Certified Medication Aide

Certified Medication Aide

FLEX Program Application for Kiamichi Tech, Spiro Campus
Dear Prospective Student:

Kiamichi Tech – Poteau and Spiro campus offers a 56-hour Certified Medication Aide certification course for individuals seeking the LTCNA certification through the Oklahoma State Department of Health - Nurse Aide Registry. Students may complete this training through our FLEX program offered at the Spiro campus. Students must be at least 16 years old to enroll and must have worked as a Certified Nurse Aide for a minimum of 6 months in an Oklahoma long term care facility to be eligible to take this course. For more information, please contact the Workforce & Economic Development Center.

Course Tuition:
- Tuition: $510.00
- Book Fee: $25.00
- Testing Fee: $30.00
- Fees/Supplies: $25.00
- WED Fee: $10.00
Total $600.00

Total payment for the course or a funding letter AND a completed registration packet is required to complete enrollment.

The following records are REQUIRED when enrolling for class:
- Driver’s License or Photo ID
- Social Security Card (Coordinator must verify the names on DL & SSN Card match)
- Negative TB Test - Kiamichi Tech is not responsible for keeping personal medical records. If a trainee is needing a copy of TB test results, please refer to the TB testing facility.
- Copy of CPR certification card – if you are not already CPR certified upon enrollment, you may enroll in American Heart Association's Basic Life Support CPR for $80.
Students are required to wear plain navy blue scrubs and closed-toe shoes for class and clinical days. Students must provide his/her own transportation to and from class and to the clinical site. If you have any questions or to enroll, please call the Workforce & Economic Development Center at 918-647-4525.

Sincerely,

Shannen Hamby
Workforce & Economic Development Coordinator

* Please note: If students choose to receive a refund prior to the class starts, students will not be refunded the $10.00 fee for background check.

Possible Funding Sources for Short-Term Programs:

Chickasaw Nation Higher Education: Darius Roebuck (580)421-7711

Choctaw Nation Career Development: Leflore/Latimer Counties: Cynthia Martin (918)448-7508 or David Billy (918)448-4808

Haskell/Hughes/Macintosh Counties: Jane Buffington (918)967-9085

Choctaw Nation resources for other tribes: WIOA (Reimbursement Program only), Voc. Rehab, Vocational Development Ginger Crawford (800)522-6170

Cherokee Nation Career Services: Jennifer Davis (918)776-0416

Oklahoma Workforce: Leflore County - Tara Tate or Jennifer Walker (918)647-5599; Latimer & Haskell Counties - (580) 559-1780

Vocational Rehabilitation: Lisa Smith (918) 647-8121
Personal Information
Name*

First NameMiddle NameLast Name
How will your course tuition be paid?*

Self PayEmployerSteps to Success Scholarship (Tuition ONLY; Open to students who have graduated from a LeFlore County high school, home school, or earned their GED/HiSET in the last 2 years)Third Party (Ex: Choctaw Nation Career Development, Oklahoma Workforce, etc.)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Date of Birth*

MonthDayYear
Date
Race*

American IndianAsianBlack/African AmericanWhite/CaucasianLatinoOther
Education Level*

Less than High SchoolHigh School Graduate/GED/HiSETSome CollegeTechnical DiplomaAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate Degree
Gender*

MaleFemale
Repeat Customer: Have you taken a course with Kiamichi Tech in the past 2 years?

YesNo
Do you consider yourself a person with a disability?*

YesNo
If you answered yes, please list the accommodations you are requesting to support your education:
Have you ever entered a plea of Guilty or Nolo Contendere to, or been convicted of, a state (any state) or federal felony offense?*

YesNo
Several occupations require certification or licensure which may be denied if a felony record exists. In addition, certain licensure boards require submission of a Social Security Number before training can begin. No person seeking admission will be unilaterally excluded solely on the basis of a felony conviction, but those with felony convictions are subject to administrative review. If this is a concern, please discuss your questions with your career advisor or technology center representative.
BY SIGNING BELOW, I UNDERSTAND IT IS KIAMICHI TECH’S POLICY THAT STUDENTS ARE NOT ELIGIBLE FOR A TUITION REFUND AFTER THEY ATTEND 1 HOUR OF TRAINING.

