Bldg. 557 Phone: (254) 526-1883

Fax (254) 526-1765 (ATTN: HT) Email: mlt.pbt.ht@ctcd.edu

Hours: M-Thur 7:30 AM-5:30 PM Fri 7:30 AM-11:30 AM

HISTOLOGY LABORATORY TECHNICIAN PROGRAM

APPLICATION DOCUMENTS

Please complete and return to the HT Office

Revised 08/01/2021

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STUDENT CHECKLIST

REQUIREMENTS NEEDED BEFORE APPLYING FOR THE HISTOLOGY TECHNICIAN PROGRAM

□ Acceptance to CTC. To apply for admission to CTC, go to www.ctcd.edu, and click on the ‘Apply Now’ button□ Have all official College and/or High School transcripts sent to Incoming Transcripts at CTC (Bldg. 119)□ Go to www.ctcd.edu/advisorappointment to schedule a time to meet with a CTC Academic Advisor – bring official and

unofficial College and/or High School transcripts with you.□ Complete the Texas Success Initiative (TSI) requirements and be cleared by an Academic Advisor. You will need to

complete the TSI Verification Request Form in etrieve and provide the results as an attachment to verify if you areexempt or complete for the TSI.

REQUIREMENTS NEEDED BEFORE ENTRY INTO THE HISTOLOGY TECHNICIAN PROGRAM

□ High School Diploma, GED, or College Unofficial Transcripts□ Precheck Account with:□ Health screen□ Immunization Record including all vaccines listed below:

a. Influenza Vaccine (Every Oct 1st)b. COVID Vaccinec. Bacterial Meningitis Vaccication/MCV (Within 5 years)d. Tetanus/Tdap (Within 10 years)e. Hepatitis B series or positive Titer (series of 3 over a 6 month

period)f. MMR (Mumps, Measles, Rubella): MUST show 2 doses MMR or

positive Titerg. Varicella Vaccination, positive titer and/or waiverh. Polio recommended but not required

REQUIREMENTS NEEDED ONCE ACCEPTED INTO THE HISTOLOGY TECHNICIAN PROGRAM

□ Student ID and Parking sticker (Student Life Center, Bldg. 215)□ New Student Orientation will be mid-July; invitation is given to students who turn in completed packets.□ Textbooks (CTC Bookstore, Bldg. 224)□ Laboratory coat – Long (CTC Bookstore, Bldg. 224)□ Scrubs – Royal Blue (CTC Bookstore, Bldg. 224)□ Shoes – Leather/nylon, close-toed (not canvas or fabric and no open-toe shoes)

REQUIREMENTS NEEDED ONCE ACCEPTED TO CLINICAL ROTATIONS

□ CPR Certification (Must be AHA and “BLS Care” Level or military BLS – available through CTC254-526-1586)

□ Background Check (DO NOT get this done before clinical acceptance)□ Drug Screening (DO NOT get this done before clinical acceptance)□ US Birth Certificate (or VISA) – DO NOT need until clinical orientation & badging□ Picture ID (Passport, Driver’s License, Military ID)

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VERIFICATION of RECEIPT of POLICIES & PROCEEDURES

Please acknowledge receipt of the following documents by checking the appropriate box:

YES NO

I have received a copy of the Central Texas College Course Catalog.

I have read the current Central Texas College Course Catalog.

I have received a copy of the Central Texas College Schedule Bulletin.

I have received a copy of the Central Texas Student Handbook.

I have read and understood the CTC Student Handbook.

I am planning to attend mandatory program orientation.

I have attended the mandatory program Orientation.

I have a current Central Texas College Student Identification Card.

_______________________________ ______________________________ Student Signature Date

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ACCEPTABLE SCIENCE CREDITS FOR THE HT PROGRAM

For students without a completed science related degree (AAS or BS) credits in Anatomy & Physiology I II, and Chemistry will only be acceptable toward a student’s HT Degree Plan if they have been completed NO MORE THAN 5 YEARS prior to the student starting their first semester in the program. Science credits older than 5 years, or without a completed degree, will not be applied to the student’s HT Degree Plan, and the courses will have to be retaken.

