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Paramedic

TRAINING PROGRAM APPLICATION PACKET

SOUTH HOWELL COUNTY AMBULANCE 1951 EAST STATE ROUTE K

WEST PLAINS, MO 65775 PHONE: 417-255-2223

FAX: 417-257-1353 WWW.SHC-EMS.COM

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Dear Applicant,

Thank you for your interest in the Paramedic Program offered by South Howell County Ambulance

Education Department. The application process is structured in a manner to be fair, balanced,

consistent, and allows us to assess your ability to perform well in the program. This packet describes

the steps involved in making application.

South Howell County Ambulance Education Services does not discriminate on the basis of race,

color, religion/creed, age, gender, disabling condition, handicap, or national origin. To be admitted to

the Paramedic Program, students must first meet the basic entrance requirements of South Howell

County Ambulance Education Services.

Prehospital medicine is physically and emotionally challenging, as is this course. A functional

paramedic job description is available via any internet search. It is the applicant’s responsibility to

understand what the course and career entails.

If you believe you have a disability that will require accommodations during the application process

or during your enrollment as a student, please contact the Education Department as soon as possible.

While we assure that everyone is offered equal opportunity during application and instructional

processes. You should be aware that to complete the program you must complete ALL of the

program’s requirements.

This packet also includes a list of the program’s pre-requisites and several forms. Please complete the

forms carefully and provide any necessary attachments. You should consult the checklist at the

bottom of the form to ensure your application is complete. Please be aware that the timeframe for

immunizations is lengthy and you should plan accordingly.

Again, thank you for your interest in our Paramedic Program. If you have any questions do not

hesitate to call or email me.

Best regards,

Richard Cotter

Education Operations Manager

Office: 417-255-2223

Cell: (417) 274-0095

Email: richardcotter@shc-ems.com

Website: www.shc-ems.com

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GENERAL OVERVIEW OF PARAMEDIC PROGRAM HOURS:

560 Hours of didactic (classroom/laboratory)

372 Hours of field clinical experience

200 Hours of hospital clinical experience

DIDACTIC EDUCATION: The didactic portion provides the theoretical foundation necessary for success as a student & a professional Paramedic. LABORATORY EDUCATION: Laboratory education allows students to develop hands on skills & apply concepts to clinical decision-making. HOSPITAL/FIELD CLINICAL EDUCATION: Hospital & Field Clinical education provides an opportunity for students to develop & apply theoretical knowledge & laboratory skills to the actual treatment of patients. Students will participate in various supervised clinical experiences within local hospitals & on EMS paramedic units (ambulances). SUMMATIVE FIELD EVALUATION: The summative field evaluation provides students with the opportunity to function as a team leader on actual 911 emergency calls, with EMS paramedics serving as mentors & preceptors, applying the knowledge & skills outlined above. CLINICAL SITES: Students will complete training in the following clinical areas: Emergency Department Pediatric Departments (Cox Health Systems) Labor & Delivery Units Stress Unit Surgery Department, Anesthesia Respiratory Care Intensive Care Units South Howell County Ambulance (Field Clinical Site) Other Sites deemed necessary

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EMS Paramedic Training Program Application Process This handout details the application process for South Howell County Ambulance Districts EMS Paramedic Training Applicant. There are 6 Phases to the application process. All phases must be completed before an application is eligible for entrance into the course. Phase completion does not guarantee that an applicant will be offered entrance into the course. Phase I Completion of Application &Submission of Documents Phase II EMT examination Phase III Physical Phase IV Oral Interview Phase V Drug/Alcohol Screen Phase VI Background Check Phase I COMPLETION OF APPLICATION & SUBMISSION OF DOCUMENTS The application must be completed in its entirety & submitted with all required documents. The application packet can be delivered via mailed, emailed, faxed or in person at the station. Mail/Physical address: Attn Richard Cotter, 1951 E. State Route K, West Plains, MO 65775 Email: richardcotter@shc-ems.com Fax: 417-257-1353 Phase II EMT Examination This allows us to assess your knowledge. Phase III PHYSICAL Applicants must provide their/a physician with a copy of the Functional Job Description along with the physician verification of student health status record to access the applicants ability to meet job requirements. Phase IV ORAL INTERVIEW Applicants will be interviewed by the Instructor and/or the Education Coordinator. Those applicants meeting the selection criteria will be notified & offered a conditional acceptance into the course contingent on successful completion of Phases IV & V. Phase V Drug/Alcohol Screen Upon conditional acceptance into the course, applicants will be scheduled for a drug/alcohol screen.

