OFFICE

USE

ONLY

STUDENT ID# TUITION/FEES PD: $

CK# CASH CC SPONSOR WAIVER ADMISSION FEE: $

STUDENT MASTER TOTAL PAID: $

DIXIE APPLIED TECHNOLOGY COLLEGE ADULT APPLICATION FORM

First Name Social Security #

Middle Name

Last Name

Gender

Address

City

State

Home Phone

Cell Phone

Male Female

Zip

Birthdate (Mandatory) Are you Hispanic? Yes No

Please select one or more of the following:

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Pacific Island

White

Email Address

Emergency Contact

Emergency Phone #

High School Graduate: Yes

Year of High School graduation:

Name of High School last attended:

No

State:

Is this the first college you have attended since exiting

Payment Method: high school? Yes No

Self Pay Vocational Rehab DWS US Citizen Student Visa Resident Alien

Employee Waiver

Scholarship How did you hear about DXATC?

Employer

Employer Address The following information is optional and will be kept confidential. Are you

currently receiving assistance from any of the programs listed below?

Employer Phone # Food Stamps Single Parent Displaced Homemaker

Other Medical USOE Credit Unemployment Insurance

Name of Program or Class you are registering for: Disabled Displaced Worker

FEP (Aid to Families w/Dependent Children)

RECORDS DISCLOSURE: Specific information may be released provided a signed consent form is in the student’s file. In accordance with FERPA 34 C.F.R. Part 99, Subpart D, certain governmental

institutions have access to student records without prior consent for disclosure. It is the responsibility of each student to be informed of services provided to students, as noted in the College

catalog, and to keep the College updated regarding personal information such as mailing addresses and other contact information.

NOTICE OF NONDISCRIMINATION: Dixie Applied Technology College does not discriminate on the basis of race, color, national origin, sex, or handicap in admission or access to, or treatment or

employment in, its educational programs or activities. Inquiries concerning Title VI, Title IX and Section 504 may be referred to Kelle Stephens, Campus President, c/o DXATC 1506 S. Silicon Way,

St. George, UT 84770, (435) 674-8400 or the Office of Civil Rights, US Department of Education, 1961 Stout Street, Denver, Colorado - 80294 1/11/12

PRIVACY NOTICE: Section 6109 of the Internal Revenue Code requires students to provide their correct social security number to the College who must file information returns with the IRS to

report certain information. An eligible educational institution must obtain their SSN or Tax Identification Number to file the information and to furnish a statement to you. The returns the College

must file contain information about qualified tuition and related expenses.

PENALTY: Failure to furnish a correct SSN makes a student subject to a penalty of $50 unless the failure is due to a reasonable cause and not to willful neglect.

I certify that all information I have provided on this application is true. I agree that, upon acceptance as a student of the College campus, I will agree to abide by all policies and procedures of the

College.

Signature Date

SEE OTHER SIDE

STATEMENT OF UNDERSTANDING REGARDING TUITION/FEE PAYMENT

Tuition/fees are due on or before the student’s first scheduled day of training. Tuition/fees paid after this

date will be assessed a late fee as per DXATC late fee schedule.

Payment options are: cash, check, Visa, Master Card, or the online payment process through the Northstar

Student Portal.

Students are given until the 10th of each month to pay their tuition (late fees will be assessed after the

student’s first scheduled school day). If a student fails to pay their tuition by the 10th, the student will be

dropped from the schedule on the 20th of the same month.

If a student has missed 10 consecutive class days they will be dropped from their schedule. To re-enroll the

student MUST pay their balance of tuition/fees/late Fees and a $20.00 re-enrollment fee.

It is the student’s responsibility to withdraw from classes (per DXATC withdrawal process) when they have

either completed their objectives or when they decide to quit attending. If student fails to withdraw, tuition

will continue to assess until the student is dropped for non-payment. The tuition/fees are due and payable

regardless of whether the student attended class.

A student is responsible for paying his/her bill on time even if they do not receive a reminder notice or

billing statement. A student can also be notified of a balance due through the Northstar Student Portal login

(a balance due message will show in red at login).

If a student is sponsored, he/she must contact their sponsor, counselor or advisor to make sure their

sponsorship documentation is complete and the outstanding balance is paid in full.

An agency or employer sponsorship payment is the responsibility of the student. If a sponsor fails to

continue a student’s sponsorship, it is the student’s responsibility to ensure that all required sponsorship

information has been submitted to DXATC Student Services in a timely manner (on or before the student’s

first scheduled school day).

Financial Aid is handled separately. If a student has or is applying for financial aid, payments are still due

even if financial aid is pending. Refund of a student’s financial aid does not automatically mean

tuition/fees have been paid in full. A student must check on his/her account status after any refunds have

been received.

A student receiving VA GI-Bill Educational Benefits is required to follow Dixie Applied Technology College tuition policy and pay all program application fees, monthly tuition, books, and additional course fees prior to training.

Certificates, transcripts, grades, or enrollment verification will not be issued until the student has resolved

all charges against their account.

Late, re-enrollment, book, application, graduation, and any specialty fees are not refundable.

Checks returned for non-payment will result in a $25 processing fee plus any applicable collection fees.

Should it become necessary for DXATC to retain an attorney or collection agency to secure payment of any

amount due, a student must pay all collection costs incurred, which are not limited to attorney fees and

court costs. The student may be assessed additional fees plus a fee of 18% or greater, which will be added

to the principal balance.

The court venue for any litigation from this agreement is Washington County, Utah.

By signing this registration application I agree that I have read, understand and agree to adhere to and be bound by the rules and regulations as stated in DXATC policies and all legal collection processes.

Student Signature Date:

ARITHMETIC

34 - Diesel, HVAC, DXATC Admissions

50 - All other programs

READING COMP

55 - Diesel, HVAC, DXATC Admissions

60 - All other programs

SENTENCE SKILLS

60 - Diesel, HVAC, DXATC Admissions

75 - All other programs

*** PICTURE IDENTIFICATION *** IS REQUIRED on day of test.

ASSESSMENT CENTER FORM

1. Meet with DXATC Student Services Advisor.

2. Determine which tests to take.

3. Complete this Assessment Center Form. (sign off below)

4. Schedule test with Student Services Advisor. (sign off below)

5. Pay for test at the Cashier. (sign off below)

6. Show up on time at Assessment Center for test with ID.

TEST - Please Select One:

CPT ACCUPLACER $15: All 3 Units $10: Math only $10: Reading only $10: Sentence only

Other: ___________________________

PROGRAM - Please Select One:

Medical Assisting Pharm Tech C N A Office Management Drafting IT

Diesel Tech HVAC CATAPULT Other: _______________________

FIRST NAME LAST NAME

Student Phone Number DXATC Student Number *** Required***

Student E-mail

On the Day of the Test: • BRING:

o Picture ID o This completed form o Pen, Pencil, Scratch Paper o Bottled water

• The CPT test is untimed, but will take approximately 2 hours for the three units. MATERIALS ALLOWED: NO Calculators or Phones Allowed

Special Instructions/Accommodations:

_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

SIGN-OFFS ~ Administrative Use Only ____________________________________________________ Student Services Advisor ____________________________________________________ SCHEDULE: Day: Date: Time: ____________________________________________________ Cashier Amount Paid $ ____________________________________________________ Scores Sent to Program Director Date: Name:

Rev 09-2014

�

DXATC Dixie Applied Technology College � 1506 S. Silicon Way � St. George, UT 84770 � www.dxatc.edu

CATAPULT Training � Debi Barmonde, Director � (435) 674-8620 � Office #3C-2 � dbarmonde@dxatc.edu

Rev 09-2014

OVERVIEW: The Accuplacer CPT Test is a computerized placement test that provides you with

information about your academic skills in Arithmetic, Reading Comprehension, and Sentence Skills.

You cannot "pass" or "fail" the CPT, but it is important to do your best so that DXATC program directors

have an accurate measure of your academic skills. We HIGHLY encourage you to prepare by reviewing

sample questions and brushing up on your skills before the test. Being unprepared may needlessly

increase educational costs and time needed to complete your coursework. Preparation is always smart!

If you find that you do not place where you would like to on the CPT, Dixie Applied Technology College

has options—refresher classes, tutoring, and online courses are here to assist you in becoming fully

prepared to succeed in your desired course of study. Your success is our common aim.

COMPUTER ADAPTIVE TESTING

The Accuplacer CPT is an “adaptive” test. This means that the questions are chosen for you on the basis

of your answers to previous questions. This technique selects just the right questions for your ability

level. Because the test works this way, you must answer every question as it is given. The test is

untimed and you can give each question as much thought as you wish. If you do not know the answer to

a question, try to eliminate one or more of the choices, and then pick from the remaining choices. For

more info on how the test works, go to www.collegeboard.com/student/testing/accuplacer/.

SECTIONS: The Accuplacer CPT has three sections:

1. ARITHMETIC: Basic math, fractions, ratios, percentages, measurement, word problems

2. READING: Paragraph structure, critical thinking, comprehension, meaning

3. SENTENCE: Parts of speech, grammar, spelling, sentence structure, punctuation

TIME: The CPT test is untimed, but allow about 2 hours to complete all three sections. You can retest

weekly. You may choose to retest on only one section, if desired. The cost of retesting is $10/section

COST: $15 for all three sections. $10 for single sections (retake).

