Admission Packet - Estrella Mountain Community College

MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Page 1 of 5
ADMISSION REQUIREMENTS
Carefully read the steps for admission. Some actions must be completed prior to meeting with an advisor.
After you have successfully passed your Placement Test, you are ready to complete an admission packet.
Steps for Admission
Obtain Student ID number. You can do this from anywhere! 1) Visit main website at
My.maricopa.edu. If you have never attended a college in the Maricopa County Community College
District (MCCCD), select “New Student? Start Here” or if you have attended within MCCCD, select
“Student Center” in Student Tools column to retrieve your student ID and MEID; or 2) Visit EMCC
Enrollment Services in person.
Take Placement Tests. This must be done prior to meeting with an advisor.
Meet with SWSC advisor. (Admission packet will be available from the advisor or you can
download prior to meeting with an advisor.)
Verify that Placement Test scores meet program admission requirements
Request Official Transcripts (if submitting prior coursework)
Bring original Valid Driver’s License – or – Birth Certificate to advisor
Complete “Student Declaration of Citizenship or Status” (Attached)
Complete “Education Disclosure” (Attached)
Complete “Criminal Background Check Disclosure Acknowledgement” (Attached)
Obtain Level One Unrestricted Finger Print Clearance Card (See advisor for forms)
Complete “Health and Safety Documentation” (submit documentation of vaccines or lab
results with this form and must be signed by licensed healthcare examiner) (Attached)
Complete “Vaccination Declination” (Note The influenza vaccine is not an admissions
requirement but may be required depending on externship location.) (Attached)
Bring “Healthcare Provider” CPR Card to advisor (See page 2 for list of providers)
Bring Certified Profile background clearance results to advisor (instructions attached)
Your SWSC advisor will collect COMPLETE admission documents only and make photocopies
as required. The advisor will verify that all admission requirements are met.
Payment
If you applied for and received financial aid, please have your Estimate Award letter
at the time you submit your complete admission packet. The Estimate Letter can be
found in your student email account.
The SWSC advisor will provide you with a Payment Form.
You must take the Payment Form to “Cashier” services to have your fees assessed for
“Buy- In” or “Third Party” payment options, if applicable. Please ask for two receipts:
one for your record and return one to the advisor.
Student signs Registration Form. The SWSC advisor will prepare the Registration Form for
you. After you sign this form, you are officially accepted and will be enrolled.
Congratulations! All admission requirements are done. Enjoy your program!
Completed √
__________
Student ID
__________
Maricopa ID (MEID)
Don’t Forget
Password!

MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Page 2 of 5
The Admission Packet requirements for SouthWest Skill Center Programs are subject to change.
Students should consult with Academic Advisor to ensure appropriate requirements are met.
** For assistance contact Cynthia Bass (623) 935-8961 or Oscar Castillo (623) 935-8964. Or you may
email them at swsc.advisor@estrellamountain.edu or askadvisor@estrellamountain.edu.
Two Step TB
Hepatitis B
Secure Funding
MMR/Varicella
Fingerprint …
Background Check
Completed Packet
How Long Should It Take To Complete The Admissions Process?
Weeks 2
Weeks 4
0 1 2 3 4 5 6 7 8 9 10
VERIFICATION OF COMPLETE PACKET
Bring your COMPLETE Admission Packet to your advisor. Bring original documents. The SWSC advisor will
make photocopies as required. The advisor will verify that all admission requirements have been met by
completing your Student Checklist.
Partial Packets will not be accepted
All Packets must be hand delivered, No exceptions
Submission of packet does not guarantee admission.
Admission is based on eligibility, completed documents and space in the program
CPR CARD REQUIREMENT AND ACCEPTABLE PROVIDERS
Having a current CPR card is required. It must be valid for one year from the start of the program. The training
cannot be online and it must include hands-on training AED, Adult, Child and Infant CPR. Provided is a list of
acceptable CPR provider cards.
ISSUER LEVEL OF TRAINING
American Heart Association Healthcare Provider
American Red Cross Professional Rescuer
American Safety & Health Institute (ASHI) CPR Pro (CPR for Healthcare Professionals)
National Safety Council Professional Rescuer
Weeks 6
This is the last thing you do once everything else is complete!
Weeks 8
Weeks 8
Takes up to 2 weeks
Heart Savers CPR Pro (CPR for Healthcare Professionals)
Weeks 10

MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Page 3 of 5
FINANCING YOUR EDUCATION
Students are responsible for the total program cost, which includes tuition and fees, out of pocket expenses, and
any additional expenses associated with this Program. Each student is expected to secure sufficient financial
aid or Agency funding, and/or an established payment plan during their enrollment.
PROGRAM TUITION AND FEES
Registration Fee* $15.00
Tuition per Clock Hour (830 hrs X $5.00/hr) $4,150.00
Course Fees $512.00
Commencement Fee $15.00
TOTAL Tuition and Fees + $4,692.00
* Registration Fee is per Fiscal Year: July 1 – June 30. If a student’s program crosses over
June 30th, a second Registration Fee will be assessed. Add $15.00.
+ All tuition and fees are subject to change pending MCCCD Governing Board Approval.
OUT OF POCKET EXPENSES (COSTS WILL VARY)
Stethoscope $25.00
Scrub Uniform and White Shoes $75.00
Immunizations & Physical Examination $250.00
Fingerprint Clearance Card: Fingerprint Rolling $15.00
Fingerprint Clearance Card: Application Fee $65.00
Required Textbooks** $475.00
Certified Background Check ($67.00 if paying with money order) $57.00
Healthcare Provider CPR Card $40.00
After program starts, Urine Drug Screen (see “Additional Expense”) $33.00
Estimated Out of Pocket Expenses $1,035.00
**A book list will be distributed at Orientation
Additional Expense. Student will be responsible for obtaining a urine drug screen within a specified
time. This screening is done on a random basis. Do not obtain a drug screen on your own as it cannot
be used. Screen results from tests taken prior to the start of the class will not be accepted. Information
concerning the urine drug test will be given at orientation. The charge for testing is approximately
$33.00.
If any illegal substance is detected during the drug screening, the student will be immediately
withdrawn. A positive screen for any reason (e.g.: diluted urine, RX drugs) will require a review by the
Medical Review Officer and will result in an additional cost of $40.00.
Anticipate an investment in your future of $5,727.00.

HOW TO PAY FOR YOUR EDUCATION
MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Page 4 of 5
AGENCY FUNDING. Obtain required paperwork from agency (Maricopa or Phoenix Workforce
Connection, Arizona Youth Resources, etc.). These agencies have specific criteria that must be met so
please work carefully with your agency. A firm obligation/intent to pay with student name and amount
must be received from the agency prior to enrollment.
FINANCIAL AID. This program does qualify for financial aid because it has 830 clock hours. Only
programs that are 600+ clock hours qualify for financial aid funding.
o Financial Aid processing takes approximately 4-6 weeks.
o Apply on line at www.fafsa.gov. Use SWSC school code 031563.
o A minimum of 3 weeks prior to the start of the Program, submit your Estimate Award letter and
COMPLETE packet. The Estimate Award letter can be found in your student email account. If
the letter is not submitted 3 weeks prior to the start of your program, you are liable for all tuition
and fees, until your financial aid has been completed.
PAY IN FULL (BUY-IN). Use, cash, check, or credit card to pay in full at time of packet acceptance and
admission into program.
PAYMENT PLAN (BUY-IN). The student will be responsible for signing up for the Equal Payment Plan
and make their first payment prior to the start of their program. The student will be required to make
their payment by the 1 st of each month for the amount of their payment plan.
PAYMENT PLAN AMOUNT (DAYTIME ONLY)
$4,707.00* divided by 8 payments (length of program)
PAYMENT PLAN AMOUNT (EVENING ONLY)
$4,707.00* divided by 14 payments (length of program)
Monthly Payment (Rounded)
$589.00
Monthly Payment (Rounded)
$337.00
* Registration Fee is per Fiscal Year: July 1 – June 30. If a student’s program crosses over
June 30th, a second Registration Fee will be assessed ($15.00 added).
YOUR FINANCIAL ACCOUNT
For your convenience you can view account activity & make credit card payments at www.my.maricopa.edu.
Credit card payments are also accepted via phone at (623) 935-8888. Questions regarding your account, contact
Velvet Aguirre (623) 935-8074.
NONDISCRIMINATION POLICY
The Maricopa County Community College District does not discriminate on the basis of race, religion, color,
national origin, sex, handicap/disability, sexual orientation, age or Vietnam era/disabled Veteran status in
employment or in the application, admission, participation, access and treatment of persons in instructional or
employment programs and activities.

MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Page 5 of 5
DISABILITY RESOURCE CENTER, CLASSROOM ACCOMMODATIONS
Students with disabilities who believe that they may need accommodations in a class or program must contact
the Disability Resource Center (DRC) in Building Komatke-B at (623) 935-8863 or (623) 935-8935, or (623)
935-8928. The manager of Disability Resource Center is responsible for determining a student’s eligibility for
services and will notify the faculty in writing of the accommodations requested. During the first class session,
faculty members shall announce that students may meet with them during office hours if they need special
accommodations for a disability. If you have any questions or concerns, please contact the DRC. For more
information about accommodating students, visit our website at www.emc.maricopa.edu/disability/.
READMISSION PROCESS
One class failure or withdrawal
o The student may be granted only one readmission to the program
o The student will submit a letter requesting re-entry into the program when he/she has
determined that re-entry is the intent.
The letter must identify factors that resulted in the prior withdrawal and the steps that
have been taken to address those factors.
o Upon submitting the re-entry letter, the student will set up an interview with the Program
Manager or designee to help determine/ensure the likelihood of success in the program.
Re-entry may be dictated by class space availability.
o The student will ensure that all documentation concerning immunizations, certifications,
clearances, etc. are updated prior to consideration for readmission.
Financial Aid recipients should contact the Financial Aid department to obtain information of how
their financial aid will be impacted by a withdrawal/drop.
o Students will need to contact the financial aid department to discuss if they are eligible for
reinstatement of their financial aid funding.
o Reinstatement takes approximately 3 weeks.
NOTICE
The SouthWest Skill Center reserves the right to change, without notice, any materials, information, curriculum
requirements, and regulations stated in this publication.

STUDENT DECLARATION OF
CITIZENSHIP OR STATUS FORM
STUDENT DECLARATION OF CITIZENSHIP OR STATUS
State law now requires that a person who is not a citizen or legal resident of the United States or who is without lawful immigration status is not entitled to
classification as an in-state student pursuant to A.R.S. Section 15-1802 or entitled to classification as a county resident pursuant to A.R.S. Section 15-1802.01.
Although you have previously enrolled at this or another Maricopa County Community College, it is important that you provide this information, even if you
have been asked to provide similar information in the past.
Failure to provide the information requested below may result in your being now classified as an out-of-state student for tuition and fee purposes. The
responsibility of providing the proper residency classification is placed upon the student. Any student who falsifies his/her residency may be subject to
dismissal from the college and /or criminal action.
Only those with a lawful presence in the US may qualify for Maricopa County Community College District scholarships or federal financial aid. Any
information you provide about your legal status when you apply for financial aid or scholarships may be subject to mandatory reporting to federal
immigration authorities under Arizona Law, A.R.S. 1-501, 1-502.
________________________________________|_________________________________________________
Student ID Number College
________________________________________|__________________________|_______________________
LEGAL NAME: Last Name First Name Middle Name
________________________________________|_________________________________________________
Date of Birth (mm/dd/yyyy)
United States Citizen
Legal Immigrant/Permanent Resident
__________________________________|__________________________|_______________________
Alien Registration Number Date of Issue Date of Expiration
Lawful Refugee or Asylee
__________________________________|__________________________|_______________________
Alien Registration Number Date of Issue Date of Expiration
Legal Nonimmigrant
__________________________________|__________________________|_______________________
Alien Registration Number OR I-94 Number Date of Expiration of I-94 Specify Visa or Status
Do Not Qualify for Any of the Above
Country of Citizenship _____________________________________________________________
Arizona Department of Motor Vehicle
__________________________________|__________________________|_______________________
License Number or Identification Number Date of Issue Date of Expiration
I do not possess an Arizona Department of Motor Vehicle License or Identification Card.
By signing this declaration, I swear under penalty of perjury that the document(s) that I have submitted to demonstrate lawful presence in the United States are true and
the information provided on this form is true and complete.
__________________________________________________________________|_______________________
Signature Date
For additional information, visit: www.maricopa.edu/residency. All of the information on this form is confidential and in compliance with the Family Education
Rights and Privacy Act of 1974. The Act’s provisions are explained in the General Catalog.