• BY SIGNING BELOW, I UNDERSTAND IF I DO NOT SHOW UP FOR MY TRAINING I FORFEIT THE COURSE FEE.

• BY SIGNING BELOW, I GRANT KIAMICHI TECH THE ABSOLUTE RIGHT AND PERMISSION TO PUBLISH PHOTOGRAPHIC PICTURES OR VIDEOS OF ME, IN WHICH I MAY BE INCLUDED IN WHOLE OR PART, IN ADVERTISING, PROMOTIONAL, OR OTHER LAWFUL PURPOSES WHATSOEVER.
Signature*

Clear
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to the Student*
Student Signature*

Clear
Date*

MonthDayYear
Date
Certified Medication Aide Employment Verification

Students must be able to prove 6 months of employment in an OK long term care facility to enroll; home health does not qualify.
Name of Employer/Facility*
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name*

First NameLast Name
Supervisor's Title*
Supervisor's Phone Number*
Please enter a valid phone number.
Supervisor's Email*
example@example.com
Starting Employment Date*

MonthDayYear
Date
Ending Employment Date (use today's date if currently employed)*

MonthDayYear
Date
Position Worked*
Attendance Policy for FLEX Helathcare Programs
The Oklahoma State Department of Health requires students to complete 96 hours
of professional training in order to obtain Certified Medication Aide certification.

Attendance in this training program is mandatory. While this training program is
setup with a FLEX schedule, students must complete the 56 hours of training within
30 days of their start date.

All absences must be approved in writing by the Healthcare Instructor via email.

While this is a FLEX program, there are established class times students are
expected to adhere to. Students are expected to arrive to class on time, take
their lunch at the established lunch time, and will be dismissed at the end of the
class day.

Students are expected to communicate with the Healthcare Instructor if they are
unable to adhere to the set class schedule, or with any changes and
emergencies. You are expected to notify your instructor of any and all absences via email, as soon as you know you will not be attending class. Phone calls to the campus are not sufficient.

You must attend a minimum of 14 hours per week or you are subject to being dropped from the program, as you will not complete on time.
Signature*

Clear
Date*

MonthDayYear
Date
Personal Background Check
According to Oklahoma State Statute 310:677-3-7. Criminal Arrest Checks:

(a) An employer-based program shall complete the State required criminal
arrest check. The record of the finding shall be maintained by the employer.
These records shall be destroyed after one (1) year from the end of employment
of the person to whom such records relate. [63:1-1950.3(H)].

(b) A non-employer based program shall notify trainees that if a criminal arrest
check reveals a cause which bars employment in a health care entity, then the trainee shall be withdrawn from the training program.

(c) If a non-employer based training program does not require an OSBI criminal arrest check as part of the admission requirements to the training, the training program shall provide the trainee with written notification of 63:1-1950.1 as part of the training program application.

[Source: Added at 12 Ok Reg 3087, eff 7-27-95; Amended at 19 Ok Reg 2106, eff 6-27-02].

Kiamichi Tech is a non-employer-based program that requires a personal criminal history background check for acceptance into its short-term healthcare programs.

By signing below, I verify that I have received a copy of the Background Check guidelines and that those guidelines have been reviewed verbally with me on the date indicated below.

