CALIFORNIA RURAL INDIAN HEALTH BOARD, INC. 1020 Sundown Way*Roseville, CA 95661*(916) 929-9761*Fax (916) 929-7246

Dear Applicant,

Thank you for your interest in becoming a Medical Scribe through the Shasta

College certificate program.

You may apply just to the Shasta College program alone.

You may additionally apply to the CRIHB Tribal Cohort which will be a

group of students in the Shasta College program.

You do not need to be part of the CRIHB Tribal Cohort.

This cohort will receive additional benefits such as:

Tribal clinic specific trainings on NextGen and other relevant topics;

Training for physicians in mentoring Scribes;

Full financial coverage of tuition and books.

To be a part of the CRIHB Tribal Cohort you must:

Be employed by a CRIHB Member Tribal Health Program

Be an enrolled member of a CRIHB Member Tribe

Be accepted into the Shasta College certificate program

Complete the attached one-page CRIHB application.

CRIHB Full Member Tribal Health Programs:

Anav Tribal Health Clinic

Mathiesen Memorial Health Clinic

Pit River Health Service

Sonoma County Indian Health Project

Tule River Indian Health Center

Toiyabe Indian Health Project

United Indian Health Service

Warner Mountain Indian Health Project

Tribes of CRIHB Full Member Tribal Health Programs:

Bear River Band of Rohnerville Rancheria

Big Lagoon Rancheria

Big Pine Paiute Tribe of the Owens Valley

Bishop Paiute Tribe

Bridgeport Indian Colony

Blue Lake Rancheria

Cher-Ae Heights Indian Community of the Trinidad Rancheria

Chicken Ranch Rancheria

Cloverdale Rancheria of Pomo Indians

Death Valley Timbisha Shoshone Tribe

Dry Creek Rancheria Band of Pomo Indians

Elk Valley Rancheria

Federated Indians of Graton Rancheria

Fort Bidwell Indian Community of the Fort Bidwell Reservation

Fort Independence Indian Community of Paiute Indians

Kashia Band of Pomo Indians of the Stewarts Point Rancheria

Lone Pine Paiute Shoshone Tribe

Lytton Rancheria

Manchester Band of Pomo Indians of the Manchester Rancheria

Pit River Tribe

Quartz Valley Indian Reservation

Resighini Rancheria

Tolowa Dee-ni’ Nation

Tule River Indian Tribe

Utu Utu Gwaitu Paiute Tribe of the Benton Paiute Reservation

Wiyot Tribe

Yurok Tribe of the Yurok Reservation

If you are interested in applying or would like more information, please contact

Christy Tonel at ctonel@crihb.org or 916-929-9761.

Medical Scribe Training – CRIHB Tribal Cohort Application Name:

Cell Phone Number:

Email:

Residential Address:

Tribal Membership:

Tribal Health Program employer or other employer:

Position Title:

Able to dedicate 2-3 hours / day toward classwork for months (in addition to full-time work)?

Yes No

To Be Completed by Tribal Health Program Human Resources Director Tribal Health Program:

Is there a current or near-future (within 12 months) Medical Scribe position opening at your clinic to which the applicant would be able to apply upon successful completion of this program?

Yes No

Can the Tribal Health Program provide hours of preceptorship with a physician mentor for this applicant should they enter this program?

Yes No

Does the Tribal Health Program understand that this program will require 2-3 hours of self-directed study outside of normal work hours?

Yes No

Do you recommend this applicant for the CRIHB Tribal Cohort within the Shasta College Medical Scribe Training Program?

Yes No

Signature:

Printed Name:

Date:_____________________

Please submit to mthomas@crihb.org by July 1, 2019.

Counseling/AssessmentDevelop an Education Plan and determine English and math placement options by scheduling an appointment online at:www.shastacollege.edu/counselingor in person by calling your local campus. Bring a copy of your unofficial transcript

Register for ClassesOnce you have completed all five steps, acquire your registration date and time at the Counseling window in room 126 or on MyShasta.

Payment is due at the time of registration.

EnrollmentSTEPS TO

Apply OnlineWelcome to Shasta College! To apply online, go to:www.shastacollege.edu/admissionsYour application may take 24 hours to process

Apply for Financial Aidwww.shastacollege.edu/faGo to Applying for Financial Aid tab.

Complete FAFSA application at:www.fafsa.ed.govCheck your status on MyShasta > MyForms

Request TranscriptsSend official transcripts (high school/college) to:

Shasta College Admissions & RecordsP.O. Box 496006Redding, CA 96049-6006

Complete Orientationhttps://orientation.shastacollege.edu/StudentCourse/CreateOrientations can be completed online at:www.shastacollege.edu/counselingor in person by calling your local campus.

www.shastacollege.eduShasta College is an equal opportunity educator and employer.

(530) 242-7656

Enrollment Services

Check the box after each step has been completed.

