Download Dear Paramedic Applicant: Thank you for your interest in the Arnot

Dear Paramedic Applicant:
Thank you for your interest in the Arnot Health 2016 - 2017 Paramedic program. Please consult this
checklist to answer general questions and assure a complete application. Final acceptance to the
program will not be granted until all requirements have been met by August 11, 2016.
The following are the prerequisites that need to be completed in full prior to the beginning of the program:




Be at least 18 years old
High school diploma or GED
Be currently certified as a New York State EMT
Complete application
The following documentation must be submitted by the date noted above to Department of EMS
Education, 1058 West Church Street, Elmira, NY 14905

Paramedic Training Program Application

Arnot Ogden Medical Center Release of Medical Information

EMT: Paramedic Health Form including the “Medical Care Provider Statement” (Physical Exam page)
and the “Immunization & Tests” page must have all the appropriate fields entered.

A copy of your current NYS EMT card
If you possess an EMT certification from another state, it is imperative that you apply for New York
State reciprocity. This can be accomplished by contacting the New York State Department of Health.
This process can take some time so please allow for this. Please visit
http://www.health.ny.gov/nysdoh/ems/certification/reciprocity.htm for more information regarding the
reciprocity process.
If you have any questions or need to check the status of your application, please call EMSTAR Training
Center at (607) 732-2354. Again, thank you for your interest in the program and we look forward to
seeing you in August.
PARAMEDIC CURRICULUM
Within the past 25 years, the development of the Emergency Medical Services has significantly
improved the caliber of care provided prior to arrival at the hospital. Arnot Ogden Medical
Center and EMSTAR have developed a training and educational program for paramedics, which
prepares students to meet the incresing demands of pre-hospital emergency care.
The standard track Paramedic course is an eleven (11) month course. In this program, students
receive instruction in the practice of pre-hospital emergency medicine through lecture, labs,
clinical and field training. The curriculum is designed to involve students in the four components
of training concurrently. This enables the paramedic students to master theory and practical
application quickly.
The didactic material provides the foundation for understanding the purpose and objectives of
clinical treatments. The Department of EMS Education believes that this is the distinction
between the clinician and the technician. The Arnot Ogden Medical Center and EMSTAR
maintain an extensive array of training manikins, models and equpment specifically for practice
of psychomotor skill development.
The curriculum has been designed to provide the student with an opportunity to obtain
certification in:
American Heart Association – BLS Healthcare Provider (CPR)
American Heart Association – Advanced Cardiac Life Support (ACLS)
American Heart Association – Pediatric Advanced Life Support (PALS)
American College of Emergency Physicians – International Trauma Life Support (ITLS)
As students are instructed in the theoretical practice of pre-hospital emergency medicine, they
participate in various supervised clincial experiences. These expereinces are designed to
develop the skill involved with patient care. During the clinical and field training, students have
an opportunity to rotate through some of the most respected health care facilities in the area.
While in training, each student completes rotations through the following clinical areas:
Emergency Department, Intensive Care Unit, Cadaver Lab, OR/Recovery Room (PAR),
Intravenous Team, Respiratory Therapy, Pediatrics, Geriatrics, Psychiatric,
Obstetrics/Gynecology (Labor Suite, Delivery Room & NICU), and Cath Lab.
As part of the program, students serve a minimum of 192 hours of filed internship with
paramedic ambulance services. This training enables students to apply their knowledge and
clinical skills in the pre-hospital environment. Each student is assigned an experienced
paramedic preceptor who will serve as a mentor throughout the program.
The curriculum of the program meets or exceeds all of the minimum training requirements
established by the United States Department of Transportation in the EMT-Paramedic National
Standard Curriculum Guidelines. Upon successful graduation from the program, the student is
able to sit for the New York State Paramedic Certification examination and the National Registry
of Emergency Medical Technician EMT-Paramedic exam.
ADVANCED STANDING POLICY
Students may be allowed advanced standing for clinical experience. Advance standing waivers
will be granted by the Medical Director. To be eligible, a student must submit an “Application for
Advanced Standing” for EACH AREA in which the student would like to receive advanced
standing. All applications for advanced standing must be received by September 12, 2016.