Effective August 1, 2016, if a student has EARNED A DEGREE WITHIN 5 YEARS of admission in a science-related major (2 or 4-year degrees both acceptable), science credentials from that degree may count towards the HT Degree Plan, regardless the year/semester taken. An unofficial transcript, a syllabus of the applicable courses and a copy of the diploma/certificate must be submitted to the Program Director for consideration.

Credits for electives will count toward the HT Degree Plans regardless of date.

By singing below, I acknowledge that I have read and understood the above stated rules and regulations regarding the application of science credits toward the HT Program and Degree Plan.

__________________________________ ________________________ Student Signature Date

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COMPETITIVE STATUS FOR CLINICAL COURSES

Upon acceptance to the HT Program at Central Texas College, students are in competitive status during the first year for the ten spaces available in the Clinical courses. Additional spaces may be available depending on academic standing, completion of documents and requirements, and Affiliate availability.

Selection for the Clinical courses of the program is based on progression requirements as stated in the HT Student Handbook. Evaluation of the student’s attitude, academic, and practical performance in the HLAB, academic and Science Courses is a function of the member of the Advisory Committee.

My signature indicates I have read the progression requirements and fully understand the competition for clinical spaces.

____________________________ _______________________ Student Signature Date

TRAVEL TO CLINICAL FACILITIES

Travel to the Clinical affiliates is required to participate in the Clinical courses, which are an integral part of the HT program. Clinical facilities include:

• Adventhealth Hospital – Killeen (2 blocks)• Seton Medical Center – Harker Heights (9 miles)• Scott & White – Temple (30 miles)• Veterans Hospital – Temple (33 miles)

Students are randomly assigned to rotate through various clinical facilities during the clinical course. The list of clinical facilities may change during the course of the program.

Students must have adequate transportation and arrive on time. Clinical hours vary by site and require 8.5 hours per day between 6:00 AM and 5:00 PM. Students are required to be present and prompt to each assigned clinical site. Students do NOT rotate through clinical facilities as a group. Requests for preferential treatment to remain in the Killeen are will not be considered.

My signature indicates I have read the preceding information and fully understand the requirements for travel during clinical courses.

_______________________________ ___________________________ Student Signature Date

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DISMISSALS

A Student is subject to immediate dismissal for any of the following reasons:

1. Any behavior which would put a student’s right to registration in question.2. Failure to maintain academic standards (minimum 2.5 GPA).

a. A student may only fail 2 degree plan courses (with a grade of less than a 70 for any non- HLAB classes, and less than a 75 for HLAB classes) before automatic dismissal for academic deficiency. Any such student will automatically be dropped from the HLT program.

b. Each student (per this handout) is allowed readmission into the program only once. See Progression Requirements.

3. Insubordination.4. Unprofessional, unethical, or dishonest behavior.5. Excessive, unexcused absences or tardiness

a. 4 in all courses, including lecture, lab and clinicals.b. 3 absences will result in a letter grade dropc. 4 absences will result in dismissal from the program

6. Using drugs or intoxicating liquors to an extent which affects your professional competence.

7. Positive urine drug screen.8. Criminal history as reported on the Criminal Background Check.9. Conviction for a felony, or a crime involving moral turpitude.10. Conviction for violating and municipal, state, or federal narcotic law.11. Gross negligence in the practice of medical technology or acting as an HLT.12. It is understood that the student has the right to appeal any dismissal decisions.

I have read and understood the above stated rules and regulations regarding the HT professional course and Clinical courses.

Student Name (print) _________________________________

Student Signature ___________________________________ Date___________________

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CENTRAL TEXAS COLLEGE Criminal Background Check and Drug Screen

Release of Information

I, _____________________________, (print name) agree to allow the CTC HT Program Director to release the results of the Criminal Background Check and Drug Screen to the clinical facilities to which I will be assigned during enrollment in the clinical course (s).

I agree to inform the program director and / or the clinical facility if criminal activity or substance abuse occurs after the initial Criminal Background Check and Drug Screen is completed.

I agree to a “for cause” Drug Screen at a site identified by the college should a faculty member, clinical instructor or the program director deem it necessary.

I have read and understand the Central Texas College Policy and Standard for Drug Screening and Criminal Background Checks.

