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Bartow Medical and Fire Academy EMR Course 17 18 SY

17/18 SY Emergency Medical Responder

Required Paperwork

Please return this packet to the instructor with all required signatures.

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Bartow Medical and Fire Academy EMR Program

Required Paperwork

Student Name (please print): ___________________________________________________

ITEMS ON THIS PAGE ARE FOR CLINICAL EDUCATION OFFICE USE ONLY

Item # 1 _______ Student Contact Information Form

Item # 2 _______ Free From Addiction and/or Disease or Defect Ability

Item # 3 _______ Compliance Agreement

Item # 4 _______ Rescue / Injury Release Form

Item # 5 _______ Copy of Government Issued I.D. / Health Insurance

Item # 6 _______ Physical Examination Form

Item # 7 _______ Immunization Schedule

Item # 8 _______ Affidavit of Good Moral Character

Item # 9 _______ Background / Drug Screen Notice

Item # 10. _______ Bartow Fire Department SOP/ Release Form completed

Item # 11. _______ Auburndale Fire Department SOP/ Release Form completed

Item # 12._______ Blanket Field Trip Form

Item # 13 _______ Medical Treatment Authorization

Item # 14 _______ Classroom/Clinical/Skills/High Fidelity Simulation Labs SOP

This will be entered by instructor when received after testing at the academy.

Item # 15. _______ Background Check Results received

Item # 16. _______ Drug Screen Results received

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Required Paperwork

Item # 1

Please print neatly!!!

Student

Last Name: __________________________________ First Name: __________________________________

Street Address: _____________________________________________________________________________

City: ________________________________________ State: ________________ Zip Code: _____________

Cell Phone: __________________________________ Home Phone: ________________________________

Date of Birth: _________________ Gender (circle one): M / F Age: ________________________

E-Mail address: ______________________________________________________________________

EMR Program Instructor: ___________________________________________ Period: _______________

Parent or Guardian


Street Address: _____________________________________________________________________________




Street Address: _____________________________________________________________________________



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Required Paperwork

Item # 2

STATEMENT AFFIRMING FREEDOM FROM ADDICTION AND/OR DISEASE

I, ______________________________________________, hereby attest that I am free from addiction to alcoholic

beverages and/or any controlled substances. Furthermore, I hereby attest that I am free from physical and/or mental defects or disease, which may impair my ability to perform as an EMS Program student.

____________________________________________ Student Signature

____________________________________________ Parent Signature

________________Date ____________________________________________ Notary Signature

____________________________________________ Date

Affix Notary Seal

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Required Paperwork

Item # 3

COMPLIANCE AGREEMENT

This agreement is required so as to ensure that all students have been informed of certain rights that the student is entitled according to the standard college policy.

I, ______________________________________________, have read the EMR Program policies manual, have obtained a current Student Handbook, and have read the sections entitled:

Students Rights and Responsibilities

Due Process

Health Services

Class Attendance and Absences

Student Conduct

Discipline and Due Process

I understand and agree to comply with the policies, rules, and regulations in both publications.

______________________________________________________________________________ Applicant Signature Date

______________________________________________________________________________ Parent Signature Date

____________________________________________ Notary Signature

____________________________________________ Date

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Required Paperwork Item # 4

RESCUE/INJURY RELEASE FORM

This form is required to ensure, and document, that all students have been informed that the clinical portion of the training program could be the cause of injury, incapacitation, and/or death to the student.

I, ______________________________________________, have been informed and understand that the clinical aspect of The Bartow Medical and Fire Academy EMR Program includes a fire-rescue/EMS field experience component which is inherently dangerous. Thus, I hereby understand that there is a great deal of potential for me to be injured and/or permanently incapacitated if not killed. As a result, I hereby, agree to follow all of the directions of the Fire Rescue/EMS preceptor who is supervising my activities on any given date. Furthermore, I agree that both myself and/or any other person attempting to represent me at any time (past, present, or future) will hold Bartow Medical and Fire Academy and/or any of its affiliated partners harmless of any financial liability that may arise because of an injury and/or death to me.

__________________________________________________________________Applicant Signature


_________________Date


____________________________________________ Date

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VERIFICATION OF HEALTH INSURANCE AND I.D.:

Those currently covered by a health insurance plan; please attach a copy of your current health insurance card and initial the first selection below. Those who do NOT have any health insurance coverage at present; please initial the second selection below. Polk State College is not financially liable for any injuries that may occur while a participant of the EMS training program.

Also, please attach a copy of your Driver’s License, Florida ID or Passport to this sheet.

I, ______________________________________________, understand that I shall be financially responsible for the treatment of any injury and/or illness that occurs while I am engaged in any type of program activity, whether on or off-campus.

PLEASE INITIAL ONE OF THE FOLLOWING:

_____ I have a current health insurance policy, which I agree to keep current throughout the duration of the EMS program. Said company’s name, policy number, and/or other claims related information, is listed on the card which I have provided a copy of.

_____ I DO NOT have a current health insurance policy. Thus, I understand that, Polk State College affords students minimal accidental injury coverage. Moreover, I understand and agree that I am liable for any remaining financial liability resulting from an accident, injury, illness and/or death incurred by me while partaking in any Polk State EMS program activity.

_________________________________________________________ Applicant Signature


___________________________Date


____________________________________________ Date

ATTACH A COPY OF YOUR HEALTH INSURANCE CARD AND I.D. BELOW

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PRE-ENTRANCE PHYSICAL EXAMINATION

The medical examiner is required to make a careful physical examination. Impairments found after admission may lead to the rejection of the applicant due to the inability of the applicant to meet patient care responsibilities. According to Florida Law, General Authority Section 15; Chapter 73-125: An applicant must be free from any physical or mental defect or disease, which might impair the applicant’s ability to attend on an ambulance.

- STUDENT INFORMATION -

Name: ___________________________________________________ DOB: _______________ Sex: M F

Past Medical History: ____________________________________________________________________________

Medications: __________________________________________________________________________________

Allergies: _____________________________________________________________________________________

- FINDINGS OF PHYSICAL EVALUATION –

Height: _________ Weight: _________ Blood Pressure: _________ Pulse: _________

Vision: R 20/_____ L 20/_____ Corrected: Y / N Contacts: Y / N Glasses: Y / N

INDICATORS NORMAL? ABNORMAL FINDINGS / COMMENTS

General Appearance YES Head/Neck YES Eyes/Sclera/Pupils YES Ears: YES Ear Drums YES Gross Hearing YES Nose/Mouth/Throat YES Lymph Glands YES Cardiovascular: YES Heart Rate YES Rhythm YES Murmur ABSENT If murmur present Standing makes it: Louder Softer No change

Squatting makes it: Louder Softer No change Valsalva makes it: Louder Softer No change Femoral Pulses YES Lungs: Auscultation/Percussion YES Chest Contour YES Skin YES Abdomen (liver, spleen, masses) YES Neck/Back/Spine: YES

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INDICATORS NORMAL? ABNORMAL FINDINGS / COMMENTS

Range of Motion YES Scoliosis ABSENT Upper Extremities: YES Range of Motion YES Strength YES Stability YES Lower Extremities: YES Range of Motion YES Strength YES Stability YES Neurological: YES Balance YES Coordination YES Reflexes YES Additional Observations: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physician/ARNP Certification Statement

After a complete and thorough physical examination, it is my opinion that the person whose name is listed on the front of this form is in good health. In addition, this person is able to participate in any physical activity associated with any facet of Polk State College’s EMS Program without any restrictions.

Please print or stamp the facility or physician’s name and address below.

_____________________________________________________________________________________________________________________ X________________________________________________

Physician/ARNP Signature Please sign and date

THE PHYSICAL ACTIVITY REFERENCED ON THE CERTIFICATION STATEMENT ABOVE INCLUDES, BUT IS NOT LIMITED TO; HEAVY LIFTING, TWISTING, BENDING, AND PROLONGED PERIODS OF PHYSICAL EXERTION. IN ADDITION, EMS PROGRAMS PARTICIPANTS HAVE AN ELEVATED RISK OF BEING EXPOSED TO COMMUNICABLE AND/OR INFECTIOUS DISEASES.

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Please PRINT student’s name HERE: _______________________________________________________

Complete this form in its ENTIRETY. Include all NAMES, SIGNATURES, and AND ADDRESSES.

T-DAP within the last 10 years Name/Title of Agency (print or stamp) Date administered ________________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________

Measles, Mumps, and Rubella (MMR) Name/Title of Agency (print or stamp) Date administered ________________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________

Varicella (TITER is required) Name/Title of Agency (print or stamp) Date drawn: ________________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________

Report: Positive _____ Negative _____ All students MUST have the above blood test (TITER) drawn regardless of how many times you may have experienced the disease or who can attest to your medical history.

PPD (TB skin test within the last 3 months) Name/Title of Agency (print or stamp) Date administered ________________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________

Report: Positive _____ Negative _____

Positive results of PPD require a chest x-rayDate of chest x-ray: _________________ By: _______________________________ Assessed by: _________________________ Signature: _________________________ Signature: ___________________________


Hepatitis C TITER (antibody testing within the last 6 months) Name / Title of Agency (print of stamp) Date drawn: _________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________


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Heptovax Series

If the applicant chooses not to receive this immunization, the waiver at the bottom of this form must be signed.

Name / Title of Agency (print of stamp) Date Administered ________________________ ____________________________________ By: _______________________________ ____________________________________ Signature: _________________________ ____________________________________



Rejection of Immunization

This will certify that I, the undersigned, understand the risk of exposure and possible complications that may occur because of contact with patients who have Hepatitis B. Should I contact Hepatitis B while on hospital or field affiliation as an EMS Program student, I will not hold Polk County Public Safety, the hospital, nursing home, or Polk State College responsible.