EDUCATION DISCLOSURE FORM
DECLARATION OF HIGH SCHOOL GRADUATION OR GED
Name of High School _____________________________________________________________________
City _____________________________________ State _________________________________________
Date of Graduation ______________________ (or) GED Date of Completion ________________________
I certify that the information provided is correct and true.
I acknowledge that I may be asked to present this information when applying to a certifying body.
Inability to provide these documents could prevent applicant from obtaining national certification
and/or finding gainful employment within the industry.
Signature Date
Printed Name

CRIMINAL BACKGROUND CHECK
DISCLOSURE ACKNOWLEDGEMENT
CRIMINAL BACKGROUND CHECK DISCLOSURE ACKNOWLEDGEMENT
MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT
APPLICABLE TO STUDENTS SEEKING ADMISSION ON OR AFTER SEPTEMBER 1, 2011
In applying for admission to a Nursing or Allied Health program (“Program”) at the Maricopa County
Community College District (MCCCD), you are required to disclose on the Arizona Department of Public
Safety (DPS) form all required information and on the MCCCD authorized background check vendor data
collection form any arrests, convictions, or charges (even if the arrest, conviction or charge has been dismissed
or expunged), or participation in first offender, deferred adjudication, pretrial diversion or other probation
program on this form. Additionally, you must disclose anything that is likely to be discovered in the MCCCD
supplemental background check that will be conducted on you.
Please complete the DPS form, the MCCCD authorized background check vendor form and any clinical agency
background check form honestly and completely. This means that your answers must be truthful, accurate, and
complete. If you know of certain information yet are unsure of whether to disclose it, you must disclose the
information, including any arrest or criminal charge. Additionally,
By signing this acknowledgement, you acknowledge the following:
1. I understand that I must submit to and pay any costs required to obtain a Level-One Fingerprint
Clearance Card and an MCCCD supplemental criminal background check.
2. I understand that failure to obtain a Level-One Fingerprint Clearance Card will result in a denial of
admission to a Program or removal from it if I have been conditionally admitted.
3. I understand that I must submit to and pay any costs required to obtain an MCCCD supplemental
background check.
4. I understand that failure to obtain a “pass” as a result of the MCCCD supplemental criminal background
check will result in a denial of admission to a Program or removal from it if I have been conditionally
admitted.
5. I understand that, if my Level-One Fingerprint Clearance Card is revoked or suspended at any time
during the admission process or my enrollment in a Program, I am responsible to notify the Program
Director immediately and that I will be removed from the Program.
6. I understand that a clinical agency may require an additional criminal background check to screen for
barrier offenses other than those required by MCCCD, as well as a drug screening. I understand that I
am required to pay for any and all criminal background checks and drug screens required by a clinical
agency to which I am assigned.
7. I understand that the both the MCCCD supplemental or the clinical agency background check may
include but are not limited to the following:
Nationwide Federal Healthcare Fraud and Abuse Databases
Social Security Verification
Residency History
Arizona Statewide Criminal Records
Nationwide Criminal Database
Nationwide Sexual Offender Registry
Homeland Security Search