_________________________________ ______________________________ Student Signature Date

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MyStudentCheck Web Address: https://candidate.precheck.com/StudentCheck?schoolId=16359 Version: 03/2019

CENTRAL TEXAS COLLEGE - HISTOLOGICAL TECHNICIAN - IMMUNIZATION TRACKING STUDENT INSTRUCTIONS

Students are required to provide proof of various immunizations and vaccinations prior to beginning a clinical rotation. Once you have ordered the immunization package per the instructions below, you will receive additional communication via email. You will then be required to submit forms and accompanying documentation such as lab work for titers to SentryMD in partnership with StudentCheck for review.

GETTING STARTED

Follow this link to MyStudentCheck If you are unable to access the link, you may type in the web address located at the bottom of this page.

• Confirm the school name matches: Central Texas College - Histological Technician - Immunization Tracking

• Select your program from the drop down menu, and then select the required services.

• Log in with your username and password. If you do not have an existing profile, please create a new account.

• Enter the required information, provide authorization, and continue to enter payment information.

• If you need further assistance, please contact PreCheck at StudentCheck@PreCheck.com.

• You will be provided with a receipt and confirmation page when your order is placed.

IMMUNIZATIONS

Your confirmation will contain a link to the immunization requirements and documents which should be presented to your physic ian for completion. Your name should be legible on all documentation. Once the documents are completed please submit the forms to SentryMD at https://mysentrymd.com/sentrymd.html#/upload. You will receive confirmation that the upload was successful. Email any questions about your immunizations tracking to: CTC@SentryMD.com

PRICING

Immunization Tracking $35.00

Applicable taxes will be collected for residents of Texas and New Mexico.

FREQUENTLY ASKED QUESTIONS

1. What does PreCheck do with my information? Your information will only be used for the services ordered. Your credit will not be investigated and your name will not be given out to any businesses.

2. I selected the wrong school, program or incorrect information. Please email StudentCheck@PreCheck.com with the details.

3. I have been informed that my immunization forms are deficient, what do I do? Contact a SentryMD representative by emailing questions to CTC@SentryMD.com.

4. How do I know my documentation was received?

A confirmation email will be sent immediately if your upload was successful. Within 3 business days your compliance will be emailed to you from a representative at SentryMD.

5. I was denied entry into a program because of information on the report, who can I contact? Call PreCheck’s Adverse Action hotline at 800-203-1654.

Central Texas College

Health Requirements

PART I STUDENT INFORMATION | This must be completed by the student and submitted to Sentry MD.

Name: (Please Print)

Last, First, MI

CTC ID Number:

Date of Birth:

/ /

DD MM YYYY

Cell Phone:

(__ __ __) __ __ __ - __ __ __ __

Email Address:

__________________________@________________

Select your program:

❑ Histology

❑ Medical Lab Tech

❑ Phlebotomy

PART II ADDITIONAL DOCUMENTATION | These items must be submitted to Sentry MD via the

Secure Student Uploader at hhttps://mysentrymd.com/sentrymd.html#/upload/94.

• BLS for the healthcare Provider CPR- ONLY BLS through American Heart Association OR BLS

through Military Training Network certification is accepted, submit a copy of your BLS card or e-

certificate.

PART III STUDENT CONSENT STATEMENT | This must be completed by the student and submitted to

Sentry MD.

I have reviewed this immunization history for completeness and agree to release the information listed in

the student health requirement packet to authorized members of the Central Texas College staff and

authorized staff of cooperating clinical agencies, as directed by CTC throughout the duration I am

enrolled.

Student Signature Date

Student Name (Print) DOB

Central Texas College

Health Requirements

PART IV STUDENT IMMUNIZATION RECORD | Please have the following form completed, signed,

and stamped your healthcare provider OR LEAVE BLANK and submit all requirements listed below on the

original forms from the clinic or provider you received them at.

Last Name: First Name: Date of Birth:

Measles, Mumps and Rubella (MMR): Two dose vaccine series (Dose #1 given at age 12-15 months and Dose #2 given approx. 28 days after first

dose) OR Positive QUANTITATIVE IgG antibody titers for Mumps, Measles and Rubella (titers must include numerical result and or numerical

reference ranges). *If a titer results in non-immunity; a booster dose and follow-up titer must be completed.