I grant Kiamichi Tech permission to run a background check on my personal record.
Signature*

Clear
Date*

MonthDayYear
Date
Non-Disclosure Agreement

Please read all sections below. If you have any questions regarding thisagreement, please ask your instructor or program coordinator before signing.Upon request, you may receive a copy of this agreement for your own records,and the training facility will maintain a copy in your student file.
DISCLOSURE OF PATIENT INFORMATION:

The student recognizes and acknowledges that the services of the Clinical Affiliate(s) performs for its patients are confidential, and that to enable the Affiliate to perform those services, its patients furnish to the Affiliate and Physician, confidential information concerning themselves and their affairs, that the good will of the Affiliate, depends, among other things, upon its keeping such services and information confidential, and that by reason of the student’s duties, the student may come into the possession of information concerning the services performed by the Physician or Affiliate for its patients even though the student does not take any direction or furnish the services performed for those patients. The student accordingly agrees that, both during and after his/her clinical rotation at the Affiliate, the student shall NOT:
1. Disclose any such services or information to any person whatsoever;
2. Permit any person whatsoever to examine of make copies of any reports or other documents contained in the Affiliate’s files or coming into his/her possession or under his/her control;
3. Remove from the Affiliate premises any report or records pertaining to any patient.
Student recognizes that the disclosure of confidential information may give rise to irreparable injury to the patient or owner of such information, and that accordingly, the patient or owner of such information may seek such LEGAL remedies against the student.

I have read, understand, and agree to abide by the terms of this agreement.
Signature*

Clear
Date*

MonthDayYear
Date
Student Liability Record
I hereby understand and certify the following:

I hereby waive all responsibility on behalf of the Clinical Facilities for any liability related to accidents which said student might incur while in training and/or while participating in any activities related to my rotation as part of any training program.

CONTRACT FACILITIES

Spiro Nursing Home, Inc.
The Oaks Healthcare Center

I also understand that my presence in these facilities is voluntary and for the purpose of training; therefore, I cannot be considered an employee for the purpose of Workman’s Compensation or other insurance.
Signature*

Clear
Date*

MonthDayYear
Date
Contract for Clinical Rotations
This contract is to be strictly observed at all times during your clinical rotation.

In the medical profession, there has evolved through the years, a system of ethics that is observed and practiced by all persons in the medical family.
1. I will make it my responsibility to know, understand, and keep within the guidelines of each clinical rotation in order to assume the health and well-being of each patient.
  *Invariably the people with whom we deal are in different stages of ill health, which creates in each of them a different outlook. They become anxious, nervous, and quite often impatient. The afflicted require the best use of our technical and human relations skills.
2. I will make every effort to be courteous, efficient, and accurate when helping patients through this stressful time in their lives.
  *Patients will often gain confidence in us and share their innermost thoughts. We also come to know a great deal about a patient from hearing reports and reading charts.
3. I understand that discussing:
  - A confidence
  - A disease
  - A diagnosis or prognosis
  - A family history
  - A treatment
  of a patient with other students, mends, or family is in violation of the "sacred trust in confidentiality." I will uphold the patient's "right to privacy" as I would a member of my own family.
4. I will wear:
  - Clean navy blue scrubs
  - Non-slip shoes
  - A watch with a second hand
  - Hair pulled back or worn off the collar
  - Cosmetics and jewelry in moderation
  - The proper Kiamichi Tech name tag at all times
  - Be washed and clean with deodorant and good hygiene (no foul odors like body odor, cigarette smoke, or marijuana)
5. I will not visit other units or departments
6. I will not take or make personal calls at the nursing station or in other areas. Cell phones are not allowed in classroom, laboratory, or clinical sites.
7. I will not leave the unit without checking with the person in charge.
8. I will notify the instructor if I will be late or absent.
9. I will conform to any direction from the clinical coordinator immediately without question while in the clinical setting. Any questions of such matter will be handled in private.
10. I will not discuss my private life while in the presence of patients.
11. Illnesses I have observed will not be discussed in the presence of patients.
12. If an accident occurs while in the clinical area (regardless of how minor), I will report such immediately to the clinical instructor and file the necessary incident report as directed by my supervisor or instructor.
13. I will respect and properly care for all equipment and supplies.
14. I will complete and understand the self-study prior to my assigned clinical rotation. If I am unable to do so, I will discuss this with my coordinator.
15. I intend to arrange the priorities in _my life in order to make this a learning experience that will benefit me greatly in my future health career.
16. If I should feel that I cannot meet the expectations of this contract, I will request a conference with my coordinator immediately.
17. I understand that if I break this contract, disciplinary measures will be taken and termination from the program may be necessary.
Signature*