CRIMINAL BACKGROUND CHECK
DISCLOSURE ACKNOWLEDGEMENT
CRIMINAL BACKGROUND CHECK DISCLOSURE ACKNOWLEDGEMENT (CONTINUED)
8. By virtue of the MCCCD supplemental background check, I understand that I will be disqualified for
admission or continued enrollment in a Program based on my criminal offenses, the inability to verify
my Social Security number, or my being listed in an exclusionary database of a Federal Agency. The
criminal offenses for disqualification may include but are not limited to any or all of the following:
Social Security Search - Social Security number does not belong to applicant
Any inclusion on any registered sex offender database
Any inclusion on any of the Federal exclusion lists or Homeland Security watch list
Any conviction of Felony no matter what the age of the conviction
Any warrant any state
Any misdemeanor conviction for the following-No matter age of crime
violent crimes
sex crime of any kind including non-consensual sexual crimes and sexual assault
murder, attempted murder
abduction
assault
robbery
arson
extortion
burglary
pandering
any crime against minors, children, vulnerable adults including abuse, neglect, exploitation
any abuse or neglect
any fraud
illegal drugs
aggravated DUI
Any misdemeanor controlled substance conviction last 7 years
Any other misdemeanor convictions within last 3 years
Exceptions:
Any misdemeanor traffic (DUI is not considered Traffic)
9. I understand that I must disclose on all background check data collection forms (DPS, MCCCD
background check vendor and a clinical agency background check vendor) all required information
including any arrests, convictions, or charges (even if the arrest, conviction or charge has been dismissed
or expunged), or participation in first offender, deferred adjudication, pretrial diversion or other
probation program. That includes any misdemeanors or felonies in Arizona, any other State, or other
jurisdiction. I also understand that I must disclose any other relevant information on the forms. I further
understand that non-disclosure of relevant information on the forms that would have resulted in failing
the background check will result in denial of admission to or removal from a Program. Finally, I
understand that my failure to disclose other types of information of the forms will result in a violation of
the Student Code of Conduct and may be subject to sanctions under that Code.
10. I understand that, if a clinical agency to which I have been assigned does not accept me based on my
criminal background check it may result in my inability to complete the Program. I also understand that

.
CRIMINAL BACKGROUND CHECK
DISCLOSURE ACKNOWLEDGEMENT
CRIMINAL BACKGROUND CHECK DISCLOSURE ACKNOWLEDGEMENT (CONTINUED)
MCCCD may, within its discretion, disclose to a clinical agency that I have been rejected by another
clinical agency. I further understand that MCCCD has no obligation to place me when the reason for
lack of placement is my criminal background check. Since clinical agency assignments are critical
requirements for completion of the Program, I acknowledge that my inability to complete required
clinical experience due to my criminal background check will result in removal from the Program.
11. I understand the Programs reserve the authority to determine my eligibility to be admitted to the
Program or to continue in the Program and admission requirements or background check requirements
can change without notice.
12. I understand that I have a duty to immediately report to the Program Director any arrests, convictions,
placement on exclusion databases, suspension, removal of my DPS Fingerprint Clearance Card or
removal or discipline imposed on any professional license or certificate at any time during my
enrollment in a Program
Signature Date
Medical Assistant Program
Printed Name Desired Health Care Program