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Applicants must meet the following requirements: 1. Must be a U.S. Citizen 2. Must be 18 years of age in order to enter the program 3. High School Diploma or a G.E.D. 4. Valid Driver’s license 5. Current EMT Certification 6. Successfully passing the Department’s comprehensive EMT examination with a score of 70%. 7. Pass the following medical examinations: a. Alcohol & Drug Screen 8. Physically able to perform the duties of a paramedic 9. Current immunizations status: a. Verification of immunization against tetanus/diphtheria/mumps/measles/rubella/Varicella b. Negative results from a tuberculosis skin test or chest x-ray performed within the last 12 months 10. Must pass criminal background check 11. Must have 2 letters of recommendation 12. Must successfully clear interview process If you wish to have the Hepatitis B Vaccination completed prior to beginning clinicals; it is suggested that you have the 1st Hepatitis B vaccination (1 of 3) either before starting the course or within the first couple weeks of the course beginning. Evaluation of Applicants (Paramedic Students) The number of students in the program is limited by spaces available for clinical experience in affiliated hospitals & EMS provider organizations. Competitive selection of students may be necessary if the number of applicants exceeds the number of seats available. In this event, the Medical Director & Education Coordinator will review applicants. Factors that may be considered if competitive selection becomes necessary include: 1. Previous academic coursework & performance 2. Comprehensive departmental EMT exam scores 3. Prior work experience in EMS 4. Oral Interview results 5. Letters of Recommendation (2)

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CRIMINAL BACKGROUND AFFIDAVIT

1. Have you ever received a DUI/DWI violation? YES NO

2. Are there any criminal charges currently pending against you? YES NO a. If Yes please explain: ______________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Are you currently on probation or parole? YES NO

4. Have you had any voluntary surrender, disciplinary action, consent order or settlement imposed, or is any disciplinary action pending on your license/certificate in any state or

jurisdiction? YES NO

5. Have you had other than an honorable discharge from the military? YES NO 6. Have you been named in a civil/malpractice case relating to your employment as a health

care worker? YES NO

7. Have you had clinical privileges suspended, revoked, or limited? YES NO 8. Have you had or have a physical, mental, or emotional condition that might affect you

ability to practice safely as a certified EMT? YES NO 9. Have you ever been arrested, charged with, convicted of, or pled guilty or no contest to, or been sentenced for any criminal offense, including all misdemeanors or felonies in

Missouri or any state? YES NO NOTE: Even though an arrest or conviction has been pardoned , expunged, dismissed, or deferred, & you civil rights have been restored, you must answer “Yes” & attach certified copies of the bill of information or clerk of court records regarding any offenses. I authorize the South Howell County Ambulance District to conduct a Criminal History check on me. ____________________________________________ _______________ (Signature) (Date)

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STUDENT APPLICATION Last: _________________________First:___________________________ Middle:__________________

Current Employer Name and Address: ______________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Job Title:_______________________________ Job Functions: __________________________________

Employed From:_____________ To:______________

Reason for Leaving: ___________________________________________________________________

Previous Employer Name & Address: ______________________________________________________

Job Title: ______________________________ Job Functions: __________________________________

Reason for Leaving: ____________________________________________________________________

How do you learn best (Select all that apply): Reading; Doing; Seeing, and/or Hearing

Do you have any health problems that might interfere with your abilities to perform the standards of

being and EMT? Yes No If Yes, please state: ____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Current EMS Certification (s) Certifying Agency (S)

Where did you complete your previous EMS Education?

Certification Level School Month/Year Did you receive College credit?

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Accomplishments that have given you great satisfaction: Your reasons for selecting this program as a career: Your plans & future aspirations: Hobbies & sports: include interests, hobbies, recreational activities, involvement in civic

organizations, & other community service. Include Service awards:

MILITARY SERVICE

1. Were you ever in any branch of the US Armed Forces? YES NO Branch:_____________________ (If NO skip this section) 2. Selective Service Number:_________________________________________ (If unknown, call 1-847-688-6888 or visit www.sss.gov to obtain) You must provide a DD Form 214 (Discharge) for each period of Non-continuous service.