QuestionsIf you need help with the Steps to Enrollment, please contact the:

Student Success Center (530) 242-7671, Room 102www.shastacollege.edu/SSC

Parking PermitsParking Permits are available for purchase at: • Admissions & Records, Room 139• Business Office, Room 105• Tehama Campus Main Office, Room 7101

CALIFORNIA RURAL INDIAN HEALTH BOARD, INC. 1020 Sundown Way*Roseville, CA 95661*(916) 929-9761*Fax (916) 929-7246

Dear Applicant,

Thank you for your interest in Shasta College’s Medical Scribe Certificate Program.

These are the steps to complete an application to Shasta College:

1. Review Shasta College’s Steps to Enrollment flyer.

2. Review Shasta College’s Medical Scribe Part I Pre-Enrollment Clinical

Requirements Check-Off List.

3. Attend CRIHB’s Informational Webinar to learn more about the program and

how to receive assistance on the application process.

a. May 12th, 2019 at 12pm

b. May 16th, 2019 at 8:30am

4. We will offer an opportunity for an application workshop via webinar in June

2019. You will have an opportunity to fill out the application during the

workshop.

If you are interested in applying or would like more information,

please contact Christy Tonel – Provider Outreach Coordinator

at ctonel@crihb.org or 916-929-9761.

Health Sciences & University Programs

Medical Scribe Part 1 Pre-Enrollment Clinical Requirements Check-Off List Last Reviewed & Revised 3/4/2019

Make a personal copy of all records prior to submission to Health Sciences office. If you have questions, contact the Health Sciences office at (530) 339-3600

NAME: ______________________________________________________________________________________________________ (Please Print) (Last) (First) (MI) Student ID #

EMAIL ADDRESS: _____________________________________________________________________________________________ This checklist is being provided to assist you in completing the enrollment steps and collecting the official documents that are required for enrollment. SUBMIT copies of all original records together in a large manila envelope. Incomplete packets will not be accepted.

Note: Once a Pre-enrollment documentation packet has been submitted, all materials will be verified. All materials, including copies of immunization documentation, become the property of Shasta College and cannot be returned to the students.

Part 1 Pre-Enrollment Clinical Requirements Check-Off List: Steps A through F

A. Clinical Requirements Checklist - Complete program “Clinical Requirements Checklist” form 1. CPR Certification for Healthcare Professional or Provider Level – Adult, Infant, Child, 2-rescuer resuscitation – valid

2 years. NO ONLINE COURSES ACCEPTED. Must provide copy of current card. 2. Immunizations - Submit copies of your original vaccine record or lab test results (titers) showing immunity:

• Hepatitis B Series – 3 doses of vaccine or titer documenting immunity • Tetanus/Diphtheria/Pertussis (TDaP) - one-time dose of vaccine as adult; Td booster every 10 years following • Measles/Mumps/Rubella (MMR) - 2 dose vaccine series or titer documenting immunity • Varicella (Chickenpox) - 2 dose vaccine series or titer documenting immunity • Influenza Vaccine for current Influenza season (September through April)

3. Tuberculosis (TB) Screening – 2-Step process is required • The first TB screening must be within 12 months prior to class start date and turned in with the Part 1 Pre-

Enrollment packet. The second TB screening is time-sensitive and is due with the Part 2 Pre-Enrollment packet. • Students with known positive Tuberculosis Screening (PPD) must complete TB Questionnaire - Confidential

form, submit documentation of either a Quantiferon Gold TB blood test within the past year or a chest x-ray within the past two years, and receive clearance from their health care provider.

• Students with a previous BCG vaccine may choose to obtain a Quantiferon Gold TB blood test (requires physician order). If a Quantiferon Gold TB test is required, please wait to complete until instructed to start the Part 2 Pre-Enrollment packet.

WARNING: Tuberculosis test must be done before, or a minimum of 30 days after, any live vaccination (MMR, Varicella) to avoid false positive.

B. Technical Standards Disclosure Sheet – Must be able to perform all standards listed with or without accommodations. A copy of the form must be provided to your health care provider at the time of your physical exam.

C. Health Science Program CONFIDENTIAL Application for Clinical Practice – Must see Dean or Program Director for any issues related to criminal history.

D. Student Data Form This information will be kept on file while you are enrolled in the program. It is your responsibility to notify the Health Sciences office of any changes in your contact information by filling out the contact information change form available on the Health Sciences website.

E. Signed Acknowledgment Forms a. Student Handbook Acknowledgment b. Use of Electronic Devices Agreement c. Student Honor Contract d. Photography and Publication Release e. Assumption of Risk and Release Form

F. Typing Certificate - A 5 minute professional typing certificate issued by a staffing service or college course reflecting a

typing speed of 55 wpm with 98% accuracy.

IMPORTANT: Documentation of all the above requirements and results must be on file and submitted as complete to the Health Sciences Division office by the deadline indicated on the Health Sciences website in order to receive your Program Invitation Letter. Applicants who do not submit required documentation by the deadline will not be invited into the program.

