Dental Hygiene Program Application for Fall 2015

TARRANT COUNTY COLLEGE
APPLICATION FOR ADMISSION
Dental Hygiene
For Program Beginning Fall Semester 2015
DHY
Deadline to submit all application materials: 5:00 pm, February 2, 2015
Submit application materials to:
Tarrant County College Northeast Campus
Selection Committee for Health Sciences
Attn: Dental Hygiene
828 W. Harwood Rd., NHSC 1118
Hurst, TX 76054-3299
1.Program application (complete)*
2.Official transcripts from all colleges attended,
Including a current TCC transcript
3.AFS approval, if applicable
4.Dental Experience Form, if applicable, from dental office
5.Health Form (complete)
Be sure to send OFFICIAL TRANSCRIPTS* from ALL Institutions, INCLUDING TCC TRANSCRIPTS.
*NOTE: 2 sets of transcripts will be needed; send 1 to the Selection Committee and 1 to the Registrars’ Office.
Check here if you have previously applied to ANY Health Care Professions Program (TREC)
Program and date of application if you checked above: ______________________________________________________
Check here if you participated in a Health Care Profession’s Program (TREC) or EMS or Dental Hygiene
Programs (NE) but did not complete that program. Are you in good standing to be accepted into another Health
related program? Have the program coordinator of that program sign here: _____________________________________
Name:
Last
First
Middle
Other (e.g. maiden name)
City
State
Zip
County
Mailing
Address:
TCCD
ID:
Email:
TCCD Colleague ID#
Phone:
Home/
Work/
Cell/
Have you applied to Tarrant County College?
Yes
No
You must apply to TCC and also submit official transcripts to the registrar's office from all colleges you
have attended, and request a transcript evaluation be com pleted. Failure to apply to TCC will
result in ineligibility for Dental Hygiene Program selection.
Do you have less than 12 semester college hours?
Yes
No
If "yes," you are required to turn in your official High School Transcript or GED with Score Report. If
"no," you will need to submit ALL official college transcripts only.
Are you applying under AFS/Academic Fresh Start?
Yes
No
If you selected "yes," attach a copy of the AFS paperwork. AFS applicants must fulfill the competency
requirements for Reading, Writing and Math with current coursework or with THEA or ACCUPLACER
testing.
If you are applying under AFS at which campus did you apply? AFS is institution specific; you must
apply at TCC even if you have applied for AFS at another Texas college.
Date/campus of AFS at TCC, if applicable: _______________________________________
Are you applying with International Transcripts?
Yes
No
Yes
No
If you selected "yes," attach a copy of the TCC International Evaluation. International students must
fulfill the competency requirements for Reading, Writing and Math with coursework accepted by TCC or
with THEA or ACCUPLACER testing.
Have you met the competency requirements for Reading, Writing and Math as
indicated in the information packet for this program? See the General Information
Document and Entrance Requirements.
Tarrant County College District is an Equal Opportunity institution that provides educational opportunities on the basis of merit and without
discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.
EDUCATION:
List the high school from which you received your diploma or enter GED/Home School, if applicable.
Enter all Colleges/Universities attended and level of completion. You do not need to list non-accredited
institutions. Check with Admissions or the Registrar's Office for information on accredited institutions.
Schools
Location
Entrance
Departing
Level of Completion:
Semester &
Semester & Year
Year
Name of School
City/State
Semester
Year
Semester
Year
Total Semester Hours or Degree
Obtained
Failure to list all college-level institutions is grounds for dismissal from program, if selected. Failure to list all
schools and provide required transcripts deems your application as incomplete.
Repeated Coursework:
List all courses that you have repeated/retaken to improve your GPA or to replace a low/failing grade. Failure to list repeated
classes on this application can adversely affect your final rating for program selection. It is your responsibility to list ANY
and ALL repeated coursework below. We do not review transcripts to search for duplicate coursework.
Please include classes from which you withdrew (usually designated with a "W").
If necessary list coursework on an additional sheet of paper
Grade
Institution where
Repeated
Course
Received
course was taken
Course
Do you have a Bachelor's Degree?
Yes
Institution where course
was retaken
Grade
Received
No
If Yes, where was your Bachelor's Degree awarded?
What was your major?
Yes
No
Yes
No
I f yes to either or both questions please subm it the "Dental Experience Form " per instructions.
Do you have observation experience in a dental care setting?
Have you worked as a dental assistant in a dental office?
Please read carefully: I attest that this application to the Dental Hygiene Program is complete and correct. I understand
that by signing and submitting this application I am not guaranteed a place in this program and that I am only eligible for
selection according to the terms listed in the information packet. I also understand that by signing the application I am
responsible for submitting ALL documents and information required for application to this program; and failure to do so
could result in an incomplete application. I have read and understand the requirements and procedures for admission into
the Dental Hygiene program as outlined in the Information Packet.
Signature
Required:
Date:
*Applicants will NOT be notified if items are missing. It is the sole responsibility of the applicant to make sure that the entire
application, including all materials needed to complete the application, have arrived and are on file by the application deadline.
