Respiratory Therapy Program Program Chair: Greg Carter, BS, RRT Phone: 253-566-5231 Email: gcarter@tacomacc.edu Program Assistant: Sean Vandommelen Phone: 253-566-5076 Email: svandommelen@tacomacc.edu The Respiratory Therapy program leads to an Associate of Applied Science degree. The program is full-time, sequential, consisting of seven (7) quarters of instruction offered during daytime hours. Students complete classroom and laboratory work on campus and gain clinical experience in affiliated clinical sites. Students acquire skills in reviewing and recording clinical patient data, performing respiratory therapeutic procedures, and providing for the comforts and needs of the patient during the procedures. Respiratory therapists work under the direction of a physician to assist in diagnosis and treatment for patients with cardiopulmonary diseases and disorders. Positions are available in acute/critical care hospitals, extended care facilities, outpatient clinics, private physicians’ offices, home care companies, sleep studies, pulmonary function testing, and equipment sales. Thoroughness, accuracy, mechanical aptitude/ability to troubleshoot equipment, and empathy are traits needed by people interested in this program. Prospective respiratory therapists should also be versatile and able to follow precise and detailed directions. Upon successful completion of this program, graduates are eligible to take the Therapist MultipleChoice Examination (TMC) administered by the National Board for Respiratory Care (NBRC). The Therapist Multiple-Choice Examination is designed to objectively measure essential knowledge, skills, and abilities required of entry-level respiratory therapists, as well as determine eligibility for the Clinical Simulation Examination. There are two established cut scores for the Therapist Multiple-Choice Examination. If a candidate achieves the lower cut score, they will earn the CRT credential. If a candidate achieves the higher cut score, they will earn the CRT credential AND become eligible for the Clinical Simulation Examination. The CRT and/or RRT credentials are used as the basis for the licensure in all of the 49 states that regulate the practice of respiratory care. Washington State Requirements for Licensure: Respiratory therapists must be licensed by the state as Respiratory Care Practitioners. Requirements include: completion of an approved training program; a background investigation; and passing the entry level certification examination given by the National Board for Respiratory Care (NBRC). The Respiratory Therapy program is accredited by the Commission on Accreditation for Respiratory Care (www.coarc.com). 04/22/15 Commission on Accreditation for Respiratory Care 1248 Harwood Road Bedford, Texas 76021-4244 (817) 283-2835 1 Program Admission Requirements To be considered for the program, applicants must submit the following: 1. College Assessment Test (Reading, English, Mathematics); assessment at college level or eligibility to take English 101 is required. Below college level test scores will result in placement in remedial courses and will delay eligibility to apply. 2. Official college transcripts submitted to the Registration Office (Bldg 7) showing completion of prerequisites with a grade of “C” (2.0) or better. Each prerequisite course must have been successfully passed within two attempts of taking the course. Withdrawals (W) or (WI) do not count as an attempt 3. Completion of the program prerequisites listed below with an overall GPA of 2.5. 4. Applicants must be at least 18 years of age at the beginning of the program in Fall quarter, be fluent in the English language, and possess the physical and emotional ability to complete the program as described in the technical standards (see page 10 – 12 of the application) Admission policies are subject to change. Applications will be accepted under the terms in place at the time an application is received by the Allied Health Office. It is the responsibility of the applicant to keep up-to-date on any changes that may affect his/her qualifications for acceptance. 04/22/15 2 Respiratory Therapy Program Online Application Process Beginning January 2, 2015 the Respiratory Therapy application will be available online. Applications will be accepted until June 15, 2015 at 5:00pm. Applications will only be accepted via the online submission process. To apply to the Respiratory Therapy program, you will need to be an admitted or registered student at Tacoma Community College and have access to the student portal and a TCC e-mail account. If you have not attended TCC in the past 12 months, please fill out the admission application link on the main TCC web page, or you can type in the following link: http://www.tacomacc.edu/gettingstarted/theenrollmentprocess/ It may take 24-48 hours for your account to be activated and for you to be granted TCC student portal and email access. There is no fee to apply to the Respiratory Therapy program. Here is how to access the online application. 1. Sign into the TCC portal (requires you to have an active TCC student account) 2. Go to your Quick links area and expand the All Reports and Applications 3. Select the Academics tab and click on make button for the Allied Health/Nursing link 4. You should now see a button called Allied Health/Nursing on your Quick Links list. 5. This will allow you to access a series of pages that walks you through the application process. Note the application is very straight forward and mainly involves selecting the program you are applying for (Respiratory Therapy), the quarter (Fall 2015) and uploading the required documentation. 