Phlebotomy Technician
Program
12800 Abrams Road
Dallas, Texas 75243-2199
972.238.6920 or 972.238.6248
www.richlandcollege.edu/hp
Mathematics/Science/Health Professions
Sabine Hall 205
PhlebotomyTechnicianProgram
ApplicationPacket
Equal Opportunity Institution.
IT ALL BEGINS HERE.
JOBDESCRIPTION
APhlebotomyTechnicianisanintegralmemberofthemedicallaboratoryteamwhoseprimary
functionisthecollectionofbloodsamplesfrompatientsbyvenipunctureormicrotechniques.The
phlebotomytechnicianfacilitatesthecollectionandtransportationoflaboratoryspecimensandis
oftenthepatientsonlycontactwiththemedicallaboratory.Theneedtoassurequalityandpatient
safetymandatesstrictprofessionalbehaviorandstandardsofpracticeforthesepractitioners.
SpecificDutiesInclude:
•
•
•
•
•
•
•
•
•
•
•
correctidentificationofpatientspriortosamplecollection
collectionofappropriateamountsofbloodbyvenipunctureordermalpuncture
selectionofappropriatespecimencontainersforspecifiedtests
correctlabelingofspecimenswithrequiredinformation
appropriatetransportationofspecimensinatimelymanner
professionalinteractionwithpatientsandclinicpersonnel
processingofspecimensfordeliverytoappropriatelaboratorydepartments
maintenanceofrecordsmanuallyandelectronically
compliancewithallsafetyregulations/CLIAwaivedtests/OSHA
maintenanceofprofessionalupdates
professionalisminappearanceandconduct
•
ECGtrainingoptionavailableforadditionalskillset
Workplace
Phlebotomistsworkunderthesupervisionofamedicallaboratorytechnician,medicaltechnologist,
physician,orotherindividualwithanadvanceddegreeinbiomedicalorrelatedsciences.
Employmenttendstobeinhospitallaboratories,veterinarylaboratories,multi-physicianclinics,
doctorsoffices,healthdepartmentlaboratories,referencelaboratories,insurancecompanies,and
specializedclinics.
SkillRequirements
Phlebotomistsmusthavefinemotorcoordination,clearspeech,normalhearing,andgoodvisual
acuitytodistinguishcolors.Theymustbeabletousebothhandsandhavelegiblehandwriting.
Occasionallightlifting,stoopingandbendingisnecessary.Thephlebotomistmustbeabletomove
readilyfromonelocationtoanotherintheworkplace.Thephlebotomistmusthavegood
communicationskills.
ProgramGoals
Thegoalsofthisprogramaretoprovidequalifiedstudentswiththeknowledge,skillsandattitudes
requiredforthemtodemonstrateentrylevelcompetenceinthemultipletasksanddutiesofa
PhlebotomyTechnicianasdefinedbytheAmericanMedicalTechnologyCouncil.Thesegoalsinclude
to:
1)Servetheprofessionbyprovidingskilled,professionalphlebotomists
2)Servethepatientbyprovidingexcellenceincare
3)Servethestudentbyprovidingqualitytraininginasatisfyingcareer
4)Servethecollegebyprovidingaprogramthatcontributestoitsmission
Page -2-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
ProgramCompetencies
The following competencies are defined as critical for students to master in order to successfully
completeanapprovedPhlebotomyprogram.Studentswillbeprovidedmultipleopportunitiesinthe
classroom,lab,andexternshiptomastertheseskills:
1.
Basiclaboratoryskills
2.
Aworkingknowledgeofhumananatomyandphysiology
3.
Compositionofblood
4.
Venipunctureproceduresincluding:
a. Vacutainer
b. Syringe
c. Butterfly
5.
Bloodculturecollection
6.
Bloodsmears
7.
Skinpunctures
8.
ResponsibilitiesofthePhlebotomist
9.
Professionalismandethics
10.
LegalissuesassociatedwithPhlebotomy
11.
Healthandsafetyinthelaboratory
12.
Infectioncontrol
13.
Isolationprocedures
14.
Qualitycontrol
15.
Timedlaboratoryprocedures
16.
Indwellinglines
17.
Hospital/laboratorydepartments
18.