More explanation of advanced standing will occur on the first night of class.
2016-2017 Paramedic Training Program Application Form
PERSONAL DATA
Last name____________________________ First name_________________________ MI ______
Birthdate __________________________ Age ______
Sex
___male
___female
Social Security (last four)____________________________ Citizen of U.S. ____Yes ____No
Address ________________________________________
City ____________________________ State _________ Zip code __________________
Cell phone (
)_________________ other (
)__________________
E-Mail Address __________________________________________
EMT Certification Number ________________________
Shirt Size(polo) _______
*Expiration Date ___________________
Level of Certification ___EMT ___EMT-I ___EMT-CC
*Attach a copy of your current NYS EMT & CPR card- must remain current through class
EDUCATION
(High School, College, Post-Graduate, EMT School, Other)
Name & Address of Institution
Type
Dates of Attendance
Degree/Diploma/Cert.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I, the applicant, whose name appears below this statement, acknowledge that the information set forth
by me in the above application is true and accurate.
I do affirm that I have not been convicted, nor am I currently charged with any crime(s) related to:
murder, manslaughter, assault, sexual abuse, theft, robbery, drug abuse or the sale of drugs.
Name (printed)______________________________________
Signature of Applicant_____________________________________ Date________
Admission into the EMS training program is nondiscriminatory with respect to race, creed, sex, sexual
orientation, age or national origin.
Arnot Ogden Medical Center
Release of Medical Information
Paramedic Program
I, _____________________________, understand that my medical history as reported
on my program application may be requested by the Arnot Ogden Medical Center and
various clinical site agencies. I understand that by signing this form, I agree to allow
Arnot Ogden Medical Center to release my medical history to any requesting clinical site
agencies.
My signature below confirms my acceptance of the above.
Paramedic Student Name (print) ___________________________
Signature of Paramedic Student ___________________________ / ________
Date
Paramedic Health Form
PLEASE PRINT
Last name____________________________ First name_________________________ MI ___
Birthdate __________________________
Address ________________________________________
City ____________________________ State _________ Zip code __________________
Cell phone (
)_________________ other (
)__________________
EMERGENCY CONTACT:
NAME _______________________________________________
HOME ADDRESS
_________________________________________________________________________
HOME PHONE ______________________ CELL PHONE ______________________
WORK ADDRESS
_________________________________________________________________________
WORK PHONE _________________________
EMT: PARAMEDIC HEALTH FORM
An accurate Health Form is essential and enables AOMC to provide appropriate care and guidance to
students. It is considered a CONFIDENTIAL document.
All students who plan to enter the Paramedic program must complete this Health Form. All paramedic
students are required to have a physical examination by their healthcare provider and provide
documentation of the identified immunizations/screenings noted in this form BEFORE beginning the
paramedic courses. The student “Self Report” section should be completed before going to your
healthcare provider.
Please make a copy of the Health Form -- submit the original form with required documentation to:
Department of EMS Education
1058 West Church Street Elmira, NY 14905
Student Name ______________________________________________
STUDENT SELF-REPORT SECTION
DIRECTIONS: ANSWER ALL QUESTIONS. CHECK WHERE APPLICABLE
1.
2.
Family History
Father: Age ____
Mother: Age ____
If either parent is deceased, identify
and give cause –
Among your blood relatives, is there
a present or past history of:
___ Heart Disease
___ High Blood Pressure
___Stroke
___Tuberculosis
___Diabetes
___Cancer
___Anemia
___Allergies
___Seizures
___Kidney Disease
___Arthritis/Gout
___Stomach, Intestinal Problems
___Emotional Problems
___Cirrhosis
___Migraine
___Deafness
___Blindness
3.
Are your allergic to any of the
following:
___Penicillin
___Sulfa
___Horse Serum
___Insect bites, Stings
___ Other Medicines
Specify __________________
________________________
___Other Substances
Specify _________________
_______________________
4.
5.
Have you ever had, or do you have:
___Hay Fever
___Hives
___Eczema
Have you ever had: (optional)
___Surgery
Describe ______________________
6.
Have you had, or do you have:
___Rheumatic Fever
___Heart Problems
___Asthma/Lung/Bronchial Disease
___Hypertension
___Diabetes
___Kidney Disease
___Bladder Disease
___Ulcer
___Intestinal Disease
___Hepatitis
___Frequent Indigestion
___Frequent Diarrhea
___Sexually Transmitted Disease
___Frequent Sleep Problems
___Frequent Appetite Problems
___Frequent Breathing Problems
___Persistent Nervousness
___Persistent Anxiety/Depression
___Recent gain or loss of weight of
10 pounds or more