HEALTH & SAFETY DOCUMENTATION
ALLIED HEALTH PROGRAMS
MARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS
HEALTH AND SAFETY DOCUMENTATION
Please attach documentation (test results, etc.) for all immunizations to this Health and Safety Documentation
Home Phone: __________________ Cell Phone: ___________________ Student ID Number: _____________________
A. MMR (Measles/Rubeola, Mumps, and Rubella): Requires documented proof of two MMRs in lifetime or a positive titer
for each of these diseases.
1 st MMR Date: _______________ 2 nd MMR Date: _______________
OR
Date and results of titer: Measles/Rubeola _____________ Mumps ______________ Rubella _____________
B. Varicella (Chickenpox): Requires documented proof of two (2) vaccinations or positive IgG titer.
1 st Varicella Date: ______________ 2 nd Varicella Date: ______________
OR
Date & results of IgG titer:___________________________________________
C. Tetanus/Diphtheria/Pertussis (Tdap): One-time dose of Tdap, followed by a Td booster every 10 years.
Tdap Date: __________ Td (update): ____________
D. Tuberculosis*:
Two-Step Testing** for initial skin testing of adults who will be retested periodically
TWO-STEP TESTING
Use Two-Step Testing for initial skin testing of adults who will be retested periodically.
- If first test positive, consider the person infected.
- If first test negative, give second test 1-3 weeks later.
- If second test positive, consider person infected.
- If second test negative, consider person uninfected.
- If both parts of Two-Step test are negative then subsequent testing is done annually with one step procedure
INITIAL TEST:
Test Given_______________Date Read___________Result_____________________________
SECOND TEST (1-3 weeks after initial test):
Test Given: Date Read: _________ Result_____________________________
OR
Annual TB skin test (PPD): (only if two step testing completed previously)
Test Given______________ Date Read___________Result_____________________________
OR
Previous Positive PPD test:
Provide documentation of negative chest x-ray/evidence of TB disease free status
Date of chest x-ray____________________Result____________________________________
*If applicant has ever had a positive reaction, the test is not to be repeated. Other evidence that the applicant is free from Tuberculosis will be required.
**Core Curriculum on Tuberculosis What the Clinician Should Know, Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination, Atlanta, Georgia, 4 th Edition, 2000.
(Continued next page)

HEALTH & SAFETY DOCUMENTATION
ALLIED HEALTH PROGRAMS
HEALTH AND SAFETY DOCUMENTATION
E. Hepatitis B: Documented evidence of completed series or positive antibody titer or declination. If beginning series, first
injection must be according to your Program’s required timeline and the series must be completed within 6 months.
Date of 1 st injection: ___________ Date of 2 nd injection: ___________ Date of 3 rd injection: ____________
OR
Hep B Titer Date: _________________ Titer Results: _____________________________
OR
Signed Declination Form attached
Note: Clinical Placement may require a student to provide documented evidence of influenza vaccination within the past year
or declination. (Influenza Vaccination does not need to be completed at time of admission packet and will be dependent on
externship placement.)
Date of injection: ______________________________
OR
Signed Declination Form attached
F. Clearance for Participation in Clinical Practice
It is essential that allied health students be able to perform a number of physical activities in the clinical portion of their
programs. At a minimum, students will be required to lift patients and/or equipment, stand for several hours at a time and
perform bending activities. Students who have a chronic illness or condition must be maintained on current treatment and be
able to implement their assigned responsibilities. The clinical allied health experience also places students under considerable
mental and emotional stress as they undertake responsibilities and duties impacting patients’ lives. Students must be able to
demonstrate rational and appropriate behavior under stressful conditions.
I believe the applicant __________ WILL OR __________ WILL NOT be able to function as an allied
Health student as described above.
If not, explain: ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Licensed Healthcare Provider (MD, DO, NP, or PA) Verification of Health and Safety
Print Name: _________________________________________ Title: __________________________________
Signature: ___________________________________________ Date: _________________________________
Address: ____________________________________________________________________________________
City: _______________________________________________ State: _________________________________
Telephone: _________________________________________

VACCINATION DECLINATION
ALLIED HEALTH PROGRAMS
MARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS
VACCINATION DECLINATION
(PRINT) Student Name _________________________________________________ Date_________________________
(Complete the sections that are appropriate for this student.)
Hepatitis B Vaccination Declination
I understand that due to my exposure to blood or other potential infectious materials during the clinical portion of my
allied program, I may be at risk of acquiring Hepatitis B virus (HBV) infection. The health requirements for the allied
health program in which I am enrolled, as described in the Student Handbook, include the Hepatitis B vaccination series
as part of the program’s requirements. I have been encouraged by the faculty to be vaccinated with Hepatitis B vaccine;
however, I decline the Hepatitis B Vaccination at this time. I understand that by declining this vaccine, I continue to be at
risk of acquiring Hepatitis B, a serious disease. By signing this form, I agree to assume the risk of a potential exposure to
Hepatitis B virus and hold the Maricopa Community College Allied Health Program as well as all health care facilities I
attend as part of my clinical experiences harmless from liability in the event I contract the Hepatitis B virus.
Student Signature Date
Faculty Signature Date
Influenza Vaccination Declination
I understand that due to the nature of health care and the volume of individuals that I may come in contact with, I may be
at risk of acquiring an influenza virus. The health requirements for the allied health program in which I am enrolled, as
described in the Student Handbook, include the current influenza vaccination as identified by the Centers for Disease
Control for the current influenza season as part of the program’s requirements. I have been encouraged by the faculty to
be vaccinated; however, I decline the influenza vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring influenza. By signing this form, I agree to assume the risk of potential exposure to
influenza and hold the Maricopa Community College Allied Health Program as well as all health care facilities I attend as
part of my clinical experiences harmless from liability in the event I contract the virus. I also understand that, due to the
contagious nature of the virus, that a health care setting may not accept my placement if I refuse vaccination.
Student Signature Date
Faculty Signature Date