6. When you have completed the application the system will send a confirmation e-mail to your TCC e-mail. This is the only e-mail that Tacoma Community College/Allied Health Division will use to communicate with students on their Respiratory Therapy Education application. 04/22/15 3 Application Factoring System Admission into the Respiratory program is a competitive process. There is no waitlist and there are more applicants to the program than there are available positions. Therefore if a student takes all of the prerequisite classes and meets the other requirements for a completed application, it does not guarantee admission into the program. Each applicant will receive a score based on: Grades received in the 5 prerequisite courses. Additional college level science and math courses passed with a B or better (2 pts. each) Additional healthcare related experience. Admission into the program will be offered to the top scores. Calculating an Application Score All completed prerequisites are based on a 4.0 scale. Points Awarded for Grades Earned in the 5 Prerequisite Courses A = 4.0 A- =3.7 B+ = 3.3 B- = 2.7 C+ = 2.3 C = 2.0 B = 3.0 <C Not Accepted All applicants may attempt to earn additional points towards their overall application score by providing proof of patient related healthcare experience (paid or volunteer). A completed form must be included with the application submission. A direct supervisor must verify and sign this form. All experience will be verified upon submission of the application. Falsification or inability to verify this form will result in disqualification of the application. Additional Points Based on Optional Direct Patient Care Experience 100 – 199 hours 200 – 299 hours 300 – 399 hours 2 points 4 points 6 points The following are examples of direct patient care related healthcare that are accepted and do not require prior approval. These include, but may not be limited to: 1. CNA experience (Clinical time from CNA courses) 2. EMT/Paramedic – please provide an estimate of time spent working with patients 3. Certified, Registered or licensed LPN, RN, Radiology Technologist, Sonography technologist, Medical Assistant, Dental Assistant/Hygienist For direct patient related experience obtained but not listed above, written approval is required from the Program Director or Director of Clinical Education PRIOR to application submission. Applicants will be notified of their admission into the Respiratory Therapy program via their TCC Email and will be asked to confirm their acceptance of admission. In the event class openings occur, others will be considered for admission. 04/22/15 4 Prerequisites 1. Math 95 or TMATH 100 – Intermediate Algebra or higher (5 credits) 2. BIOL 241 and 242 – Anatomy and Physiology I & II(12 credits) 3. PSYC 100 or 200 – General Psychology or Lifespan Psychology (5 credits) 4. HIT 130 – Medical Terminology (3 credits) All of the above prerequisites courses must be completed with a grade “C” or better and within two attempts before application can be taken. There is a ten-year time limit for all math and science courses. Co-requisites 1. ENGL 101 – College Freshman Composition (5 credits) 2. Communications – Choose one of the following: CMST 101 – Introduction to Communication, CMST 220 – Public Speaking, CMST 110 – Multicultural Communication (5 credits) 3. Basic Computer Course- Choose one of the following: CU 102, 103, 104, or CU 105 – Word I, Excel I, Power Point (IT 235 substitute is acceptable.)(1-5 credit requirement) All of the above co-requisites courses must be completed with a grade “C” or better and within two attempts. These courses may be taken while in the respiratory program, and MUST be completed to receive your degree and eligibility to take national board examination. It is recommended that the additional non-respiratory support courses be taken prior to entry in the program. Clinical Requirements for In-Program Students To complete the required clinical rotations, Allied Health students need to provide the following additional documentation prior to starting respiratory care classes. This information will be covered in the mandatory orientation for accepted students. Please make an effort to obtain your past immunizations, as the requirements are changing to include shots received as an infant. If you do not have records from your youth, you may be required to complete an additional series of 3 tetanus shots, one of which must be the Tdap (tetanus with pertussis vaccine). Health Clearance- Documentation of current immunizations for: 1. TB Test- TB Skin Test (single TB skin test in second year of program required). 2-step TB Test, if not tested in the last 12 months (this is a series of 2 skin tests within a week of each other. Have one skin test placed and read within 48-72 hours. Have the second skin test placed a week later, and read within 48-72 hours. New + TB results F/U by healthcare provider (chest X-ray and symptoms check), may also need to complete health questionnaire for facilities 04/22/15 5 2. 3. 4. 5. 