CUT OFF SCORES: The cut off scores for acceptance into DXATC are:

• MATH: 34 (DXATC Program enrollment, Diesel Technology, HVAC)

50 (Medical Assisting, Medical Billing/Coding, Pharm Tech, Office Management,

Drafting, Info Technology)

• READING: 55 DXATC Program enrollment, Diesel Technology, HVAC)

60 (Medical Assisting, Medical Billing/Coding, CNA (reading only), Pharm Tech, Office

Management, Drafting, Info Technology)

• SENTENCE: 60 (DXATC Program enrollment, Diesel Technology, HVAC)

75 (Medical Assisting, Medical Billing/Coding, Pharm Tech, Office Management,

Drafting, Info Technology)

"

DXATC Dixie Applied Technology College � 1506 S. Silicon Way � St. George, UT 84770 � www.dxatc.edu

CATAPULT Training � Debi Barmonde, Director � (435) 674-8620 � Office #3C-2 � dbarmonde@dxatc.edu

Rev 09-2014

TEST PREPARATION: You are HIGHLY encouraged to prepare for the test. While you cannot fail the CPT

Test, it will determine whether you will be admitted to the coursework you desire. For an accurate

indicator of your skill level, take some time to brush up. See the “PREPARATION RESOURCES” that

follow.

TO TAKE THE TEST:

1. Complete DXATC Registration Forms before taking the test.

2. Meet with our Student Services Advisor to determine the assessment you will need

3. With the help of the Student Services Advisor, fill out the “Assessment Center Form” that shows

you the steps to follow. ***Get sign-off signatures.

4. Schedule an Accuplacer CPT appointment at Student Services. ***Get sign-off signatures.

5. Pay the cashier. ***Get sign-off signatures.

6. Tests are given on Thursdays at 3:00 PM at the DXATC “Office Management” Computer Lab,

Building 3C. If you come early, please wait in the Student Services Lobby, Building 2-C.

7. Please come on time! If you are more than 10 minutes late, you will need to reschedule.

8. You must bring your photo ID to take the test. No exceptions.

NOT HAPPY WITH YOUR RESULTS?

• REFRESHER: Refresher classes are offered through DXATC CATAPULT Training. There is no

cutoff score required for enrollment in CATAPULT. So those who fall below the DXATC Program

enrollment scores will be considered. However, prospective students may be referred to local

literacy programs if they fail to meet minimum literacy requirements.

• REVIEW: Take some time on your own to review the concepts that gave you trouble (see

“Preparation Resources” that follow.) Then retest.

• CPT LAB: DXATC now offers the “CPT LAB,” a self-paced, online personalized course that will

allow you to focus on the areas where you need extra help. To sign up, you will need to talk to

the Student Advisor, who can enroll you. On Tuesday from 3:00 – 4:00 PM a tutor is available

for CPT LAB students at the DXATC Main Campus (please make an appointment with Debi

Barmonde, see contact info below). But you are free to do your work whenever and wherever

works for you, at your own pace. Let your Student Advisor know if this is a good solution for

you. The cost is about $140 for the 10 week course.

• iPHONE/iPAD APP: There IS an app for that! For $2.99 you can purchase the Official Accuplacer

Study App on iTunes. For Math help, Khan Academy also has a great FREE app on iTunes.

• RETEST: You can retake the Accuplacer CPT test weekly for $10 per test. But please study so that

you will show an improvement!

-

DXATC Dixie Applied Technology College � 1506 S. Silicon Way � St. George, UT 84770 � www.dxatc.edu

CATAPULT Training � Debi Barmonde, Director � (435) 674-8620 � Office #3C-2 � dbarmonde@dxatc.edu

Rev 09-2014

“The Official ACCUPLACER Study App” $2.99 www.itunes.apple.com or your App Store

The Official ACCUPLACER® Study App has been developed by the College Board and is

intended to familiarize you with the basic content areas of the ACCUPLACER test. Includes

“Learn as You Go” and sample tests. (This App is not designed to serve as a substitute for an actual

ACCUPLACER test, nor does it guarantee that you will receive a specific score on an actual ACCUPLACER test.)

www.khanacademy.org

A fabulous site with numerous subjects. All video based. ~ See “DEVELOPMENTAL MATH”

With a library of over 2,600 videos covering everything from arithmetic to physics,

finance, and history and 218 practice exercises, we're on a mission to help you learn what

you want, when you want, at your own pace. *** Also, there is a free KHAN ACADEMY

app. Check out iTunes or your App Store.***

www.algebrahelp.com

Algebra software that solves YOUR algebra homework problems with step-by-step help!

Lessons & Worksheets.

www.studyguidezone.com/accuplacertest.htm

Includes help specific to the Accuplacer CPT Test, including flash cards,

study guide, practice questions, reading, sentence and math practice.

www.mathgoodies.com/students.html

FREE – Features interactive lessons, worksheets, and

homework help. Started in 1999 as a pioneer of

interactive instruction, they now offer hundreds of

unique resources.

www.lavamind.com/study/index.html

Offers Testing Tactics, Tutorials, Resources, Quiz Center,

Vocabulary. Resources for Reading, English and Math.

Real world approach to test-taking. Lots of tricks and tips!

3

APPLICATION/ENROLLMENT PROCESS FOR THE DIXIE APPLIED TECHNOLOGY COLLEGE

PHARMACY TECHNICIAN PROGRAM

The Pharmacy Technician Program is approximately 420 classroom and 180 externship hours (subject to alterations) for a total of 600 hours. Applicants are admitted into the DXATC Pharmacy Technician Program by satisfactorily completing the following steps. Open enrollment periods are February (for the cohort beginning in July) and August (for the cohort beginning in January).

To be eligible for acceptance, complete the following steps #1 - #6

1. Complete the following: a. DXATC admissions form (DXATC Student Services) b. Pay $40.00 admission fee (DXATC Cashier) c. Obtain Application Packet (DXATC Student Services)

2. Academic Evaluation:

Applicants must show entry level competencies in English, reading and math through Accuplacer CPT or ACT scores. If a CPT test has been taken within the past two years, and the equivalent scores are met as indicated below, there is no need to retake the test. Please provide a dated copy of the assessment score with your program application. Assessment Scores:

ENGLISH: Accuplacer CPT score of 75 or higher/ACT-16 READING: Accuplacer CPT score of 60 or higher/ACT-16

MATH: Accuplacer CPT score of 50 or higher/ACT-16

a. If necessary make an appointment to take the Accuplacer CPT Test by calling DXATC Student Services at 435-674-8400.

Once the applicant has successfully completed the student placement testing with the required scores, he/she should obtain a program application from Student Services and attach the score sheet to the program application.

4

In the event the scores do not meet the minimum requirements, the applicant will be given the option to apply to CATAPULT for refresher courses. Upon successful completion of CATAPULT, the applicant may again be considered for admittance into the Pharmacy Technician Program.

3. Complete the following items found in the application packet:

a. Pharmacy Technician Application i. Ensure the application is filled out completely and signed

ii. Attach a picture iii. Attach a self-written letter titled “Why I Want to be a Pharmacy

Technician” iv. Attach two letters of recommendation

b. Pharmacy Technician Interview Form Interview a pharmacy technician currently working in a pharmacy.

c. Statement of Physical Health This form is to be completed by a licensed healthcare provider who has examined the applicant within the past year.

d. Mental & Physical Job Requirements Read carefully, sign and date. e. Minor Student Consent Form Have parent/guardian read, sign and date (if applicable) f. Background Screening Student Information Read carefully, sign and date g. Drug Screening Test

(Additional information is located in the application packet.) i. Pay either $20 for urine or $25 for saliva drug screening.

ii. Make appointment with Student Services, 435-674-8400. iii. Bring receipt and photo ID to fingerprinting appointment.

h. Background Check (BCI) and Fingerprinting (must be 18 years old) (Additional information is located in the application packet.)

I. Pay $55 to DXATC Cashier for fingerprinting and background check. II. Make appointment with Student Services, 435-674-8400.

III. Bring receipt and photo ID to fingerprinting appointment. Note concerning fingerprinting & background check – High school students under the age of 18 are not required to complete the fingerprinting and background. However, after turning 18 and before being placed in an externship, the student must complete these items.

d. Proof of Immunizations Provide immunization documentation. Applicant may need to contact the county health department, school personnel or a childhood doctor to obtain the necessary information if it is not available in personal or family records.

5

i. Tetanus/Diptheria (TD every 10 years) ii. MMR (Measles, Mumps, Rubella) 2 immunizations required and/or titer

iii. Influenza Vaccine (annually) iv. Hepatitis A Series* 2 immunizations required and/or titer v. Hepatitis B Series* 3 immunizations required and/or titer (If Hepatitis A

& B are given in a combination dose, only 3 total injections are required) vi. Negative Tuberculosis Skin Test (TB Skin Test/PPD) within the last 12

months. In the event the applicant has a positive skin test, a negative chest x-ray is required.

vii. Varicella (Chicken Pox) immunization. (This can be accomplished by having the actual 2 series immunization, laboratory titer test (blood test) or a written letter from a physician stating that the applicant had the chicken pox.)