EXPLANATION OF HEALTH AND
SAFETY REQUIREMENTS
ALLIED HEALTH PROGRAMS
EXPLANATION OF HEALTH AND SAFETY REQUIREMENTS
All immunizations must be documented on the Health and Safety Documentation Form provided.
1. MMR (Measles/Rubella, Mumps, & Rubella) Options to meet this requirement:
a. Attach a copy of proof of positive antibody titer for Measles/Rubella, Mumps, and Rubella or
completion of two separate series of MMR immunizations. One “series” of immunizations includes
immunizations for each disease on separate dates at least 28 days apart. Persistent
negative/equivocal titers will only be accepted if proof of 4 immunizations (2 MMR series) is
provided.
b. If you had all three illnesses OR you have received the vaccinations but have no documented proof,
you must have an MMR titer drawn.
i. If the titer results are POSITIVE, attach a copy of the lab results to the Health Declaration Form.
ii. If any of the titer results are NEGATIVE or EQUIVOCAL, you must get your first MMR
vaccination and attach documentation to this health and safety documentation checklist. The second
MMR must be completed after 28 days and proof submitted to the Spanish Medical Interpreter
Department. You will then be required to have another titer drawn 30 days later & submit it
to the Spanish Medical Interpreter Program Department. This proof must be submitted prior to
externship or students will not be allowed to begin.
2. Varicella (Chickenpox) Options to meet this requirement:
a. Attach a copy of proof of a positive IgG titer for Varicella, OR
b. If the titer is NEGATIVE or EQUIVOCAL, attach a copy of proof to this health and safety
documentation checklist that you received the first vaccination. Complete the second vaccination
within 4 to 8 weeks and submit proof to the Spanish Medical Interpreter Program Department. You
will then be required to have another titer drawn 30 days later and submit it to the Spanish
Medical Interpreter Program Department prior to externship or students will not be allowed to
begin.
3. Tetanus/Diphtheria/Pertussis (Tdap) Options to meet this requirement:
Tdap: Tetanus / Diphtheria / Pertussis
Td: Tetanus / Diphtheria
You must provide proof of a one-time dose of Tdap, followed by a Td booster every 10 years. The most
recent immunization must be within the past two years. Attach proof of a Tdap vaccination and Td if
indicated.

EXPLANATION OF HEALTH AND
SAFETY REQUIREMENTS
ALLIED HEALTH PROGRAMS
4. Tuberculosis (TB)
What is the Two-Step TB Skin Test? It consists of an initial TB skin test and a boosted TB skin test 1-3
weeks apart. Follow these steps:
a. After the first test is placed and read, have a second test placed and read 1-3 weeks later.
b. If you have had the initial 2-step test, include the subsequent annual updates. Annual update testing
must have been done within the last 6 months.
c. Documentation for TB skin testing requires date given, date read, result and the name and signature
of the healthcare provider.
d. If you have a positive skin test, provide documentation of a negative chest X-ray within the last 2
years and annual documentation of a TB disease-free status by completing a Tuberculosis Screening
Questionnaire.
5. Hepatitis B
Select one of the four options to meet requirement:
a. Present proof of a positive HbsAg titer.
b. Attach a copy of your immunization record, showing completion of the three Hepatitis B injections.
c. If the series is in progress, attach a copy of the immunizations received to date. You must obtain the
first two injections. You must remain on schedule for the remaining immunizations and provide the
additional documentation. One to two months after your last immunization, you may have an HbsAg
titer drawn.
d. Submit a signed Hepatitis B Vaccination Declination Form
6. Health Care Provider Signature
A health care provider MUST sign the Health and Safety Documentation Form within six (6) months of
program admission and indicate whether the applicant will be able to function as a Spanish Medical
Interpreter Program student. Health care providers who qualify to sign this declaration include a
licensed physician (M.D., (D.O.), a nurse practitioner, or physician’s assistant.