Processinglaboratoryspecimens
19.
Significanceoflaboratorytests
20.
Physicalproblemsthatoccurinthefield
21.
Patientproblemsandcomplications
22.
Diseasesthatcouldeffectlaboratorypersonnel;i.e.AIDS,Hepatitis
23.
CPRcertification
24.
Computerskills
WorkplaceCompetencies
Inadditiontoprofessionalcompetencies,studentsarerequiredtodemonstrateaworkingknowledge
oftheworkplace(SCANS)competencieslistedbelow:
5. Interpersonalskills
1. Basicskillsinreading,writing,
mathematicsandcommunications
6. Informationacquisitionandapplication
2. Criticalthinking
7. Systems
3. Personalqualities
8. Technology
4. Resourcemanagement
Page -3-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
PROGRAMOVERVIEW
ProgramMission
Richland College Health Professions Programs provide students with quality, affordable and accessible healthcare
education and training to produce job-ready individuals who fulfill the needs of healthcare employers and the
community.
ProgramDescription
Theprogramisbasedontheguidelines,modelsandrequirementsoftheapprovingagency.Itconsistsof159contact
hoursand120hoursofpracticalexperience/externshipatanapprovedlaboratory.Studentscompletingtheprogram
haveseveralavenuesleadingtocertification.
Theprogramconsistsofthreecourses.ThePhlebotomyTechnicianProgramrequiresthatadmittedstudentscomplete
theCPRforHealthcareProfessionalseitherbeforebeginningtheprogram,orduringthePhlebotomyIcourse.TheprerequisiteforPhlebotomyIandIIisBasicMedicalTerminologyandAnatomy&Physiology.ThePhlebotomyIandIIfocus
ontheskillsandknowledgespecifictotheactualdutiesperformedbyaphlebotomist.Thecapstonecourseisan
externshipinamedicalclinicorhospital.Intheexternship,participantswillpracticeandmasterthedutiesofa
phlebotomistunderthesupervisionofacertifiedprofessional.
COURSES
CONTACT
HOURS
TUITION
ALLREQUIREDIMMUNIZATIONRECORDSMUSTBESUBMITTEDPRIORTOENROLLMENT
7hours
$80
BasicMedicalTerminologywithA&P
48hours
$288
PhlebotomyI
(withLiabilityInsuranceaddedtotuition)
48hours
SemesterI CPRforHealthcareProfessionals
$288
+$5-$11.70
(LiabilityInsurance)
$336
PhlebotomyII
SemesterII PhlebotomyClinicalExternship
+$5-$11.70
LiabilityInsurance
(ifrequired)
56hours
120hours
$315
LiabilityInsurance
(ifrequired)
LiabilityInsurance
Inordertoprovideliabilityprotectionforthestudentandtheexternshipsite,RichlandCollegehasenteredintoa
contractwithacompanytoprovideacosteffectivestudentliabilityinsuranceforclinicalclassesandexternships.The
cost(thoughsubjecttochange)ispro-ratedat$11.70forfallsemesterclasses,$8forspringsemesterand$5forsummer
semestercourses.Liabilityinsuranceispaidonceanacademicyear.CoveragestaysineffectuntilAugust31stofeach
year.
Externships
Thisprogramrequiresthestudenttocompletea120-hourunpaidexternshipinanaccreditedlabandunderthe
supervisionofaCertifiedPhlebotomyTechnicianorMedicalTechnologist.Studentsmusthavesuccessfullycompletedall
programcourseworkwithapassinggradeofA,B,orCanda90%attendanceineachcourse(asrequiredbytheStateof
Texas,)immunizationrequirements,drugscreen,criminalbackgroundcheck,andpurchasedliabilityinsuranceinorderto
beeligiblefortheexternship.StudentsmustbeavailableMondaythroughFridayfrom8am-5pm,somesitesdooffer
12hourshifts.Thestudentmustmakeeveryattempttobeavailableduringthesehours.Studentsregisterandpay
tuition(orhavetuitiondeductedfromTPEGaward,ifapplicable)fortheexternship,justasanyotherclass.Students
mustobtainasignedregistrationformfortheexternshipfromeithertheMedicalProgramsDirectorortheExternship
CoordinatoronlyandtakeittotheContinuingEducationDepartmenttoregister.