*If immunizations are not current, applicants may be accepted into the program on a provisional basis while immunization series are completed. If immunization requirements are not met within the first three months of the program, the applicant will be dropped. The Southwest Utah Public Health Department, which services Washington County, can provide your immunizations for you. Contact them at (435) 673-3528 for dates, times, and costs of immunizations.

e. Minor Student Consent Form: Parent or legal guardian must read, sign and return if applicant is a minor.

4. Transfer of Competency: Entry level competency in certain courses may be shown after an applicant has presented high school or college transcripts (excluding UCAT campuses) showing equivalent courses taken within the past two years which have been passed with a ‘B’ average.

Additionally, a competency test may be required to demonstrate mastery of the course information at 85% proficiency.

Entry level courses transferred from another UCAT campus require current (within 2 years) official transcripts and records for evaluation. Transfer of competencies is accepted after the transcript has been reviewed and approved by the program instructors. Transfer of competencies from another DXATC program will be handled on an individual basis. Students must formally apply to the program and meet all of the application requirements. Instructors and Student Services will work together to assess and give credit for applicable DXATC classes. Student must be formally withdrawn from the former program and be officially accepted into the Pharmacy Technician Program.

6

5. Application Submission and Placement Score Evaluation: The applicant will submit the completed application packet to DXATC Student Services. The application packet will be reviewed for completion and submitted to the DXATC Pharmacy Technician Program Acceptance Committee for consideration.

6. Notification:

Once the required items have been completed, submitted and reviewed, the applicant will be contacted for an interview. After interviewing, applicant will be notified by email regarding the status of the application. If there are any deficiencies in the application packet, the application will not be processed.

7. Course Work: The Pharmacy Technician Program outline below details the courses required for completion.

PHARMACY TECHNICIAN COURSES:

Basic Medical Math

Computer Literacy

American Heart Association - Basic Life-saving Skills (CPR) Career Development Pharmaceutical Math Pharmacology I Pharmacology II Comprehensive Exam Review

PHARMACY TECHNICIAN EXTERNSHIP: 180 hours, non-paid clinical experience

After acceptance into the Pharmacy Technician Program, complete the following:

8. Financial Authorization:

a. A financially sponsored student must present to the Dixie Applied Technology College (DXATC) office an authorization referral form from the sponsor indicating financial assistance in the Pharmacy Technician Program.

b. A self-pay student can make payments or set up a payment plan with the DXATC Cashier in Student Services.

c. A student wishing to apply for financial aid must contact Kami Alldredge at 435-674-8400

For any other questions, please contact Camille Lyman at 435-674-8400 or Linda Duke, CPhT 435-467-3522.

7

DXATC Policies

DISABILITY NOTICE:

Applicants with a documented physical or mental impairment that will substantially limit a major life activity should contact

Brendan Dalley, CTE & Special Projects Director, for necessary documentation. Mr. Dalley and the DXATC Student Services staff

will assist you in analyzing your eligibility for services. As part of the partnership agreement with Dixie State University, if

additional testing is needed, DSU will provide the appropriate testing. If you are deemed eligible, reasonable accommodations

that are appropriate for your disability will be assigned. If you have any questions concerning this process, please contact the

office at 674-8400.

Proper documentation of a disability is required in order to receive services or accommodations. Any applicants eligible for and

requesting reasonable academic accommodations due to a disability must provide a letter of accommodation to their instructor

from the Disability Resource Center within the first two weeks of the beginning of classes. Please contact the Center on the

main campus to follow through with the documentation process. We are located in the Student Services Center, or applicants

may call for an appointment and further information regarding the Americans with Disabilities Act (ADA) at 674-8400.

Non-Discrimination Policy

Dixie Applied Technology College does not discriminate on the basis of race, color, national origin, sex, age, or handicap in admission or access to, or treatment or employment in its education programs or activities.

Inquiries concerning Title VI, Title IX may be referred to the DXATC Student Services Office or to the Office for Civil Rights, US Department of Education, 1961 Stout Street, Denver, CO, 80294.

Other:

*Written information provided about the DXATC Medical Assistant Program is, to the best of the College’s knowledge, correct

at publication. This publication is not a contractual agreement. The DXATC reserves the right to cancel and change programs

and course offerings at any time with regard to the improvement and betterment of the program.

*The DXATC is a member institution of the Utah College of Applied Technology and operates under the direction of the DXATC

Board of Directors, The Utah College of Applied Technology Board of Trustees and the Utah State Board of Regents.

Revised 8/2014

8

9

APPLICATION FOR ADMISSION

PHARMACY TECHNICIAN PROGRAM DIXIE APPLIED TECHNOLOGY COLLEGE

You must apply for formal admission to the Pharmacy Technician Program at the Dixie Applied Technology College (DXATC). Please complete all of the items in this application. Return the completed application along with the other required admission documents to the DXATC office.

1. Print Full Name: ________________________________________________________________ Last First Middle Initial 2. Date of Birth:___________________________________ 3. Cell Phone:____________________________Home Phone: _____________________________

4. Mailing Address: _______________________________________________________________ Number and Street City State Zip Code 5. Emergency Contact: _____________________________________________________________ Name Relationship ______________________________________________________________________________ Number and Street City State Zip Code Telephone #

You will be contacted regarding the status of your application by email. Upon acceptance to the Pharmacy Technician Program, you will be issued an XMAIL.DXATC.EDU email. This will be the email that will be used to distribute important information. It will be your responsibility to check your email on a regular basis. DXATC will not be responsible for students missing important information delivered through email.

6. _____________________________________ Alternate Email Address (1)

10

7. Please provide information concerning high school, college, university, technical school, or other schools attended including health care training. Please also list any school you are currently attending.

NAME OF SCHOOL

CITY AND STATE DATE OF ENTRANCE

DATE OF EXIT DEGREE OR CERTIFICATION RECEIVED

8. If you have any paid health care employment experience, provide the following information. Do NOT

include volunteer experience or experience that was part of a health care educational program. Start with your most recent position.

NAME OF EMPLOYER

CITY AND STATE # MONTHS FULL TIME

# MONTHS PART TIME

POSITION HELD

If you have had NO paid health care employment, but have observed or volunteered in a health care facility, or have been enrolled in a health care educational system, provide the following information.

A. Name of facility: ____________________________________________________________ B. Location of facility: __________________________________________________________ C. Total hours and dates of observation / volunteering / education: Hours: ___________________________ Dates: ____________________________

11

9. Please provide information about other non-health related employment you may have had. Start with the most recent.

NAME OF EMPLOYER

TYPE OF WORK # MONTHS FULL TIME

# MONTHS PART TIME

POSITION HELD

10. Satisfactory progress during Pharmacy Technician training requires regular attendance. As with

any employer, the expectation is 100% attendance as outlined. Student must maintain a minimum of 80% attendance as outlined. In addition, the externship hours may include evenings, nights and weekends. Can you commit to follow the prescribed hours and course study required for Pharmacy Technician training?

YES NO 11. List below any extracurricular activities, awards, honors, scholarships, student government, etc.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 12. The ability to communicate clearly both verbally and in writing is an essential skill for all

health care professionals. Please provide on an attached piece of paper, a written statement of “Why I Want to be a Pharmacy Technician.” Include the following information: (1) your reasons for selecting Pharmacy Technician as a career, (2) things you have accomplished that have given you the greatest satisfaction, (3) any special reasons for desiring to enter this school, and (4) your plans and aspirations for the future. Please attach to the back of the application.

13. Please provide two letters of recommendation from individuals who are familiar with your

character, work ethic, etc. 14. Prior to being considered for acceptance into the Pharmacy Technician Program at DXATC, every student is fingerprinted, and a background check is conducted by the Federal Bureau of Criminal Investigation. Acceptance into the Pharmacy Technician Program is conditional upon passing the background check. Conviction of a felony, misdemeanor A or misdemeanor B may prevent you from becoming employed as a Pharmacy Technician. Individuals found guilty of a felony or misdemeanor A or B must disclose this information and submit court documents to the Pharmacy Technician Certification Board for review to determine eligibility to sit for the

12

Pharmacy Technician Certification Exam. If the information in this application conflicts with the results of the background check, you will

automatically be released from the DXATC Pharmacy Technician Program. Utah State Law 58-17b-307 states, “If convicted of one or more felonies, an applicant must

receive an absolute discharge from the sentence for all felony convictions five or more years prior to the date of filing an application for licensure under this chapter.”

Have you ever been convicted of a felony, misdemeanor A or misdemeanor B or pled guilty to a

felony, misdemeanor A or misdemeanor B? YES NO

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

15. If at any time while I am in the Pharmacy Technician Program I am charged/convicted with any

of the above, I agree to inform DXATC Pharmacy Technician instructors.

YES _______ NO_______

16. Optional – For statistical purposes only.

Ethnic Background:

Black Non-Hispanic

Asian or Pacific Island

Hispanic

White Non-Hispanic (Caucasian)

Other _______________________

Gender:

Female

Male

I do hereby certify that the statements in this application are true and complete to the best of my

knowledge. I understand that falsifying information on this application may be grounds for denial of

admission or dismissal from the Pharmacy Technician Program and could result in dismissal from

DXATC. If I voluntarily drop or are dismissed from the Pharmacy Technician Program, I understand

that admission fees, tuition and other fees paid are non-refundable.