___Joint Injury (severe)
___Arthritis/Joint Disease
___Shoulder Dislocation
___Knee Problems
___Back Problems
___Broken Bones
___Head Injury (with
unconsciousness)
___Concussion
___Seizures/Blackouts
___Meningitis/Encephalitis
___Weakness/Paralysis
___Frequent Headaches
___Mumps
___German Measles (Rubella)
___Measles (Rubeola)
___Mononucleosis
___Chicken Pox
___Malaria
___Other Tropical Diseases
Specify _________________
___Anemia
___Sickle Cell Disease
___Hemophilia or other
___Bleeding Problems
FOR FEMALES:
___ Chronic Vaginal Infections
___ Irregular Menses (Period)
___ Excessive Bleeding with
Menses (Period)
DISABILITY (Optional) A
disability is a problem that cause
long-term impairment of your
ability to work or function. Do you
have a disability?
___Yes
___No
Specify:
___Speech
___Chronic Illness
___Mobility Impairment
___Visual
___Hearing
___Emotional
___Substance Misuse
___Learning
Would you like your name given to
the Disability Services Office and/or
your academic advisor to discuss
accommodations:
___Yes
___No
MEDICAL CARE PROVIDER STATEMENT
PHYSICAL EXAMINATION:
Height ___________
Weight __________
Blood Pressure _____________
Significant History: _______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Present Medication(s) Requirements __________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
CLINICAL EVALUATION:
Eyes
Head, Ears, Nose, Throat
Teeth
Skin
Respiratory System
Cardiovascular System
Gastrointestinal System
Genitourinary System
Metabolic Endocrine System
Musculoskeletal System
Neuropsychiatric System
Pap Smear – Date
Pelvic Exam
Breast Exam
Testicular Exam
Vision Testing: Left _____________
Lab Results:
Normal
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
Abnormal
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
Remarks
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Right _____________ Recommendation: ________________________________
SMA 12 ________________________
CBC _____________________
UA ______________________
DETAILS OF ABNORMALITIES: (Please review any abnormalities with student)
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you have any special instructions (restrictions, medications, recommendations) concerning this student?
___________________________________________________________________________________________
___________________________________________________________________________________________
Healthcare Provider Signature ___________________________________________ Date _________
Student Name ______________________________________________
IMMUNIZATIONS AND TESTS: REQUIRED PPD required annually
TUBERCULIN SKIN TEST: PPD (MANTOUX intradermal skin test) REQUIRED within 6 months before the start of
classes, unless the student has a history of a past positive skin test, which must be indicated and chest x-ray submitted. Tine test is
not acceptable.
Date administered ________________ Date interpreted (within 48-72 hours) _________________ Induration _________ mm
Month/Day/Year
Month/Day/Year
Certifying health professional: _________________________________________________________________
IF PPD is positive, CHEST X-RAY REQUIRED subsequent to positive PPD result. Attach copy of report. Do not send film
Has student had INH? ___ Yes, date: ________
___ No Has student had BCG vaccine? ___ Yes, date: ________ ___ No
IMMUNIZATION RECORD
DATES MUST BE WRITTEN
MONTH/DAY/YEAR
MEASLES (REQUIRED)
Date vaccine given
Initials of certifying
health professional
Physician-diagnosed
disease history
(date of onset)
Serology date/results
(copy of lab report
MUST be attached)
(Month/Day/Year)
#1
/
/
#2
/
/
MUMPS (REQUIRED)
/
/
RUBELLA (REQUIRED)
/
/
OR Combined as MMR
#1
/
/
(REQUIRED)
#2
/
/
THE FOLLOWING ARE RECOMMENDED BUT NOT REQUIRED FOR ADMISSION.
Provide date of most recent tetanus vaccine
TETANUS/DIPHTHERIA
/
/
VARICELLA
#1
/
/
#2
/
/
HEPATITIS B
#1
/
/
Or Hepatitis declination --signature below
#2
/
/
Signature ____________________ Date ____
#3
/
/
MENINGOCOCCAL
/
/
Or refusal of vaccination – signature below
Signature ____________________ Date ____
PHYSICAL EDUCATION (Check all that apply)
May participate in:
Physical Education Classes
Strenuous Competitive Sports
Intercollegiate Sports
Limited Physical Education
Physical Education for the Handicapped
________________________
________________________
________________________
________________________
________________________
Identify specific restrictions that may apply to your participation in Physical Education.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
_________________________________________________________
Healthcare Provider’s Signature
_____________________________________________________
Print Healthcare Provider’s Name
_______________________________________________________________________________________________________________
Healthcare Provider’s Address
____________________________________________
Healthcare Provider’s Phone
________________________
Date