_________________________________________________ _____________________________ Program Participant’s Signature Date


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Exhibit “A”

Affidavit of Good Moral Character

I hereby attest that I am of good moral character, that I have not been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

1. Section 415.111 relating to adult abuse, neglect, or exploitation of aged persons or disabled adults 2. Section 782.04 relating to murder 3. Section 782.07 relating to manslaughter 4. Section 782.071 related to vehicle homicide 5. Section 782.09 relating to killing an unborn child by injury to the mother 6. Section 784.011 relating to assault, if the victim of the offense was a minor 7. Section 784.021 relating to aggravated assault 8. Section 784.03 relating to battery, if the victim of the offense was a minor 9. Section 784.045 relating to aggravated battery 10. Section 787.01 relating to kidnapping 11. Section 787.02 relating to false imprisonment 12. Section 794.011 relating to sexual battery 13. Chapter 796 relating to prostitution 14. Section 798.02 relating to lewd and lascivious behavior 15. Chapter 800 relating to lewdness and indecent exposure 16. Section 806.01 relating to arson 17. Chapter 812 relating to theft, robbery, and relating crimes if the offense is a felony (See 812.014, 812.016, 812.019, 812.081, 812.13, 812.133, 812.135, 812.14, and 812.16) 18. Section 817.563 relating to fraudulent sale of controlled substances, only if the offense was a felony 19. Section 826.04 relating to incest 20. Section 827.03 relating to aggravated child abuse 21. Section 827.04 relating to child abuse 22. Section 827.05 relating to negligent treatment of children 23. Section 827.071 relating to sexual performance by a child 24. Chapter 847 relating to obscene literature 25. Chapter 893 relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.

I further attest that I have not been judicially determined to have committed abuse or neglect against a child as defined in s.3901 (2) and (36), Florida Statutes; nor do I have a confirmed report of abuse, neglect, or exploitation as defined in s.415.102, or abuse or neglect as defined in s.415.503 (3), which has been uncontested or upheld under s.415.103 or s.415.504, Florida Statues; nor have I committed an act which constitutes domestic violence as defined in s.741.28, Florida Statutes.

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BEFORE ME this day personally appeared, ______________________________________, who, being duly sworn, deposes and says: Under the penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.

____________________________________ Applicant

___________________________________ Parent Signature Date

OR

To the best of my knowledge and belief, my record may contain one of the foregoing disqualifying acts or offenses.

____________________________________ Applicant

____________________________________ Parent Signature Date

SWORN TO AND SUBSCRIBED before me this ______ day of _______________________, 20___, by

_______________________________________________, who is personally known to me or has produced

______________________________________, as identification, and who did take an oath.

____________________________________ Signature of Notary Public – State of Florida

____________________________________ Notary Seal

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Background Check / Drug Screen Notice

All students enrolled in the course listed above are hereby advised; continued enrollment in this course is contingent upon a satisfactory result on a seven-year criminal background history check and negative results on a ten-panel drug screen. Failure to comply with one or both of these requirements will result in your immediate dismissal from EMR without any refund of uniform, dues and/or lab fees.

For a sample list of criminal and/or felony offenses, which will yield an unsatisfactory result on the seven-year criminal background history, refer to Item # 8; which is the previous page. However, anyone who has been convicted, or plead guilty, or nolo contendre to a felony violation, regardless of adjudication, is strongly urged to consult with a Program Director – EMR prior to the start of classes.

The ten-panel drug screen will check for the presence of: Amphetamines Cannabinoids Cocaine Phencyclidine

Methaqualone Opiates Barbiturates Benzodiazepines

Methamphetamine Propoxyphene

A positive result for any of the above substances will disqualify a student from participation in the Emergency Medical Responder Program. Thus, dismissal from Bartow Medical and Fire Academy will ensue without any refund of uniform, dues and/or lab fees.

I understand that my continued enrolment in Bartow Medical and Fire Academy is contingent upon meeting the above requirement. As such, I agree to be dismissed from the program if I should fail to meet the minimum accepted standards as outlined. Furthermore, I agree to be bound by the terms listed above, specifically those parts, which state no refund will be issued if I am dismissed from the course.

The Medical and Fire Academy has made arrangements to have this testing done on campus for a $100 fee. This is a onetime only deal. If you do not get the testing done at this time it will be up to you to have the testing done by the deadline given. Students are not allowed to ride or go to clinical without this testing. Students need to bring this paper signed by a parent or guardian and a driver’s license, Florida ID card or Passport when testing in the Nursing Lab.

I am giving the Polk County School Board permission to test my student.

Parent Name:_______________________________________________________

Parent Signature:____________________________________________________

Please declare if you are taking any prescribed or over the counter Medications:____________________________

_____________________________________________________________________________________________

_____________________________________________________ _________________Student Signature Date _____________________________________________________ _________________________Printed Student Name Student Identification Number

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Item # 10

Bartow Fire Department Effective Date: ___05/26/17_______Standard Operating Procedure Revision: ______________________

Ride Along Program Fire Chief: _____________________

The Bartow Fire Department and the Fire Chief reserve the right to change this policy as needed to fit the changing needs of the fire department.

The Fire Department will occasionally allow individual citizens, high school students, and / or other individuals to spend time at the fire department to learn more about what we do. The following policy will govern who can spend time here and who can ride on the apparatus to emergency calls.

General: The Fire Department will recognize individuals in this program as either “shadows” or “students”. A shadow will be an “observe only” participant in the program. A student will be an individual deemed to have the appropriate level of training to be able to assist with

patient care. This status will be at the discretion of the fire chief. All individuals wishing to participate in any aspect of the program will sign a personal consent waiver. This will

be based on informed consent. The individual will be told, in advance, what they could possibly experience. No participant shall be less than 13 years of age without specific permission of the fire chief. No participant shall be allowed to go to calls, or ride the apparatus, unless they are 16 years of age or older

and have signed the informed consent waiver. The fire chief may grant special exceptions, if the participant is enrolled in the Bartow High School Emergency Medical Responder program.

Before their first ride date, a student / shadow will meet with BFD staff and shift they will be assigned to. On / before their first ride date, a student / shadow will be issued an ID card. This card will be worn at all times

while performing ride along activities or in the station for skills practice.

Participants:

All shadow/students will maintain a professional appearance while riding with our department All males will be clean shaven Males and Females will have hair cut or put up so that is at or above their collar No visible facial piercing items are allowed to be worn while riding Earrings are not allowed for males and should be post style only for females, no hoops No loose bracelets or necklaces will be worn for safety reasons

All shadows/students will ride in a seat with safety belt and have them fastened properly. All shadows/students, outside of a vehicle, at any call other than a medical call, will wear an approved

reflective vest. All shadows/students will be assigned to a preceptor. The shadow/student will arrange all ride time through

that preceptor. The shadow/student may be allowed to ride with another preceptor if their initial preceptor clears them.

In order to ride with a different preceptor, or on a different shift, a student must meet the following requirements: Must do at least three ride along shifts with their original preceptor Must complete listed skills during those three shifts and have approval of preceptor. Skills: Universal Precautions, Pulses, Respirations, BP by Auscultation, BP by Palpation, Stretcher Lifting,

Patient Assessment, Pulse Oximetry, O2 Tank Prep, O2 Admin, C-Collar Standing, C-Collar Supine, Dressing and Bandaging, Radio, BVM, EKG Setup, IV setup.

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Must make arrangements with another student on a different shift to swap places. This is only if the preceptor is assigned two or more students. If the preceptor to which the student is transferring has only one student, the preceptor may accept a second at their discretion.

O nce a student changes shifts / preceptors, they need to be evaluated and checked off by the new preceptor to assure accountability and continuity of training.

Shadows/students will follow all orders of their preceptor and / or any firefighter on the scene. Shadows/students will not go on a call unless they are with one of the recognized preceptors, chief, deputy

chief, Lieutenants or OIC (Officer In Charge). Any shadow/student not following the expressed instructions of their preceptor, or any officer or incident

commander of the fire department, will have their privilege of going on calls revoked. No shadow/student shall be allowed to participate in any fire attack activities, extrication, or any removal

of people from wrecked vehicles. No shadow/student will enter the interior of a wrecked vehicle for any reason. No shadow {observer only} shall be allowed to participate in the treatment of any patient. Students of the Bartow High School Emergency Medical Responder program may be allowed to participate in

patient care provided the student is wearing proper personal protective equipment. Other qualified individuals with an approved level of training may be allowed to participate in patient care,

provided they are wearing proper personal protective equipment, at the discretion of the fire chief. Shadows/students may, at the discretion of the training officer, be allowed to participate in training activities

not involving live fire, live smoke, or other dangers. At a fire scene or vehicle crash scene, the shadow/student should remain in the response apparatus until

cleared to approach the scene. The shadow/student should then be assigned to observe the IC or the accountability officer, or work with their preceptor.

This is a place of business and business conduct is expected. There will be no sleeping while on duty Any student / shadow found sleeping during their ride time will be referred to BHS staff rep for discipline Students / shadows will participate in all non-hazardous station duties and functions that take place Students / shadows will not be allowed to answer the telephones or the front door of the fire station All students coming to the station for skills practice will be required to be in uniform and to be wearing their ID

tag Students not in the ride along program will not be allowed in the station unless pre-approved by the officer in

charge of the shift Any student in station for practice, who is not riding on that date, will be required to leave the station if all

firefighters have to leave for a call. Students ride hours will be from 07:00 -22:00 on non-school (Holiday) weekdays, 14:30 - 21:00 on school days

and 07:00 – 22:00 on Weekends. Students are allowed to ride on Saturdays and Sundays. Students will be allowed to ride on school holidays and may ride on teacher workdays from 07:00 – 22:00.