13

Signature: ________________________________________

Date: ____________________________________________

Have you included the following items? If not, your application is incomplete:

Completed application – signed where requested

Personal letter (Why I Want to Be a Pharmacy Technician)

2 letters of recommendation

Photo

Receipt from fingerprinting/background check

Receipt/results from drug test

Proof of completed/in-process immunizations

CPT/ACT test results with required scores

High School or College Transcripts (if applicable)

Completed Health Assessment

Completed PhT Interview form

Signed Background Screening Student Information

Signed Minor Consent Form (if applicable)

For more information call or email:

Dixie Applied Technology College 1506 S. Silicon Way St. George, UT 84770 435-674-8400 435-674-8630 lduke@dxatc.edu

14

Dixie Applied Technology College

Background Screening Student Information

Students who wish to pursue education in programs or courses with direct patient care and/or controlled substance

interaction are required to submit to federal background screening as established by Dixie Applied Technology College

Policy, Educational Affiliation Agreements, and Utah Statutes and Rules, Title 58 Chapter 17b Section 307, Title 58

Chapter 17b Section 305.

Upon registration and/or acceptance to the program(s), students must pay a nonrefundable $40 to Student Services in cash,

check, or credit card. Prior to acceptance into the program electronic fingerprints must be taken and a background query

will be sent to the Federal Bureau of Investigation. Drug testing must also be completed (See Application/Enrollment

process for directions and authorization form.)

Background check results will not be accepted from any outside entity.

Students frequently ask what findings on their federal background screen will disqualify them from attending a course or

program. If an individual has been convicted of a felony, misdemeanor A, or a non-excluded misdemeanor B, the

individual may not provide direct patient care and/or work with controlled substances, which will result in the inability to

enroll and/or complete the program. Misdemeanor B charges will be reviewed on a case-by-case basis if the misdemeanor

did not involve the following: violence against a child, family member, animal; or sexual conduct with a child or disabled

adult. Traffic violations are excluded from consideration.

The following factors will be used in deciding under what circumstances, if any, the student will be allowed to provide

direct patient care, work with controlled substances, or for other designated externships:

• Types and number of offenses

• Passage of time since the offense was committed

• Circumstances surrounding the commission of the offense

• Intervening circumstances since the commission of the offense

• Relationship of the facts to the individual’s suitability to work in their chosen career field (e.g., working with

children, disabled persons, elderly adults, and/or controlled substances)

If you have questions regarding your eligibility to enroll in a course or program, you can discuss your concerns with the

program department head. However, students with criminal backgrounds can only be officially cleared for registration by

the Campus Review Committee. Student Services staff and program department heads cannot, under any circumstance,

make decisions regarding clearance of criminal background check results.

I have read and understand the DXATC Background Screening Student Information. I am aware that, regardless of

findings, the $40 fee is nonrefundable. I understand that criminal convictions may lead to ineligibility for a course,

program, and ultimately employment. The DXATC Tuition Refund Policy (available in the DXATC Catalog) will apply

to all students who are dismissed or withdraw.

_________________________________ ________________________

Student Name (please print) Date

_________________________________

Student Signature

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DRUG SCREENING Contact: DXATC Security Office, 435-674-8400 Cost: $20 Urine $25 Saliva Payable to DXATC. YOU MUST BRING YOUR RECEIPT TO YOUR APPOINTMENT.

Where: DXATC Student Services Security Office, #3A-6. Please call ahead for an appointment. Results: Results should be available the same day. Note: If results return positive for any reason and/or you dispute the results you will be required to

get another test from the providers below within 24 hours and bring those results back to DXATC. The $20/$25 fee will be waived here at DXATC on any positive screening which is proven to be incorrect.

Where: Info: Call individual drug testing locations for hours and pricing Note: After additional drug screening is completed, results must be returned in a sealed envelope to

DXATC

FINGERPRINTS / BACKGROUND CHECK Contact: Security Office at the Student Services Building, #3A-6, 435-674-8400 Cost: $55.00 Payable to DXATC. YOU MUST BRING YOUR RECEIPT TO YOUR APPOINTMENT Where: DXATC Student Services Security Office, #3A-6

Please call ahead for an appointment. The following items MUST be brought to fingerprinting appointment: a. The receipt for the fingerprinting/background check b. A picture ID (driver’s license or passport)

IMMUNIZATIONS Note: Must make an appointment (Primary care physicians can also administer immunizations) Where: Washington County Public Health 620 South 400 East #400 St. George, UT 84770 When: Mondays, Tuesdays, Thursdays 9:00 am—11:30 am plus 1:00 pm—4:00 pm Wednesdays 1:00 am—6:00 pm Phone: 435-673-3528

Any Lab Test Now 175 W. 900 S. #5, St. George, UT 84770 1-435-628-2220

D.A.T. Express Test 368 E. Riverside Dr. #C, St. George, UT 84790 1-435-656-1122

Detect Lab Several locations – call for info 1-800-371-2838

Quest Diagnostics 736 S. 900 E. #103, St. George, UT 84790 1-435-628-3419

Redrock Drug Testing 511 E. St. George Blvd., St. George, UT 84770 1-435-652-3784

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PHARMACY TECHNICIAN PROGRAM IMMUNIZATION REQUIREMENTS

1. Tetanus and Diphtheria (TD). Must be up to date with one every ten years. 2. Two (2) MMR vaccinations or a positive antibody titer to show immunity. 3. Three (3) Hepatitis B vaccinations. Any student who works directly with patients or body fluid

specimens is required to have completed a 3 dose series of Hepatitis B Vaccine. 4. Influenza Vaccine. Must be received annually. 5. Verification of TB testing within the past year. This must be done by an intradermal PPD test. If PPD

test is positive, students must show that they have had an adequate work-up for tuberculosis and are currently NOT communicable. (chest x-ray report, physician or health department note.)

6. Varicella (Chicken Pox): 2 vaccinations, written verification of the disease by a Healthcare provider or laboratory blood titer test.

7. Two Hepatitis A vaccinations. Any student who works directly with patients or body fluid specimens is required to have completed a 2 dose series of Hepatitis A Vaccine. Hepatitis A and B are often given as a single dose called Twinrix.

PROGRAM:

IMMUNIZATION

RECEIVED

DATE

PRIMARY

SERIES

GIVEN/

COMPLETED

DATE

BOOSTER

GIVEN

DATE

BOOSTER

GIVEN

PERSON ADMINISTERING

IMMUNIZATION (IF

AVAILABLE)

NAME SIGNATURE

Tetanus & Diphtheria TD

Mumps, Measles, and

Rubella (MMR) Combined#1 #2

Mumps, Individual Vaccine #1 #2

Measles, Individual Vaccine #1 #2

Rubella, Individual Vaccine #1 #2

Hepatitis A #1 #2

Hepatitis B #1 #2 #3

Influenza-Annually

Tuberculosis Skin Test

(Annually)

Date:______________

NEGATIVE POSITIVE POSITIVECHEST X-RAY Date:________

Neg. Pos.

Chicken Pox #1 #2 Letter: Titer date:

NAME:

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PHARMACY TECHNICIAN PROGRAM MENTAL & PHYSICAL JOB REQUIREMENTS

Professional and pleasant, friendly attitude

Willingness to learn new concepts and skills within the scope of practice

Attention to detail in a stressful environment

Maintains a high level of integrity in dealing with confidentiality

Shows respect for staff and patients through good communication skills

Willingness to be punctual and reliable

Must have good health

Physical stamina to stand on their feet 8-10 hours a day

Minimal breaks with 30 minute lunch breaks

Able to stoop and bend frequently

Able to lift approximately 25 lbs.

Provide current immunization record as dictated by the medical/pharmacy field

Be drug and alcohol free

The Department of Occupational and Professional Licensing (DOPL) states: Practicing or attempting to practice as a pharmacy technician when physically or mentally unfit to do so, in violation of Subsection 58-1-501 (2) (f) initial offense: $100 - $500 and subsequent offense(s): $200 - $1000 R156-17b-402.63 I have read and understand the “Mental & Physical Job Requirements”. I do not have any mental or physical limitations that would prevent me from carrying out these requirements to the best of my knowledge. ________________________________ _____________________________ Student Name (please print) Date

Student Signature Revised 8/2014

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Statement of Physical Health

This “Statement of Physical Health” is an affidavit which is provided to Dixie Applied Technology College

Health Occupations Programs by a student candidate. It indicates that the student has been evaluated by a

licensed medical provider and determines whether or not they are mentally and physically capable of

participating in the health occupations training and its required expectations. Based on licensed provider’s

recommendations, concerns and deficiencies will be evaluated on an individual basis for admittance into the

program.

IDENTIFICATION:

Name: ________________________________________________________________________

Date of Birth: _____________ Age: _____ Gender: ______ Height: ________ Weight: _______

GENERAL INFORMATION:

Please indicate if any of the following have caused health related problems:

YES NO YES NO

Asthma Heart Trouble

Convulsions/Seizures Bleeding Disorders

Diabetes High blood pressure

Kidney Disease Lung Disease

Fainting Spells Vision complications

Hearing complications

Explain ________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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ASSESSMENT DATA:

Provide the following information after complete examination.