6. History of + TB results provide proof of chest X-ray (lifetime, except if symptomatic) and submit negative symptom check in past 12 months. If no proof of + TB Test, then re-test with 2-step TB test. History of BCG vaccination test with 2-step TB Test Hepatitis B Series of 3 shots over the period of 6 months to a year, plus titer. First shot given Second shot one month after first shot Third shot given 6 months to one year after the second shot Titer to ensure immunity. Proof of immunity by vaccination or titer. Negative titer must repeat vaccine series. Student will be allowed in clinical while completing series or during repeat series. Considered a non-responder to vaccination after 2 complete vaccine series and titer negative. MMR (Measles, Mumps, Rubella) Proof of vaccination (2 doses) or proof of rubella, rubeola, and mumps immunity by titer. Varicella (Chicken Pox) Proof of vaccination or proof of immunity by titer. If born after 1994, student must have proof of 2 doses of varicella vaccination. Tetanus Vaccination with last 10 years. Tdap required if immunized after 6/1/07 If no record of baby immunizations is available, student may be required to repeat the series of 3 tetanus shots (Td, Td, Tdap). Flu Vaccine Proof of vaccination, repeated yearly while in the program Current CPR- Card for Health Care Providers. (Provided as part of RC 175) AIDS Education Certificate – 7 hour course (Provided as part of RC 175) Proof of Health Insurance – Required by clinical sites. Certified Background Check – Starting Fall 2009, the vendor for criminal background checks is CertifiedBackground.com©. It is the student’s responsibility to arrange for dependable transportation to and from the clinical site. Some clinical rotations begin as early as 6:00 am, some may be evening or night shift, and may be 6, 8, or 12 hour shifts. Dependable child/dependent care is necessary. 04/22/15 6 Tuition and Miscellaneous Costs Tuition as of Fall 2014 1st Quarter – 17 Credits 2nd Quarter – 14 Credits 3rd Quarter – 15 Credits 4th Quarter – 16 Credits 5th Quarter – 14 Credits 6th Quarter – 15 Credits 7th Quarter – 16 Credits Approximate TOTAL $1,466.83 $1,307.86 $1,360.85 $1,413.84 $1,307.86 $1,360.85 $1,423.84 9641.93 Additional fees added at time of registration include: Facility Fee - $ .50 per credit to 15 credits, maximum rate $7.50 Technology Fee - $1.75 per credit to 10 credits, maximum rate $17.50 Safety Fee - $15.00 per student Course Fees – as displayed in class schedule for individual classes Please note: Tuition rates subject to change by Washington State Legislature. Tuition and fees are due at the time of registration and payment must be completed within 2 business days of registration. Continuing students and new students who register early may defer fee payment until the published deferment date (see Quarterly Class Schedule calendar). Some courses have additional fees assessed. Washington Online (WAOL) students are assessed a $40.00 course fee once each quarter. This fee is non-refundable once the course begins. U.S. citizens and permanent residents who have not yet established Washington residency may now attend TCC at state resident rates. This optional waiver has been approved by the TCC Board of Trustees, but may not be available at all state colleges. A student who plans to transfer to a college that does not participate in this waiver is advised to establish Washington residency before transfer. Residency information is available at the Admissions Counter. Approximate Miscellaneous Costs: Course, Lab and Clinical Fees Books Uniform (Scrubs) per set Shoes Name Tag Stethoscope Watch with Second Hand Conference fees (Vary by Location) DataArc Certified Background Check and Health Clearance Tracking 04/22/15 7 $250 $1,500 $50 $100 $6 $60 Variable $250 60 $125 Graduation and National Board Examination Fees Therapist Multiple Choice Exam (CRT) Clinical Simulation Exam (RRT) State License fee Graduation Regalia (optional) $190.00 $200.00 $210.00 $25.00 Respiratory Therapy Program Curriculum Associate of Applied Sciences Degree Pre-requisites Credits BIOL 241 & 242 Anatomy and Physiology I & II ............................................................. 12 College Algebra (Math 99 or higher) ................................................................................ 5 PSYC 100 or 200General Psychology or Lifespan Psychology....................................... 5 HIT1301 Medical Terminology .............................................................................. 3 ___________________TOTAL CREDITS_____________________________________ 25 First Quarter – Fall Credits RC 1752 Respiratory Care Orientation .................................................................... 2 RC 150 Fundamentals of Respiratory Care I ......................................................... 4 RC 160 Cardiopulmonary A & P and Pathophysiology .......................................... 4 RC 170 Respiratory Therapy Equipment I ............................................................. 3 RC 180 Respiratory Therapy Clinical I .................................................................. 4 RC 193 Respiratory Pharmacology I ..................................................................... 1 Total Credits ........................................................................................... 18 Second Quarter – Winter Credits RC 151 Fundamentals of Respiratory Care II ........................................................ 4 RC 161 Arterial Blood Gases ................................................................................ 3 RC 171 Respiratory Therapy Equipment II ............................................................ 3 RC 181 Respiratory Therapy Clinical II ................................................................. 3 RC 194 Respiratory Pharmacology II ................................................................... 1 Total Credits ........................................................................................... 14 Third Quarter – Spring Credits RC 152 Mechanical Ventilation ............................................................................. 4 RC 162 Advanced Pathophysiology ..................................................................... 