telephone interactions, and

cries for help. The candidate must be able to tolerate odors and work in close and crowded areas.

Communication Effectively communicate in written and verbal form (this includes basic computer keyboarding)

The candidate must be able to process and communicate effectively in oral and written forms. The

candidate must communicate clearly, effectively, and sensitively with other students, faculty, staff,

patients, and other medical professionals. He or she must be able to follow oral and written instructions

to perform laboratory test procedures correctly.

Cognitive Ability to master information presented in lectures, written material, and images

Cognitive ability to assess data, make decisions based on data, and provide complete and

accurate results on laboratory testing for quality patient care

The Medical Laboratory Technician program candidate must be able to measure, mathematically

calculate, reason, analyze, integrate, and synthesize information. The candidate must be able to read

and comprehend technical and professional materials. He or she must be able to evaluate information

and engage in critical thinking in the classroom and clinical setting.

Behavioral/Emotional Emotional stability in potentially stressful circumstances

Behavioral restraint, emotional maturity, and sensitivity to others

The candidate must possess the emotional health required to use his or her intellect in exercising

appropriate judgment and prompt completion of all responsibilities. The candidate must have the

emotional stability to provide professional and technical services under stressful conditions such as

emergency demands and distracting environments. The candidate must be a team member, honest,

compassionate, ethical, responsible, and able to manage time in order to complete technical procedures

within a reasonable time frame.

Professional Conduct Professionalism and ethical conduct

Candidates must recognize the importance of operating in a moral, ethical way in the clinical laboratory

and the necessity of abiding by high standards of practice. Candidates must recognize the need for

confidentiality.

These standards identify the requirements for admission, retention, and graduation from the program.

It is the responsibility of the student with disabilities to request those accommodations that he or she

feels are reasonable and needed to execute the essential functions described.

References:

Fritsma, G., Fiorella, B., Murphy, M. (1996). Essential Requirements for Clinical Laboratory

Science.” Clinical Laboratory Science, 9(1), p. 40-43.

American Society of Clinical Laboratory Scientists. (2004). Body of Knowledge, Clinical Laboratory

Scientist. Bethesda, MD: ASCLS.

American Society of Clinical Laboratory Scientists. (2004). Entry Level Curriculum, Clinical

Laboratory Scientist. Bethesda, MD: ASCLS.


PHLEBOTOMY PROGRAM

ESSENTIAL QUALIFICATIONS RECEIPT AND ACKNOWLEDGMENT FORM

The undersigned applicant to the Moberly Area Community College Medical Laboratory Technician

Program hereby acknowledges receiving, reading, and understanding this essential functions

document.

The applicant understands that completion of the MACC Medical Laboratory Technician program

does not mean that the American Society of Clinical Pathologists will issue the applicant a certificate.

___________________________________________________ _________________

Signature Date

STATE OF____________________________

COUNTY OF__________________________

On this________________day of ____________________, 20___, before me,

____________________________, Notary Public in and for said state, personally

appeared,_______________________________, known to me to be the person who executed the

within instrument and acknowledged to me that ____________________ executed the same for the

purposes therein stated.

IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal the day and

year last above written.

Notary Public


PHLEBOTOMY PROGRAM

IMMUNIZATION RECORD FORM

PROOF OF ALL IMMUNIZATIONS MUST BE ATTACHED TO THIS FORM

Date(s) Received Immunization Comments

1.

2.

Two MMR immunizations or

positive titer

TDap or DTap

(within last 10 years

1.

2.

2 Step Tuberculin Test

(result must be negative or file

needs chest X ray)

Varicella titer or immunization

1.

2.

3.

Hepatitis B vaccine series

(3 doses or at least begun the

series)

Influenza vaccine


PHLEBOTOMY PROGRAM

DIRECTIONS TO MID-MO DRUG TESTING COLLECTION SITE

Please send results to:

Alese Thompson

Advanced Technology Center

2900 Doreli Lane

Mexico, MO 65265

or

Fax: 573-581-3766


PHLEBOTOMY PROGRAM

MLT 261 ADVANCED PHLEBOTOMY COURSE INFORMATION

This course reviews techniques and concepts learned in MLT 260 Phlebotomy and continues the

clinical experience. The focus is on clinical assay types and professional issues including

interpersonal communication, professional behavior, quality assurance, phlebotomy department

management, and government regulations that pertain to phlebotomy.

The prerequisite for this course is MLT 260.

It will be offered in the second eight weeks of the spring and fall semester:

March –May and October – December.

The structure of the course is similar to MLT 260; that is, eight weeks of lecture on Tuesday

evening 6:00 PM to 8:30 PM and 64 hrs. of clinical practice at an affiliate site.

At the end of the two phlebotomy courses students will have had 40 clock hours of classroom

experience and 100 hours of clinical experience. Students must have 100 successful venipunctures

and/or skin punctures. Then, they will be eligible to take the American Society of Clinical Pathology

phlebotomy examination to become a certified phlebotomist.

IMPORTANT!

If you wish to enroll for this course as well, please notify the Nursing Administration office so

that we can add this course to your enrollment form. The enrollment form must be signed by

MLT Program Coordinator before you can enroll.

dear prospective phlebotomy student - macc€¦ · dear prospective phlebotomy student: thank you...

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