Blood Pressure: / ; Pulse ; Respirations: __________

History / Physical: (Are there diseases or concerns)

YES NO Year Explain

Serious illness _________ ____________________ Serious injury _________ ____________________ Deformity _________ ____________________ Surgery _________ ____________________ Skin / Glands _________ ____________________ Ears _________ ____________________ Eyes _________ ____________________ Nose _________ ____________________ Teeth / Mouth _________ ____________________ Chest / Lungs _________ ____________________ Heart _________ ____________________ Stomach / Bowels _________ ____________________ Kidneys / Urine _________ ____________________ Menstrual _________ ____________________ Hernia _________ ____________________ Musculoskeletal / back _________ ____________________ Nervous conditions _________ ____________________ Mental concerns _________ ____________________ Limitations / Restrictions: Explain / Instructions: __________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Medical Provider Performing the Examination:

Print Name: ___________________________________ Title:

Signature: ____________________________________ Date: ___________________________

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PHARMACY TECHNICIAN INTERVIEW

As a prospective Pharmacy Technician, it is important for you to understand the role the professional Pharmacy

Technician performs within the current health care environment. To assist you in learning about the Pharmacy

Technician Profession, all students who apply for admission to the Dixie Applied Technology College

Pharmacy Technician Program need to interview a working pharmacy technician and complete the following

worksheet.

It is your responsibility to identify and set up an interview time with a pharmacy technician who is currently

employed in a clinic, retail or other pharmaceutical setting. You should contact the pharmacy technician and

schedule an appointment prior to your interview to avoid drop-in visits which may be inconvenient. Do not

limit yourself to the questions listed on the form. Remember, you may be doing part of your internship at the

location you choose to interview, so respect and professionalism on all counts should be adhered to.

Student: _________________________________________

Date: ___________________________________________

Interview a working pharmacy technician and inquire about the following:

1. How long have you worked as a pharmacy technician?

2. How did you receive your training?

3. Are you a Certified Pharmacy Technician?

4. To your knowledge, what is the salary range for pharmacy technicians in this area?

5. What hours and days do you work?

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6. How many clients do you interact with daily?

7. What are the major duties you perform?

8. What entry-level skills do you feel are the most important for a new pharmacy technician?

9. What do you like most about your job?

10. What do you dislike about your job?

11. What advice would you give me as I pursue my pharmacy technician education and career?

Pharmacy Technician’s Signature: __________________________________________________

Employer: _____________________________________________________________________

Employer Telephone Number (for verification or interview): _____________________________

22

Pharmacy Technician Program

MINOR STUDENT

Consent Form

Due to the sensitive nature of the health care provider’s duties and responsibilities to clients and/or patients, we teach many aspects of the reproductive system. Information regarding sexuality issues, sexually transmitted diseases, erectile dysfunction, birth control, plan B and genital infections. As we relate drugs to disease states, we will discuss in an open classroom all of the above. Furthermore when the student goes into their externship, they will work with many/all of the drugs that pertain to sexual issues. As they come in contact with customers/patients, they will need to have a working knowledge of these drugs and what they do. Any student who is under the age of 18 requires the signature of a parent or legal guardian for permission to enter a Pharmacy Technician Program offered by DXATC. I give permission for my student to participate in discussions and study regarding the basic anatomy and physiology of the reproductive system, and the duties and responsibilities of a Pharmacy Technician during class and clinical externships. Student Signature ___________________________________ Date _____________________ Parent/Guardian Signature _____________________________ Date _____________________ Instructor Signature __________________________________ Date _____________________ Please return this form to your student’s instructor. If you have any questions, please feel free to contact the Medical Programs Facilitator @ 435-674-8633. UCAT Policy 619: Clinical Experiences for Minor Students Revised 2/2014

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Course Syllabus

Pharmacy Technician Program

Instructor Information Instructors: Linda R. Duke, Ashley Harmon & Robert Hardy Office Location: DXATC Campus - Medical Programs Building B Telephone: Office 435-674-8630 or Cell 435-467-3522 E-mail: lduke@dxatc.edu Office Hours: M & W, 9:00 a.m. to 5:00 p.m., T & TH, 1:00 p.m. to 9:00 p.m.

Program Identification Course Name: Pharmacology I and Pharmacology II Course Hours: 600 Course Location: DXATC Campus - Medical Programs Building-B Class Times: T & TH: 5:00 p.m. to 9:00 p.m., Pharmacy Technician Program Core

M, T, W, TH: 5:00 to 6:00 p.m. Computer Literacy (30 hours * 3.5 weeks) Pre-requisites: CPT Test Scores of English - 75; Reading - 60; and Math - 50

Program Description/Overview Pharmacology I is designed to introduce students to the history, roles, and practice of the Pharmacy Technician. It prepares students to perform as technicians to assist pharmacists in the packaging and distribution of medications to patients, understanding technical operations in drug distribution, management of inventory control, bulk compounding, sterile solution preparation, and performing critical dosage calculations. Embedded is a law module and labs. Pharmacology II is designed to introduce students to the evolution of medicinal drugs, the practice of pharmacology, and specific administration technics of pharmacologic agents. Students will be exposed to the different types and classifications of medications as they relate to the different body functions, disease processes, and physiologic body systems.

Program Learning Objectives Students will recognize the term pharmacology and how it relates to federal laws, marketing of medications and development of specific practice through the ages. They will understand the roles and responsibilities of the Pharmacy Technician. Understand the benefits of drugs and their interactions with pharmacokinetics in both the use and the development of new drugs and identify

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the major types of drugs and classifications as they relate to the different body organs and functions. Become proficient in the basic pharmaceutical calculations and measurements.

Program Resources

Pharmacology for Technicians, Fifth Edition with Study Partner CD and Pocket Guide Pharmacy Calculations for Technicians, Fifth Edition with Study Partner CD

Pharmacy Practice for Technicians, Fifth Edition with Study Partner CD Pharmacy Labs for Technicians, second edition with NRx Simulation CD Drug Flash Cards www.emcp.net/pharmacology5e www.emcp.net/pharmpractice5e

Course Supplies Pencil Books Scrubs Notebook Binder-3 ring, 2” Calculator

Media Support Computers Smart Board TV/Projector Copy Machine Power Point Support Video Camera Wireless Service

Course Breakdown TOPICS CHAPTERS

Profession of Pharmacy Evolution of Drugs Basic Concepts of Pharmacology

PPB-1, PB-1 & 2

Dispensing Medications Developing Literacy Skills Mastery of Common Abbreviations

PPB-3, PB-3

Continuation of Lecture

Dosage Forms & Routes of Administration

PPB-4

Vitamins, Nutritional Supplements, Antidotes and Emergencies

PB-17

Community Pharmacy PPB-6

3

Community Pharmacy PPB-7

Non-Sterile Pharmaceutical Compounding

PPB-8

Hospital Pharmacy Practice, Infection Control, Preparing and Handling Sterile Products

PB-9, 10 & 11

Continuation of Lecture

Your Future in Pharmacy Practice – Panel

PPB-14

Pharmacy Practice and Calculations

PCB-5

Lab #1 Reading and Filling Prescriptions

Lab #2 Non-Sterile Compounding, Unit Dosing

Lab #3 Aseptic Technique

Lab #4 HIPAA, Insurance & Billing

Sterile Technique Didactic Module

Emotional Intelligence Guest Speaker

Prescription Fraud Safety Guidelines

Law and Ethics

Medication Errors

Antibiotics Ch. 4 - PB

Fungal & Viral Infections Ch. 5 – PB

Anesthetics & Narcotics Ch. 6 - PB

Psychiatric & Related Drugs Ch. 7 - PB

Central Nervous System Ch. 8 - PB

Respiratory Drugs Ch. 9 - PB

Gastrointestinal Urinary Tract

Ch. 10 & 11 PB

Cardiovascular & Circulatory Ch. 12 PB

Muscle & Joint Disease Ch. 13 PB

Hormone, Topical, Ophthalmic & Otic

Ch. 14 & 15 PB

Chemotherapy & Recombinant

Ch. 16 PB

Review & Clinical Packets Placed in Externship

4

Grading/Testing Classes are graded on a pass/fail basis. Each module must be completed with at least an 80% and tests must be passed with 85% proficiency. There are no points allotted for attendance (see attendance policy). Students that do not pass an exam with at least 85% will be allowed to remediate the exam one time. If you do not pass the exam in two attempts, then it will be determined through an interview with the director of the Pharmacy Program whether remaining in the program is viable. Letter grades are not given as this is a competency based program. Tests are required to be taken the day they are given. If a student is absent, they must make an appointment with the instructor to take the exam.

Late Assignments Students are expected to turn in all assignments on the day that they are due. With approval of the instructor, late assignments may be accepted on a case by case basis. Students having a hard time understanding a concept can see the instructor for additional practice exercises or instruction on the topic. Many resources are available and students are expected to show initiative by seeking out additional help on their own as well.

Course Policies Program Entrance Requirements The following policies are program specific to the DXATC Pharmacy Technician Program and may differ from or exceed the general DXATC requirements as listed in the online Student Handbook. All the policies for the DXATC Pharmacy Technician Program have been reviewed and approved by the DXATC Pharmacy Technician Advisory Board Committee. Students must take the College Placement Test (CPT) and/or show competency through ACT scores of 16 or better. Current, within the last two years, High School and/or College transcripts showing a “B” Grade in Math and Computers may also be used, before being considered for admission into the Pharmacy Technician Program at DXATC. Students must pass the CPT test with the following scores to be considered: English – 75; Reading – 60; Math – 50. If a student does not pass with these scores, they will be referred to CATAPULT for refresher courses before applying for the program again. Attendance Policies Attendance is mandatory in the DXATC Pharmacy Technician Program. Absences are not excused and are counted against student progress. Daily training is given on which students will be tested and graded. It is important that students be in class each day in order to understand the concepts taught. Excessive absence may jeopardize student’s enrollment in the program. The DXATC Pharmacy Technician Advisory Board has reviewed and voted on setting four consecutive absences maximum. If students are absent for four consecutive class days, they will automatically be dropped from the program.