3 RC 172 Respiratory Therapy Equipment III ........................................................... 4 RC 182 Respiratory Therapy Clinical III ................................................................ 3 RC 195 Respiratory Pharmacology III ................................................................... 1 Total Credits ........................................................................................... 15 1 If students have already completed co-requisite classes but still need course credits for financial aid purposes, RC 299 (Independent Study) can be substituted for 1-5 credits as needed at any point during the program. 2 The orientation is a week-long class. The class is completed between Summer and Fall Quarters. 04/22/15 8 Fourth Quarter – Summer Credits CMST 101 Introduction to Communication ................................................................. 5 RC 153 Alternative Procedures in Respiratory Therapy ........................................ 3 RC 165 Evolving Roles in Respiratory Therapy ..................................................... 2 RC 183 Respiratory Therapy Clinical IV ................................................................ 4 RC 290 Ethics & Professionalism in Respiratory Care........................................... 2 Total Credits ............................................................................................ 16 Fifth Quarter – Second Fall Credits RC 192 Advanced Mechanical Ventilation ............................................................. 4 RC 240 Advanced Assessment & Diagnosis ......................................................... 3 RC 263 Pulmonary Functions .............................................................................. 3 RC 280 Specialty Clinical Rotation ........................................................................ 4 Total Credits ........................................................................................... 14 Sixth Quarter – Second Winter Credits Computers Word I, Excel I, and/or Power Point ......................................... 1-5 variable RC 251 Respiratory Pathophysiology Cases ......................................................... 2 RC 261 Pediatric and Neonatal Respiratory Care ................................................. 4 RC 281 Advance Critical Care Clinical Rotation .................................................... 4 Total Credits ........................................................................................... 15 Seventh Quarter – Second Spring Credits ENGL 101 English Composition................................................................................. 5 RC 262 Review of Application of Respiratory Care (hybrid) .................................. 4 RC 272 Pulmonary Rehabilitation, Home Care & Assistance in Specialty Procedures ...................................................... 3 RC 282 Neonatal Clinical Rotation ....................................................................... 2 RC 283 Specialty Clinical Rotation II ..................................................................... 2 Total Credits ........................................................................................... 16 Additional Program Course for students requiring fulltime schedule for Financial Aid Individual Study (RC 299)............................................................................... 1-5 variable Total Program Credits .................................................................... 132-136 Transfer Information The Associate in Applied Sciences degree is not a transferable degree to a four-year institution, although some courses within the degree may be accepted for transfer. Graduates may need to complete requirements for the Associate of Arts and Sciences degree for that purpose. Students wishing to transfer to a 4-year institution after graduation from the respiratory program are encouraged to take support courses for the general Associate of Arts and Sciences. Recommended courses that could be considered transferable include: English 102 Sociology Humanities History Foreign Language 04/22/15 9 Please refer to the college catalog of the school you wish to transfer to for complete degree requirements and/or speak with program faculty. Technical Standards for Respiratory Therapy Students The profession of respiratory therapy is a highly respected one. The reasons for this are many, but a great deal of it has to do with the fact that patients put their lives in our hands. Patients place their trust in healthcare providers and we, in turn, must be worthy of that trust. In order to become a member of a trustworthy allied health profession, there are several requirements that are essential. These have to do with responsibility, accountability, knowledge, skill and safety. The Respiratory Program has the responsibility to the public to assure that it’s students and graduates are competent in all of these areas and at the appropriate level. The program adheres to the definition, requirements, and procedures for licensing as defined in the state statutes (WAC 246-928-410 and WAC 246-928-510). The faculty models professionalism and requires that students be accountable and assumes a measure of responsibility to adhere to the standards of practice. The profession of respiratory therapy requires the acquisition of respiratory science knowledge and technical skills. Respiratory faculty, students, as well as graduates are held to these laws. The educational process to achieve the Associate of Applied Science Degree in Respiratory Therapy requires assimilation of this knowledge, as well as the development of critical thinking, judgment