3. Are you currently on active duty? YES NO (If yes, provide the information below) Branch: _____________________________________ Date Entered: _____________________________________ Length of Commitment: _____________________________________ Actual or Estimated Date of Separation: _____________________________________ Grade/Rank: _____________________________________ Current M.O.S.: _____________________________________ Supervisor: _____________________________________ Unit Mailing Address: _____________________________________ 4. List all military service. (Attach additional pages if necessary) Dates of Service: _____________________________________ Branch of Service: _____________________________________ Complete Unit Address: _____________________________________

_____________________________________ M.O.S.: _____________________________________ Highest Rank: _____________________________________ Type of Discharge: _____________________________________

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Reason for Discharge: _____________________________________ Disciplinary Action: _____________________________________

EMERGENCY CONTACT INFORMATION

APPLICANTS NAME _____________________________________________________________________________________________________________________ First Middle Last

Preferred First Name:__________________________ _________________________________________________________________________________ Address City State Zip County

Date of Birth: ____________________ Age: ____________________ SS # ____________________ Place of Birth: ____________________ City State Country ____________________ Email Address: ___________________________________________ Home # ___________________________________________ Cell # ___________________________________________ Alternate # ___________________________________________ Employed by ___________________________________________ Employers # ___________________________________________ In case of Emergency, Illness, accident; SHCA is authorized to proceed as indicated below: (Please number each below in the order of desired action)

Contact: Relationship Phone #(s) ___________________|_________________|______________________

Contact Physician Doctors name: _________________|Phone # ___________________

Take to Emergency Room

Take to a licensed Physician

Other desired procedures:

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List any other name(s) that you have used or by which you have been known. Explain full Why,

Where & When it was used. Include nicknames, aliases, maiden name, & previous married name(s).

Attach additional pages if needed. _____________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PHYSICIAN’S VERIFICATION OF STUDENT HEALTH STATUS I have reviewed the health status of: _________________________________ & the attached Functional Position Description defining the technical standards of the Paramedic Program offered by South Howell County Ambulance Education Services. Based on these reviews I have determined that: This student will be able to meet all of the Program’s technical standards without accommodations. This student will be able to meet all of the Program’s technical standards if reasonable accommodations are provided. I have attached a signed, dated statement on my office letterhead describing the student’s functional limitations relative to the Program’s technical standards & appropriate accommodations to these limitations. This student will NOT be able to meet the Program’s technical standards, even with reasonable accommodations. I have attached a signed, dated statement on my office letterhead describing the reasons for this determination. _________________________________________________________________________________ Physician’s Signature Date _________________________________________________________________________________ Printed Name License Number

_________________________________________________________________________________

Office Telephone Number

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ADMISSION DRUG & ALCOHOL TESTING Acceptance of students to the EMS Education Program is contingent upon satisfactory compliance of physical examination & testing for illegal drugs. The initial drug screen will determine if any drugs are present. You will be asked to list all prescription & over-the-counter drugs you are taking, & the name & telephone number of the doctor who prescribed them. The cost for this test is included in your application & testing fee. If the initial test is positive, a confirmation test to identify the drug will be done. The testing is a condition of final acceptance as a student into the program. Applicants (students) who test positive for illegal drug will be refused admission to the program. An applicant who refuses to comply with this policy will not be accepted into the program. The applicant (student) will be responsible for the drug confirmatory testing, with payment made to South Howell County Ambulance District in the form of cash or money order. The in-house test will consist of a saliva swab test for drugs & a disposable chemical activated breathalyzer for alcohol. To protect all of our patients & employees, the sample must be taken under monitoring conditions. Failure to cooperate fully in this process will result in immediate withdrawal of the conditional offer of admission. As an applicant (student), I give permission for the drug test results to be released to South Howell County Ambulance District Education Services. I agree to comply with the enrollment process, as indicated above. _________________________________________________________________________ Applicant Signature Date _________________________________________________________________________ I do not agree to comply with the enrollment process as indicated above. _________________________________________________________________________ Applicant Signature Date