Page -4-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
CompletionCriteria
Successfulcompletionoftheprogramrequiresthatthestudentmeetthefollowingcriteria:
A. Attendance:Studentsmustattendaminimumof90%ofallscheduledclassroomtime.
B. Demonstrate mastery in the program competencies. Students will receive a syllabus with these course
competencies at the beginning of each course. Instruction will be developed to train students to achieve the
coursecompetencies.Studentswillbeevaluatedontheirachievementofthesecompetencies.
C. Achieveadditionalrequirementsdefinedbytheinstructor.
D. Successfullycompletetherequiredcoursesandunpaidexternship.
ACertificateofCompletionwillbeissueduponsuccessfulcompletionofthisprogram.Transcriptsmayberequestedas
proofofindividualcoursecompletions.
NationalCertification
Certificationmeansthatapersonhaspassedanationalexaminationbasedonnationalstandardsforaprofession;inthis
case,PhlebotomyTechnicians.Certificationisanindicationtotheemployerthatthecandidateshavemastered
nationallyapprovedskills.CertifiedPhlebotomiststendtohavegreaterjobopportunitiesandwages.Tobecomea
CertifiedPhlebotomyTechnician,thecandidatemustpassanationalexamination.TheHealthProfessionsPhlebotomy
TechnicianProgramatRichlandCollegewilltrainparticipantstonationallyapprovedcurriculumstandards.Completers
oftheprogrammaysitfornationalcertificationexamsuponcompletionofthisprogram.
Thefollowingorganizationsallprovidenationalcertificationexaminationsforphlebotomists.Requirementstositforthe
examinationsvaryamongorganizations,asdotheschedulesforadministrationandthecost.Specificinformationshould
berequestedbycontactingtheorganizationdirectly:
ŸAmericanSocietyofClinicalPathologists(ASCP)BoardRegistry
P.O.Box12270
Chicago,Illinois60612
312-738-1336www.ascp.org
ŸNationalPhlebotomyAssociation(NPA)
5616LandoverRoad
Hyattsville,Maryland20784www.nationalphlebotomy.org
ŸNationalCertificationAgencyforMedicalLaboratoryPersonnel(NCA)
7910WoodmontAvenue,Suite1301
Bethesda,Maryland20814
http://www.marist.edu/science/medicallab/ncerexam.html
Page -5-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
ADMISSIONSPROCESS:STEPBYSTEP
AdmissionAssessments*
Academic assessment tools assist applicants in determining if they have the skills to achieve program goals, objectives
andcompetencies.Withtheinformationgainedfromtheassessments,theHealthProfessionsAdmissionsCoordinator
canassisteachapplicantindevelopinganappropriatestudyplan.
1. Candidatesmustselectoneofthefollowingtwoassessmenttools:
A. Documentationofa“C”averageoraboveinpreviouscreditcollegecoursework,orapprovedscoresonThe
NewTSIAssessment.Minimumscoresforeachacademicarea:
ReadingComprehension
351+, SentenceSkills363+
Arithmetic335+
ApplicantswholearnedEnglishasasecondlanguageandhavenevertakencreditcollege-levelcourseworkintheUnited
StateswillbereferredtotheRichlandCollegeMulticulturalCenterforassessment.
Becausethepurposeoftheadmissionscriteriaistoprovideincreasedassuranceofacademicsuccess,theProgram
Administratorhastheauthoritytopermitapplicantswithscoresclosetotheabovecriteriatoenrollinamaximumoftwo
courses.Iftheapplicantperformssuccessfullyinthecoursework,theadmissionscriteriamaybewaived.
2. Applicantsmustdemonstrateentrylevelcomputerskillstoenrollinthecomputer-relatedcourses.
3. Applicantsmustdemonstratebasicskillsinwordprocessing(MicrosoftWord).
* Theseareminimalrequirementsforadmission.
Individualcourseshaveprerequisiterequirements.