Preceptors:

Preceptors need to read and understand all aspects of this SOP. Preceptor will re-check any vitals or treatment performed by a student. This is for monitoring of the student’s

skills. Preceptor has the right to tell a shadow/student they cannot go to a scene that may be violent. Preceptor will not allow a shadow/student to “ride in” with the ambulance Preceptor will be responsible for scheduling time with the shadow/student. Only when the assigned preceptor

clears it, can a shadow/student ride with a different preceptor. No shadow/student shall be assigned to any staff function at any scene. They may assist and observe only with

these functions. Any preceptor that allows a student / shadow to sleep will be subject to departmental discipline and removal

from the preceptor list Any preceptor that allows a student into any hazardous situation as described above will be removed from the

preceptor list.

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Lieutenants:

Lieutenants need to read and understand all aspects of this SOP. The on duty lieutenant or officer in charge has the right and responsibility to tell any shadow/student they can

not go to any scene which may be violent. The on duty lieutenant or officer in charge will need to document the shadow/student’s time in and their time

out in the daily log. It is very important that these times be documented accurately. Lieutenants will not be allowed to be preceptors OIC qualified personnel are not allowed to have a student / shadow while they are functioning as the shift

officer.

Student__________________________________________________

Parent___________________________________________________

Hold Harmless Agreement

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For the Bartow Fire Department

I ______________________________, the parent of ___________________________ realize that normally only employees of the City of Bartow are allowed to ride on Bartow Fire Department vehicles. Therefore, in consideration of the above named student being allowed to ride on the vehicles owned and operated by the City of Bartow, I do hereby release the School Board of Polk County, Florida, the City of Bartow, Florida, the Bartow Fire Department and the operators of these vehicle from any and all damages, claims and causes of action what-so-ever that may occur while I am riding with the Bartow Fire Department.

This release is effective against my heirs, executors, administrators, and assigns and precludes anyone from recovering either against the School Board of Polk County, Florida, the City of Bartow, Florida, the Bartow Fire Department or operators of such vehicles for events occurring while I am riding in the vehicle or accompanying City employees in connection with the operation of the Bartow Fire Department.

I understand that by not signing this agreement, my child would not be allowed to ride the above described vehicle but would still be allowed to participate in the classroom instruction for the First Responder program.

Dated this ______ day of _________________, 20_____.

Notary:

____________________________ ______________________________ Student/Observer

____________________________ ______________________________ Commission Expires Student/Observer Signature

_____________________________Parent/Guardian

____________________________Parent/Guardian Signature

Item # 11

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Auburndale Fire Department POLICY No. 227 Effective Date: ___03/11/15_______Standard Operating Procedure Revision: ______________________

EMR Student Ride Along Program Fire Chief: _____________________

The Auburndale Fire Department and the Fire Chief reserve the right to change this policy as needed to fit the changing needs of the fire department.

The Fire Department will allow high school students, enrolled in the EMR (Emergency Medical Responder) Program to be assigned to a Firefighter Preceptor at the fire department to learn more about what we do, and have professional assistance in strengthen their skills required in the EMR program.

The following policy will govern the student and preceptor expected conduct while students are participating in the EMR ride along program. This policy will define the rules for riding in the fire department apparatus, and participation in the actual emergency incidents.

General: The Fire Department will recognize individuals in this program as “students”. A student will be an individual deemed o have the apocopate level of training to be able to assist with patient

care. The student must be enrolled in the EMR program. All students wishing to participate in any aspect of the program will sign a personal consent waiver. This will

be based on informed consent. The individual will be told, in advance, what they could possibly experience at the fire station and during an actual emergency incident.

All participants shall be a student enrolled in the approved EMR program at BHS. No participant shall be allowed to go to calls, or ride the apparatus, unless they are 16 years of age or older

and have signed the informed consent waiver. Before their first ride date, a student will meet with AFD staff and shift they will be assigned to. On / before their first ride date, a student will be issued an ID card by BHS. This card will be worn at all times

while performing ride along activities or in the station for skills practice.

Participants:

(Must read and sign a copy of: AFD Policy 204 DEPARTMENT PHOTO AND ELECTRONIC IMAGING)

All students will maintain a professional appearance while riding with our department All males will be clean shaven Males and Females will have hair cut or put up so that is at or above their collar No visible facial piercing items are allowed to be worn while riding Earrings are not allowed for males and should be post style only for females, no hoops No loose bracelets or necklaces will be worn for safety reasons

All students will ride in a seat with safety belt and have them fastened properly. All students, outside of a vehicle, at any call other than a medical call, will wear an approved reflective vest. All students will be assigned to a preceptor. The student will arrange all ride time through that preceptor. The

student may be allowed to ride with another preceptor if their initial preceptor clears them. In order to ride with a different preceptor, or on a different shift, a student must meet the following

requirements: Must do at least three ride along shifts with their original preceptor

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Must complete listed skills during those three shifts and have approval of preceptor. Skills: Universal Precautions, Pulses, Respirations, BP by Auscultation, BP by Palpation, Stretcher Lifting,

Patient Assessment, Pulse Oximetry, O2 Tank Prep, O2 Admin, C-Collar Standing, C-Collar Supine, Dressing and Bandaging, Radio, BVM, EKG Setup, IV setup.

Must make arrangements with another student on a different shift to swap places. This is only if the preceptor is assigned two or more students. If the preceptor to which the student is transferring has only one student, the preceptor may accept a second at their discretion.

O nce a student changes shifts / preceptors, they need to be evaluated and checked off by the new preceptor to assure accountability and continuity of training.

Shadows/students will follow all orders of their preceptor and / or any firefighter on the scene. Shadows/students will not go on a call unless they are with one of the recognized preceptors, chief, deputy

chief, Lieutenants or OIC (Officer In Charge). Any shadow/student not following the expressed instructions of their preceptor, or any officer or incident

commander of the fire department, will have their privilege of going on calls revoked. No shadow/student shall be allowed to participate in any fire attack activities, extrication, or any removal

of people from wrecked vehicles. No shadow/student will enter the interior of a wrecked vehicle for any reason. No shadow {observer only} shall be allowed to participate in the treatment of any patient. Students of the Bartow High School Emergency Medical Responder program may be allowed to participate in

patient care provided the student is wearing proper personal protective equipment. Other qualified individuals with an approved level of training may be allowed to participate in patient care,

provided they are wearing proper personal protective equipment, at the discretion of the fire chief. Shadows/students may, at the discretion of the training officer, be allowed to participate in training activities

not involving live fire, live smoke, or other dangers. At a fire scene or vehicle crash scene, the shadow/student should remain in the response apparatus until

cleared to approach the scene. The shadow/student should then be assigned to observe the IC or the accountability officer, or work with their preceptor.

This is a place of business and business conduct is expected. There will be no sleeping while on duty Any student / shadow found sleeping during their ride time will be referred to BHS staff rep for discipline Students / shadows will participate in all non-hazardous station duties and functions that take place Students / shadows will not be allowed to answer the telephones or the front door of the fire station All students coming to the station for skills practice will be required to be in uniform and to be wearing their ID

tag Students not in the ride along program will not be allowed in the station unless pre-approved by the officer in

charge of the shift Any student in station for practice, who is not riding on that date, will be required to leave the station if all

firefighters have to leave for a call. Students ride hours will be from 14:30 - 20:00 on weekdays and 08:00 – 20:00 on Sunday. Students are not

allowed to ride on Saturdays. Students will not be allowed to ride on school holidays unless approved by the Chief or Training DC. Students may ride on teacher workdays from 08:00 – 20:00.

Preceptors:

Preceptors need to read and understand all aspects of this SOP. Preceptor will re-check any vitals or treatment performed by a student. This is for monitoring of the student’s

skills. Preceptor has the right to tell a shadow/student they cannot go to a scene that may be violent. Preceptor will not allow a shadow/student to “ride in” with the ambulance Preceptor will be responsible for scheduling time with the shadow/student. Only when the assigned preceptor

clears it, can a shadow/student ride with a different preceptor. No shadow/student shall be assigned to any staff function at any scene. They may assist and observe only with

these functions.

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Any preceptor that allows a student / shadow to sleep will be subject to departmental discipline and removal from the preceptor list

Any preceptor that allows a student into any hazardous situation as described above will be removed from the preceptor list.

Lieutenants:

Lieutenants need to read and understand all aspects of this SOP. The on duty lieutenant or officer in charge has the right and responsibility to tell any shadow/student they can

not go to any scene which may be violent. The on duty lieutenant or officer in charge will need to document the shadow/student’s time in and their time

out in the daily log. It is very important that these times be documented accurately. Lieutenants will not be allowed to be preceptors OIC qualified personnel are not allowed to have a student / shadow while they are functioning as the shift

officer.

Student__________________________________________________

Parent___________________________________________________

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Hold Harmless Agreement

For the Auburndale Fire Department

I ______________________________, the parent of ___________________________ realize that normally only employees of the City of Auburndale are allowed to ride on Auburndale Fire Department vehicles. Therefore, in consideration of the above named student being allowed to ride on the vehicles owned and operated by the City of Auburndale, I do hereby release the School Board of Polk County, Florida, the City of Auburndale, Florida, the Auburndale Fire Department and the operators of these vehicle from any and all damages, claims and causes of action what-so-ever that may occur while I am riding with the Auburndale Fire Department.

This release is effective against my heirs, executors, administrators, and assigns and precludes anyone from recovering either against the School Board of Polk County, Florida, the City of Auburndale, Florida, the Auburndale Fire Department or operators of such vehicles for events occurring while I am riding in the vehicle or accompanying City employees in connection with the operation of the Auburndale Fire Department.

I understand that by not signing this agreement, my child would not be allowed to ride the above described vehicle but would still be allowed to participate in the classroom instruction for the First Responder program.

Dated this ______ day of _________________, 20_____.