Student Signature: ________________________________________________________ Date Submitted: _________________

Health Sciences & University Programs

Clinical Requirements Checklist Last Reviewed & Revised 2/25/2019

Page 1 of 2

Name ______________________________________________

Date: ______________________________________________

SC STUDENT ID# _____________________________________

Directions: Complete all the sections below and turn into the Health Sciences Division Office along with a copy of your official immunization documentation. Students who cannot complete or provide documentation of immunization requirements by the designated deadline will not be allowed to enroll in a Health Sciences program.

NOTE: HIT/HIM Students will not be authorized to enroll in their Professional Practice Experience course without turning in the required documents.

Student is to record immunization information on this checklist. (This form is a reporting document for Shasta College Health Sciences -- Not intended to be an official record from healthcare provider). Official immunization documentation must be attached.

CPR Certification - must show documentation of current certification in:

Basic Life Support (BLS) for the Healthcare Professional including Adult, Child & Infant Resuscitation and two-person rescue. Note: CPR certification will be included in Medical Assisting program.

Expiration Date: _____________________

Tetanus, Diphtheria, Pertussis (TDaP) - must show documentation of either:

A. One time dose of TDaP (includes pertussis) required for all Healthcare Personnel younger than age 65.

OR

Date _______________________________

B. Subsequent Td booster every 10 years following one-time TDaP Date _______________________________

Varicella** - must show documentation of either:

A. Two doses of Varicella vaccine administered at least 4-8 weeks apart OR Date #1 __________ Date #2 __________

B. Proof of quantitative IgG titer showing positive/immune to Varicella Date _____________ Results ___________

** Note: A previous diagnosis of chickenpox is NOT accepted as proof of Varicella immunity. Must submit documentation of either A or B as outlined above.

Measles, Mumps, Rubella (MMR) - must show documentation of either:

A. Two doses of MMR vaccine administered at least 4-weeks apart OR Date #1 __________ Date #2 __________

B. Proof of quantitative IgG titer showing positive/immune to Measles, Mumps, and Rubella

Measles: Date ________ Result _________ Mumps: Date ________ Result _________ Rubella: Date ________ Result _________

� Associate Degree Nursing � Medical Scribe � Dental Hygiene � Pharmacy Technician � Health Information Technology � Physical Therapist Assistant � Health Information Management � Vocational Nursing � Medical Assisting

Health Sciences & University Programs

Clinical Requirements Checklist Last Reviewed & Revised 2/25/2019

Page 2 of 2

Hepatitis B - must show documentation of either:

A. Three doses of vaccine. This series can be administered over a period of 4-6 months depending on your healthcare provider’s preference; please start this series early. • CDC standard recommendations are for series to be given at 0, 1, and 6

months. • CDC minimum requirements allow for series to be given at 0, 1, and 4

months. OR

Date # 1 ___________________________

Date # 2 ___________________________

Date # 3 ___________________________

B. Proof of titer (Hep B AB [antibody], NOT Hep B AG [antigen]) (at least 10 mlU/mL)

Date ____________ Results ____________

Tuberculosis Screening - must show documentation of either:

A. Two negative TB skin tests (PPD) results. 1st PPD must be completed within 12 months prior to program start date. 2nd PPD must be within 6 months prior to program start date. OR

Date # 1 ___________ Result ___________

Date # 2 due with Part 2 Packet

B. If PPD is positive or there is a history of positive PPD, there must be a record of a negative Quantiferon Gold TB test within the past year or chest X-ray within the past 2 years. A Confidential TB screening questionnaire must be completed by the student and healthcare provider. OR

Date ____________ Results ____________

C. If applicant has previously had the BCG vaccination, they may be eligible to take the Quantiferon Gold TB Test. (Please contact the Health Sciences office for more information.)

Date ____________ Results ____________

Influenza - must show documentation of:

One dose of influenza vaccine annually during the recommended flu season (September through April). DO NOT OBTAIN THE VACCINE OUTSIDE OF THE SPECIFIED FLU SEASON.

Date ________________________________

Student Statement: I hereby certify that all materials presented and all statements made are true and correct. I authorize investigation of all records submitted and am prepared to provide original documentation when requested. I understand that any misrepresentation of material facts may be cause for immediate disqualification and removal from the program. Signature of Applicant: ____________________________________________ Date: ___________________________________

For Health Sciences Division Use Only

Date Received:

Immunization official documentation verified by:

Health Sciences & University Programs

Technical Standards Disclosure HIT, HIM, Med Scribe, Pharm Tech - Health Sciences Programs

Last Reviewed & Revised 3/6/2019 Page 1 of 1

In the interest of your own personal safety and the safety of your patients, there are significant requirements that must be met before your admission to the program is finalized. The attendance requirements and stamina demands requires the Health Sciences student to be in good physical and mental health. Please read this form carefully and initial each technical issue standard if you can comply with the standard. When complete, please sign, date and return original in your Pre-Enrollment Clinical Requirements Packet. Note: This is a self-assessment – to be completed by you, not a health care provider. Applicants must present a copy of their completed Technical Standards to their healthcare provider for review at the time of the physical examination. Please see the Health Sciences Dean if you require an accommodation or cannot comply with the standard.