5

It is the personal responsibility of the student to make up all work assigned during an absence from any class or lab. Students are expected to contact other students to find out what work has been missed or obtain homework assignments from the instructors. Leave of Absence Leaves of absence are not allowed in the Pharmacy Technician Program. If students are unable to complete the program with their current cohort, they will be required to drop and reapply with the next available cohort. Food and Drink Policy Students will not be allowed to have food or drink (except closed water containers) in the classroom. Eating is allowed only in the break room or outside areas. Tobacco Free Campus This is a tobacco free campus. No smoking, chewing or tobacco use of any kind will be allowed on campus. Furthermore, students who smell of tobacco use will not be allowed in the classroom and will be asked to leave until they are odor free. Strong Odors Students must agree to come to school showered/bathed with clean hair and free of any strong odor including, but not limited to, tobacco, body odor, perfume, strong lotions, etc. As pharmacy technicians learning to serve patients, they must be aware and considerate of patient health as it pertains to allergies and sensitive to smells. Dress Policy Students enrolled in the Pharmacy Technician Program will be required to dress in scrubs at all times when in class. Scrubs are expected to be neat, clean and wrinkle free. They must not have holes or stains and must be hemmed to the student’s height. Scrub bottoms are not allowed to drag on the ground or have frayed hems. Close-toed and close-heeled shoes with socks are required by OSHA. They should be neat and clean and appropriate for a pharmacy. Students are also required to wear a name tag. Students who arrive at school without one or all of the required dress items will be asked to sign out and return home for the missing items. Hair Policy Students are required to keep their hair neat, clean and out of their face. Keep your scalp healthy and if flaking is a problem, use a lint roller to keep your clothes free of flakes.

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Cheating Policies The Medical Assisting/Pharmacy Technician Programs at Dixie Applied Technology College believe that personal honor is the foundation for student behavior while obtaining an education as well as in the healthcare field as a graduate. The honor system is based on the belief, “that DXATC students are mature and self-respecting, and can be relied upon to act as responsible and ethical members of society.” As instructors, our hope is that our students will behave in responsible and ethical ways at all times. However, situations will arise in which it is clear, beyond a reasonable doubt that a student has cheated. See the following for a specific definition of cheating. “Cheating” is defined as unauthorized help on any assignment, quiz, or exam as follows: 1) A student may not receive from another student or give to another student any

information, answers, or help during an exam. 2) A student may not use unauthorized sources for answers during an exam, must not take

notes or books to the exam unless authorized by the instructor ahead of time, and must not refer to any book or notes while taking any exam unless the instructor declares the exam an “open book” exam.

3) A student must not obtain exam questions illegally before an exam or tamper with an exam after it has been corrected.

If it is determined that cheating has occurred, beyond a reasonable doubt, the student will receive one warning, and the exam will be given a grade of ‘F’. If the situation occurs again, the student will be referred to Student Services to determine the level of discipline deemed appropriate. Possible discipline includes probation, suspension or expulsion. Transfer of Credit/Testing Out Students that want to transfer credits from another institution or high school must provide official transcripts listing the classes to be transferred. All credits to be transferred must have been taken within the past two years and passed with a “B” Grade. If more than two years have passed since the student completed the course, a proficiency test will need to be taken. The student will have one attempt to take the test. The testing must be completed in one attempt. Students may not take a partial test on one day and return to complete it the next day. If the test is passed at an 85% or above, the class will be waived. However, if the test is not passed at 85% proficiency, the class will need to be re-taken. Emergency Response The emergency response booklet and map of the campus is posted in every classroom. Students will be required to dress in scrubs that must be hemmed to the student’s height. Scrub bottoms are not allowed to drag on the ground or have frayed hems. Students must wear closed toed shoes per OSHA standards. Students will be aware of first aid kits that are available in each building on campus. Job-related health, safety and fire-prevention are discussed and implemented in each class.

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DXATC: ADA Statement In accordance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (“ADA”), the DXATC offers accommodations to students with documented learning, medical, physical and/or psychological disabilities. It is the responsibility of the student to contact the Disability Services Coordinator, preferably prior to the beginning of the course, to initiate the accommodation process and to notify instructors as soon as possible so accommodations can be made early on in the course. Reasonable accommodations will be made to allow each student to meet course requirements. Students needing assistance or accommodations should contact the Disability Services Coordinator, Brendan Dalley at 435-674-8403 or email him at dalley@dxatc.edu.

Other The DXATC is committed to providing equal educational and employment opportunity regardless of sex, marital status or parental status, race, color, religion, age, national origin, and physical or mental disability, unless it is a bona fide qualification, as required by Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendment of 1972, and the Age Discrimination Act of 1975. In addition, the DXATC complies with state and federal safety guidelines of the Occupational Safety and Health Administration. Student health facilities are not available on campus. *Written information provided about the DXATC Pharmacy Technician Program is, to the best of the College’s knowledge, correct at publication. This publication is not a contractual agreement. The DXATC reserves the right to cancel and change programs and course offerings at any time with regard to the improvement and betterment of the program. *The DXATC is a member institution of the Utah College of Applied Technology and operates under the direction of the DXATC Board of Directors, the Utah College of Applied Technology Board of Trustees and the Utah State Board of Regents.

Revision 4/2014

2014-2015 Dixie Applied Technology College Financial Assistance Information

The decision to invest in your future by attending college is one of the most important choices you will ever make. DXATC’S educational costs can be paid for with a combination of cash payments, federal need and/or non-need based aid, and other programs available to those who qualify. The Financial Aid Office is prepared to assist in determining which types of aid you “may” be eligible to receive, as well as in providing the information

required by your other programs or sponsors.

TO APPLY FOR FINANCIAL AID The DXATC priority deadline for the FAFSA is May 15, 2015

1. To be considered for federal financial aid you must:

PIN: Request a PIN Number to utilize electronic signature for the FAFSA – www.pin.ed.gov. You may also apply for your pin at the end of the FASFA application.

FAFSA: Complete and submit the 2014-2015 (FAFSA) Free Application for Federal Student Aid which is available on line at: www.fafsa.ed.gov. DXATC Title IV School CODE is 041217.

VERIFICATION: The U.S. Department of Education (USDE) randomly selects federal aid applications for a process called verification. After your application has been processed, you may review your Student Aid Report to see if you have been selected for verification. The law says that before awarding Federal Student Aid, we may ask you to confirm information you reported on your FAFSA. To verify that you provided correct information, we will compare your FAFSA with the information on the institutional verification document and with any other required documents. If there are differences, your FAFSA information may need to be corrected. You will be contacted by the Financial Aid Office and sent verification documents. This process takes about 6 weeks.

If your Student Aid Report indicates that you do not qualify because your income was too high for 2013, and if your financial circumstances have changed, there is an appeals process called “Professional Judgment” whereby your eligibility might be regained. This process takes about 6 weeks.

2. Once you have completed the steps above please call Student Services (674-8400) for an appointment to complete your application process.

Meet with the Student Advisor to discuss requirements for your program of interest. If you plan to transfer credits from another institution, you will need to bring a copy of the transcripts with you to this meeting. After meeting with the Student Advisor, you will need to make an appointment with the Financial Aid Office to complete the Pell Grant application process.

You must be enrolled as a matriculated1 student before any formal offer for financial assistance can be made. In order to be considered a matriculated student you must submit the following during your appointment:

A DXATC Registration Form (given to the registrar’s office)

A $40 Admission fee payment (paid to the cashier’s office)

Results from a College Placement Test (Accuplacer, ACT, etc.)

A signed DXATC Enrollment Agreement which includes detailed program data

Proof of your high school graduation, and (Official College Transcript(s) if transferring credit hours) 3. Satisfactory Academic Progress (SAP) must be met in order to receive or renew financial assistance. Please refer to the DXATC

College catalog for SAP requirements.

Once you have been admitted to DXATC and the Financial Aid Office receives the required items listed above, your file will be reviewed for eligibility for financial assistance. This process can take up to four weeks. If you are eligible for financial assistance, you will receive an Award Letter either by mail or email. Once you receive your award letter, you may begin school. You may start your program before your Pell Award Letter arrives if you have some other method of payment, such as: self-pay, scholarships, or sponsorships. The total amount of grant and loan awards will not exceed the cost of attendance (COA) which may include tuition, loan fees, required books/supplies, estimated room and board, personal, travel, and sometimes child care expenses. DXATC designs all initial awards packaging to assist with direct educational costs only.

TIPS TO REMEMBER

Always apply early when institutional, federal, state, and other programs are required in order to attend. Read all instructions carefully and answer all questions accurately.

File the FAFSA electronically at www.fafsa.ed.gov for quick and accurate processing. The Paperwork Reduction Act: No one is required to respond to a collection of information unless it displays a valid OMB control number; for a FAFSA (1845-0001).

Notify the Financial Aid Office immediately if there are changes in your family’s financial situation or if you receive an outside scholarship(s).