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HEPATITIS B VIRUS VACCINE I, _______________________________, understand that due to my occupational exposure to blood & other potentially infectious materials while I am a student with South Howell County Ambulance Education Services, I may be at risk of acquiring Hepatitis B Virus (HBV infection). I have been informed that it is the policy of South Howell County Ambulance Education Services faculty to strongly encourage students to be vaccinated with Hepatitis B vaccine, & that the vaccine is available through a private physician. The cost of the vaccine is the student’s personal expense & is approximately $_______ for the 3-series of injections I understand, by declining the Hepatitis B vaccine, I continue to at risk of acquiring Hepatitis B a seriously & potentially fatal disease. I understand that as a student with South Howell County Ambulance Education Services, I am expected to abide by the protective precautions as outlined in the Districts policy regarding transmission of blood borne pathogen disease. (AIDS & Hepatitis) I, _______________________________, decline to receive the Hepatitis B vaccine. I have read & understand the above stated comments of the District. I, _______________________________, agree to receive the Hepatitis B vaccine. I have already or will during first block of the program, receive the Hepatitis B vaccine. I have read & understand the above stated comments of the District. I, _______________________________, already have received the Hepatitis B vaccine & have attached my immunization record. I have read & understand the above stated comments of the District. _________________________________________________________________________ Witness Signature Date

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APPLICANT AGREEMENT RECORD I,________________________________________, the undersigned applicant for the (print name)

EMT training course, at South Howell County Ambulance (SHCA) hereby agree to the following: 1. I understand my completed application must be received by SHCA, on or before (date)

2. Type or print an answer to every question. If a question does not apply, indicate with N/A. If you are not sure if a question applies, contact SHCA.

3. I further understand that all of the requested information in the application will be provided by me, all statements are true & correct to the best of my knowledge, & that withholding pertinent information of providing inaccurate information may nullify my application.

4. Incomplete forms in any part of the application will not be processed & further consideration may not be given to the application.

5. I understand that I will be required to comply in a specified time period with any written of oral request communicated to me by any individual representing SHCA as it applies to my application.

6. I understand that this application process is part of the student select process only & is not to be considered an indication or obligation by SHCA in making an appointment for acceptance.

7. Failure to acknowledge or comply with any of the statements above may result in my disqualification as a candidate & delay of reapplication until the next EMT course.

NOW THEREFORE, I hereby acknowledge that I have read & fully understand each of the statements contained herein above, & further, that I had the opportunity to ask for clarification of each of the statements, & that my signature was not placed hereon until I fully understood each statement.

Signature: __________________________________ Date: _______________

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Admission Process

1. If you believe you have a disability that will require accommodations during the application process or during your enrollment as a student, please contact the Education Office as soon as possible. Disabilities include but are not limited to: reading, ability to take tests, ADHD, Dyslexia, Vision (blurred/color blind etc.,), hearing loss 2. Complete & sign all the Application records: a. Emergency Contact Record

b. Admission Drug & Alcohol Testing Record

c. Student Applicant Record

d. Hepatitis B Virus Vaccine Record

e. Physicians Verification of Student Health Status Record must be completed by your physician & returned to the Education Office as a means of verifying that your health will permit you to meet the technical requirements defined by the functional position description, either with or without reasonable accommodations

f. Applicant agreement Record

g. Military Service Record

h. Criminal Background Affidavit

i. Request for Criminal Background Check

3. Exam 4. Obtain & attach the following documents: a. High school diploma/GED

b. Two (2) letters of recommendation

c. Verification of immunization against tetanus, diphtheria, mumps, measles, and rubella, & Varicella, Negative results from a tuberculosis skin test or chest x-ray performed in the last 12 months.

d. Copy of your current driver’s license

e. Copy of your social security card

f. Copy of your negative 2-Step TB Skin test/negative chest x-ray i. You are able to obtain this from the Howell County Health Department.

g. Copy of your EMT License

h. Copy of your current CPR license *optional

i. Copy of your hepatitis B vaccinations *optional

5. Submit your completed application with the accompanying documents to the Education Department.

6. After we receive your application & verify it is complete, we will contact you to schedule a time for a personal interview.

7. When you receive your acceptance letter, you’re ready for class!