Notary:

____________________________ ______________________________ Student/Observer

____________________________ ______________________________ Commission Expires Student/Observer Signature

_____________________________Parent/Guardian

____________________________Parent/Guardian Signature

Item # 12

Form No. TRNS 0082 Appendix A

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THE SCHOOL BOARD OF POLK COUNTY, FLORIDA BLANKET FIELD TRIP PERMISSION FORM

TO WHOM IT MAY CONCERN:

_____ _____________________________ has my permission to participate in all Name of student

field trips to be taken by __Bartow Senior Medical & Fire Academy/ HOSA/FPSA____ Name of organization/group during the __2017 - 2018__ school year. As parent/guardian I acknowledge the following:

1.School officials are authorized to obtain emergency medical treatment for this student as necessary.

2.The School Board has made available to this student the opportunity to purchase student accident insurance.

3.During this field trip, that the School Board will not be liable for injury to this student as result of the negligence, errors, and omissions of others (i.e., charter bus owners and drivers, or amusement park owners or workers), their agents, heirs, employees or assigns either through their action or inaction.

4.If your child takes personal belongings on this field trip, he or she will be responsible for them. The School Board accepts no responsibility for personal items, such as watches, purses, money, cameras, and wallets, etc. If a student stores personal items in a locker at an amusement park, that entity may be responsible for any loss or damage.

______________________________________ _________________ Signature of parent/guardian Date NOTES:

1. THIS BLANKET FORM MAY BE USED FOR TRIPS OF A SIMILAR NATURE, WHICH ARE REPEATED DURING THE SCHOOL YEAR.

2. FOR ALL OUT-OF-COUNTY TRIPS, A NOTARIZED MEDICAL TREATMENT AUTHORIZATION FORM MUST ALSO BE AVAILABLE. THE MEDICAL FORM MUST BE COMPLETED PRIOR TO THE STUDENT'S FIRST OUT-OF-COUNTY TRIP AND SHOULD BE RETAINED FOR USE DURING THE REMAINDER OF THE SCHOOL YEAR.

All students must provide transportation to and from all functions. Students are required to stay for the entire function and are not permitted to leave unless the instructor in charge of the function has been notified and the parent has given permission for the student to leave. Please sign below if you will allow your student to drive to and from all functions and leave only when the function is over.

_____________________________________________ Parent Signature

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Item # 13 Form No. TRNS 00797 Appendix D

THE SCHOOL BOARD OF POLK COUNTY, FLORIDA

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MEDICAL TREATMENT AUTHORIZATION FORM

TO WHOM IT MAY CONCERN:

I the undersigned parent/guardian of ________________________________________ hereby authorize any necessary medical treatment for this student while participating in field trips conducted under the sponsorship of Bartow Medical & Fire Academy ALL HOSA/FPSA Events_ during the 2017-2018_school year and guarantee payment of all charges incurred as a result of this medical treatment.

INFORMATION: Please Print

ALLERGIES TO FOOD, MEDICATION, ETC. (If none, so state.) _______________________

SPECIAL MEDICAL CONDITIONS (If none, so state.)________________________________FAMILY PHYSICIAN __________________________________________________________OFFICE ADDRESS ______________________________PHONE NO____________________PARENT/GUARDIAN NAME____________________________________________________PARENT/GUARDIAN HOME ADDRESS__________________________________________

HOME PHONE___________________________WORK PHONE________________________

______________________________ _______________________________________________Insurance Company Policy No. or Group No.______________________________________________________________________________PARENT/GUARDIAN SIGNATURE DATE

STATE OF FLORIDA, COUNTY OF ______________________________

I hereby certify that the foregoing was executed before me this ____________ day of_________,

by________________________________________, who is personally known to me or who has produced _______________________as identification and who did (did not) take an oath.

____________________________________

Notary Public, State of Florida

THIS FORM IS TO BE USED FOR ALL OUT-OF-COUNTY FIELD TRIPS EXCEPT ATHLETIC ACTIVITIES. THE FORM SHOULD BE COMPLETED PRIOR TO THE STUDENT’S FIRST OUT-OF-COUNTY TRIP AND RETAINED ON FILE FOR THE REMAINDER OF THE SCHOOL YEAR.English Version 8/00

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Item # 14 Student Name: _________________________________________

Throughout the remainder of this syllabus: Print your initials on the blank lines to the left to acknowledge that you have read, reviewed, comprehend, and agree to be bound by the statements on the right.

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Classroom/Clinical/Skills/High Fidelity Simulation Labs SOP

2-0.1 ______ Uniforms identify you as an EMR-Intern and are to be worn while attending all program functions; unless you are otherwise informed. The uniform policy will be strictly enforced. Failure to adhere to the uniform policy will result in a reprimand, which is the first in a series of steps to dismiss said student from class. Nothing will excuse a student from adhering to this policy.

2-0.2 ______ all students are expected to be well groomed and clean. Hair must be kept above the collar. In addition, uniforms must be kept neat and free of wrinkles while shoes should be polished as needed.

2-0.3 ______ the use of jewelry is limited to one (1) ring per hand, only. Students are not to wear any kind of jewelry above the collar during clinical rotations, regardless of gender and/or clinical site.

2-0.4 ______ there are no hats of any kind, which may be worn.

2-0.5 ______ the outermost layer of clothing worn by all students must identify them as EMR Program participants. Thus, regardless of whether students decide to wear the EMR-Intern polo, EMR Program t-shirt, or an EMR Program sweatshirt, any additional layers of clothing must be worn under the EMR Program attire.

2-0.6 ______ most uniform components are available for purchase at any other medical uniform retailer. However, uniform shirts must be purchased from the program classroom.

2-0.7 ______ Students may NOT use any non-prescribed eyewear (i.e. sunglasses) or hats of any kind while class is in session or while participating in the skills and/or simulation labs.

2-0.8 _______ Due to the potential for injury, all types of open style footwear are prohibited in all areas of the EMS building. This includes “flip-flops”, “crocs”, and all other similar style shoes. Anyone found to be in violation of this code will be asked to leave and return once proper footwear is being worn. Any time missed from class will be counted as outlined in the Course Attendance Policy.

Uniform Components

2-0.9 ______ appropriately sized Black waist belt.

2-0.10 ______ Black shoes devoid of any logos and/or any other coloring with matching black socks.

2-0.11 ______ Navy blue pants (standard as set by Polk County Fire/Rescue EMS)

2-0.12 ______ EMT-Intern polo style shirt purchased from the vendor listed above or an EMS Program t-shirt.

2-0.13 ______ Stethoscope.

2-0.14 ______ working watch. If using a traditional style watch then it must be equipped with a sweeping second hand; if using a digital watch, then it must include a display for seconds.

2-0.15 ______ EMS Program Sweatshirts if necessary (review rule 2-0.5 to determine if you will need this component)

Skills and High Fidelity Simulation Labs

Procedures and Conduct Guidelines

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2-1.0 _____ generally, the EMR Skills and High Fidelity Simulations labs are open every class period and from 0630 till 1500 every day. In the event that the BHS campus is closed due to school wide closure the program will do make up time on designated make up days.

2-1.1 _____ since the schedule listed above is subject to change, students bear responsibility to verify with an EMR Program Director whether there has been any change during the current semester.

2-1.2 _____ the purpose of the EMR Program’s Skills and High Fidelity Simulation Labs is to provide ALL course participants with a place to practice the skills necessary to complete the course objectives in order to develop competency in skill performance. ALL course participants are encouraged to visit the lab facilities prior to testing in order to practice sufficiently. EMR Program instructor/preceptors are always present to assist you with any particular skill.

2-1.3 _____ Students must attend the Skills and High Fidelity Simulation labs during regular scheduled classroom time to complete several practical skills and scenarios. Failure to do so will result in a failing grade being issued for and student will not be eligible to receive a certificate of completion until he or she completes the skills and practical exams the amount of time required to complete these various tasks will vary amongst all students. Thus, the student bears all responsibility for ensuring that all course deadlines are met.

2-1.4 _____ frequently students will have to perform skills in the presence of other students. It is expected that all students maintain a professional attitude and be courteous to the student testing.

2-1.5 _____ the consumption and/or possession of any alcoholic beverage and/or controlled substances, is strictly prohibited, not only on every campus, but at all clinical rotation locations as well. In addition, students must NOT be under the influence of alcohol or other controlled substances at any time during which they are representing the EMR Program. This includes on and off campus locations. Violation of this rule will result in disciplinary action up to and including immediate dismissal from the program.

2-1.6 _____ the use of electronic devices such as pagers, cell phones, and laptops; is strictly prohibited within the EMR Skills and High Fidelity Simulation labs. Furthermore, any electronic device in your possession while inside either the lab; must be turned off and kept out of sight. In the event, that a student or group of students desires to use such devices for a study session they are instructed to speak with an instructor so that if another area is available for use, the students can be granted access.

2-1.7 _____ Failure to comply with the electronic device policy will result in the following:

1st infraction will result in a one-point (1) drop on the grading rubric used for EMR.

2nd infraction will result in a five-point (5) drop in grade on the grading rubric used for EMR.

3rd infraction will result in dismissal from EMR.

*An infraction is described as; any time the device is visible to a staff member in plain sight.

2-1.8 _____ every student will receive an EMR Skills Check-off form as part of the course syllabus. This form not only outlines every skill which students are expected to develop proficiency on, but will also serves as a record of said development. Therefore, all students are advised to have this form in their possession every time they visit either of the labs. This form documents the dates of completion and the instructor initials every time a student demonstrates competency with the skill at hand.

2-1.9 _____ Instructors working in the labs when a student successfully demonstrates competency on any skill will date and initial the individual skill sheet and the skills check-off form. However, the student is responsible for

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ensuring that they have not only brought the appropriate paperwork to the lab, but that an instructor has signed and dated the forms as well. Failure to follow this procedure could result in a student having to repeat all the work done up to that point.

2-1.10 _____ upon entering the skills lab, all students are expected to sign-in on the EMR Lab Attendance book located just left of the entryway. In addition, to entering their own name, students must obtain and record another student’s vital signs on to this book as well.