Issue Description Standard/Physical Requirement Initials

Mobility Physical ability, flexibility, strength and stamina

Standard work day requires various abilities including standing, walking, sitting, bending, flexing, lifting, twisting, stooping, kneeling, reaching, stretching, pushing and pulling to gather and stock supplies, operate equipment (computers, various types of medical devices, etc.), and perform required functions of patient care. Often must lift, carry or move objects weighing up to 40 pounds.

Motor Skills Physical ability, coordination, dexterity Gross and fine motor abilities sufficient to perform required functions of clinical placement assignments; hand-wrist movement, hand-eye coordination, and simple firm grasping required for fine motor-skills and manipulation; fine and gross finger dexterity required;

Comprehension Comprehend and process information; perform algebraic and complex calculations

Engage in written and oral directives related to clinical placement assignments, retaining information given by faculty/ healthcare providers to assimilate and apply to patient care; comprehend and process instructions accurately; perform mathematical functions/calculations regarding medication administration.

Tactile Use of touch Normal tactile feeling required.

Hearing Use of auditory sense Ability to hear and interpret many people and correctly interpret what is heard; i.e., healthcare provider, or supervisor orders whether verbal or over telephone, patient communications, fire and equipment alarms, etc.

Visual Use of sight Interpret written words accurately, read characters and identify colors on the computer screen. Ability to operate a computer and/or laptop through proficient typing, clicking, and viewing a monitor for extended periods.

Critical Thinking Ability to problem solve Integrate information through critical thinking based on information gathered during clinical sessions/ rotations, and during class sessions that are applied in the clinical process.

Communication Speak, read, write, & use English language effectively. Communicate effectively in interactions with others verbally, nonverbally & in written form

Effectively interacts with the environment and other persons. Fluent in English. Ability to communicate with wide variety of people and styles and to be easily understood. Reading, writing, recording, and documenting critical patient information required.

Behavioral Emotional & mental stability Functions effectively under stress; flexible, concern for others; able to work in environment with multiple interruptions and noises, distractions, and unexpected clinical assignment changes.

_________________________________________ _______________________________________________ ____________________ Print Name Student Signature Date

Health Sciences & University Programs CONFIDENTIAL Application for Clinical Practice

Last Reviewed 2/25/2019 Page 1 of 2

Indicate program of application: � Associate Degree Nursing (RN) � Dental Hygiene (DH) � Health Information Technology (HIT) � Health Information Management (HIM) � Medical Assisting (MA) � Medical Scribe

� Nursing Assistant/Home Health Assistant (NA/HHA)

� Pharmacy Technician � Physical Therapy Assistant (PTA) � Vocational Nursing (LVN)

Applicant information: Last Name

First Name MI Maiden

Address

City State Zip

Email Phone (day)

Phone (eve) Phone (cell)

Criminal Public Record Check:

� Yes � No Have you ever been convicted1 of any crime2 under your current name or any other name?

If the above answer is yes, please detail information for each conviction on the back of this form.

� Yes � No Do you have a criminal case now pending?

� Yes � No Clinical assignments are in health facilities that allow access to drugs and medications. Have you ever been arrested for an offense involving controlled substances? (Cal Labor Code 432.7f, Cal Health and Safety Code 11590)

� Yes � No Clinical assignments are in health facilities that allow you regular access to patients. Have you ever been arrested for a sex offense for which registration as a sex offender would be required upon conviction? (Cal Labor Code 432.7f, Penal Code 290)

� Yes � No Do you understand that a background check; reference verification; and drug screening, is a part of the enrollment decision making process, and if you are invited to participate in the program that you consent to complete a background investigation?

1 “Convicted” means plea, verdict of finding of no contest or guilt, regardless of whether sentence was imposed by the court. 2 “Any crime” means misdemeanors or felonies including motor vehicle/driving violations excluding minor traffic infractions, conviction for marijuana more than two years ago, and convictions for which the records has been sealed, expunged, eradicated, or judicially dismissed.

Applicant Statement I hereby certify that all statements made on this form are true and correct, and I authorize investigation of all statements herein recorded. I release from liability persons and organizations reporting information required by this application. I understand that any misrepresentation or falsification of material facts in this application may be cause for immediate disqualification and removal from program. Signature of Applicant: _________________________________________ Date: ____________________ *Existence of convictions will not necessarily disqualify an applicant from enrollment. However, failure to fully disclose may be considered falsification and will result in offer of enrollment being rescinded; and is grounds for immediate termination upon discovery at any time during enrollment.