and appropriate decision-making. State licensure requires for reporting of unprofessional conduct (WAC 246-928-710). With the acquisition of this knowledge, students and graduates must be able to function as safe practitioners. Patient safety is a major concern for establishing requirements for capabilities of students. In order to safely function in the roll of a student and/or respiratory therapist, one must exhibit physical, cognitive and behavioral abilities that are required for satisfactory completion of all aspects of the respiratory therapy program. Collection, evaluation and synthesis of data are vital to this discipline. In addition, there are professional attributes that are required by the profession. All of these are every bit as important as the knowledge and skill The therapeutic modalities provided by respiratory care practitioners require technical skills involving manual dexterity and a mechanical aptitude to perform in a safe and acceptable manner. Respiratory Therapists must be mobile and have the ability to operate in relatively small spaces. These requirements are necessary because of the critical and accurate care that is often provided in crisis situations. To make sure these requirements can be met. The Respiratory Care program at Tacoma Community College has come up with the following technical standards. Physical Demands: Respiratory therapy students must be able to display the medium strength rating, as described by the Dictionary for Occupational Titles, which reflects the ability to exert 20 to 50 pounds of force occasionally (occasionally: activity of condition exists up to 1/3 of the time), and/or 10 to 25 pounds of force frequently (frequently: activity or condition exists from 1/3 to 2/3 of the time), and/or greater than negligible up to 10 pounds of force constantly (constantly: activity or condition exists 2/3 or more of the time) to move objects. Motor Skills: Respiratory therapy students must be able to execute motor movements including the physical/dexterity strength to stand and ambulate and possess the physical/dexterity strength to lift and transfer patients. Candidates/current respiratory therapy students must also have the physical strength to perform cardiopulmonary resuscitation. 04/22/15 10 Respiratory therapy procedures require coordination of both gross and fine muscular movements, equilibrium, and functional use of the senses of touch and vision. For this reason, candidates for admission to the Program of Respiratory Therapy must have manual dexterity and the ability to engage in procedures involving grasping, pushing, pulling, holding, manipulating, extending and rotating. Examples of such procedures would include, but not limited to: Draw venous and arterial blood Perform endotracheal suctioning Provide percussion and postural drainage for bronchial hygiene Perform manual resuscitation (CPR) in the event of a cardiac emergency Maintain and modify equipment in routine emergency situations Be able to move life support equipment in a rapid manner during a crisis situation Be sensitive to changes in pressure when performing emergency breathing with a manual resuscitator in the newborn and small infant as compared to the adult victim Tactile sensitivity required to perform arterial puncture on the newborn and small infant. Sensory/Observational Skills: Respiratory therapy students must be able to observe demonstrations and participate in laboratory experiments as required in the curriculum. Respiratory therapy students must be able to observe patients and be able to obtain an appropriate medical history directly from the patient or guardian. Such observation requires the functional use of vision, hearing, and other sensory modalities. Respiratory therapy students must have visual perception which includes depth and acuity. Communication Skills: Respiratory therapy students must be able to communicate in English effectively and sensitively with patients. In addition, candidates/current respiratory therapy students must be able to communicate in English in oral and handwritten form with faculty, allied personnel, and peers in the classroom, laboratory, and clinical settings. Respiratory therapy students must also be sensitive to multicultural and multilingual needs. Such communication skills include not only speech, but reading and writing in English. Respiratory therapy students must have the ability to complete written assignments and search and evaluate the literature. Respiratory therapy students must have the ability to complete written assignments and maintain written records. Respiratory therapy students must have the ability to complete assessment exercises. Respiratory therapy students must also have the ability to use therapeutic communication, such as attending, clarifying, coaching, facilitating, and touching. These skills must be performed in clinical settings, as well as the didactic and laboratory environments. Intellectual/Conceptual, Integrative, and Qualitative Skills: Respiratory therapy students must have the ability to measure, calculate reason, analyze, and synthesize data. Problem solving and diagnosis, including obtaining, interpreting, and documenting data, are critical skills demanded of respiratory therapists which require all of these intellectual abilities. These skills allow students to make proper assessments, sound judgments, appropriately prioritize therapeutic interventions, and measure and record patient care outcomes. Respiratory therapy students must have the ability to learn to use computers for searching, recording, storing, and retrieving information. Behavioral/Social Skills and Professionalism: Respiratory therapy students must demonstrate attributes of empathy, integrity, concern for others, interpersonal skills, interest and motivation. Respiratory therapy students must possess the emotional well-being required for use of their intellectual abilities, the exercise of sound judgment, the prompt completion of all responsibilities attendant to the evaluation and care of patients, and the development of mature, sensitive, and effective relationships with patients. Respiratory therapy students must be able to adapt to ever-changing environments, display flexibility, and learn to function in the face of 04/22/15 11 uncertainties and stresses which are inherent in the educational process, as well as the clinical problems of many patients. Respiratory therapy students must be able to maintain professional conduct and appearance, maintain client confidentiality and operate within the scope of practice. Candidates/current respiratory therapy students must also have the ability to be assertive, delegate responsibilities appropriately, and function as a part of a medical team. Such abilities require organizational skills necessary to meet deadlines and manage time. The Respiratory Care program at Tacoma Community College will makes every effort to provide the physically compromised student the opportunities to learn and develop into a safe, rational respiratory care practitioner. It is incumbent upon the student to realize that certain manual, technical, and professional tasks must be mastered in order to achieve passing grades and to successfully complete the respiratory therapy curriculum. RESPIRATORY THERAPIST (Pierce County Employment & Training Consortium- Information Sheet Job Description Treat people who have difficulty breathing due to heart or lung problems. Determine most suitable method of administering inhalants, precautions to be observed, and potential modifications needed, compatible with physicians’ orders. Perform the tests that aid in the diagnosis and evaluation of respiratory problems using special apparatus and administering therapies. Determine requirements for treatment, such as type and duration of therapy, and medication and dosages. Monitor patient progress. Teach patients how to use prescribed respiratory treatment methods and equipment. Provide emergency respiratory care. Employment Outlook • Faster-than-average employment growth is projected for respiratory therapists. • Employment of respiratory therapists is expected to grow 19 percent from 2006 to 2016, faster than the average for all occupations. • Job opportunities will be best for therapists with cardiopulmonary skills or experience working with newborns and infants. Average Annual Earnings in Pierce County* Entry Level: $35,200 Median: $47,420 Experienced: up to $50,000+ *Based on a survey of earnings from May 2006. On-line Sources for Additional Information The National Board of Respiratory Care, Inc. (NBRC): www.nbrc.org American Association for Respiratory Care (AARC): www.aarc.org Respiratory Care Society of Washington (RCSW): www.rcsw.org Commission for Accreditation of Respiratory Care (CoARC): www.coarc.com 04/22/15 12 Healthcare occupations that could transition into Respiratory Therapy, with training: Lab Assistant/Phlebotomist, Health Unit Clerk, Service Workers (including housekeeping and food services), Nursing Assistant or Medical Assistant. Career Advancement Respiratory therapists advance in clinical practice by moving from care of general to critical patients who have significant problems in other organ systems, such as the heart or kidneys. Respiratory therapists, especially those with 4-year degrees, may also advance to supervisory or managerial positions in a respiratory therapy department. Respiratory therapists in home care and equipment rental firms may become branch managers. Some respiratory therapists advance by moving into teaching positions. 04/22/15 13 04/22/15 14 Healthcare/Patient care Verification Form – Respiratory Therapy Program For additional points, please provide proof of patient-related volunteer or paid patient related healthcare experience. Please fill out this form and have your direct supervisor verify and sign. Points will be given based on overall hours. Please refer to page 4 for examples of accepted direct patient-related healthcare experience. Print Name: _____________________________________________________________ Signature: ______________________________________________________________ Hospital/Clinic/Facility: _____________________________________________________ Number of Hours: ____________________ Start Date: _____________________ End Date: _____________________ Please list specific type of healthcare/patient care experience. Supervisor: Print Name: ____________________________________ Signature: _____________________________________ Phone: ________________________________________ *By signing above you verify that this applicant has had direct patient related healthcare experience. 04/22/15 15 Hospital Visitation Form – Respiratory Therapy Program Applicant’s Name: Hospital: Date/Time: Number of Hours: Exams Observed: Applicant’s comments regarding visitation session: Respiratory Therapist’s Signature: Applicant’s Name: Hospital: Date/Time: Number of Hours: Exams Observed: Applicant’s comments regarding visitation session: Respiratory Therapist’s Signature: 04/22/15 16 Hospital Visitation Intent Form – Respiratory Therapy Program (To be filled out if no visitation was completed) Applicant’s Name: Hospital/Clinic Attempted to visit: ____ Reason for not being able to visit: ___________________________________________________ 04/22/15 17