AdmissionPrerequisites
Thepurposeofprerequisitesistoensurethatparticipantshavetheentry-levelskillsnecessarytosucceedinthe
PhlebotomyTechnicianProgram.DevelopmentalstudiesorEnglishforSpeakersofOtherLanguagesclassesareavailable
forcandidateswhohavedeficitsinmeetingtheacademicprerequisites.RichlandCollegewillassistcandidatesby
planningarecommendedcourseofstudytoacquirenecessaryeducationalprerequisites.TheProgramAdministratorhas
theauthoritytowaiveaneducationalprerequisitebasedoncriteriathatindicatesthattheapplicantwillbesuccessfulin
theprogram.
AllAdmissionPrerequisitesfollowthe
RichlandCollegeStrategicPriorityofStudentSuccess.
AdmissionProcess:Step-By-Step
AllprospectivestudentsforthePhlebotomyTechnicianProgramwillneedtocompletethefollowingstepstobegin
theapplicationforadmissionprocess:
A. ProspectivestudentsshouldattendtheHealthProfessionsInformationSession,orviewitonlineat
www.rlc.dcccd.edu/hp.Additionaldocuments;financialaiddirections,programdocumentchecklistareavailable
onlineandattheliveInformationSessions.Onceadeterminationofacademicreadinessbyunofficialtranscripts
orassessment,theapplicantthengathersandsubmitsthefollowingrequireddocumentationtotheHealth
ProfessionsAdmissionsCoordinator(WH244)ortheMedicalProgramsCoordinator(WH240)tobeginthe
applicationprocess:Studentswillneedtosubmitthefollowing:
1. Completed,signedanddatedapplicationpage(fromtheProgramApplicationPacket)
2. CompletedStudentDocumentofUnderstanding(fromtheProgramApplicationPacket)
3. Proofofage(Driver’slicense,StateID,orPassport)wewillmakeacopy
4. ProofofhighschoolgraduationorhighschoolseniororGEDorunofficialcollegetranscriptsshowingcredit
collegecourseworkcompletedwithintheUnitedStates.(Forthosewhohavesubmittedtheirhighschool
transcriptorGEDand/ortransferredtranscriptsfromoutsideoftheDCCCDtoanyoftheDCCCDcolleges,we
canaccessyourstudentrecordswhenwemeetwithyou.)
5. Thoseapplicantswhohavenevertakencreditcollege-levelcourseworkwithintheUnitedStateswillbe
referredforappropriateacademicassessmentontheRichlandCollegeCampus.Aftercompletingthe
assessment,applicantsreturntomeetwiththeAdmissionsCoordinatororMedicalProgramsDirectorto
reviewassessmentscoresanddetermineprogrameligibility.
Page -6-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
6. SubmitrequireddocumentationtotheAdmissionsCoordinator,planyourfirstclassorclassesandreceivea
signedregistrationformfromtheAdmissionsCoordinator.IftheACisunavailable,pleaseseetheMedical
ProgramsDirectortosubmitapplicationforadmissionsdocuments.
7. DocumentationofWorkplacePrerequisites
a. Candidatemustbeaminimumof18yearsofage
b. Validationofaphysicalexaminationandcurrentimmunizations(SchoolHealthExam)
c. ValidationofagreementtoabidebytheSCANScompetencies
B. DocumentationofWorkplacePrerequisites
1.
2.
3.
4.
Candidatemustbeaminimumof18yearsofage
Validationofaphysicalexaminationandcurrentimmunizations†
ValidationofagreementtoabidebytheSCANSCompetencies
SignedanddatedStudentDocumentofUnderstandingconfirmingthatacriminalbackgroundcheckand
drugscreenmustbecompletedpriortoprogramclinicalexternshipandthatstudentsmustregisterand
payfortheclinicalexternship,justasanyothercourse.††
AdditionalInformation
Pleasenote:
† Applicantsandstudentsmayrefusetotakethevaccinesbysigningawaiverandclaimingareligious,
conscientiousormedicalexemptionthroughtheDepartmentofHealth
†† Mostexternshipsitesrequireadrugtestand/oracriminalbackgroundcheck.Eachstudentis
responsibleforthisexpense(acombinedcostofapproximately$85)andtheclinicalexternship
TransfersandWaivers
Applicantsmaytransferequivalentcourseworkorworkexperienceintothisprogram.Thisequivalencymustbein
content,contacthoursandcompetency.AnytransfersorwaiversmustbeapprovedbytheMedicalProgramsDirector.