Clear
Date*

MonthDayYear
Date
Please take time to review the Kiamichi Tech Workforce & Economic Development Student Handbook.
Please check ALL statements in this section to verify you have read and understand Kiamichi Tech's healthcare handbook student expectations. Please reach each box carefully! This will become part of your education record.*

I have read the program requirements and understand that if I have difficulty in any of those areas, I may not be successful in passing the program.I have read the Kiamichi Tech Short-Term Healthcare Student Handbook and understandthe policies and procedures stated within. I understand that if I cannot support and abide bythese policies and procedures, it may be in my best interest to seek another program in which todevelop my training skills.I have been informed of the clinical rules, regulations, agreement, and time required tocomplete the requirements for these courses.I have read and understand the short-term program refund policy.I have read and understand the Program Requirements for Certification and Employment.I have read and understand the Drug/Alcohol screening policy. I understand that somefacilities will require a drug/alcohol screening test. I authorize that the results of the alcohol/drugscreening test be given to officials at Kiamichi Tech for review of continuous enrollment in healthcareer programs. I also release and hold harmless Kiamichi Tech, its Board of Education,superintendent, management, instructors, or any other agent or employee for the use of anyinformation received as a result of the screening process.I have read and understand the Student Liability section.I understand I must have 100% attendance to complete the CNA Program (96 hoursminimum), (60 hours for CMA), (8 hours CMA Advanced RG, IA), (8 hours for CMA CEU) (HomeHealth 16 plus CNA), 75/230hours combined courses for CCMA).I understand I have to complete 100% of scheduled classroom/lab/and clinical hours.I give my permission for Kiamichi Tech to send a copy(s) of my immunization records, including background checks, CPR certifications, and state certifications and/or licensures to the required clinical sites. I further understand that this information is considered protected and private and will be treated as such.I authorize Kiamichi Tech to release information (attendance/educationrecords/conduct/concerns) to my funding source and/or employer per the Family EducationalRights and Privacy Act (FERPA.)I have read and understand that Kiamichi Tech is a weapons, tobacco, drug, and alcohol-free campus.I understand that it is my responsibility to RENEW my certification every 1 or 2 years(depends on certification).I have been informed that I have 10 DAYS to notify the OSDH- Nurse Aide Registry of any address changes so that I may be notified promptly in case the need arises for a due process hearing.I understand that there will be a charge to retest all Skills and/or Computer Exams each time and I agree to the charges discussed in the no-shows, cancellations, and refunds for clinical skills testing section of this document.I have read and acknowledge that I understand the list of barrier offenses. By signing this, I affirm that I have not been found guilty/or pled no-contest to any said offenses.I understand and acknowledge, and I hereby give Kiamichi Tech the absolute right and permission to publish photographic pictures of me, in which I may be included in whole or in part, in advertising, promotional or other lawful purposes whatsoever. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, or the use to which it may be applied.I have read and understand that Kiamichi Tech is NOT RESPONSIBLE for any accidents (caused by my negligence) or injuries sustained while in the class, lab, or during clinicals. By checking this line – I understand that I am on MY OWN insurance. I am aware that Kiamichi Tech assumes no financial responsibility for accidents/illness/injury during school/lab/ or clinicals.I have been provided the link to the Kiamichi Tech Student Handbook and understand thepolicies, procedures, and campus rules stated within and must abide by them at all times.Failure to do so may result in immediate dismissal from the course without a refund.I understand that I am required to be in class 100% of the time and if I miss, I understand that there may NOT be an opportunity to make up any time missed resulting in dismissal from the course. I also understand that IF there is an available option, I will be required to pay $40/hour for each hour missed.I have read and understand my rights and responsibilities as a student according to the short-term health handbook.I understand by signing this document, my records including grades, transcripts,suspicions of drug/alcohol use, any counseling statements, time spent in the program, historywithin my program, progress and attitude may be discussed with employers, or other schoolpersonnel that are appropriate. I understand that I am on my own medical insurance while inthe class/lab/or clinical site. I will self-disclose to Kiamichi Tech any arrest, conviction, or chargesfiled against me while enrolled in this course. Kiamichi Tech reserves the right to deny a studentadmission to any health career program if the student refuses to sign this statement ofunderstanding.
Signature*