2-1.11 _____ during the course of a semester, students may “test” on any given skill as many times as necessary to demonstrate competency. However, students will be limited to no more than two (2) testing attempts on any one skill during the same lab date on the same skill, which they have failed. In addition, students may not re-test on any skill, which was successfully completed during the same day.

2-1.12 _____ In order to record competency on all practical skills, the EMR Skills Check-off form is composed of four (4) columns; the first column identifies each particular skill while the remaining columns must be dated and initialed by either an EMR Program Instructor or an approved EMR Program Preceptor on three (3) separate occasions as outlined below:

2-1.12a _____ First or initial check-off is completed in the skills lab prior to any clinical attendance.

2-1.12b _____ Second check-off; completed during the first three (3) field clinical in a mostly discussion type scenario between the student and their assigned preceptor.

2-1.12c _____ Third or final check-off; completed once the student performs a skill on a “live” patient during clinical rotations. *Since the opportunity to perform some skills on a “live” patient may not be available, students may visit the skills lab and request to be checked-off for the third column using during a simulated scenario.

2-1.13 _____ any act of dishonesty, including but not limited to forgery, alteration, or misuse of any college document, record or instrument of identification will result in dismissal from the Emergency Medical Responder program. In addition, infractions of this rule; may, at the discretion of the EMR program director, result in a permanent ban from participation in any future Bartow Medical and Fire Academy programs course.

Clinical Rotation Standard Operating Policies and Procedures

Clinical Uniform Policy

2-2.0 ______ Uniforms not only identify you to the patient as an EMR-Intern, but to anyone else you may meet, as well. Additionally, the uniform presents a more professional appearance while assisting in the prevention of cross contamination by separating everyday clothes from “work” clothes.

2-2.1 ______ Uniforms are to be worn while attending all program functions; unless you are otherwise informed. The uniform policy will be strictly enforced. Failure to adhere to the uniform policy may result in your dismissal from the assigned clinical area, which will result in a reprimand and the time not counting to toward course completion. Nothing will excuse a student from adhering to this policy during clinical rotations.



2-2.4 ______ any, and ALL tattoos must be kept covered, thus out of sight, during all hospital clinical rotations.

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2-2.5 ______ there are no hats of any kind, which may be worn during any clinical; regardless of location.

2-2.6 ______ the outermost layer of clothing worn by all students must identify them as EMR Program participants. Thus, regardless of whether students decide to wear the EMR-Intern polo, EMR Program t-shirt, or an EMR Program sweatshirt, any additional layers of clothing must be worn under the EMR Program attire.

2-2.7 ______ most uniform components are available for purchase at any other medical uniform retailer. However, uniform shirts must be purchased from the Instructor in the classroom:



2-2.10 ______ Navy blue pants (standard as set by Fire/Rescue EMS)

2-2.11 ______ EMR-Intern polo style shirt purchased from the vendor listed above. DO NOT WEAR THE EMR PROGRAM T-SHIRT TO CLINICAL SITES unless it is being used as an undershirt to the EMR-Intern polo style shirt.

2-2.12 ______ one set of bandage scissors, also known as trauma shears.



2-2.14 ______ Eye Protection, which must be worn anytime you are treating a patient.

2-2.15 ______ Gloves, which must be worn during all patient contact (this item is provided to you).

2-2.16 ______ EMR Program Sweatshirts if necessary


Field Clinical Policy

2-3.0 ______ the field clinical preceptor is not obligated to allow student riders on their assigned apparatus. The ability for students to ride is made possible by an interest the preceptor has in providing clinical experience to the student. Thus, the EMR preceptor may terminate this relationship at any time, with or without cause.

2-3.1 ______ Fire Rescue /EMS and their employees are under no obligation to provide clinical experience for students. If a student is deemed "unsafe”, said student will be removed from the program. Unsafe is defined as: A student not taking proper safety precautions that might endanger themselves or others.

2-3.2 ______ upon completing all clinical prerequisites, students will be assigned to a field clinical preceptor who they will complete their first three (3) days of field clinical rotations with. During this time, the students are expected to complete the second or middle column of the EMR Skills Check-off form.

2-3.2a ______ In the event that a student is unable to complete the second or middle column of the EMR Skills Check-off form during the initial internship (first three (3) field clinical rotations), said student will be required to return to their assigned preceptor and complete this section of the form. Any time earned during this period will not be credited towards the amount necessary for course completion.

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2-3.3 ______ Once a student has completed their initial internship as well as the middle column on the EMR Skills Check-off form, he or she may ask the instructor for access to the “ride book” in order to schedule additional clinical.

2-3.4 ______ all field clinical ride times must be scheduled in advance; students must visit the instructor, during class hours only, to schedule and/or change clinical dates and/or times.

*Any change to clinical schedule that is initiated by the student, must be done in person. The instructor will NOT make any changes on your behalf if your request is received via phone calls, text messaging, email, or any other means of communication (except when leaving early or arriving late).

2-3.5 ______ Field clinical rotations are scheduled on what we refer to as the “ride book”. The “ride book” is composed of an upcoming period of approximately three (3) weeks. All clinical time is available on a “first come, first served” basis. Once a student has signed up for a particular location and date, no other student may sign up for that same date and location.

2-3.6 ______ Field clinical must be a minimum of a six (3) hour period anytime between 0700 and 2100 hours (BFD) or 1500 and 2000 hours (AFD).

*Any field clinical that is less than six (6) hours will result in the student receiving a reprimand and the time will not be credited towards course completion.

2-3.7 ______ Clinical rotations will not extend past 2100 hours (BFD) and 2000 hours (AFD). However, at the preceptor’s discretion, a student participating in a clinical, which is taking place, at the station may stay as late as 2200 hours.

*The above restriction is not applicable if the unit on which the student is “riding” is not at the station at the time listed. However, once said unit returns to the station students must expeditiously complete their paperwork and leave the station.

2-3.8 ______ as a general courtesy, students are asked to contact preceptors by calling their duty station prior to the scheduled shift and the day of the ride time.

2-3.9 ______ Students are expected to be on time to every field clinical that they schedule. However, in the event that something precludes a student from arriving on time or attending at all, the student MUST contact instructor and preceptor prior to the start of the scheduled clinical. In addition, if a student needs to leave the clinical prior to their scheduled departure time MUST be contacted as well.

2-3.10 ______ every student must be evaluated by a minimum of three (3) field clinical preceptors.

2-3.11 ______ EMR Program students are to complete field clinical with Fire Rescue/EMS approved preceptors only. Failure to do so will result a group 2 offense reprimand and the time spent will not be credited towards course completion.

2-3.12 ______ Students who complete a field clinical on a day, which they did not previously schedule, will forfeit any time spent at that clinical location on that date.

2-3.13 ______ Students are not to operate any vehicle at any time or under any circumstance while attending a clinical rotation. *This includes any vehicle regardless of whether it is an official apparatus or a privately owned vehicle.

2-3.14 ______ Food and/or beverages are prohibited within the fire apparatus or ambulance.

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2-3.15 ______ In the event that an EMR program intern is injured during a clinical, the incident and/or injury MUST be reported to a Preceptor, Dept. Administration and Instructor promptly.

2-3.16 ______ Pursuant to Chapter 64E-2.036(1a) Florida Administration Code No student shall be subject to call while participating in class, clinical or field sessions.

2-3.17 ______ Pursuant to Chapter 64E-2.036(1b) Florida Administration Code EMR interns MUST function under the direct supervision of an EMR Program/Department approved preceptor. Therefore, EMR Programs’ interns will NOT be alone during patient care and/or transport and shall not be used to meet an agency’s staffing requirements.

2-3.18 ______ Students are hereby asked to contact Instructor anytime they need an answer, which pertains to the lab and/or clinical rotations. *Failure to follow this advice could result in a reprimand.


Special Detail Policy

2-4.0 ______ Special Details are the result of a carefully orchestrated effort by several people. Despite this fact the number of days available to complete these is very limited. As a result, with regards to special details, the attendance policy in place is strictly adhered to and listed below:

2-4.1 ______ Special Detail dates will not have less than five (5) students scheduled.

2-4.2 ______ once a student has committed to attending on a particular date, they are not to make any changes unless another student is willing to “swap” days. If there is another student willing to do the exchange, a Swap Agreement Form must be completed and turned into the EMR Program Instructor.

2-4.3 ______ Students are expected to arrive on time; on their scheduled special detail day. Failure to arrive on time or failure to attend the detail altogether will result in the student being assigned to a “make-up” special detail work date and a group 2 offense reprimand will be issued. This will consist of working in the main storage room, detailing the ambulance and fire apparatus and also working in the classroom/labs area to make up the time.

2.4.4 ______ A second episode of tardiness or absence will result in an administratively withdrawal from EMR. Thus, said student would have to repeat EMR, during its next available offering.

Policy on Injury or Illness Incurred During Clinical

2-6.0 ______ it is the intention of the EMR Programs to provide a safe lab and clinical environment to all program participants and visitors. However, due to the nature of the profession it is impossible for The Bartow Medical and Fire Academy or any of its staff to accept any financial liability concerning a student’s accident, injury, illness, and/or death, which is the result of clinical activities. Students are, hereby advised that during the clinical experience they (the students) may be exposed to situations, which could result in an accident, injury, illness, and/or death to the student. Thus, it is imperative that all students comply with any commands given by the preceptor immediately. Furthermore, students must follow all safety procedures instituted by the EMR program, its staff, or any of its educational partners. Lastly, students are, hereby advised that it is the student who bears all financial responsibility for treatment of any accident, injury, illness, and/or death, which occurs while the student is engaged in The Bartow Medical and Fire Academy EMR Program sanctioned activity. This includes but is not limited to needle stick injuries and disease exposure.