TheprocessisinitiatedbycompletingtheRichlandCollegeContinuingEducationWaiverFormandattachingthe
appropriatedocumentation.DocumentationmayincludecompletionofafinalexamasgiveninthePhlebotomyclasses
atRichlandCollege,transcripts,and/orlettersfromemployersandofficemanagerswheretheapplicanthasworked.In
uniquecircumstances,courseworkmaybewaivedbasedonexperience.Inthiscase,theMedicalProgramsDirectorand
facultywilldesignatooltodetermineiftheapplicant’sexperiencesareequivalenttothecompetenciesrequiredinthe
course.Nomorethan40%oftheprogramcanbewaived.WaivermustberequestedbeforeenrollinginthePhlebotomy
TechnicianProgram.
FinancialAid
Qualifyingstudentsmaybeeligibleforfinancialaid.Prospectivestudentsbeginthefinancialaidprocessbycompleting
theFAFSAapplicationforthecurrentorupcomingacademicyear.Visitthewww.fafsa.govWebsiteandcompletethe
applicationonline.OncetheStudentAidReport(SAR)hasbeenprocessed,studentsshouldthenprintouttheTPEG
ApplicationformfromtheDCCCDWebsitewithcourseinformationforeachclassthatthestudentswishestoregisterfor
eachsemester.
TheTexasPublicEducationGrant(TPEG)isavailabletoassistnon-creditstudents.
TheTPEGpaysfortuitiononly,upto$1500peracademicyear(fall,Spring&Summer.)
TheDCCCDFinancialAidCallCenterphonenumberis972.587.2599.
Page -7-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
Workplace(SCANS)Competencies
FiveCompetencies
Resources:Identifies,organizes,plans,andallocatesresources
A. Time-selectsgoal-relevantactivities,ranksthem,andallocatestime,andpreparesandfollowsschedules
B. Money-usesorpreparesbudgets,makesforecasts,keepsrecords,andmakesadjustmentstomeetobjectives
C. MaterialandFacilities-acquires,stores,allocates,andusesmaterialsorspaceefficiently
D. HumanResources-assessesskillsanddistributesworkaccordingly,evaluatesperformanceandprovidesfeedback
Interpersonal:Workswithothers
A. ParticipatesasMemberofaTeam-contributestoagroupeffort
B. TeachesOthersNewSkills
C. ServesClients/Customers-workstosatisfycustomers’expectations
D. ExercisesLeadership-communicatesideastojustifyposition,persuadesandconvincesothersresponsibly,
challengesexistingproceduresandpolicies
E. Negotiates-workstowardagreementsinvolvingexchangeofresources,resolvesdivergentinterests
F. WorkswithDiversity-workswellwithmenandwomenfromdiversebackgrounds
Information:Acquiresandusesinformation
A. AcquiresandEvaluatesInformation
B. OrganizesandMaintainsInformation
C. InterpretsandCommunicatesInformation
D. UsesComputerstoProcessInformation
Systems:Understandscomplexinterrelationships
A. UnderstandsSystems-knowshowsocial,organizational,andtechnologicalsystemsworkandoperateseffectively
withthem
B. MonitorsandCorrectsPerformance-distinguishestrends,predictsimpactsonsystemoperations,diagnoses
deviationsinsystems'performanceandcorrectsmalfunctions
C. ImprovesorDesignsSystems-suggestsmodificationstoexistingsystemsanddevelopsneworalternative
systemstoimproveperformance
Technology:Workswithavarietyoftechnologies
A. SelectsTechnology-choosesprocedures,toolsorequipmentincludingcomputersandrelatedtechnologies
B. AppliesTechnologytoTask-understandsoverallintentandproperproceduresforsetupandoperationof
equipment
A. MaintainsandTroubleshootsEquipment-prevents,identifies,orsolvesproblemswithequipment,including
computersandothertechnologies
Page -8-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
AThree-PartFoundation
BasicSkills:Reads,writes,performsarithmeticandmathematicaloperations,listensandspeaks
A. Reading-locates,understands,andinterpretswritteninformationinproseandindocumentssuchasmanuals,