Health Sciences & University Programs CONFIDENTIAL Application for Clinical Practice

Last Reviewed 2/25/2019 Page 2 of 2

Information Regarding Criminal History:

Date Conviction Conviction Type Court Name City County

Exclusion from Clinical Placement In collaboration with the clinical agencies used by Shasta College, a student will be excluded from participation in clinical rotations and therefore unable to complete the Shasta College Health Sciences programs for the following background check/drug screen findings:

• Capitol felony conviction at any time in student’s past • Felony conviction within past 7 years3 • Misdemeanor convictions with past 3 years3 • Medicare fraud • Any crime that results in requirement to register as a sex offender • Positive drug screen

3Note: Felony or misdemeanor convictions involving crimes against persons or property, any drug charges, and driving under the influence must fall outside the above time lines for students to be eligible for enrollment.

There are some specific restrictions imposed by the State for the Dental Hygiene students and Nurse Assistant/Home Health Aide** students which require additional clearance. **For individuals applying to the Nurse Assistant/Home Health Aide program that have any convictions or have questions about their ability to obtain the DOJ background clearance, they may request an “inquiry” with the California Department of Public Health. Signature of Applicant: _________________________________________ Date: ____________________ *Existence of convictions will not necessarily disqualify an applicant from enrollment. However, failure to fully disclose may be considered falsification and will result in offer of enrollment being rescinded; and is grounds for immediate termination upon discovery at any time during enrollment.

Health Sciences & University Programs

Medical Scribe Program Medical Scribe Student Data Form

Last Reviewed & Revised 2/26/2019

Date _________________

Medical Scribe Program Student Data Form

This information to be kept on file with the Health Sciences Division while you are enrolled in the Medical Scribe (Med Scribe) program.

Are you a veteran? □ Yes □ No

Are you sponsored by: □ Smart Center □ CalWORKS □ other □ none

Are you receiving Financial Aid for school? □ Yes □ No (i.e. California College Promise Grant, Pell Grant, Scholarship, Loan)

Address: ____________________________________________

____________________________________________ County of Residence: __________________________

Email: ___________________________________

Phone: ________________Alternate #: ___________

Student Name:

________________________________________

Student ID#: _____________________________

Age: _______ Birthdate: __________

Male Female

Are you a re-admit student from the Shasta College Med Scribe program? □Yes □No

Have you attended another Med Scribe Program? □Yes □No

If yes, what school did you attend and what was the reason for not completing that program? ___________________________________________________________________

___________________________________________________________________________

Do you have previous work experience in a healthcare facility? □Yes □No

If yes, in what position? _______________________________________________________

Ethnic Background:

□ Asian □ Hispanic

□ Black □ Native American

□ Caucasian □ Pacific Islander

□ Filipino □ Other

Health Sciences & University Programs

Student Handbook Acknowledgment Last Reviewed 07/23/2018

Page 1 Student Handbook Acknowledgement I have received, reviewed and sought clarification of the Student Handbook and its contents. I am aware that this Manual:

• is referenced in the Course Information handouts for the program • makes reference to the current Shasta College Catalog • includes the policies referenced in the Student Handbook

I have received the Course Information. I am aware that I can find the Shasta College Catalog online at www.shastacollege.edu. I have read the entire Student Handbook and understand my responsibilities as a student in the Health Sciences program to be accountable for the standards set forth in the Student Handbook. I realize that periodic quizzes will be given by the faculty to validate my knowledge and understanding of the handbook content and program policies. I understand that departmental policies and handbook information are subject to revision throughout my program and I am responsible for remaining current on these changes. This acknowledgement will be placed in my student file. _________________________________________ _________________ Name of Student (Printed) Date _________________________________________ Name of Student (Signature)

Health Sciences & University Programs

Use of Electronic Devices Agreement Last Reviewed & Revised 07/06/2018

Page 1 Use of Electronic Devices Agreement I have reviewed and sought clarification of the Standards for Use of Electronic Devices. I am aware that I can find the Standards for Use of Electronic Devices online. I understand these standards are designed to protect individual and patient rights and that I have the responsibility to be aware of confidentiality issues and maintain appropriate conduct in the use of electronic devices both during classroom/clinical skills sessions and during clinical experiences in the healthcare facilities. I understand that violation of the standards for use of electronic devices in the classroom and clinical skills lab setting will result in the loss of the privilege of using such devices to support my learning strategies and may result in being placed on contract by instructor. I understand that violation of the standards for use of electronic devices during clinical experiences in the healthcare facilities and within patient care areas will result in the loss of the privilege of using such devices to support my clinical care activities and learning and will result in being placed on contract by my instructor. I understand that violation of the standards may result in HIPAA violation claims against me and that I could be liable for consequent legal action. In addition, I understand that according to the program’s Dismissal policy, a HIPAA violation is cited as an example of an incident or clinical situation that puts the patient, student, clinical affiliate, faculty or college at risk and therefore, deems the student subject to dismissal from the Health Science program. This agreement will be placed in my student file. _______________________________________ _________________ Name of Student (Printed) Date ______________________________________ Name of Student (Signature)

