Medical Assisting Information Session Confirmation Form

Please check the appropriate boxes:

I certify that I have viewed and understand the online presentation of information for the Medical Assisting program at Caldwell Community College & Technical Institute.

I still have questions that were not answered in the presentation. I will contact Student Services or the Program Director for assistance.

I understand that in order to complete the Information Session admission requirement that I must submit this form to Student Services immediately. The date that this form is received by CCC&TI will be used to meet this requirement in my admission folder.

I have made a copy of this confirmation for my personal records.

Please read the Technical Standards document before completing this section.

I have read and understand the technical standards required for Human Services Technology, I hereby declare that:

I am/the student is able to meet the above listed essential technical standards

I am/the student is unable to meet the above listed essential technical standards based on the following:

Please list standard that cannot be met and give rationale

Clinical Eligibility & Licensure/Certification/Registry Eligibility for Health Sciences Students

Clinical: Clinical education is a vital component in the training of health sciences students. The college maintains a formal clinical affiliation agreement with each facility where students are sent for clinical instruction. These affiliation agreements specify requirements similar to those required of facility employees and may include health and immunization requirements, personal health insurance, mandatory HIPAA and OSHA training, criminal background checks and drug screens.

Not all facilities impose the same requirements, and these requirements may change with little or no notice. After admission to the health science program students are required to submit to a criminal background check and urine drug screen through Castlebranch.com or the school’s designee. Any dispute concerning unsatisfactory background findings or drug screen will be between the student and the party providing the service. Background checks and drug screens are to be completed on or before the date set by the student’s individual program.

Any of the following positive findings may cause a student to be ineligible for clinical:

Felony conviction (class A-E)
Class A1 misdemeanor conviction (examples: assault inflicting serious injury with a deadly weapon, assault on a female, assault on a child under 12 years of age, assault on a state officer or employee, assault by pointing a gun, violation of a valid protective order)
Class 1 misdemeanor conviction ( examples: breaking or entering buildings, larceny of property, unauthorized use of a motor vehicle, worthless checks for $2,000 or less from a closed account, willful and wanton injury to real property, communicating threats, possession of drug paraphernalia, misrepresentation to obtain employment security benefits [worth $400 or less])
Listing on the national sex offender list
Listing by the Office of Inspector General (OIG) disbarring individual from participation in health care programs

Students who show any of the above findings will have a flag on their background screen and may be ineligible for participation in clinicals subject to approval by each individual assigned facility.

Many of the facilities scrutinize the student background checks themselves and may impose stricter standards. If a facility deems that a student must be excluded from their site, the student will be unable to progress in the program. If you have any questions about this policy please contact your program director or the department chair for Health Sciences.

Licensure/Certification/Registry Eligibility: When considering whether to admit an individual into a specific program of study, the College shall take into account that federal law prohibits states from granting professional licenses to undocumented immigrants. Furthermore, graduation from a CCC&TI health science program alone does not guarantee that the student has met all eligibility requirements for licensure, certification, or registry required in order to practice in the related medical field. Prospective students should contact the appropriate agency prior to enrollment if they have any questions concerning their eligibility for credentialing examinations and legal ability to practice.

Your typed initials below will be considered your electronic signature.(Required)

I have read and understand the policy for required criminal background checks as it relates to my eligibility for progression within all health science programs at CCC&TI. I also have read and understand that graduation from CCC&TI does not automatically guarantee my eligibility to sit for any required licensure, certification, or registry exams.

Student Name:(Required)

Date of Birth(Required)

Last 4 of SSN(Required)

Your typed name below will be considered you electronic signature.(Required)

First Last

Date(Required)

Student ID #(Required)

Your email:(Required)

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Medical Assisting Information Session Confirmation Form

Clinical Eligibility & Licensure/Certification/Registry Eligibility for Health Sciences Students

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