Dear Prospective Phlebotomy Student: Thank you for your ...€¦ · Dear Prospective Phlebotomy Student: Thank you for your interest in the Phlebotomy Certification course at MACC

Dear Prospective Phlebotomy Student:

Thank you for your interest in the Phlebotomy Certification course at MACC located in Mexico,

Missouri. Enclosed you will find an application packet for the fall/spring Phlebotomy

Certification course. Please review all documents carefully. The deadline for returning all

documents for the spring semester course is the first Friday in January. The deadline for

returning all documents for the fall semester course is the first Friday in August. All completed

application forms, immunization records, background checks and drug screen results are

all required in our office before enrollment in the class is allowed.

Please use the following checklist as a guide to help you through the application process:

Completed Form/Document

MACC Application Online at https://www.macc.edu/admissions/steps-to-admissions

Phlebotomy Program Application

Record Review Permission Form

Release of Information Form

Fingerstick Release Form

Instructor Reference Form

Employer Reference Form

Other Reference Form

Essential Qualifications Form NOTARIZED

Immunization Records Form

Missouri State Highway Patrol Background Check ($14.00 Name Search) Form or

Hard Copy Results

Background Check Advantage Request Form ($2.50 check or money order made

payable to MACC for this background check)

Caregiver Background Screening Form

Directions to Mid-Mo Drug Testing Collection Site

https://www.macc.edu/admissions/steps-to-admissions

Immunizations

Proof of the following immunizations are required before enrolling into the Phlebotomy

Certification course:

Hepatitis B vaccine: There are three inoculations. Students must have at least begun the

series;

Two MMR immunizations or positive titer;

Positive immune varicella titer or an immunization;

DPT inoculation series;

A 2-step TB test or documentation of having had two TB tests in two years or chest x-ray

if a positive reaction has been documented;

Some sites may require an influenza vaccine; please be advised this might be necessary

too, once your clinical site has been decided

Drug Screen

Proof of a negative 11 panel drug screen must be received before enrollment in the phlebotomy

class is allowed. A map to the collection site is included in this packet.

MSHP Criminal Background Check

Send the completed Missouri State Highway Patrol Criminal Background Check, with $14.00

payment, directly to the Missouri State Highway Patrol (see address on the form). Send for the

background check early because it may take up to six weeks to be completed and arrive in our

office. For a small additional processing fee, a faster service option is available. The Missouri

Automated Criminal History Site (MACHS) may be accessed at www.machs.mshp.dps.mo.gov.

If you select the online option, you will need to print and include the results with your

application packet.

Caregivers Background Check

Fax or mail the Caregivers Background Screening to the fax number or address on the back of

the form. Use “Option 4” in the bottom right hand corner as the correct fax number or mailing

address. We can fax this form for you if you do not have access to a fax machine.

Office of Inspector General Background Check

Complete the MHA “Background Check Advantage” OIG form and send it to our office with

cash, check or money order in the exact amount for $2.50. Make checks payable to MACC.

We will process this background check ourselves.

Reference Forms

In addition, please be advised that all reference forms must be returned to our office in a sealed

envelope from the persons of your choosing. References should be from teachers, ministers or

supervisors. No friends or relatives please.

Course Enrollment Form

Once you have submitted your completed application packet, please contact the MLT Program

Coordinator or the Nursing Administration office to obtain your enrollment form for the course.

You may not enroll for this course without this enrollment form. The enrollment form must be

signed by MLT Program Coordinator before you can enroll.

http://www.machs.mshp.dps.mo.gov/

I look forward to working with you and the rest of your class. If you have further questions, do

not hesitate to contact me via email or phone at the number listed below.

Sincerely,

Alese M. Thompson MS, MLS (ASCP)CM

Executive Director of MHPC Medical Laboratory Technician Program

(573) 582-0817 ext. 13624

[email protected]

mailto:[email protected]

MACC

PHLEBOTOMY CERTIFICATION COURSE

APPLICATION

The deadline for returning all documents for the spring semester course is the first

Friday in January. The deadline for returning all documents for the fall semester

course is the first Friday in August.

Legal

Name_____________________________________________________________________

Last First Middle

Previous Names: _______________________________________________________________

Address_______________________________________________________________________

Street City State Zip

Phone Number (_____) _______________Email Address: ______________________________

Emergency Contact: ________________________________________ (_____) _____________

Last First Phone Number

PREVIOUS EDUCATION

Schools

Attended Name and Location Dates

Certificate, Diploma, or

Degree Awarded Year

High School

College or

Universities

MLT Schools

Other

MACC does not discriminate on the basis of race, color, national origin, sex, disability, age, and marital or parental

status in admissions, programs and activities, and employment.