Health Sciences & University Programs

Health Science Program Honor Contract Last Reviewed 10/06/2017

Page 1 of 1 Health Science Program Honor Contract I understand that Health Sciences Division Program students are expected to maintain an environment of academic integrity. I further understand that actions involving scholastic dishonesty violate the professional code of ethics. I have been informed and understand that any student found guilty of scholastic dishonesty is subject to dismissal from the Health Science Program and may be ineligible for re-admission. I have read the Scholastic Honesty Standard in the Health Sciences Program Student Handbook. I understand the Scholastic Honest Standard and I agree to fully abide by this stated policy. _______________________________________ _________________ Name of Student (Printed) Date _______________________________________ Name of Student (Signature)

Health Sciences & University Programs Program Practice – Publication Release

Last Reviewed & Revised 01/31/2019 Page 1 of 1

Student Photography and Release Policy Photographs of the student may be taken during course activities (non-client contact) and utilized by the program for professional educational activities (i.e. bulletin boards, audiovisual presentations, pamphlets, catalogues, websites, etc.). It is the responsibility of the student to notify the photographer at the time if they do not wish to have their photograph taken or utilized. Signing the Shasta College Publication Release Form signifies that the student has read and understood this policy, and gives the college permission to use the print or digital reproduction at its sole discretion.

Publication Release Form

I have voluntarily agreed, without compensation of any kind, to appear or allow my art work or image to appear in any print, film, digital likeness or videotape produced by the Shasta-Tehama-Trinity Joint Community College District. The Shasta-Tehama-Trinity Joint Community College District shall have the right and may grant to others the right to disseminate, print, alter and publish my name, likeness and biographical material, in connection with any publicity and promotion of the print, film, digital likeness, videotape or art work, except for the direct endorsement of any product. I hereby release and discharge the Shasta-Tehama-Trinity Joint Community College District and its respective agents, employees, successors, assigns, and licensees from any and all claims, liabilities and obligations of any kind of nature that may arise from my appearance or participation or art work incorporated in the print, film, digital likeness or videotape of any exhibition thereof. I agree that the Shasta-Tehama-Trinity Joint Community College District has no obligation to exhibit or televise my performance or art work or otherwise use my likeness or art work in its print, film, digital or videotape. Signature: _______________________________________

Print Name: _______________________________________

Date: _______________________________________

Health Sciences & University Programs

Hazardous Activity Class Student Assumption of Risk and Release Form

Last Reviewed 3/6/19 Page 1 of 2

I, _______________________, wish to enroll in and participate in the following class:

Print Name

Indicate program of application: � Associate Degree Nursing (RN) � Dental Hygiene (DH) � Health Information Technology (HIT) � Health Information Management (HIM) � Medical Assisting (MA)

� Medical Scribe � Nursing Assistant/Home Health Assistant

(NA/HHA) � Pharmacy Technician � Physical Therapist Assistant � Vocational Nursing (LVN)

Please initial each of the following statements.

____ Release of Liability and Waiver: In return for being permitted to enroll and participate in the above Program, including any associated use of the premises, facilities, staff, equipment, transportation, and services of the Shasta-Tehama-Trinity Joint Community College District (District), I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue the District, the Board of Trustees, directors, officers, employees, and agents (collectively the “District”), from liability from any and all claims, including the negligence of the District, resulting in personal injury (including death), accidents or illnesses, and property loss in connection with my participation in the Program and any use of District premises and facilities.

____ Assumption of Risks: I understand that enrollment and participating in the Program

involves the risks associated with blood borne pathogens and the other activities described in the course outline of record. I further understand that certain inherent risks in the Program cannot be eliminated regardless of the care taken to avoid injuries.

I have been advised and am aware of the risks associated with enrolling and participating in the Program, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence or the condition of the Program location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in the Program and further agree to accept all Program rules and requirements for the program participation, travel policies, program schedules, and to follow the instructions given by supervisory personnel involved in the program and related classes.

I am voluntarily participating in the Program and I acknowledge and fully assume the risks associated with my enrollment and participation.

____ Indemnification and Hold Harmless: I also agree to indemnify and hold the District

harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of my involvement in the Program, and to reimburse it for any such expenses incurred.

____ Medical Certification and Consent: I certify that I am physically capable and have received

medical clearance for participating in the Program and that I have no medical condition which would interfere with my ability to safely participate. In the event of any medical emergency, as determined by District supervisory personnel, I authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical procedure or treatment, and hospital care deemed necessary for my safety and protection.

Signature required on Page 2

Health Sciences & University Programs

Hazardous Activity Class Student Assumption of Risk and Release Form

Last Reviewed 3/6/19 Page 2 of 2

____ Governing Law and Severability: I understand that this document is written to be as broad and

inclusive as legally permitted by the State of California and agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I agree this Agreement shall be governed by the laws of the State of California, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the Courts of the State of California.