Failure to comply with these requirements may result in the denial or termination of your packaged award.

Students must have an NSLDS record on file in the Financial Aid Office, as well as all transfer credits determined in order to be considered for a final award package. Begin the transfer process in a timely manner. Please keep copies of submitted documents for your personal records.

1 A student is considered matriculated when the student is officially admitted to the college and has been accepted into the desired program that will lead to the awarding of a certificate.

DXATC STUDENT SERVICES

1506 South Silicon Way St. George, UT 84770 Phone (435) 674-8400

Fax (435) 674-8450

RELEASE OF INFORMATION AUTHORIZATION Student Name (please print): _________________________________________________________________ I.D. Number: _____________________________________________________________________________ I hereby authorize DXATC to release, discuss or share information contained in my College record with my: Parent/Guardian Name(s) _________________________________________________________ School Counselor Sponsoring Agency Case worker Other Name and Title ___________________________________________________________

I do not authorize DXATC to release, discuss or share any information contained in my College record in

accordance with the Family Educational Rights and Privacy Act (FERPA). I understand that I can rescind this in writing at any time by completing a Release of Information Authorization form containing my signature and the date of authorization.

I understand that my student record will be held under strict confidentiality and will only be used for the stated purpose and reviewed by authorized DXATC staff. I understand that I can rescind this authorization in writing at any time by notifying Student Services with a written notice containing my signature. A photocopy or fax copy of this authorization shall be acceptable and considered as valid as an original signed document. I, as undersigned, acknowledge my understanding of this Release form. I further understand that I agree to provide this authorization throughout the period of time that I am enrolled in my college program. _____________________________________________ _____________________________ Student Signature Date

Your Financial Aid Essentials How the Pell Grant works:

The Federal government divides and disburses your Pell Grant by payment periods. Your start date and the length

of your program will determine your payment periods. Any program length over 900 hours will be divided into

three or four payments that span two academic Pell Grant years. Any program that is 900 hours or less will be

divided into two equal payments that could span one or two academic Pell Grant years depending on your start

date.

An academic year starts on July 1st of one year and ends on June 30th of the next year. If you are enrolled in a

program that will cross two academic years, the payment period that you are in when you cross over into the next

academic year will be considered a cross over payment and can be awarded from either Pell Grant award year.

The College retains funds from your Pell disbursements to cover the ENTIRE cost of the payment period for which

you are registered. Any residual money left over, after your program is paid in full, will be refunded to you if it is

determined that you are maintaining Satisfactory Academic Progress. Residual checks are scheduled to be cut

about every six weeks. A schedule of these check runs can be found on our website at www.DXATC.edu.

You MUST maintain Satisfactory Academic Progress (SAP) each payment period to receive the funds. SAP is defined as:

Progress: Pass your classes at 67% or better progress

Attendance: Attend 85% of the time

Contract: Pell Grant regulations require that you enroll in and attend 12 hours or more per week. Satisfactory Academic Progress will be monitored on a continual basis. If you fall below 67% progress at any time, you will receive a letter warning you that you are at risk of losing Pell Grant eligibility. You will be evaluated at the end of each payment period to determine if you are in Satisfactory Academic Progress. If you fall below 67% progress after your first or second payment period, you will be placed on warning status (if your progress is 50% to 67 %,) or on probation (if your progress is 49% and lower.) A student on warning status may continue to use his/her Pell Grant money to pay for tuition, books, and fees only. A student may only have one payment period on warning status. A student on probation is no longer eligible for their Pell Grant funds and will be considered a self-paying student, if they continue. Eligibility can be regained through DXATC’s appeals process. An academic plan may be required to continue eligibility, if your appeal is granted. The chart below indicates the conditions of these statuses:

The full Student Financial Aid Policy can be found at www.DXATC.edu. If you have questions, please contact DXATC Student Services.

Eligibility Status Warning Status Probation Status

Progress 67% and above 50% to 66% 49% and below

Eligible for Pell funds Yes Yes; for tuition, books,

and fees only No; considered self-payer

Appeal required to

reinstate Pell funds N/A No Yes

Academic Plan required N/A No Determined by the appeals

committee

The Family Educational Rights and Privacy Act

Guidance for Eligible Students

February 2011

The following guidance provides eligible students with general information about the Family Educational Rights and Privacy Act (FERPA). This document is a compilation and update of various letters and guidance documents previously issued that respond to a variety of questions about FERPA. While this guidance reflects our best and most current interpretation of applicable FERPA requirements, it does not supersede the statute or regulations. We will attempt to update this document from time to time in response to questions and concerns. FERPA is a Federal law that is administered by the Family Policy Compliance Office (Office) in the U.S. Department of Education (Department). 20 U.S.C. § 1232g; 34 CFR Part 99. FERPA applies to all educational agencies and institutions (e.g., schools) that receive funding under any program administered by the Department. Parochial and private schools at the elementary and secondary levels generally do not receive such funding and are, therefore, not subject to FERPA. Private postsecondary schools, however, generally do receive such funding and are subject to FERPA. Once a student reaches 18 years of age or attends a postsecondary institution, he or she becomes an "eligible student," and all rights formerly given to parents under FERPA transfer to the student. The eligible student has the right to have access to his or her education records, the right to seek to have the records amended, the right to have control over the disclosure of personally identifiable information from the records (except in certain circumstances specified in the FERPA regulations, some of which are discussed below), and the right to file a complaint with the Department. The term "education records" is defined as those records that contain information directly related to a student and which are maintained by an educational agency or institution or by a party acting for the agency or institution. FERPA generally prohibits the improper disclosure of personally identifiable information derived from education records. Thus, information that an official obtained through personal knowledge or observation, or has heard orally from others, is not protected under FERPA. This remains applicable even if education records exist which contain that information, unless the official had an official role in making a determination that generated a protected education record. Under FERPA, a school is not generally required to maintain particular education records or education records that contain specific information. Rather, a school is required to provide certain privacy protections for those education records that it does maintain. Also, unless there is

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an outstanding request by an eligible student to inspect and review education records, FERPA permits the school to destroy such records without notice to the student. Access to Education Records Under FERPA, a school must provide an eligible student with an opportunity to inspect and review his or her education records within 45 days following its receipt of a request. A school is required to provide an eligible student with copies of education records, or make other arrangements, if a failure to do so would effectively prevent the student from obtaining access to the records. A case in point would be a situation in which the student does not live within commuting distance of the school. A school is not generally required by FERPA to provide an eligible student with access to academic calendars, course syllabi, or general notices such as announcements of specific events or extra-curricular activities. That type of information is not generally directly related to an individual student and, therefore, does not meet the definition of an education record. Under FERPA, a school is not required to provide information that is not maintained or to create education records in response to an eligible student's request. Accordingly, a school is not required to provide an eligible student with updates on his or her progress in a course (including grade reports) or in school unless such information already exists in the form of an education record. Amendment of Education Records Under FERPA, an eligible student has the right to request that inaccurate or misleading information in his or her education records be amended. While a school is not required to amend education records in accordance with an eligible student's request, the school is required to consider the request. If the school decides not to amend a record in accordance with an eligible student's request, the school must inform the student of his or her right to a hearing on the matter. If, as a result of the hearing, the school still decides not to amend the record, the eligible student has the right to insert a statement in the record setting forth his or her views. That statement must remain with the contested part of the eligible student’s record for as long as the record is maintained. However, while the FERPA amendment procedure may be used to challenge facts that are inaccurately recorded, it may not be used to challenge a grade, an opinion, or a substantive decision made by a school about an eligible student. FERPA was intended to require only that schools conform to fair recordkeeping practices and not to override the accepted standards and procedures for making academic assessments, disciplinary rulings, or placement determinations. Thus, while FERPA affords eligible students the right to seek to amend education records which contain inaccurate information, this right cannot be used to challenge a grade or an individual’s opinion, or a substantive decision made by a school about a student. Additionally, if FERPA’s amendment procedures are not applicable to an eligible student’s request for amendment of education records, the school is not required under FERPA to hold a hearing on the matter.

