Certified Phlebotomy Technician with NHA Certification

Certified Phlebotomy Technician with NHA Certification
Dear Prospective Student:

Kiamichi Tech – Poteau Campus offers a 48-hour Phlebotomy Technician training program that includes National Certification through the National Healthcareer Association. Students must be 18+ to enroll in this training program, have a high school diploma or GED, and must successfully complete 10 capillary and 30 venipuncture draws during their training in order to be eligible to sit for NHA’s Certified Phlebotomy Technician exam. Your tuition for this program includes your book, supplies, and testing fees for one attempt at the NHA national exam. In the event you do not pass the NHA exam on your first attempt, it is your responsibility to pay for any future attempts out-of-pocket directly to NHA.

Attendance in this training program is mandatory, students are only permitted to miss a maximum of 8 training hours. If a student missed more than 8 hours of class, they will be dropped from the program. Students must submit a negative TB Skin Test with enrollment.

Students are required to wear plain navy blue scrubs and closed-toe shoes for all classes.

Course Tuition Breakdown:

Tuition: $200.00
Book: $25.00
Testing: $75.00
Supplies + Fees: $450.00
Total: $750.00

Total payment for this course or a funding letter AND completed enrollment packet is due before the first day of class and is required to hold your seat in the class. Funding letters should be sent via email to Chelsea Waggoner at cwaggoner@ktc.edu and should include your name, class name, total amount to be paid on your behalf, and signed by an authorized person on official letterhead.

If you have any questions about the program, or would like to enroll in the course, please call Chelsea Waggoner or Shannen Hamby at 918-647-4525.

Thank you for your interest in Kiamichi Tech’s healthcare training programs!

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 $20.00 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
Who is paying your tuition for this course?*

Self PayEmployerSteps to Success Scholarship (Covers Tuition ONLY; open to students who have graduated from a LeFlore County high school, home school, or earned their GED/HiSET in the last two years)Third Party Funding (Ex: Oklahoma Workforce, Choctaw Nation Career Development, etc.)
Are you 18 years old or older?*

YesNo (if you are not 18 at time of enrollment, you are not eligible to enroll in this program.)
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
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
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 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 some facilities will require a drug/alcohol screening test. I authorize that the results of the alcohol/drug screening test be given to officials at Kiamichi Tech for review of continuous enrollment in health career 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 any information received as a result of the screening process.I understand I can only miss a maximum of 8 hours for Certified Phlebotomy Technician.I understand I have to complete 100% of scheduled classroom/lab/and clinical hours.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 with the certifying entity when it's due (timeline depends on certification) and that Kiamichi Tech does not assist me with renewing.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 the policies, 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
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
The National Healthcareer Association is the certifying entity of your CPT certification and NHA might have varying barrier offenses from those listed above.
Upload a front and back copy of your current, valid Driver's License:*

Cancelof
Please upload the results from your TB Skin Test:*

Cancelof
Upload a copy of your high school diploma or GED:

Cancelof
Should be Empty:

Certified Phlebotomy Technician with NHA Certification

Personal Information

Emergency Contact Information

Personal Background Check