Clear
Date*

MonthDayYear
Date
Required Information for Trainees

HB2582 and Background Checks Certified Nurse Aides63 O.S. § 1-1950.1 (OSCN 2012)
Please take time to review the following document from Oklahoma State Department of Health's Nurse Aide Registry:
Name*

First NameLast Name
Signature*

Clear
Name of Training Program*
Nurse Aide Barrier Convictions
§63-1-1950.1 – §63-1-1951

If the results of a criminal history background check reveal that the subject person
has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, the employer shall not hire or contract with the person:
- abuse, neglect or financial exploitation of any person entrusted to the care or
  possession of such person,
- rape, incest or sodomy,
- child abuse,
- murder or attempted murder
- manslaughter
- kidnapping
- aggravated assault and battery
- assault and battery with a dangerous weapon
- arson in the first degree
If less than seven (7) years have elapsed since the completion of sentence, and the
results of a criminal history check reveal that the subject person has been convicted
of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the
following offenses, in any state or federal jurisdiction, the employer shall not hire or
contract with the person:
- assault
- battery
- indecent exposure and indecent exhibition, except where such offense
  disqualifies the applicant as a registered sex offender
- pandering
- burglary in the first or second degree
- robbery in the first or second degree
- robbery or attempted robbery with a dangerous weapon, or imitation firearm,
- arson in the second degree
- unlawful manufacture, distribution, prescription, or dispensing of a Schedule I
  through V drugs as defined by the Uniform Controlled Dangerous Substances Act
- grand larceny
- petit larceny or shoplifting
CMA Attestation

Please be certain that the information you provide is correct. The Oklahoma State Department of Health may deny,suspend, withdraw or not renew the certificate of a medication aide who intentionally provides false or misleadinginformation to a training program, a facility, or the Oklahoma State Department of Health.
OAC 310:677-13-8(a)(1-5). Certification and recertification:

(a) The following, to be evidenced by the aide's attestation, are prerequisites for certification as a medication aide:
1) Minimum age: 18;
2) Minimum education: high school or general equivalency diploma;
3) Current Oklahoma nurse aide certification with no abuse notations;
4) Experience working as a certified nurse aide for six months; and
5) Physical and mental capability to safely perform duties.
Please check each box to verify the statement as true:

I am a minimum of 18 years of age.I have a minimum education of high school or general equivalency diploma.I have worked as a Certified Nurse Aide for at least 6 months.I have a current Oklahoma nurse aide certification with no abuse notations.I have the physical and mental capability to safely perform the duties.
Signature*

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Social Security Number*
Date*

MonthDayYear
Date
Upload a front and back copy of your current, valid Driver's License:*

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Upload a copy of your high school transcript or copy of diploma/GED/HiSET:*

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Please upload the results from your TB Skin Test:*

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Upload a copy of your CPR Certification if you have it:

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Should be Empty:

Certified Medication Aide

Personal Information

Emergency Contact Information

Certified Medication Aide Employment Verification

Attendance Policy for FLEX Helathcare Programs

Personal Background Check

Non-Disclosure Agreement

Student Liability Record

Contract for Clinical Rotations

Required Information for Trainees

CMA Attestation