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Disclosure of Education Records Under FERPA, a school may not generally disclose personally identifiable information from an eligible student's education records to a third party unless the eligible student has provided written consent. However, there are a number of exceptions to FERPA's prohibition against non-consensual disclosure of personally identifiable information from education records. Under these exceptions, schools are permitted to disclose personally identifiable information from education records without consent, though they are not required to do so. Following is general information regarding some of these exceptions. One of the exceptions to the prior written consent requirement in FERPA allows “school officials,” including teachers, within a school to obtain access to personally identifiable information contained in education records provided the school has determined that they have “legitimate educational interest” in the information. Although the term “school official” is not defined in the statute or regulations, this Office generally interprets the term to include parties such as: professors; instructors; administrators; health staff; counselors; attorneys; clerical staff; trustees; members of committees and disciplinary boards; and a contractor, volunteer or other party to whom the school has outsourced institutional services or functions. A school must inform eligible students of how it defines the terms “school official” and “legitimate educational interest” in its annual notification of FERPA rights. A school official generally has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility. Additional information about the annual notification of rights is found below in this guidance document. Another exception permits a school to disclose personally identifiable information from an eligible student's education records, without consent, to another school in which the student seeks or intends to enroll. The sending school may make the disclosure if it has included in its annual notification of rights a statement that it forwards education records in such circumstances. Otherwise, the sending school must make a reasonable attempt to notify the student in advance of making the disclosure, unless the student has initiated the disclosure. The school must also provide an eligible student with a copy of the records that were released if requested by the student. FERPA also permits a school to disclose personally identifiable information from education records without consent when the disclosure is in connection with financial aid for which the student has applied or which the student has received, if the information is necessary for such purposes as to: determine the eligibility for the aid; determine the amount of the aid; determine the conditions for the aid; and/or enforce the terms and conditions of the aid. With respect to this exception, the term "financial aid" means payment of funds provided to an individual (or payment in kind of tangible or intangible property to the individual) that is conditioned on the individual's attendance at a school. Another exception permits a school to disclose personally identifiable information from education records without consent when the disclosure is to the parents of a "dependent student" as that term is defined in Section 152 of the Internal Revenue Code. Generally, if either parent

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has claimed the student as a dependent on the parent's most recent year's income tax statement, the school may non-consensually disclose the eligible student's education records to both parents under this exception. Postsecondary institutions may also disclose personally identifiable information from education records, without consent, to appropriate parties, including parents of an eligible student, in connection with a health or safety emergency. Under this provision, colleges and universities may notify parents when there is a health or safety emergency involving their son or daughter, even if the parents do not claim the student as a dependent. FERPA also permits a school to disclose personally identifiable information from education records without consent when the disclosure is to the parents of a student at a postsecondary institution regarding the student's violation of any Federal, State, or local law, or of any rule or policy of the institution, governing the use or possession of alcohol or a controlled substance. The school may non-consensually disclose information under this exception if the school determines that the student has committed a disciplinary violation with respect to that use or possession and the student is under 21 years of age at the time of the disclosure to the parent. Another exception permits a school to non-consensually disclose personally identifiable information from a student's education records when such information has been appropriately designated as directory information. "Directory information" is defined as information contained in the education records of a student that would not generally be considered harmful or an invasion of privacy if disclosed. Directory information could include information such as the student's name, address, e-mail address, telephone listing, photograph, date and place of birth, major field of study, participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, degrees and awards received, the most recent previous educational agency or institution attended, grade level or year (such as freshman or junior), and enrollment status (undergraduate or graduate; full-time or part-time). A school may disclose directory information without consent if it has given public notice of the types of information it has designated as directory information, the eligible student’s right to restrict the disclosure of such information, and the period of time within which an eligible student has to notify the school that he or she does not want any or all of those types of information designated as directory information. Also, FERPA does not require a school to notify eligible students individually of the types of information it has designated as directory information. Rather, the school may provide this notice by any means likely to inform eligible students of the types of information it has designated as directory information. There are several other exceptions to FERPA’s prohibition against non-consensual disclosure of personally identifiable information from education records, some of which are briefly mentioned below. Under certain conditions (specified in the FERPA regulations), a school may non-consensually disclose personally identifiable information from education records:

• to authorized representatives of the Comptroller General of the United States, the Attorney General of the United States, the U.S. Secretary of Education, and State and local educational authorities for audit or evaluation of Federal or State supported

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education programs, or for the enforcement of or compliance with Federal legal requirements that relate to those programs;

• to organizations conducting studies for or on behalf of the school making the disclosure

for the purposes of administering predictive tests, administering student aid programs, or improving instruction;

• to comply with a judicial order or a lawfully issued subpoena;

• to the victim of an alleged perpetrator of a crime of violence or a non-forcible sex offense

concerning the final results of a disciplinary hearing with respect to the alleged crime; and

• to any third party the final results of a disciplinary proceeding related to a crime of

violence or non-forcible sex offense if the student who is the alleged perpetrator is found to have violated the school’s rules or policies. The disclosure of the final results only includes: the name of the alleged perpetrator, the violation committed, and any sanction imposed against the alleged perpetrator. The disclosure must not include the name of any other student, including a victim or witness, without the written consent of that other student.

As stated above, conditions specified in the FERPA regulations at 34 CFR § 99. 31 have to be met before a school may non-consensually disclose personally identifiable information from education records in connection with any of the exceptions mentioned above. Annual Notification of Rights Under FERPA, a school must annually notify eligible students in attendance of their rights under FERPA. The annual notification must include information regarding an eligible student's right to inspect and review his or her education records, the right to seek to amend the records, the right to consent to disclosure of personally identifiable information from the records (except in certain circumstances), and the right to file a complaint with the Office regarding an alleged failure by a school to comply with FERPA. It must also inform eligible students of the school's definitions of the terms "school official" and "legitimate educational interest." FERPA does not require a school to notify eligible students individually of their rights under FERPA. Rather, the school may provide the notice by any means likely to inform eligible students of their rights. Thus, the annual notification may be published by various means, including any of the following: in a schedule of classes; in a student handbook; in a calendar of school events; on the school’s website (though this should not be the exclusive means of notification); in the student newspaper; and/or posted in a central location at the school or various locations throughout the school. Additionally, some schools include their directory information notice as part of the annual notice of rights under FERPA.

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Law Enforcement Units and Law Enforcement Unit Records A “law enforcement unit” means any individual, office, department, division or other component of a school, such as a unit of commissioned police officers or non-commissioned security guards, that is officially authorized or designated by the school to: enforce any local, State, or Federal law, or refer to appropriate authorities a matter for enforcement of any law against any individual or organization; or to maintain the physical security and safety of the school. The law enforcement unit does not lose its status as a law enforcement unit if it also performs other, non-law enforcement functions for the school, including investigation of incidents or conduct that constitutes or leads to a disciplinary proceeding against a student. “Law enforcement unit records” (i.e., records created by the law enforcement unit, created for a law enforcement purpose, and maintained by the law enforcement unit) are not “education records” subject to the privacy protections of FERPA. As such, the law enforcement unit may refuse to provide an eligible student with an opportunity to inspect and review law enforcement unit records, and it may disclose law enforcement unit records to third parties without the eligible student’s prior written consent. However, education records, or personally identifiable information from education records, which the school shares with the law enforcement unit do not lose their protected status as education records because they are shared with the law enforcement unit. Complaints of Alleged Failures to Comply with FERPA FERPA vests the rights it affords in the eligible student. The statute does not provide for these rights to be vested in a third party who has not suffered an alleged violation of their rights under FERPA. Thus, we require that a student have "standing," i.e., have suffered an alleged violation of his or her rights under FERPA, in order to file a complaint. The Office may investigate those timely complaints that contain specific allegations of fact giving reasonable cause to believe that a school has violated FERPA. A timely complaint is defined as one that is submitted to the Office within 180 days of the date that the complainant knew or reasonably should have known of the alleged violation of FERPA. Complaints that do not meet FERPA’s threshold requirement for timeliness are not investigated. If we receive a timely complaint that contains a specific allegation of fact giving reasonable cause to believe that a school has violated FERPA, we may initiate an administrative investigation into the allegation in accordance with procedures outlined in the FERPA regulations. If a determination is made that a school violated FERPA, the school and the complainant are so advised, and the school is informed of the steps it must take to come into compliance with the law. The investigation is closed when voluntary compliance is achieved. Please note that the eligible student should state his or her allegations as clearly and specifically as possible. To aid us in efficiently processing allegations, we ask that an eligible student only include supporting documentation that is relevant to the allegations provided. Otherwise, we may return the documentation and request clarification. This Office does not have the resources

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to review voluminous documents and materials to determine whether an allegation of a violation of FERPA is included. An eligible student may obtain a complaint form by calling (202) 260-3887. For administrative and privacy reasons, we do not discuss individual allegations and cases via email. Please mail completed complaint forms to the Office (address below) for review and any appropriate action. Complaint Regarding Access If an eligible student believes that a school has failed to comply with his or her request for access to education records, the student may complete a FERPA complaint form and should include the following specific information: the date of the request for access to the education records; the name of the school official to whom the request was made (a dated copy of any written request to the school should be provided, if possible); the response of the school official, if any; and the specific nature of the information requested. Complaint Regarding Amendment If an eligible student believes that a school has failed to comply with his or her request for amendment of inaccurate information in education records or failed to offer the student an opportunity for a hearing on the matter, the student may complete a FERPA complaint form and should include the following specific information: the date of the request for amendment of the education records; the name of the school official to whom the request was made (a dated copy of any written request to the school should be provided, if possible); the response of the school official, if any; the specific nature of the inaccurate information for which amendment was requested; and evidence provided to the school to support the assertion that such information is inaccurate. Complaint Regarding Disclosure If an eligible student believes that a school has improperly disclosed personally identifiable information from his or her education records to a third party, the student may complete a FERPA complaint form and should include the following specific information: the date or approximate date the alleged disclosure occurred or the date the student learned of the disclosure; the name of the school official who made the disclosure, if that is known; the third party to whom the disclosure was made; and the specific nature of the education records disclosed. This guidance document is designed to provide eligible students with some general information regarding FERPA and their rights, and to address some of the basic questions most frequently asked by eligible students. You can review the FERPA regulations, frequently asked questions, significant opinions of the Office, and other information regarding FERPA at our Website as follows:

www.ed.gov/policy/gen/guid/fpco/index.html

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If, after reading this guidance document, you have questions regarding FERPA which are not addressed here, you may write to the Office at the following address:

Family Policy Compliance Office U.S. Department of Education 400 Maryland Avenue, SW Washington, DC 20202-8520