graphs,andschedules
B. Writing-communicatesthoughts,ideas,information,andmessagesinwriting;andcreatesdocumentssuchas
letters,directions,manuals,reports,graphs,andflowcharts
C. Arithmetic/Mathematics-performsbasiccomputationsandapproachespracticalproblemsbychoosing
appropriatelyfromavarietyofmathematicaltechniques
D. Listening-receives,attendsto,interprets,andrespondstoverbalmessagesandothercues
E. Speaking-organizesideasandcommunicatesorally
ThinkingSkills:Thinkscreatively,makesdecisions,solvesproblems,visualizes,knowshowtolearn,and
reasons
A. CreativeThinking-generatesnewideas
B. DecisionMaking-specifiesgoalsandconstraints,generatesalternatives,considersrisks,andevaluatesand
choosesbestalternative
C. ProblemSolving-recognizesproblemsanddevisesandimplementsplanofaction
D. SeeingThingsintheMind'sEye-organizes,andprocessessymbols,pictures,graphs,objectsandother
information
E. KnowingHowtoLearn-usesefficientlearningtechniquestoacquireandapplynewknowledgeandskills
F. Reasoning-discoversaruleorprincipleunderlyingtherelationshipbetweentwoormoreobjectsandappliesit
whensolvingaproblem
PersonalQualities:Displaysresponsibility,self-esteem,sociability,self-management,andintegrityand
honesty
A. Responsibility-exertsahighlevelofeffortandperseverestowardsgoalattainment
B. Self-Esteem-believesinownself-worthandmaintainsapositiveviewofself
C. Sociability-demonstratesunderstanding,friendliness,adaptability,empathy,andpolitenessingroupsettings
D. Self-Management-assessesselfaccurately,setspersonalgoals,monitorsprogress,andexhibitsself-control
E. Integrity/Honesty-choosesethicalcoursesofaction
Page -9-
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
PHLEBOTOMYAPPLICATIONFORADMISSION
LastName
FirstName
MiddleName
StudentIdentificationNumber
Address
City
State
ZipCode
HomePhone
WorkPhoneand/orCellularPhone
E-mailAddress
EducationalHistory
School
HighSchool
CompletionDate(Pleaseattachtranscriptstothisapplication)
College
SpecialTraining
(explain)
OtherthanEnglish,whatlanguagesdo youspeakfluently?
Whatlanguagesdoyoureadand
writefluently?
EmploymentHistory
Position
Employer
CareerGoals
a.
ExplainwhyyouareinterestedinthePhlebotomyProgram.
b.
Whatpersonalattributesorskillsdoyoubringtothisprogram?
c.
Whatobstaclesdoyouhaveincompletingthisprogram(financial,workschedule,etc.)?
Attachdocumentation:¦Proofofage ¦HSDiploma,GED,orequivalent
¦Assessmentscoresorcollegetranscripts
¦Healthform
¦StudentDocumentofUnderstanding¦Immunizations
Applicant’sSignature
Page -10-
Date
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
StudentDocumentofUnderstanding
I,
,haveexaminedandunderstandthefollowing:
•
The Foundational and Workplace (SCANS) Competencies required for the Phlebotomy Technician
program. I acknowledge their importance in the workplace and in college course work. I agree to
pursuethemasanintegratedcomponentinallofmycoursework.IcertifythatIhavereadthisand
understand its meaning. I also have been given the opportunity to ask questions regarding this
statement.
•
IunderstandthatifImissmorethan10%ofaclass,Imaynotbeabletomakeitupandwillhaveto
retaketheclass.IalsounderstandthatifIamchronicallytardytoclass,pointsmaybetakenoffmy
finalgradeand/oritmaybeaddedtothe10%ofhoursmissedinclass.Thesyllabuswillexplainthe
method the instructor will use to determine the grade. He/She will determine if the absence can be
excused. I certify that I have read this and understand its meaning. I also have been given the
opportunitytoaskquestionsregardingthisstatement.
