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
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Dear Prospective Phlebotomy Student - MACC€¦ · Dear Prospective Phlebotomy Student: Thank you for your interest in the Moberly Area Community College Phlebotomy class at the Advanced
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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
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
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.
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
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.
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.
MOBERLY AREA COMMUNITY COLLEGE
Advanced Technology Center 2900 Doreli Lane Mexico, MO 65265
PHLEBOTOMY COURSE
EMPLOYER 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.