____ Understanding and Acknowledgement: I have read all previous paragraphs, including the

release of liability and waiver, assumption of risk, and indemnity agreement, know, fully understand its terms, acknowledge these and other risks that are inherent to the Program, and understand that I am giving up substantial rights, including my right to sue. I acknowledge my participation is voluntary, that I knowingly assume all such risks, and that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law. No other representations concerning the legal effect of this document have been made to me.

I am 18 years or older. I have read this document and fully and completely understand the potential risks that may be associated with the Program. I am signing this document freely.

Participant’s Name: _________________________________

Signature: _______________________________________ Date: __________________

If Participant is under 18 years of age: I am the parent or legal guardian of the Participant. I have read this two-page document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) release of District from all liability on my and the Participant’s behalf, (b) waiver of my and the Participants’ right to sue, (c) and assumption of all risks of the Participant’s participation in the Activity including travel to and from. I allow Participant to participate in this Activity and I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document. Parent/Guardian’s Name: _________________________________

Parent/Guardian’s Signature: _________________________________ Date: __________________

Health Sciences & University Programs CPR Certification Resources

Last Reviewed & Revised 7/05/2018

All students applying for Health Sciences Programs will need to have a current CPR certification that meets five (5) specific criteria. The selected course must be at the (1) Healthcare Provider level. The course will include (2) Basic Life Support (BLS) for adult, child and infant CPR and (3) 2-rescuer resuscitation with hands-on practicum and testing. The certification card issued must include the (4) American Heart Association (AHA) logo and (5) No online courses are accepted.

WHERE CAN YOU OBTAIN A CPR CERTIFICATION FOR A HEALTH PROFESSIONAL? SHASTA COLLEGE – FAID 133 CPR Professional Rescuer (See current semester class schedule for available classes.)

A+ SAFETY – (530) 222-1210 2765 Bechelli Lane, Redding CA 96002 Website: www.aplussafetyllc.com

CENTER FOR EXCELLENCE IN EDUCATION - (530) 873-6683 Peggy Tyranski - pstyranski@gmail.com Website: CEEMED.com

MED ED – (530) 276-9164 1615 Continental Street, Redding CA donnaconrad@shasta.com

ALBERTSON TRAINING CENTER – (530) 527-4997 80 Gurnsey Avenue, Red Bluff 96080

CPR Pro, First Aid, EMR – (530) 921-1455 Serving Shasta, Tehama, and Siskiyou Counties austin.kiser1@gmail.com

Additional resources within our community may meet the criteria listed above as well.

CALIFORNIA RURAL INDIAN HEALTH BOARD, INC. 1020 Sundown Way*Roseville, CA 95661*(916) 929-9761*Fax (916) 929-7246

Dear Applicant,

STOP!

1. DO NOT submit Shasta College’s Medical Scribe Part II Pre-

Enrollment Clinical Requirements Checklist until you are sent a

program invite.

2. Please review the Part II enrollment packet to determine if there are

missing requirements that need to be addressed, such as a two-step

TB screening, criminal background check and drug screening.

If you are interested in applying or would like more information,

please contact Christy Tonel – Provider Outreach Coordinator at

ctonel@crihb.org or 916-929-9761.

Health Sciences & University Programs

Medical Scribe Part 2 Pre-Enrollment Clinical Requirements Checklist Last Reviewed & Revised 2/25/2019

Make a personal copy of all records prior to submission to Health Sciences office If you have questions, contact Health Sciences office at 530-339-3600

NAME: ______________________________________________________________________________________________________ (Please Print) (Last) (First) (MI) Student ID #

EMAIL ADDRESS: _____________________________________________________________________________________________ This checklist is being provided to assist you in completing the enrollment steps and collecting the official documents that are required for enrollment. SUBMIT copies of all original records together in a large manila envelope by deadline established in your Enrollment Invitation. Incomplete packets will not be accepted. Note: Once a Pre-enrollment documentation packet has been submitted, all materials will be verified. All materials including copies of immunization documentation become the property of Shasta College and cannot be returned to the students. Part 2 Pre-Enrollment Clinical Requirements Check-Off List: Steps G through I

G. Tuberculosis (TB) Screening Results & Form– 2nd step of the 2-Step Process (continued)

IMPORTANT: If you are starting in the Fall semester, complete between June 17th and July 12th. If you are starting in the Spring semester, complete between October 7th and November 8th. If you have submitted a QuantiFERON Gold TB blood test or chest x-ray with your Part 1 Packet, please disregard this step. • Complete the TB Screening form and attach the second Tuberculosis screening results within the time frame

applicable to your start semester as specified above. WARNING: Tuberculosis test must be done before, or a minimum of 30 days after, any live vaccination (MMR, Varicella) to avoid false positive.

H. Physical Examination must be obtained within 6 months prior to enrollment. Must be documented on the Shasta College Health Sciences “Health Data & Physical Examination” form.

I. Criminal Background Check & Drug Screening – initiate process online at www.coeusglobal.com/shastacollege;

complete the drug screening at a designated facility within the allotted timeframe. Visit the Health Sciences Background Check & Drug Screening Instruction page for more information.

