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PIERCE COLLEGE EMS PROGRAMSPrerequisitesStudent Name: _____________________________________ ALL shots listed below are required to be given on an official shot record or clinical document. Records provided to us must show the date the vaccination/titer/booster was given, your name, and the medical provider in order to be eligible for enrollment. All immunization or shot records are due on or before Mandatory Orientation date. You will be provided an informational sheet that details all immunization criteria.Please submit all pre-requisites as you complete them to EMS@pierce.ctc.eduShot record with proof of: FORMCHECKBOX MMR _______ FORMCHECKBOX MMR________ FORMCHECKBOX Tdap________, (Tdap shot or booster must be less than 10 years old.) FORMCHECKBOX HepB ________, FORMCHECKBOX HepB ________, FORMCHECKBOX HepB ________ FORMCHECKBOX Varicella (Chicken Pox) ________ FORMCHECKBOX Varicella (Chicken Pox) ________ Titer (blood draws) are acceptable as long as they show immunity for the above vaccinations. FORMCHECKBOX Shot record with TB tine test________ (Taken within last year and must be valid through the duration of the term) FORMCHECKBOX Current season Flu shot required Aug 2016-April 2017 _______ FORMCHECKBOX Current American Heart Association “Healthcare Provider” or Red Cross “Professional Rescuer” CPR card. *List of some available CPR classes in the area provided by request on page 5.POST EMT ORIENTATION PREREQUISTES FORMCHECKBOX Civilian students provide printout of the completed Training Modules from Clinical Placements Northwest (CPNW) FORMCHECKBOX Military students provide a printout of NEO 66 certificate**Please note** All students will be provided with a referral for both the background check(s) and the drug test (10 panel eCup/eReader certificate) at EMT Mandatory Orientation. Please do not initiate either of these processes prior to being instructed to do so at Orientation as they are only valid for 90 days. You will be provided with referrals at orientation. No students will be admitted into program without attending Mandatory Orientation****Mandatory Orientation: June 15, 2017 @ 0830-1330 OR 1730-2230**** NO EXCEPTIONS Clinical Placements NorthwestStudent/FacultyClinical Passport RequirementsSUBMIT ONCEHEPATITIS BDocumentation of Series of 3 vaccines completed at appropriate time intervals and post vaccination titer at 6-8 weeks after series completion. If negative titer, then repeat series (consisting of doses #4-#6) and repeat titer 6-8 weeks after #6 dose; or obtain challenge dose #4 and re-titer after 6-8 weeks ORProvide documentation of positive titer (anti-HBs or HEPB Sab) ORSigned declination for students/faculty who decline vaccination Specific healthcare institutions may require vaccination without exception (i.e. no declination).MMR (Measles, Mumps, Rubella)Proof of vaccination - 2 doses at appropriate intervals ORProof of immunity by titerVARICELLA (Chicken Pox)Proof of vaccination - 2 doses at appropriate intervals ORProof of immunity by titerTETANUS, DIPTHERIA, PERTUSSIS (Tdap)Tdap required onceTD required every 10 yearsCPRCourses can be American Heart Association (AHA) BLS ProviderMilitary Training Network (MTN) courseHeartcode BLS CourseSUBMITTED EVERY YEARTUBERCULIN STATUSAnnual TST ORAnnual TB IGRA testIf newly positive TST/IGRA results – F/U with healthcare provider (chest X-ray, symptoms check and possible treatment documentation of absence of active M. TB disease) and may need to complete health questionnaire.Previously documented positive TST results and prior negative chest results: submit annual symptom check completed with one year from healthcare provider.INFLUENZAProof of seasonal vaccination (s) ORSigned declination for student/faculty who decline vaccination (specific healthcare institutions may require vaccination without exception (i.e. no declination) ................
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