Please sign and/or initial ALL forms in this section and turn in to the Phlebotomy Department Head. These will become part of your permanent record.

Statement of Understanding

After thoroughly reading and familiarizing yourself with the Phlebotomy Student Handbook policies and procedures read and initial each of the following statements.

___ I have read the Non-Academic Admissions) requirements and understand that if I have difficulty in any of these areas, I may not be successful in passing the Phlebotomy course.

___ I have read the (Phlebotomy Technician Student Handbook) and understand the policies and procedures stated within. I understand that if I cannot support and abide by these policies and procedures, it may be in my best interest to seek another program in which to develop my technical skills.

___ I have been informed of the amount of clinical time required to complete the requirements of MLAB 1166 to successfully complete the Phlebotomy program.

___ I have read the "Phlebotomy Safety Policy and Applications" in this Student Handbook. I have been informed that biological specimens and blood products utilized in student lab and clinical rotations may possess the potential of transmitting infectious diseases such as hepatitis and acquired immunodeficiency syndrome (AIDS). I understand that even though diagnostic products are tested for HIV antibodies and Hepatitis B surface antigen (HBsAg), that no known test can offer 100% assurance that products derived from human blood will not transmit disease. I understand that I will be taught the proper way to handle patient specimens and reagents prepared from biological materials (Standard / Universal Precautions) to decrease the risk of exposure and I agree to abide by them.

___ I understand that the college does not provide healthcare insurance. I have been advised to carry medical insurance and acknowledge that my health and accident insurance and/or expenses are my responsibility.

___ I understand that I must submit proof of all immunizations required by Texas law.

Student Name (printed): _______________________________

Student Signature: ___________________________________

Date: _________________________________ ___ ___

Release of Student Information

I hereby grant permission to Austin Community College to release the above information if doing so is deemed necessary by the College.

(Yes/No)

Program: _______________________________

Date: __________________________________

Name: _________________________________

Address: _______________________________

Phone: _________________________________

SSN: _________________________________ _

Signature: _______________________________

Date: ________________________________ __

Later on in the program as you near graduation and as you begin to look for a job, employers (where you apply) may contact us (a Health Sciences Department Head or faculty member) for a reference on you. They may ask questions such as, "What skills does the student have?" "What was his/her attendance record?" "Is s/he a good student?"

Please read and sign below if you grant permission for your Program Director to release this type of information.

Signature: _______________________________

Date: _______________________________ ___

You may withdraw this permission at any time but you must do so in writing and submit to the Program Director..

Consent for Drug Screening

I, _______________________________ , recognize that the use and abuse of alcohol, drugs or substances can create an unsafe clinical working environment for myself and others. I agree to provide a blood, urine and / or breath sample to the drug testing laboratory designated by Austin Community College. I also permit the testing laboratory to release the results of the drug screening testing to designated Austin Community College authorities.

Student: _______________________________

Date: _________________________________

Faculty: _______________________________

Date: _________________________________

Are you presently (or plan on) working a full- or part-time job?

(Yes/No)

If "Yes," how many hours per week? ___ ___ ___ ___

Are you receiving (or going to receive) VA benefits?

(Yes/No)