MMR 2 dose series:

1). __/__/____

2). __/__/____

OR

MMR Titer Dates:

Measles Titer: __/__/____ Result: ☐Immune ☐ Non-Immune

Mumps Titer: __/__/____ Result: ☐Immune ☐ Non-Immune

Rubella Titer: __/__/____ Result: ☐Immune ☐ Non-Immune

☐ Attach copy of quantitative titer report

If Non-immune titer:

Booster: __/__/____

Submit repeat quantitative lab

report 6 weeks after booster

dose.

Varicella (Chicken Pox): Two dose vaccine series OR Positive QUANTITATIVE IgG antibody titer (titer must include numerical result and or

numerical reference ranges). *If a titer results in non-immunity; a booster dose and follow-up titer must be completed.

Varicella 2 dose series:

1). __/__/____

2). __/__/____

OR

Date of Chicken Pox:

__/__/____

(Month/Year

Required) OR

Varicella Titer Date: __/__/____

Result: ☐Immune ☐ Non-Immune

☐ Attach copy of quantitative titer report

If Non-immune titer:

Booster: __/__/____

Submit repeat quantitative lab

report 6 weeks after booster

dose.

Hepatitis B: Three dose vaccine series OR Positive QUANTITATIVE IgG antibody titer (titer must include numerical result and or numerical

reference ranges). *If a titer results in non-immunity; a booster dose and follow-up titer must be completed.

HepB 3 dose series:

1). __/__/____

2). __/__/____

3). __/__/____ OR

HepB Titer Date: __/__/____

Result: ☐Immune ☐ Non-Immune

☐ Attach copy of quantitative titer report

If Non-immune titer:

Booster: __/__/____

Submit repeat quantitative lab

report 6 weeks after booster

dose.

Influenza Vaccine (Flu): Required seasonally, typically October 1st each year.

Flu Vaccine Date: __/__/____

Tetanus Diphtheria, Pertussis (Tdap): Tdap vaccine within the past ten years is required. TD booster is accepted ONLY IF TDAP ON FILE.

Tdap Vaccine Date: __/__/____ Lot #____ Exp_____ OR TD Booster (Tdap must be documented): __/__/____

Meningococcal (Meningitis): Vaccine must be within past five years for anyone 22 or younger.

Meningococcal Vaccine Date: __/___/___

Poliomyelitis (Polio) Optional: Primary vaccine series dates (IPV or OPV) OR one booster date is accepted if dated after 1988.

IPV or OPV: 1). __/__/____ 2). __/__/____ 3). __/__/____OR Polio Booster After 1988: __/___/___

Tuberculosis Two-Step (PPD/Mantoux): You must provide one of the following options within 3 months of your clinical start date:

1. TB Two-step (Two Separate TB skin test with negative results within 21 days of each other) and within 3 months of your clinical start.

2. T-Spot or QuantiFERON TB Gold Blood draw that is negative and within 3 months of your clinical start.

3. If a TB test is positive; a chest x-ray must be completed every year.

Annual update required: Repeat full TB Two-Step-- Two TB skin tests within 21 days of each other or the blood test each year.

TB Skin 1 Plant: __/___/___ TB Skin 1 Read: _/___/___

Result: ____mm ☐ Neg ☐ Pos

TB Skin 2 Plant: __/___/___ TB Skin 2 Read: _/___/___

Result: ____mm ☐ Neg ☐ Pos

QuantiFERON TB Gold Date: ___/___/__

☐ Neg ☐ Pos

OR

T-Spot Date: ___/___/__

☐ Neg ☐ Pos

IF positive TB; Chest X-Ray

Date: __/__/____

Result: ____mm ☐ Neg ☐ Pos

Primary Care Provider Signature AND Provider’s stamp is required for immunizations on this form to be accepted.

PLACE PROVIDER’S STAMP HERE

____________________________________________________

Provider’s Signature Date

Provider Name (printed): _______________________________

Phone Number: (____) _________________________________

Central Texas College

Health Requirements

PART V PHYSICAL EXAM | The following form completed, signed and stamped your healthcare provider.