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Clinical Misconduct Policy

2-7.0 ______ The Bartow Medical and Fire Academies’ partnership with local agencies depends a mutual understanding of each other’s roles. However, both parties reserve the right to discontinue this partnership at any time. As a result, anytime staff from either party feels that a particular student’s actions, attitude, and/or ability as an EMR Intern may, in any way, compromise patient care and/or the safety of the team; said student shall be immediately dismissed from the clinical site.

2-7.1 ______ any student asked to leave a clinical site, and does not agree with such action may follow established grievance procedures as outlined in the most current Student Handbook. However, students who opt to begin the grievance process may not return to any clinical site and/or any EMR Program detail until the matter has been resolved. In addition, there will be no credit awarded during that period.

2-7.2 ______ lastly, the following individuals may ask a student to leave a clinical site and/or classroom, if they deem it to be necessary:

EMR Program Medical Director - Dr. Joe Nelson

EMR Program Director – Kozette Hubbard

EMR Program Preceptors – Bartow Fire Dept. Auburndale Fire Dept.

EMR Program Class and Lab Instructors

Student Counseling Documentation Policy

2-8.0 ______ Student Counseling Report: Also known as a reprimand and informational report, this form is to be used as a means to document any violations of policy as well as any tardiness and/or absenteeism. The form is composed of two (2) groups which are separated by the penalty which will be applied:

2-8.1 ______ Group one (1) infractions are serious offenses, which come along with the potential for adverse criminal consequences. Any group one (1) infraction will result in an immediate removal from the clinical site and/or campus; followed by dismissal from the Emergency Medical Responder course. *Subsequently, re-admission to the EMR Program may not be an option.

2-8.2 ______ Group two (2) infractions most often relate to procedural infractions and follow a three (3) “strike” rule as follows:

First infraction = Verbal reprimand detention given to be served with academy instructor

Second infraction = Written reprimand detention given to be served with academy instructor

Third infraction = Referral given and possible dismissal from Emergency Medical program course.

2-8.3 ______ Group 2 offenses signify a reprimand in steps for dismissal. You in fact may receive 1, 2 or all-3 reprimands at one time depending upon the infraction/s disclosed.

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Clinical Documentation Policy

2-9.0 ______ Clinical Evaluation Form (Includes Field, Special Detail): This form documents clinical attendance at the various clinical internship sites in use by the EMR Program. The form is to be completed, and signed, by the clinical preceptor or instructor upon conclusion of each and every clinical. The preceptor will evaluate student performance throughout the clinical and document his or her observations accordingly on this form.

2-9.0a ______ Value System: The Clinical Evaluation Form allows preceptors to rate student performance based upon several categories. Each of these categories rates whether student performance was “Satisfactory”, “Unsatisfactory”, or “Remedial”. The instructor will then input the information from the Clinical Evaluation Form unto a computer database which assigns a numerical value to each rating as follows: Satisfactory +1, Unsatisfactory (-1), and Remedial (-2). This numerical value is collected following every clinical and averaged over the course of all clinical. Subsequently, this average is reported on both the EMR Clinical Progress Report and the EMT Terminal Clinical Evaluation Report. If this value is a negative integer; the student will have continue attending clinical until a value above zero is achieved. In the event that the deadline to complete clinical has passed, an incomplete grade will be issued and the student will be afforded an additional two (2) weeks to schedule additional field clinical in an attempt to earn a value above zero on the Terminal Clinical Evaluation Report. Failure to achieve this benchmark will result in a failing grade in EMR.

2-9.0b ______ Remedial Training: Any student who receives a REMEDIAL mark on any clinical evaluation form will be required to discontinue clinical rotations and meet with instructor. During this meeting, the instructor will make a decision as to when said student may continue clinical rotations. Typically, the issue is often resolved at this point. However, on occasion the student is asked to come back into the skills lab in order to be re-trained in those area(s) marked as remedial on the evaluation prior to continuing with clinical.

2-9.1 ______ Preceptor Evaluation Form: Completed by the student upon completion of the clinical. Students are to evaluate and rate their experience with the preceptor with whom they completed the clinical on that day (you will remain anonymous).

2-9.2 ______ Patient Care Report: PCRs or run reports are required anytime students encounter any type of patient contact. Regardless of the number of patient contacts completed previously. This rule is pursuant to State of Florida Administrative Code 64J-1.014.

2-9.3 ______ Clinical Swap Agreement Form: Used when two (2) students agree to swap their scheduled hospital clinical days. Both parties must sign the form in the presence of the instructor who will also sign it.

2-9.4 ______ Field Clinical Sign-in Form: The purpose of this form is to provide students a means to have a backup record, which documents the student’s clinical attendance. This form is not required; however, in the event that other documentation means is lost this form will serve proof of your total hours and patient contacts. Lastly, in order for this form to be valid it must have the signature of every preceptor with whom the student has completed clinical. *Responsibility to provide documentation of attendance, which fulfills the required clinical time, lies solely with the student.

2-9.5 ______ all paperwork relating to clinical completion MUST be turned into the instructor within 5 days of the date of said clinical. If you are having issues with fulfilling this requirement, contact instructor prior to the 5th day.

2-9.6 ______ Students are not to remove any confidential paperwork from their clinical locations.

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EMR Lab/Clinical Grading Policy

2-10.0 ______ Letter grades for EMR are determined by using a rubric composed of a point system which is dependent on several course completion benchmarks and their respective deadlines for completion. Students will earn five (5), three (3), zero (0), or up to negative six (-6) points in six (6) categories depending on when the tasks are completed. The six (6) categories are as follows: • Completion of the 1st column on the EMR Skills Check-off form and ALL clinical prerequisite paperwork (i.e. physical exam, immunizations, drug screen, background check, HIPAA) • Completion of the 2nd column on the EMR Skills Check-off form with clinical preceptor • Completion of the Special Detail clinical • Completion of the EMR Skills Check-off Form in its entirety • Completion of all field clinical time requirements . T.E.A.M. Day Attendance

2-10.1 ______ Grading Scale:

Total Points Earned Associated Letter Grade 25 – 21 A 20 – 14 B 13 – 0 C Below ZERO F (In other words, the cumulative total number of Points earned upon completion of course equals a Negative number)

T.E.A.M. Day

(Teaching EMS with Actual Methods) field day

2-11.0 ______ T.E.A.M. Day consists of various scenario type exercises resembling “real life” EMS events in which all EMR students MUST participate. Students will interact with each other, as well as, preceptors and instructors to apply and re-enforce their training. All student participants’ performance is evaluated as individual groups according to their respective training level during the several mock scenarios, which take place throughout day. Failure to attend T.E.A.M. Day will result in an “O” being recorded with no makeup.

2-11.1 ______ T.E.A.M. day attendance is mandatory for all EMR Program students; NO students should arrive any later than 0900 hours. However, understanding that occasionally actual real life events may disrupt plans; the following policy will be stringently adhered to during T.E.A.M. day:

2-11.1a ______ any student who arrives after 0900, but before the first scenario’s teams are announced; is subject to negative three (-3) points being included in their EMR grade rubric.

2-11.1b ______ any student who arrives after 0900, but before the second scenario’s teams are announced; is subject to negative five (-5) points being included in their EMR grade rubric.

2-11.1c ______ any student who arrives after the teams for scenario two (2) are announced; is subject to dismissal from EMR.

EMR LABCompletion Requirements

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Field Clinical Rotation Requirement3-1.0 ______ Complete a minimum of eighty (50) hours of field clinical rotations/Special Detail Events. However, of those fifty hours, a minimum of sixty (40) must be completed while on board a Fire Rescue/EMS vehicle and a minimum of ten (10) hours must be completed a Special Detail Event .

Special Detail Clinical Requirements

3-1.1 ______ Complete a minimum of ten (10) hours of special detail rotations which are scheduled over several day at several events. Each day is composed of four hour (4) hour shifts.

Practical Skill Lab Requirement

3-1.3 ______ all practical skills will be reviewed and/or performed on a minimum of three separate dates which are documented with an approved EMR instructor/preceptor on the Skills Check-Off form by

Emergency Medical Responder

Completion Requirements to be able to sit for National Registry Cerytification

3-2.0 ______ Obtain, maintain, and/or possess the Basic Life Support for Healthcare Provider certification, or a State of Florida approved equivalent, according to the standards set forth by the American Safety and Health Association.

3-2.1 ______ Complete a minimum of four (4) hours training on HIV / AIDS awareness and safety pursuant to: FS 401.2701(1) (a) 5c

3-2.2 ______ complete training on Sudden Infant Death Syndrome (SIDS) as pursuant to: FS 383.3362(1) & (3)

3-2.3 ______ Complete a minimum of two (2) hours training on State of Florida Trauma Score Methodologies as pursuant to: FS 401.2701(1) (a) 5b

3-2.4 ______ Completion of all Ride and Special Detail Hours.

3-2.5 ______ Completion of Capstone Project to be presented Senior Year.

3-2.6 ______ Completion of Mentor Hours.

3-2.7 ______ Attend and participate during T.E.A.M. day as outlined on the EMR Course Syllabus.

3-2.8 ______ Achieve a minimum of an eighty percent (70%) average on the overall class grade.

Classroom Uniform Policy

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1-0.1______ Uniforms identify you as an EMR-Intern and are to be worn while attending all program functions; unless you are otherwise informed. The uniform policy will be strictly enforced. Failure to adhere to the uniform policy will result in a reprimand, which is the first in a series of steps to dismiss said student from class. Nothing will excuse a student from adhering to this policy.



1-0.4 ______ there are no hats of any kind, which may be worn.

1-0.5 ______The outermost layer of clothing worn by all students must identify them as EMR Program participants. Thus, regardless of whether students decide to wear the EMR-Intern polo, EMR Program t-shirt, or an EMR Program sweatshirt, any additional layers of clothing must be worn under the EMR Program attire.