IMPORTANT: Documentation of all the above requirements and results must be on file and submitted as complete to the Health Sciences Division office by the deadline indicated in your Enrollment Invitation Letter. Applicants who do not submit required documentation by the deadline will be removed from the program invitation list.

Student Signature: ________________________________________________________ Date Submitted: _________________

Health Sciences & University Programs

Tuberculosis PPD Screening New & Continuing Students

Last Reviewed 2/25/2019 Page 1 of 1

Tuberculosis Screening

As per Health Sciences Program Policy - Clinical Requirements, the result of a Two-Step TB screening is required as part of enrolling in a Health Sciences program.

Complete and submit this form with healthcare provider documentation of results attached.

STOP! If you have ever had a positive PPD which required you to have a QuantiFERON Gold TB test or chest x-ray, you must not take further PPD tests. Please refer to the Clinical Requirements policy and/or talk with your healthcare provider or Health Services staff for more information. If you have had a BCG vaccine, you may be eligible to use the QuantiFERON Gold TB test instead of x-ray and medical clearance. Name: ________________________________________ Age: __________ Date: ______________________________ Student ID#: ___________________ Date of Birth: ________________ Phone #: ______________________________________ Email: ____________________________________________ NEW STUDENTS:

Date Administered #1: _____________________ Result: Positive Negative Date Administered #2: _____________________ Result: Positive Negative

Attach a copy of the 2nd TB screening administration and interpretation form from your health care provider.

I am at least 18 years of age and verify that I have completed the 2-Step Process for Tuberculosis Screening with 2 negative test results within the prior 12 months, the second of which is within 6 months prior to enrollment in my Health Science program (or within 90 days of starting clinical for the NA/HHA program only). ________________________________________________________ Date: _____________________ (Student Signature) CONTINUING STUDENTS:

Date Administered: _____________________ Result: Positive Negative

Attach a copy of the TB screening administration and interpretation form from your health care provider. I am at least 18 years of age (under 18 requires written parental consent) and verify that I have completed a Tuberculosis Screening Skin Test. ________________________________________________________ Date: _____________________ (Student Signature)

Health Sciences & University Programs

Health Data & Physical Exam Last Reviewed 3/5/19

Page 1 of 2 Part I: To be completed by Student: Indicate program of application: � Associate Degree Nursing (RN) � Dental Hygiene (DH) � Health Information Technology (HIT) � Health Information Management (HIM) � Medical Assisting (MA)

� Medical Scribe � Nursing Assistant/Home Health Assistant (NA/HHA) � Pharmacy Technician � Physical Therapist Assistant � Vocational Nursing (LVN)

Applicant information: Last Name

First Name MI Maiden

Address

City State Zip

Email Address

Birth date Gender M F

Phone (day)

Phone (eve) Phone (cell)

Person to notify in case of emergency: Full Name

Relationship

Address – Number & Street

City State Zip

Home Phone

Work Phone Cell

HEALTH HISTORY

Please rate you current health status: � Excellent � Good � Fair � Poor Certain minimum physical abilities and characteristics are required in health sciences professions. Do you have any condition that would interfere with your ability to perform the minimum technical skills standards for the program to which you are applying? � Yes � No If yes, explain: ___________________________________

____________________________________________________________________________________________ Are you pregnant? � Yes � No If yes, due date: _________________________________ Allergies/sensitivities (i.e. medications, foods, Latex/Powder): Please List: __________________________________

_____________________________________________________________________________________________ Do you have any lifting restrictions: � Yes � No If yes, explain: ___________________________________

_____________________________________________________________________________________________ The information provided is true and correct to the best of my knowledge. I am aware that any change in my physical or mental health, including pregnancy, during the program may require that I obtain medical clearance to continue in the program. Student Signature: ______________________________________ Date: _____________________

Health Sciences & University Programs

Health Data & Physical Exam Last Reviewed 3/5/19

Page 2 of 2 HEALTH DATA & PHYSICAL EXAM FORM (continued)

FOR HEALTH CARE OCCUPATIONS Applicant Name: Date:

Part II: To be completed by health care provider � I have reviewed the student’s Technical Standards Disclosure form Does your examination of the student reveal any limitations in the following:

SPINE: � Yes or � No LIFTING: � Yes or � No PROLONGED STANDING: � Yes or � No

PROLONGED SITTING: � Yes or � No BENDING: � Yes or � No � NO LIMITATIONS OF ANY TYPE

Based upon today’s exam (which includes all body systems) and the disclosed health history, does this student have any health condition that would create a hazard to self or others, or limit their ability to provide health & patient care and/or services? �Yes � No � Any health condition is under observation and/or treatment and does not create a hazard If yes, explain: Physician or Approved Licensed Health Professional Information: Agency or Clinic providing service (Name & Address or Facility Stamp)

Printed Name Title

Signature

Date