Tarrant County College District is an Equal Opportunity institution that provides educational opportunities on the basis of merit and without
discrimination because of race, color, religion, sex, age, national origin, veteran status, or disability.
Tarrant County College - Northeast Campus
Health Science Department
Dental Hygiene Program
Immunization and Health Record
Due at Time of Application - No Exceptions
Forms which are incomplete (by the first day of class) OR not submitted (with the
application) will immediately disqualify the student from participation in Health
Science classes.
Part I - To be completed by Student: Please Clearly Print All Information
Health Science Program in which you are enrolled: Dental Hygiene Program
Name:
(Last)
(First)
Age:
(Middle)
Sex:
Address:
City:
State:
Zip:
Phone:
Part II - To be completed by Healthcare Provider
To the Medical Practitioner:
Students enrolled in health related programs are required by the Texas Administrative Code* to have specific
immunizations or show proof of immunity before beginning clinical semesters. This is a TEXAS LAW and cannot be
waived by the student or medical practitioner. In addition, the DFW Hospital Council also places requirements on
students to assure the safety of both the student and the patients they encounter. The following table outlines the
requirements for immunization that must be competed in their entirety in order for the student to enter health science
programs.
*Vaccine requirements applicable to institutions of higher education, incorporated in Title 25, Health Services Chapter 97,
§97.61-§97.77 of the Texas Administrative Code.
GENERAL HEALTH STATUS (Please note physical assessment below)
An essential component of this physical exam is to determine that this student is medically capable of pursuing the
academic and clinical activities for their selected field (noted above).
Description of health status (including health problems):
Does this student have any physical or emotional limitations that would restrict participation in the academic or clinical
portion of a health care education program, including clinical activities in a hospital or clinic setting?
~ No ~ Yes, if “Yes” please explain restrictions:
TUBERCULOSIS SCREENING
Test must be administered within the year preceding the start of the program and repeated annually while enrolled.
SKIN TEST:
~ Intradermal (Mantoux)
~ QFT (IGRA blood test)
TEST RESULTS:
~
~
DATE OF TEST:
DATE READ:
READ BY:
Negative
Positive (Chest x-ray required if skin test is positive)
CHEST X-RAY RESULTS (if applicable):
~ Negative
~ Positive (if positive chest x-ray,
has treatment been COMPLETED?
~ Yes
~ No
Required treatment must be complete to
participate in Health Science programs.
Continued on back . . .
TCC DHY Health Form - NE HS 7'14.wpd
Make a COPY for Your Records
NE:HSci rev. 7/14
To be completed by Healthcare Provider
REQUIRED IMMUNIZATIONS
If the student will require an immunization containing a live virus, please perform the TB test first and give the
immunization when the student returns to have the TB test read.
Under State law, ALL IMMUNIZATIONS must be complete by the FIRST DAY of class.
There are NO grace periods or EXTENSIONS permitted. Student will be dropped from
class for incomplete immunizations.
All immunization / titers must be recorded ON THIS FORM. We cannot accept copies of
immunizations or shot records.
Date of
1st dose
Date of
2nd Dose
Date of
3rd Dose
Titer
Date
Titer
Result
TETANUS / DIPHTHERIA / PERTUSSIS**
One dose as adult within the past ten years.
If previously given TD within last ten years, must have TDaP
booster.
MMR
Two doses administered since January 1, 1957, at least 28
days apart.
MEASLES (RUBEOLA)*†
MUMPS *†
RUBELLA†
VARICELLA†
One dose before age 13; or receipt of 2 doses (administered at
least 28 days apart) after age 13 years; or serologic evidence
of immunity. Previous disease is no longer considered proof of
immunity.
HEPATITIS B
Students must receive a complete series (3 injections: initial, at
one month, and at six months) of hepatitis B vaccine prior to the
start of the semester that incorporates direct patient care; or
show serologic confirmation of immunity to hepatitis B virus.
Accelerated schedules are not acceptable.
SEASONAL INFLUENZA IMMUNIZATION
Required annually during flu season usually from August through April. The DFW Hospital Council requires this information be
documented on a separate form.
MCV4 VACCINATION
All enrolling college students must show evidence of immunization against meningococcal meningitis (as required under Senate
bill 1107 of the 82nd Texas Legislature).
Proof of menigococcal meningitis immunization is collected and monitored by the College Registrar and should not be documented
on this form. Contact the College Registrar for additional information and verification forms.
*
†
‡
**
Persons born before January 1, 1957 are considered naturally immune and vaccination is not
necessary for measles (rubeola), mumps, or rubella.
Should not be received during pregnancy.
Active duty military are exempt from all immunizations. Exclusions for medical or religious
conflict must be presented in the form of a written affidavit obtained from the State.
Required by DFW Hospital Council in addition to State law.
If exempt,
state Date of Birth
HEALTH CARE PROVIDER (Physician, Physician Assistant, and/or Nurse Practitioner only signature accepted)
NAME:
The information on this form is accurate and correct.
ADDRESS:
PHONE:
TCC DHY Health Form - NE HS 7'14.wpd
Signature of
Health Care Provider
Make a COPY for Your Records
Date
NE:HSci rev. 7/14

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