Inquiries concerning Section 504 of the Rehabilitation Act of 1973, which guarantees access to education regardless

of disability, should be directed to: Angela Duvall, Office of Student Services, 101 College Avenue, Moberly, MO

65270, 660-263-4110 ext. 278. All other inquiries concerning nondiscrimination, including equal opportunity and

Title IX, should be directed to one of the following people: Dr. Jeff Lashley, Office of Academic Affairs, 101

College Avenue, Moberly, MO 65270, 660-263-4110 ext. 216 or Sonda Stuart, Career and Placement Services, 101

College Avenue, Moberly, MO 65270, 660-263-4110 ext. 232. Students with documentable disabilities as addressed

by the Americans with Disabilities Act may register proper documentation with the Office of Student Services. The

Student Services Office will then notify appropriate instructors of suggested official accommodations. Students may

also wish to personally inform their instructors of their particular disabilities.

MACC


RECORD REVIEW PERMISSION FORM

Have the following documents sent to the address listed below:

Moberly Area Community College

Attn: Alese Thompson

Medical Laboratory Technician Program

2900 Doreli Lane, Mexico, MO 65265

The deadline for returning all documents for the spring semester course is the first

Friday in January. The deadline for returning all documents for the fall semester

course is the first Friday in August.

1. A completed, acceptable Criminal Background check (Complete the form, enclose a $14.00

check or money order made out to the “State of Missouri, Criminal Record System”, and

send to the address on the form. The State Police will send the background check to the

Program Coordinator).

2. Three letters of reference on the designated forms.

3. Submit to a drug screen through Mid-Mo Drug Testing (Once completed, the drug testing

facility will send the results to the Program Coordinator).

4. Submit inoculation records for the following to the Program Coordinator:

a. All 3 doses of Hepatitis B vaccine or documentation of having begun the series;

b. MMR vaccine series;

c. Positive immune varicella titer or an immunization;

d. DPT inoculation series within 10 years;

e. 2-step TB test or 2 TB tests within 2 years or chest x-ray if a positive reaction has

been documented.

f. Influenza vaccine

5. A completed Caregiver Registry background check (to include the Employee

Disqualification List background check) form sent to the Program Coordinator.

6. A completed, acceptable Background Check Advantage form that includes OIG

Medicare/Medicaid Fraud and Abuse background check (Complete the form, attach a check

or money order for $2.50 and send to the Program Coordinator for faxing).

7. Complete form to allow release of background information.

8. Signed and notarized Essential Qualifications form.

I understand that all information received from references as well as shot records and

background check, will be reviewed by the Program Coordinator or by an admissions

committee, and I hereby grant permission to have my records reviewed.

___________________________________________________ _________________

Signature Date

MACC


RELEASE OF INFORMATION FORM

Full Name:____________________________________________________________________

Maiden/Alias Name(s):__________________________________________________________

Address:______________________________________________________________________

City:________________________________ State:____________________ Zip:___________

Social Security Number:_________________________________________________________

Date of Birth:__________________________________________________________________

Place of Birth:__________________________________________________________________

I authorize Moberly Area Community College to request and obtain a copy of my criminal

background as provided in Section RSMo. 610.120 and make an inquiry to the Department of

Social Services regarding the “Employee Disqualification List” as provided in Section RSMo.

660.315. I also authorize Moberly Area Community College to request and obtain a copy of my

drug screen results, immunization records, a Division of Family Services background check

regarding child abuse or neglect, and a background check with the Office of Inspector General. I

also realize I must provide a criminal background check for each state in which I have lived

within the past ten (10) years.

I further authorize Moberly Area Community College to provide the necessary documentation of

all the above stated information to individual clinical affiliates, to verify my eligibility to

participate in the clinical experience.

___________________________________________________ _________________

Signature Date

___________________________________________________ _________________

Witness Date

MACC


FINGERSTICK RELEASE FORM

I, _______________________________________________release MACC, the Division of

Health Sciences, the instructor, and the student performing the venipuncture and/or fingerstick

blood collection from any responsibility. My signature constitutes that I have been informed of

potential complications and voluntarily agree to participate.