1-0.6 ______ most uniform components are available for purchase at the EMR classroom and/or any other medical uniform retailer.

1-0.7 ______ Students may NOT use any non-prescribed eyewear (i.e. sunglasses) or hats of any kind while class is in session or while participating in the skills and/or simulation labs.

1-0.8 _______ Due to the potential for injury, all types of open style footwear are prohibited in all areas of the EMS building. This includes “flip-flops”, “crocs”, and all other similar style shoes. Anyone found to be in violation of this code will be asked to leave and return once proper footwear is being worn. Any time missed from class will be counted as outlined in the Course Attendance Policy.

Uniform Components



1-0.11 ______ Navy blue pants (standard as set by Fire/Rescue EMS)

1-0.12 ______ EMR-Intern polo style shirt purchased from the instructor listed above or an EMR Program t-shirt.



1-0.15 ______ EMR Program Sweatshirts if necessary (review rule 1-0.5 to determine if you will need this component)

Grading Scale

1-1.0 ______ Letter grades are based on the following scale.

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100% - 90% = A 90.9% - 80% = B 80.9% - 70% = C 70.9% - 60% = D (Student will be put on academic probation with 2 weeks to improve) 60.9% - 0% = F (class must be repeated)

Grade Weighting

1-2.0 ______ all course work is assigned to one of the categories listed below. In addition, the overall final grade is derived based upon the weight of each category, as listed below.

Workbook/Objectives/Exam Reviews/Uniforms: 10% Chapter Quizzes: 10% Practical Exams: 10% Final Practical Scenario: 10% HC21/Written Exams: 10% Comprehensive Final Exam: 15% Ride/Special Detail/Mentor: 15%Capstone Project: 20%

Withdrawal Policy

1-3.0 ______ any student who wishes to withdraw from this course without influencing their grade point average must follow Polk School Board policy as outlined in the student catalog. 1-3.1 ______ all students who fail to meet the minimum attendance as outlined in the Course are subject to dismissal from the academy.

Attendance Policy(BMFA Rule 1 – 4) are subject to dismissal from the Emergency Medical Responder program.

1-3.2 ______ Students must not miss more than 20% of class time. Students must also be in class the whole period. Time is counted in 1 hour increments.

Course Attendance Policy

1-4.0 ______ Students are expected to attend all class meetings. However, in the event that attending class is not possible; the responsibility to obtain any information and/or assignments, which were missed, lies solely with the student.

1-4.1 ______ Attendance is checked at the start of each of class. Any student not physically present in the classroom at that time will be marked as being absent unless they ensure the instructor is aware that they arrived late and has corrected the attendance log.

1-4.2 ______Any time missed from class, whether caused by arriving late or leaving early, will be counted in hour-long increments only.

1-4.3 ______ any student who exceeds the maximum amount of missed time allowed will be subject to withdrawal from the program.

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1-4.4 ______ the maximum amount of hours, which students may miss from class, is not to exceed the equivalent of 20% of time in class

1-4.5 ______ In the event that Polk School Board officials have temporarily closed the campus affecting a normally scheduled class date the following policy will be adhered to:

I. Once the campus is re-opened students are expected to arrive no later than the scheduled Start time and policies affecting tardiness will be strictly adhered to. II. If the scheduled start time is rescheduled for another day classes will be scheduled during the normal breaks as a makeup day students will be notified as to when that class will be scheduled for a “make-up day”.

Policy for Making up Missed Work

1-5.0 ______ Workbooks and other take home assignments are due at the beginning of each class. Students who are late or absent will be issued a grade of ZERO (0) on the material that was due on that class date. No late work will be accepted if the students was not absent or if the absence is not excused.

1-5.1 ______ Students who arrive late may begin the quiz late, however once the last person who arrived on time completes their quiz, the late student’s quiz will be collected and graded “as is”.

1-5.2 ______ any quiz missed due to absence will receive a grade of ZERO (0). Students will make up the quiz the next class day.

1-5.3 ______ Exams not completed during their scheduled date due to student absenteeism, tardiness, or any other reasons not directly caused by Polk County School Board MUST be completed within the five (5) working days, which follow the exam’s date.

1-5.4 ______Students will have to visit the classroom after school in order to complete a different version of the exam missed. It is the student’s responsibility to familiarize themselves with the information for the exam.

1-5.5 ______ Failure to make-up an exam within five (5) working days will result in a grade of ZERO (0) on that particular exam.

Module Exams/ Comprehensive Final Exam

1-6.0 ______All students are to maintain a minimum average grade of eighty percent (80%) on ALL written and/or computer based examinations.

1-6.1 ______ all students who fail to achieve a minimum of eighty percent (80%) on any three (3) written and/or computer-based exams are subject to academic probation. GPA must maintain at 2.5 or student will be dismissed from the program.

1-6.2 ______ as part of the completion requirements, all participants must complete a comprehensive final exam on the scheduled exam date of class. Students must also be in uniform to take the exam.

1-6.3 ______ the exam is composed of questions, which may be drawn from any and/or all chapters contained within the textbook in use throughout the course. Time allotted for completion will not exceed one and one half (1.5) hours.

1-6.3a ______ the afore mentioned “time allotted” begins once the class instructor advises the class to

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Begin the exam. Any students, who arrive tardy, may begin their exam upon arrival. However, said students will not be afforded any additional time to complete their examination.

1-6.4 ______ Attendance is mandatory on the date during which the Comprehensive Final Exam is to take place. Failure to attend class on said date will result in a grade of “zero” being issued as the Comprehensive Final Exam grade.

1-6.5 ______ In order to successfully complete the course; students must meet a minimum benchmark of eighty percent (80%) on the comprehensive final exam regardless of their overall class average.

1-6.5a ______ any student who fails to meet the minimum benchmark of eight percent (80%) on the comprehensive final exam and despite that fact, maintains an overall class average grade at or above eighty percent (80%) will afforded the opportunity to re-attempt a different version of the comprehensive final exam.

1-6.5b ______ any student who benefits from the above rule (number 1-6.4a), will be required to meet the minimum of benchmark of eighty percent (80%) on the re-attempt. In addition, if said re-attempt results exceed the minimum benchmark the “official class grade book” will not reflect a grade higher than eighty percent (80%).

1-6.5c ______ The policy outlined above is a privilege intended as a means to assist those students whose class participation and course assignment completion have demonstrated a true desire to succeed in the Emergency Medical Responder program; yet for whatever reason they do not fare well on the final exam.

1-6.5d ______ as stated above, this policy is a privilege to the student. Thus, the classroom instructor And/or the program director reserve the right to discontinue the use of this privilege at any Time and for any reason, regardless of who is affected.

1-6.6 ______ Exam and quiz questions are highly scrutinized by staff prior to deployment. In the event, that a student wishes to challenge the validity of a question deployed in an exam and/or quiz: Students are allotted five (5) Academic Calendar days from the date during which the exam and/or quiz took place to provide the lead instructor with evidence, found within the course textbook, to support the allegation.

1-6.6a ______ Regardless of whether or not there is any valid evidence presented. Once the time period Outlined in 1-6.6 expires, no change to grades will be made.

Academic Dishonesty Policy

1-7.0 ______ this policy is intended to enhance Polk County School Boards academic dishonesty policy as outlined in the current student handbook. In the unlikely event that a conflict arises between the policies, the policy listed on the student handbook will supersede.

1-7.1 ______ there is no form of communication permitted amongst students while an exam, quiz, or any other type of academic assessment tool is in use. If the need to speak with an instructor should arise, students may approach the instructor unless told otherwise. However, the student must take extra care to ensure disruptions and/or distractions are, kept to a minimum.

1-7.2 ______ the following outlines the Academic Dishonesty Policy as outlined in the Polk County School Board student handbook:

Cheating and Plagiarism

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Polk County School Board considers academic dishonesty an assault upon the basic integrity and value of an education. Cheating, plagiarism, and collusion in dishonest activities are serious acts that erode the educational role and tarnish the learning experience, not only for the perpetrators but for the entire community. It is expected that all students understand and subscribe to the ideal of academic integrity and that they are willing to bear individual responsibility for their work. Materials (written or otherwise) submitted to fulfill academic requirements must represent a student’s own efforts. The fundamental purpose of this rule is to emphasize that any act of academic dishonesty attempted by any student is unacceptable and shall not be tolerated. Examples of academic dishonesty include:

1. Cheating or plagiarizing on tests, projects, or assignments: Cheating is defined as the giving or taking of any information or material with the intent of wrongfully aiding oneself or another in academic work considered in the determination of a course grade. Plagiarism is defined (Black’s Law Dictionary, Revised Fourth Edition) as “the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.” Plagiarism includes failure to use quotation marks or other conventional markings around material quoted from any specific source without citing that source, or paraphrasing a specific passage from a specific source, or using any sequence of material or order of wording without accurately quoting and citing that source. Plagiarism further includes letting another person compose or rewrite a student’s assignment.

The following items have been identified, by the faculty and students, as a partial list of examples of cheating and/or plagiarism:

a. Asking for information from another student before, during, or after a test, quiz, or exam situation. b. Copying answers from another’s paper during a test, quiz, or exam situation. c. Knowingly letting someone copy from one’s paper during a test, quiz, or exam situation. d. Using sources other than what is permitted by the instructor in a test, quiz, or exam situation. e. Copying material exactly, essentially, or in part from outside sources while omitting appropriate documentation. f. Copying or falsifying a laboratory report, clinical project, or assignment without doing the required work. g. Changing answers on a returned graded test, quiz, or exam in order to get the grade revised.

2. Plagiarism in written assignments: Plagiarism also includes handing in a paper to an instructor that was purchased from a term paper service, created by another student or other individual, or downloaded from the Internet and/or presenting another person’s academic work as one’s own. Individual academic Departments may provide additional examples in writing of what does and does not constitute plagiarism, provided that such examples do not conflict with the intent of this policy.