•
IunderstandthatIhavetocompleteacriminalbackgroundcheckanddrugscreenatmyownexpense,
estimated to be $85.00 and provide proof of health insurance if requested by my clinical site. I also
understand that the clinical externship must be paid for as a class. The cost of the externship is
$315.00. I also understand that I will be required to pay for liability insurance through Richland
College,estimatedcost$11.00orless.IalsounderstandthatImustrearrangemypersonalschedulein
ordertobeavailabletocompletemyexternship.Ialsounderstandthattypicalexternsitesareavailable
from8:00AM-5:00pmandsome12hourshiftsdependingonthelocation.
•
IunderstandthatpriortoregistrationforthefirstPhlebotomyclassthatIwillberequiredto:
(1)ProvideproofofimmunizationorserologicproofofimmunityforHepatitisB,Measles,Mumps,
Rubella,Varicella(Chickenpox),Tetanus/Diptheria/Pertussis,aswellastheMeningitisVaccine1(if
underage30)andanannualInfluenza1immunizationatmyownexpense;(2)betestedforTB
annually;and(3)haveacurrentCPRforHealthProfessionalscard.TheHepatitisBimmunizationseries
cantake4to6monthsandmustbestartedatthebeginningoftheprogram,ifnotalreadycompleted.
Page -11-
Applicant’sSignature
Date
Phlebotomy Technician Certificate Program
Richland College
2/2/2017
HealthEvaluationForm
HEALTHSELF-EVALUATIONCERTIFICATION
I understand it is my responsibility to update my health status changes (within 30 days of the occurrence of
symptoms,disease,accidentorinfirmity)andthatImayberequiredtosubmitmedicalclearancetoreturntothe
program.
Applicant’sPrintedName
Applicant’sSignature
Date
AllPhlebotomyTechstudentsmustsubmitalloftherequiredimmunizationdocumentation
beforethestartofthePhlebotomyIcourse.
Studentsmustattachrecordsofimmunizationsorresultsofserologicteststoconfirmimmunity.
Varicella
InfluenzaVaccine
VaccinationDates: Vaccine1________ 1_______(annual)
(2lifetime)
Vaccine2________
(ifexternship
Vaccine1_______
MMR
VaccinationDates:
(2lifetime)
Vaccine2_______
Tetanus/Diphtheria/Pertussis:
(every10years)
BacterialMeningitis
Vaccine1
*HepatitisB
Vaccine1
Vaccine2
____________
VaccinationDate: Vaccine3
(ifundertheageof30)
Studentswhodonothavetheirimmunizationrecords,butattendedhigh
schoolintheUnitedStatesmaycheckwiththeschooldistrictorthe
countyhealthdepartmentwheretheylastattendedhighschool.
Studentswhohavereceivedtheseimmunizations,buthaveno
documentationofrequiredimmunizations,willberequiredtohavetiters
completedforallimmunizationspriortoregistrationforPhlebotomyI.
Ifthetiterresultsshowalowerimmunitythan
requiredbytheStateofTexas,thestudent’s
doctorwillneedtodetermineifthestudentneeds
abooster,ortheseriesof3injections.
Phlebotomy Technician Certificate Program
Richland College
_________
_________
_________
*Pleasenotethatforstudentsthatcompletedthe
HepBimmunizationseriesmorethan18years
ago,HealthProfessionswillrequireatiterto
determinelevelofimmunity.
TuberculosisScreeningDate:____________________(attachresults)
(TBtestsareavailableforfreeintheRLCHealthCenter,T110.)
Page -12-
________
2/2/2017
PlantoGraduate
Program PHLEBOTOMYTECHNICIAN
:
ProgramDeclared: Yes No
Name: StudentID#
Date: Semester
#of
tobe
Contact
Completed
Hours
Semester1
Hours 7
NUPC1091
48
BasicMedicalTerminologyand
Anatomy&Physiology
__________ __________ ______
PLAB1023
48
PhlebotomyI
__________ __________ ______
PLAB1091
56
PhlebotomyII
__________ __________ ______
Total
159
__________ __________ ______
PhlebotomyClinicalExternship
__________ __________ ______
PLAB1060
120
___________
EMSP1019
Semester2
CPRforHealthcareProfessionals
Grade
__________ ______
Program
Total
279
TotalEarned _________ _________ _____
Page -13-
AnticipatedGraduationDate
Phlebotomy Technician Certificate Program
Richland College
2/2/2017