___________________________________________________ _________________

Signature Date

___________________________________________________ _________________

Witness Signature Date

MACC

2900 Doreli Lane

Mexico, MO 65265

Phlebotomy Certification Course

* Instructor REFERENCE

Please return this form to the Executive Director of the MHPC Medical Laboratory Technician Program, at

the MACC, Mexico by the first Friday in January if you are applying for the spring semester and by the first

Friday in August if you are applying for the fall semester. Thank you for your assistance.

__________________________is a candidate for admission into the Phlebotomy course at Mexico, Missouri.

Please note: I hereby authorize parties who receive requests to give full and complete information as may be

requested by MACC. I further agree that the information will not be disclosed to me and I

thereby waive any right to review this reference form.

___________________________________ ________________________

Student Signature Date

Please Check: APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4)

Reliability/

Accountability

Communication Skills

(Oral and Written)

Good Moral Character

Integrity

Ability to Work

With Others

Ability to Cope With

Stress/Crisis

Initiative

Please indicate whether or not you endorse the applicant:

Endorse with Enthusiasm______ Endorse_______ Do not Endorse_______

Number of courses taken with you_______*

How long have you known applicant?__________ Date:___________________________

Signature___________________________________ Address:________________________

Name:_____________________________________ _______________________________

Position:___________________________________ Telephone: ______________________

*If the potential phlebotomy student does not have a prior instructor to receive an evaluation from, due to an acceptable

reason verified by the Executive Director of the MHPC MLT program, please use this form for an additional reference

from a non-teacher.

MACC

2900 Doreli Lane

Mexico, MO 65265


EMPLOYER REFERENCE








___________________________________ ________________________


Please Check: APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4) Reliability/

Accountability


(Oral and Written)


Integrity

Ability to Work

With Others


Stress/Crisis

Initiative


Endorse with enthusiasm______ Endorse_______ Do not endorse_______

Number of years employed with you:___________



Name:_____________________________________ _______________________________

Position:___________________________________ Telephone:______________________

MACC

2900 Doreli Lane

Mexico, MO 65265


REFERENCE








___________________________________ ________________________


Please Check:

APPLICANT'S

CHARACTERISTICS

STRONGLY

AGREE

(1)

AGREE

(2)

DISAGREE

(3)

STRONGLY

DISAGREE

(4)

Reliability/

Accountability


(Oral and Written)


Integrity

Ability to Work

With Others


Stress/Crisis

Initiative


Endorse with enthusiasm______ Endorse_______ Do not endorse_______

How do you know the applicant? _____________



Name:_____________________________________ _______________________________

Position:___________________________________

Telephone:______________________

6/17/2019

MACC MISSOURI HEALTH PROFESSIONS CONSORTIUM

MEDICAL LABORATORY TECHNICIAN PROGRAM

ESSENTIAL REQUIREMENTS

Introduction A graduate with an Associate of Applied Science degree from the MHPC Medical

Laboratory Technician program is educated to enter the practice of laboratory medicine

and qualified to take the accrediting exam from the American Society of Clinical

Pathologists (ASCP). Education in laboratory medicine involves assimilation of

knowledge, acquisition of skills, and development of judgment through handling patient

specimens, manipulation of instrumentation, and working with patients, doctors, nurses,

and other health care professionals. Medical laboratory technicians must be able to work

independently and as a part of a team. They must be able to make appropriate decisions

regarding patient results.

The Medical Laboratory Technician program’s curriculum requires students to engage in

diverse complex and specific experiences primarily in the laboratory but also with

patients. Unique combinations of cognitive, affective, psychomotor, physical, and social

abilities are required to perform these functions successfully. These abilities are

necessary to ensure the health and safety of patients, fellow students, laboratory

personnel, faculty, and other healthcare providers.

Policy MACC has a vested interest in the welfare of patients served by graduates of the Medical

Laboratory Technician program. The College also has a responsibility to its clinical

affiliates, future employers, program instructors, and students enrolled in the program.

Therefore, not only have academic standards been established but also non-academic

essential requirements. These requirements, as distinguished from academic standards,

refer to cognitive, physical, and behavioral abilities that students must have to acquire the

knowledge and skills of the curriculum successfully. The standards must be met, with or

without reasonable accommodation, in order for students to participate in the program.

Discrimination is prohibited based on race, color, sex, national origin, age, disability,

marital status, religion, or veteran status in compliance with the Americans With

Disabilities Act (PL 101-336).