3. Furnishing false information to any faculty member.

4. Forgery, alteration, or misuse of any document, record, or instrument of identification.

Violations of the s policies pertaining to academic dishonesty may result in academic penalties and/or disciplinary action at the discretion of the professor. Academic penalties may include, but are not limited to, a failing grade for a particular assignment or a failing grade for a particular course. Students charged with violating the Academic Dishonesty portion of this rule are not permitted to withdraw from the course. Additionally, a student in violation of the Student Code of Conduct may be referred to the Dean of Student Services at the campus or center where the offense took place. Any student suspected of violating the Academic Dishonesty section of the Student Code of Conduct is subject to sanctions and provided due process as outlined in the Academic Dishonesty procedure.

1-7.3 ______ any student suspected of cheating will be subject to disciplinary action, which at minimum will result in said person receiving a grade of ZERO on the assignment underway when the alleged incident took place. In

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addition, the student will receive a written counseling form and a referral to speak with the EMR Program Director who will decide if the student will be subject to dismissal from the Emergency Medical Responder Program.

Classroom Code of Conduct

1-8.0 ______ the responsibility to provide any materials, including text and workbooks, which are required as part of the course curriculum lies solely with the student.

1-8.1 ______ Classroom atmosphere and/or student behavior are determined according to the course instructor’s discretion. In the event that a course instructor determines a student’s conduct is inappropriate; said student will be asked to leave the classroom at once. In addition, the student will have to meet with the EMR Program Director prior to returning to class.

1-8.2 ______ any injury incurred while taking part in a related function must be reported to a Bartow Medical and Fire Academy representative promptly.

1-8.3 ______ Students are not to enter any office area unless there is a staff member present and prior authorization to enter said office has been granted.

1-8.4 ______ Smoking is NOT allowed within any of campus buildings or campus.

1-8.5 ______ the use of the phone system is strictly limited to business related staff use only.

1-8.6 ______ the use of electronic devices such as pagers, cell phones, and laptops is strictly prohibited while classes are in session (this includes skills and simulation labs). Furthermore, any electronic device in your possession must be turned off and kept out of sight.

1-8.7 ______ Failure to comply with the electronic device policy will result in the following:

1st offense will result in a ten (10) point drop in grade on any assignments due that day.

2nd offense will result in a twenty-five (25) point drop in grade on any assignment due that day.

3rd offense will result in dismissal from the Emergency Medical Responder program.

*In the event an offense occurs while the students is participating in the skills or simulation lab the Above penalties will be enforced on the next scheduled quiz or exam.

(An offense is described as any time the device is visible to a staff member in plain sight.)

1-8.8 ______ All EMR program students are subject to disciplinary action if it is determined, they have in anyway participated in the distribution and/or disclosure of any pictures, videos, and/or any other form of communication deemed to display or disclose immoral, indecent, illegal, unethical or otherwise inappropriate material. If said disclosure relates to, and/or was acquired in conjunction to the students’ course of study while a part of EMR program. 1-8.8a ______All students are asked to respect the rights, privacy and dignity of all those with whom they interact as an EMR program student. All students should conduct themselves appropriately at all times.

1-8.8b ______ Any student/s who, at the sole discretion of the EMR Program Director, violates the above rule (number 1-8.11a), is/are subject to dismissal from the Emergency Medical Responder program.

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1-8.9 ______ the consumption and/or possession of any alcoholic beverage and/or controlled substances, whether legal or illegal, is strictly prohibited not only on every campus, but at all clinical rotation locations as well. In addition, students must NOT be under the influence of alcohol or other controlled substances at any time during which they are representing the EMR Programs. This includes on and off campus locations. Violation of this rule will result in disciplinary action up to and including immediate dismissal from the program.

1-8.10 ______ Violations of the EMR Program Code of Conduct will result in a Student Counseling Form being generated. This form is composed of two (2) groups which are separated by the penalty which will be applied:

Group one (1) offenses are serious infractions, which are associated with the potential for adverse Criminal consequences. Any group one (1) infraction will result in an immediate dismissal from the Emergency Medical Responder program. (Re-admission may not be possible)

Group two (2) offenses most often relate to procedural infractions and follow a three (3) “strike” rule as Follows:

First offense = Verbal Reprimand

Second offense = Written Reprimand

Third offense = Dismissal from the Emergency Medical Responder Program.

If a student is given detention by an instructor of the Bartow Medical and Fire Academy this detention will be served after school from 14:00 hrs. until 15:30hrs in the academy area and with the instructor who administered the detention. Student’s will be assigned a variety of duties up to and including, washing and waxing the academy vehicles, working in the academy supply room, cleaning the classrooms and lab areas, cleaning equipment and supplies, grounds clean up in and around the academy area. The academy is not responsible for providing transportation to the student who receives detention. Failure to serve the detention or refusal to perform duties assigned during detention will result in a discipline referral being generated and the student being sent to the Discipline Office to be dealt with by administration. Students and Parents need to be aware this could include suspension for failing to follow directions given and constitutes insubordination.

Bartow Medical and Fire Academy

Sample Student Counseling Form

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GROUP 1() Automatic Discharge from Academy. 1. Reporting to your clinical under the influence of alcohol or an illegal substance. 2. Theft, abuse, misuse, or destruction of property. 3. Remove or disclose confidential information without proper authorization. 4. Immoral, indecent, illegal or unethical conduct. 5. Possession of a weapon, threatening to use of such on EMS, college or hospital premises. 6. Misuse or falsification of patient, student, or official EMS / hospital records. 7. Engaging in disorderly conduct that could ultimately threaten the physical well-being of any person.

GROUP 2 (A)

() 1st Offense - Verbal Reprimand () 2nd Offense - Written Reprimand() 3rd Offense - Failing Grade and Dismissal from the Program.

8. Leaving clinical area without proper authorization AND / OR not completed time for that clinical. 9. Individual acceptance of gratuities. 10. Sleeping during scheduled clinical hours. 11. Insubordination / Refusal to obey an instructor /preceptor. 12. Inconsiderate treatment of patients, visitors, students, or EMS/Hospital employee. 13. Clinical tardiness / absence.14. Failure to be ready for clinical assignment at starting time. Inappropriate dress appearance per program regulations15. Violation of safety rules and regulations OR failure to use proper safety equipment. 16. Misuse of clinical time. 17. Smoking in RESTRICTED AREASAND Time not counting toward course completion.

GROUP 2 (B)() Time not counting toward course completion. 18. Did not sign up for and / or rode with an unapproved preceptor. 19. Paper work turned in beyond “2" week deadline. 20. Middle column incomplete post first three ride dates. 21. Rode less than six hours.

INFORMATIONAL

Class Tardiness

Did not complete 1st column of BLS skills and / or turn in prerequisite paperwork by due date.

REMARKS:

_________________________________________________________

Student Signature / Date Parent Signature / Date

___________________________________________________ ____________________________________________________ Instructor / Date School Administrator / Date

1-8.11 ______ Group 2 offenses signify a reprimand in steps for dismissal. You in fact may receive 1, 2 or all 3 reprimands at one time depending upon the offenses being disclosed by the EMR Program staff.

1-8.12 ______ lastly, the following persons may ask a student to leave the classroom area at any time they deemed it to be necessary:

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EMR Program Medical Director - Dr. Joe Nelson EMR Program Director – Kozette Hubbard EMR Program Visiting Instructors and /or Clinical Instructors

Financial Aid

1-9.0 ______The Bartow Medical and Fire Academy’s objective is to assist students who would otherwise be unable to attend the medical or fire program. Any student who may wonder if there is any such assistance available to them is encouraged to visit the class instructor for more detailed information.

Student Critical Incident Stress Debriefing (CISD) Assistance

1-10.0 ______EMR program staff is committed to providing a safe learning environment to all of its program participants. However, due to the nature of the line of work associated with the pre-hospital medical field, there are times when the tasks may become perilous to the stability of one’s emotional state. In keeping with our commitment to safety, students who feel they need to be debriefed following a critical incident are encouraged to contact a Program Instructor.

1-10.1 ______ Students who request this service will be treated no different from a practicing Fire Rescue/EMS crewmember. Thus, either a program employee or any Fire Rescue/EMS staff CISD personnel may debrief said student. Even though some incidents may not require a formal debriefing, anyone who feels uncomfortable or is having difficulty dealing with a particular response or tragic situation is encouraged to speak with their instructor, preceptor, or use the debriefing services that is available to them.

Program Evaluation

1-11.0 ______ periodically, you may be asked to complete an anonymous evaluation of your learning experiences within the EMR Program. Your constructive criticism is welcomed and combined with other measures of success in order to assure the continuous improvement of the EMS programs. Typically, the survey will be completed using Survey monkey.

Classroom/Clinical/Skills/High Fidelity Simulation Labs SOP

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I, THE UNDERSIGNED, ACKNOWLEDGE THAT THE EMR LAB/CLINICAL MANUAL WAS READ, AND EXPLAINED TO MY UNDERSTANDING. FURTHERMORE, I ALSO UNDERSTAND THAT FAILURE TO FOLLOW THE GUIDELINES LISTED THROUGHOUT THE MANUAL COULD RESULT IN DISMISSAL AND/OR A FAILING GRADE BEING ISSUED.

Student Name (please print): ________________________________________________________

Student signature: _________________________________________________________________


Date: _____________________ ____________________________________________ Notary Signature

____________________________________________ Date

Parents further understand they are to log into Parent Portal at least once a week to check your students grades and progress. Instructors do their best to keep grades current.

There may be times when work is due that a ZERO is entered before the due date. This is used as a reminder to the student to get the work completed and turned in….it is also a reminder to parents to make sure your student is getting their work done and turned in.

The Academy expects all parents to be involved their students education and to be held accountable to make sure the student is working to the best of their ability.

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