INSTRUCTIONS
CERTIFIED BACKGROUND CHECK
APPLIES TO: MEDICAL ASSISTANT (MA), PHLEBOTOMY ) PHB, SPANISH MEDICAL INTERPRETER (MIP)
About CertifiedProfile.com
CertifiedProfile is a secure platform that allows you to order your background check online. Once you have
placed your order, you may use your login to access additional features of CertifiedProfile, including
document storage, portfolio builders and reference tools. CertifiedProfile also allows you to upload any
additional documents required by your school. Your results are posted to CertifiedProfile upon completion.
Order Summary
Required Personal Information - In addition to entering your full name and date of birth, you will be
asked for your social security number, current address, phone number and email address.
Payment Information – At the end of the online order process, you will be prompted to enter your Visa
or Mastercard information. Money orders are also accepted but will result in a $10 fee and an additional
turn-around-time.
Place Your Order
Go to: www.CertifiedBackground.com and locate “Place Order” in upper right hand corner.. Enter package
code:
SI59 – SouthWest Skill Center Allied Health Background Check (Results disclosed to health care program)
You will then be directed to set up your CertifiedProfile account. Remember your login and password—you
will need this information to retrieve your results.
Follow instructions on the “Student Instructions for Maricopa Community College” page.
Note: classification refers to the start date that you are planning on attending:
Example: MA/2/25/13* - Medical Assistant Program starting 2/25/2013
PHB/2/25/13* - Phlebotomy Program starting 2/25/2013
MIP/2/2/13* – Medical Interpreter Program stating 2/2/2013
*Make sure you select the correct start date for your program.

Payment Options
INSTRUCTIONS
CERTIFIED BACKGROUND CHECK
The Cost is $57 payable with Visa, MC, Discover, Installments, Electronic Check, Certified Gift Card or
Money Order. Note: Paying with an Electronic Check or Money Order will increase the total turn time for
results.
a. Installments – student will be billed an additional $2.99 with each installment payment.
b. Credit Cards with an international billing address, the student can enter their current local address or the
school’s address.
Purchase a Badge (Not Required): When students sign up for certified background an advertisement to
purchase results on a badge is offered to the student. Purchase of the badge is NOT necessary for entry into
the program.
How to View Results
Once your account has been created, you will enter your email address to logon again.
Your results will be posted directly to your CertifiedProfile account. You will be notified if there is any missing
information needed in order to process your order. If you have any additional questions, please contact
Student Support at (888) 666-7788 Ext. 1 or email: studentservices@certifiedprofile.com.
Your order will show as “In Process” until it has been completed in its entirety. Results will be found in the
document center. The results will be a .pdf file named clearance document
Print a copy of your results to add to your admission packet.
The turnaround time for your results varies depending upon your background and mode of payment. Anticipate
the process could take 2 full weeks, but this could be lengthened or shortened depending on individual
circumstances.
Print a copy of your results to add to your admission packet.
If your results indicate a fail, please do NOT contact the school or program of study with questions. Contact
Student Services at Certified Profile at (888) 666-7788 Ext. 1 or email:
studentservices@certifiedprofile.com.

MEDICAL ASSISTANT PROGRAM
ADMISSION PACKET
Congratulations!
YOU made a great program choice.
The SouthWest Skill Center is committed to
“Building Tomorrow’s Skills—Today!