The essential abilities necessary to acquire or demonstrate competence in laboratory

medicine and necessary for successful admission and continuance in the Medical

Laboratory Technician Program include but are not limited to the following:

Motor Skills and Mobility Dexterity and fine motor skills to perform laboratory testing and specimen

manipulation

6/17/2019

Physical ability to maneuver within the laboratory area to perform testing and the

patient treatment area to collect specimens

Sufficient touch discrimination to distinguish veins when performing

venipunctures

Candidates should have sufficient motor function to move about the laboratory and the

dexterity to manipulate equipment, laboratory supplies, biohazards, chemical hazards,

and patient specimens. They must have the ability to operate instrumentation safely to

avoid harm to self or others. Laboratory workers interpret data from computer screens

and perform data input. The candidate must be able to perform phlebotomy; that is,

moving from room to room or patient to patient, stooping or bending, to draw blood

safely. The candidate must be able to lift, carry, push, and pull. The candidate must be

able to move quickly and/or continuously as well as tolerate long periods of standing or

sitting (laboratory workers spend approximately 75% of each day standing or walking).

The candidate must be able to travel to clinical laboratory sites for practical experience.

Candidates must be willing to work with blood, infectious organisms, and chemical

reagents.

Sensory/Observation Visual ability to perform and interpret test results, and to read charts, graphs,

instrument displays, and the printed word on paper or a computer monitor

Visual ability to distinguish gradients of colors Note: Color blindness does not

necessarily preclude admission to the program

Tactile ability to perform laboratory tests using assorted devices

A candidate must be able to acquire the information presented in demonstrations and

experiences in basic laboratory science. He or she must be able to discriminate subtle

structure and consistency differences in specimens and cultures both macroscopically and

microscopically. Additionally, he or she must be able to evaluate patient/client responses

correctly; accurately read results or measurements on patient-related equipment; and hear

monitor alarms, emergency signals, telephone interactions, and cries for help. The

candidate must be able to tolerate odors and work in close and crowded areas.

Communication Effectively communicate in written and verbal form (this includes basic computer

keyboarding)

The candidate must be able to process and communicate effectively in oral and written

forms. The candidate must communicate clearly, effectively, and sensitively with other

students, faculty, staff, patients, and other medical professionals. He or she must be able

to follow oral and written instructions to perform laboratory test procedures correctly.

6/17/2019

Cognitive Ability to master information presented in lectures, written material, and images

Cognitive ability to assess data, make decisions based on data, and provide

complete and accurate results on laboratory testing for quality patient care

The Medical Laboratory Technician program candidate must be able to measure,

mathematically calculate, reason, analyze, integrate, and synthesize information. The

candidate must be able to read and comprehend technical and professional materials. He

or she must be able to evaluate information and engage in critical thinking in the

classroom and clinical setting.

Behavioral/Emotional Emotional stability in potentially stressful circumstances

Behavioral restraint, emotional maturity, and sensitivity to others

The candidate must possess the emotional health required to use his or her intellect in

exercising appropriate judgment and prompt completion of all responsibilities. The

candidate must have the emotional stability to provide professional and technical services

under stressful conditions such as emergency demands and distracting environments.

The candidate must be a team member, honest, compassionate, ethical, responsible, and

able to manage time in order to complete technical procedures within a reasonable time

frame.

Professional Conduct Professionalism and ethical conduct

Candidates must recognize the importance of operating in a moral, ethical way in the

clinical laboratory and the necessity of abiding by high standards of practice. Candidates

must recognize the need for confidentiality.

These standards identify the requirements for admission, retention, and graduation from

the program. It is the responsibility of the student with disabilities to request those

accommodations that he or she feels are reasonable and needed to execute the essential

functions described.

References:

Fritsma, G., Fiorella, B., Murphy, M. (1996). Essential Requirements for Clinical

Laboratory Science.” Clinical Laboratory Science, 9(1), p. 40-43.

American Society of Clinical Laboratory Scientists. (2004). Body of Knowledge,

Clinical Laboratory Scientist. Bethesda, MD: ASCLS.

American Society of Clinical Laboratory Scientists. (2004). Entry Level Curriculum,

Clinical Laboratory Scientist. Bethesda, MD: ASCLS.

6/17/2019

RECEIPT AND ACKNOWLEDGMENT

ESSENTIAL QUALIFICATIONS

The undersigned applicant to the MHPC Medical Laboratory Technician Program hereby

acknowledges receiving, reading, and understanding this essential functions document.