Required upon entry into program only.

Last Name: First Name: Date of Birth:

The information contained in this form will be used only by CTC for purposes of determining if a health threat/risk is

posed for students or patients during clinical experiences, rotations, or clerkships. This information will remain as part of the secured

student file in and will always remain confidential. The program recommends an annual updated medical history, immunizations,

and physical examination, but requires the forms be updated if any health status issues changes in the interim.

Student Signature: _______________________________________________________________

To be completed and signed by healthcare provider

Height (inches): ____ Weight (pounds): ____ BP:____/____ Pulse:____ Vision: Right: 20/____ Left: 20/____

Enter “NE” if not evaluated

Medical Normal Abnormal Give details of each abnormality

Head, Neck, Face, and Scalp

Nose and Sinuses

Mouth, Teeth, Gingiva, and Throat

Ears – General (canals, drums, etc.)

Eyes – General (lids, pupils,

motions, etc.)

Lungs, chest, and breasts

Heart (include estimate of cardiac

function)

Vascular System (include

varicosities)

Abdomen and Viscera (include

hernia)

Anorectal and Pilonidal

Endocrine System

Genito-Urinary System

Upper Extremities

Lower Extremities

Spine and Musculoskeletal

Skin and Lymphatic (include acne)

Neurological System

Psychiatric/Behavioral Health

Are there any conditions, physical and/or emotional, which may interfere with functioning as a health professional student in the

classroom or clinic? (Circle one) No Yes

If yes, please describe:___________________________________________________________________________________

Any allergies to medications? (Circle one) No Yes

If yes, please describe:___________________________________________________________________________________

Primary Care Provider Signature AND Provider’s stamp is required for immunizations on this form to be accepted.

PLACE PROVIDER’S STAMP HERE

____________________________________________________

Provider’s Signature Date

Provider Name (printed): _______________________________

Phone Number: (____) _________________________________

Central Texas College

Health Requirements

STUDENT CHECKLIST: Please allow yourself plenty of time for your requirements to be reviewed in case

you need additional, vaccines, tests or certifications. Once received, your documents can take 24 to 48

business hours to be processed.

❑ Student Information is complete (Part I)

❑ Submit documentation of completed BLS certification (Part II)

❑ Student Consent Statement is signed by student (Part III)

❑ Health Requirements in Part IV are complete, and results are signed, dated and stamped by

your Health Care Provider or supplemental documents are obtained to meet each requirement

(Part IV)

❑ Quantitative titer reports for HepB, MMR and Varicella attached if choosing the titer option

(Part IV)

❑ Physical exam is complete (Part V)

❑ Return your completed forms by scanning as one PDF file and uploading them to

https://mysentrymd.com/sentrymd.html#/upload/94.

Please email any questions you may have to CTC@SentryMD.com!

PART VI ACCOUNT ACCESS | Please note your account will only be available after you have registered

and sent Part I of this packet into Sentry MD. Your account allows you to see your status and download/print

documents that have been processed by Sentry MD. Please make sure to submit document requirements to the

Upload link https://mysentrymd.com/sentrymd.html#/upload/94 as you are not able to upload directly to your

account, all documents are reviewed and processed prior to showing in your account (processing can take 24 to

48 business hours).

Link to Sentry MD system: https://mysentrymd.com/sentrymd.html#/home

1. Enter your User ID: (email address in all lowercase)

2. Click on ‘Need Help with Password’

3. Enter your email address (your User ID will be the email address you registered with in

all lowercase)

4. You will be sent a token to your email address

5. Enter Token from email onto site

6. Create a Password

7. Click link to go to login screen

Once you are logged into your account, you will note on the landing page how easy it is to see if you are

compliant or not with the requirements for your program. A blue checkmark next to each of the requirements

means you are compliant. Requirements without the blue checkmark indicate you are missing documentation and

these items need your attention.

In addition to viewing your status at any time, you can download and print your landing page checklist and any or

all the documents you have submitted by clicking the page icon at the bottom of the page. Only documents that

have completed processing will appear in your account; please note processing can take 48 business hours. We

hope these tools help you stay on top of your status and keep you compliant with your program requirements.