The applicant understands that completion of the MACC Medical Laboratory Technician

program does not mean that the American Society of Clinical Pathologists will issue the

applicant a certificate.

SIGNATURE OF APPLICANT

Date

STATE OF____________________________

COUNTY OF__________________________

On this________________day of ____________________, 20___, before me,

____________________________, Notary Public in and for said state, personally

appeared,_______________________________, known to me to be the person who

executed the within instrument and acknowledged to me that ____________________

executed the same for the purposes therein stated.

IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal

the day and year last above written.

Notary Public

MACC


IMMUNIZATION RECORD FORM

PROOF OF ALL IMMUNIZATIONS MUST BE ATTACHED TO THIS FORM

Please return this form to the Executive Director of the MHPC Medical Laboratory

Technician Program, at the MACC—Mexico by the first Friday in January if you are

applying for the spring semester and by the first Friday in August if you are applying for the

fall semester.

Date(s) Received Immunization Comments

1.

2.

Two MMR immunizations or

positive titer

TDap or DTap

(within last 10 years

1.

2.

2 Step Tuberculin Test

(result must be negative or file needs

chest X ray)

Varicella titer or immunization

1.

2.

3.

Hepatitis B vaccine series

(3 doses or at least begun the series)

Influenza vaccine

REQUEST FOR CRIMINAL RECORD CHECK

PLEASE PRINT OR TYPE.

Telephone (include area code)

SEND REPLY TO (Print or type your mailing label below.)

Missouri State Highway PatrolCriminal Justice Information Services Division

Post Office Box 9500Jefferson City, MO 65102

Please forward the request and fee to:

MISSOURI STATE HIGHWAY PATROL SHP-158S 11/18

fold fold

fold fold

APPLICANT'S LAST NAME FIRST

SEX

MIDDLE JR / SR

MAIDEN / ALIAS LAST NAME FIRST MIDDLE JR / SR

DATE OF BIRTH (MM/DD/YYYY) SOCIAL SECURITY NUMBER RACE

STREET - P.O. BOX CITY STATE ZIP CODE

GENERAL INFORMATION

TYPE OF RECORD CHECK — PROCESSING FEE — METHOD OF PAYMENT

$14.00 NAME SEARCH

Based on NAME, DATE OF BIRTH,AND SOCIAL SECURITY NUMBER.Response will be returned with all openrecords and records of conviction.

$20.00 FINGERPRINT SEARCH

MALE

FEMALE

BLACK

WHITE

INDIAN

ASIAN

OTHER

Fee is payable either by check or money order (NO CASH) to "State of Missouri, Criminal Record System Fund."

Either the Date of Birth OR Social Security Number MUST be provided for processing.

For faster processing criminal record checks are available online at: www.machs.mo.gov

MSHP / CENTRAL REPOSITORY RESPONSE

ADDRESS

(per Sections 43.527 and 43.530, RSMo.)

Open RecordsOpen and Closed Records

$2.00 NOTARY LETTER

Criminal Justice Information Services Division

General Information

The Missouri Criminal Records Repository (MCRR) collects, maintains, and disseminates Criminal History Record

Information (CHRI) as defined by Sections 43.500 and 589.400, RSMo. CHRI is information collected by criminal justice

agencies on individuals and consists of arrests, prosecutions, final dispositions, correctional supervision, and releases.

All felony and serious misdemeanor arrests (referred to as reportable arrests), including offender registration information

as defined under Section 589.400, RSMo, and all alcohol and drug related traffic offenses are reportable to the MCRR.

Criminal background checks may be requested by means of:

1) A Personal Identifier Search (name-based) which searches information based on the name, date of birth, and

social security number of an individual.

2) A Fingerprint Based Search which searches the state’s criminal history files by conducting a fingerprint

comparison of the applicants fingerprints with the criminal (arrest) fingerprints on file with the Central Repository.

Fingerprint images are collected and submitted using the standard federal applicant fingerprint card (FD-258).

The Personal Identifier Search requires a payment of $14.00 per request. The background check results are

considered a “possible match” and will include only open records. Any individual, business, or agency may request

and receive open record information by means of a personal identifier search. Open records include:

§ Records containing convictions, such as plead guilty to, or convicted of.

§ Arrest information that is less than 30 days old from the date of arrest.

§ Charges filed from the prosecutor, awaiting final disposition from the court.

§ Records that contain a suspended imposition of sentence (SIS) during the probation period.

A Fingerprint Based Search requires a payment of $20.00 per request. The results of a fingerprint-based background

check are considered a “positive match” and will provide either open records or closed (complete) records as

requested by the applicant.

An applicant may choose to conduct a fingerprint based criminal record check containing open records thus limiting the

dissemination of criminal history information to only open record information. The Criminal Justice Information Services

(CJIS) Division will release fingerprint-based criminal history information containing only open record information to any

individual, business, or agency when requested by the applicant.

An applicant may choose to conduct a fingerprint-based criminal record check for release of closed records thus

allowing dissemination of all criminal history information on file with the Central Repository. Closed records will only be

released with a record check submitted by means of a fingerprint comparison and will only be released directly to the

applicant or to a qualified entity if authorized in accordance with Section 610.120 and Chapter 43, RSMo. Closed

records include:

§ All criminal history data, including all arrests (filed or not filed charges).

§ Charges that have been nolle prossed, dismissed, or found not guilty in a court of law.

§ Suspended Imposition of Sentence (SIS) after the probation period is complete.

Notary Letters are provided upon request and require an additional $2.00 processing fee, per request. A notary letter

may be requested with either a personal identifier search or a fingerprint search.

PENALTY — A person who knowingly violates any provision of Sections 43.532, 43.540, 610.100, 610.105, 610.106 or

610.120 RSMo is guilty of a class A misdemeanor.

FBI Record Requests

The FBI only has open files meaning that if someone has the authority to receive the records; they receive all that is on

file.

Individuals that need a Federal or Federal Bureau of Investigation (FBI) background check, for personal reasons or for

employment purposes for entities not authorized through Missouri State Statute or the Missouri VECHS program, can

submit fingerprints with an $18.00 fee directly to the FBI. For information on how to obtain a federal background check

directly from the FBI, please refer to information regarding the FBI’s Identity History Summary Check on the FBI’s

website at www.fbi.gov.

Exhibit B

BACKGROUND CHECK ADVANTAGE - Request Form 8/8/2012 Background Check Advantage P.O. Box 6766, Jefferson City, MO 65102 Phone: 573/893-3700 Fax: 573/893-7669

Holly Whitworth

MACC--Mexico Phone: 573-582-0817 ext. 13624

First Name Middle Name Last Name

Alias/Maiden Name Check Alias Name? Will Employee’s Salary Exceed $75,000?

YES - Additional Charges May Apply

NO

Social Security Number Date of Birth Race Gender

- - M F

Mailing Address (NO P.O. Boxes) City State Zip

As part of the student, I consent to the release of my criminal background records and motor vehicle driving records or any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for student. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports. This consent will remain effective until I have affirmatively revoked it.

__________________________________________________ DATE: ______/______/________ Signature of Applicant

BACKGROUND SEARCHES

X OIG (Medicare/Medicaid Fraud & Abuse)

LIST CITY/COUNTY CRIMINAL SEARCHES NEEDED States with county by county access only: CA, MA, WV and WY

County 1:_____________State: _____ County 2:______________State: _____ County 3:_______________State: _____

*Puerto Rico Repository (Felony Only Search & requires Mother’s Maiden Name & Address) ___________________________________ Statewide Criminal—A Statewide/State Repository houses records from all jurisdictions throughout the state.

AL* AK AZ AR* CO CT* DE DC* FL GA* HI ID** IN IA** KS KY LA* ME MD MI MN MS* MT NE NV* NH** NJ NM* NY* NC ND OH OK OR* PA RI* SC SD TN TX UT* VA* VT* WA WI Note: Louisiana, Nevada & Ohio are Felony Only Illinois Healthcare—compliance with IL Healthcare Worker Background Check Act (IL Police Full-State Repository Criminal) MO—includes MO Sex Offender Search at no additional cost (MO State Highway Patrol Full-State Repository Criminal)

* Requested Form(s) & **Requested Special Form(s) must be ATTACHED when ordering or faxed to 573-893-7669

8/8/2012

Mid-Mo Drug Testing Collections: Address: 405 Bernadette Drive, Office D, Columbia, MO 65203

573-234-1872 Cash, Check or Money Order Only

Please send results to:

Alese Thompson MACC--Mexico

2900 Doreli Lane Mexico, MO 65265

or Fax: 573-581-3766

Documents

Dear Prospective Phlebotomy Student: Thank you for your ...€¦ · Dear Prospective Phlebotomy Student: Thank you for your interest in the Phlebotomy Certification course at MACC