ࡱ> lnk{ 4bjbjzz {,%zzXXX8D|X<$dPP"rrrMMM#######%R(#MMMMM#rr#Mjrr#M#:k o#rϏ7#.# $0<$e# ((o#(o#\MMM##6MMM<$MMMM(MMMMMMMMMz :  Health Screening Application for Admission Master of Athletic Training Program Checklist for Applicant _____ 1. Read the Core Performance Standards for Admission into the Master of Athletic Training Program per attachment and provide your signature stating that you presented them to your physician (M.D. or D.O.) during your physical examination. _____ 2. Complete the Medical History Form. _____ 3. Obtain a Physical Examination by your physician and have him/her complete the provided form with original signature. _____ 4. Have your physician complete and sign the Core Performance Standards for Admission into the Master of Athletic Training Program signature page after completing your physical examination. _____ 5. Provide all documentation on TB, MMR, Tetanus and Hepatitis B per attached form. _____ 6. Sign the Permission to Review Health Screening Information form. Core Performance Standards for Admission and Progression into the Master of Athletic Training Program Below are listed the performance standards of the professional Master of Athletic Training Program. You should read these standards carefully and be sure you can comply with them. The Master of Athletic Training Program expects that all applicants for admission possess and demonstrate the skills, attributes and qualities set forth below, with or without reasonable dependence on technology or intermediaries. Issue Standard Some Examples of Necessary Activities Critical Thinking Critical thinking ability Identify cause-effect relationships in sufficient for clinical clinical situations, develop and implement judgment; sufficient powers athletic training care plans; respond without of intellect to acquire, assimilate delay to emergency situations. integrate, apply and evaluate information and solve problems. Interpersonal Interpersonal abilities sufficient Establish rapport with patients/clients, to interact with individuals, colleagues and other health care personnel. families, and groups from a variety of social, emotional, cultural, economic and intellectual backgrounds. Communication Communication abilities sufficient Explain treatment procedures, initiate health for interaction with others in teaching to individual clients, document and verbal and written form. Utilizes interpret athletic training actions and effective communication skills patient/client responses. Communicate to interact with patient/client, information accurately and effectively with peers, and other health care other departments/colleagues/client/families. personnel of various ages, cultural, Evaluate written orders, care plans and economic, and intellectual treatment requests. backgrounds in a variety of settings. Mobility Physical abilities sufficient to move Move around in the athletic training room, from room to room, athletic work spaces, treatment areas & administer sidelines to athletic playing field, cardiopulmonary resuscitation. Lift, move, lift and position, maneuver in small pos. and transport patients without causing places, and physical health and harm, undue pain, and discomfort to the stamina needed to carry out athletic patient or one's self. Transport mobile eq. training procedures. in timely and cautious manner. Motor Skills Gross and fine motor abilities Calibrate, use and manipulate equipment sufficient to provide safe and properly; position patients/clients, effective athletic training care. manipulate a computer, tape and wrap bandages; maintain sterility of equipment. Sensory Sufficient use of the senses Hear emergency signals, auscluatory sounds, of vision, hearing, touch, and cries for help, perform visual assessments of smell; to observe, assess, and patients/clients. Observe patient(s/client(s evaluate effectively (both close responses; perform palpation, functions at hand and at a distance) in of physical examination and/or those related the classroom, laboratory, to therapeutic intervention. and clinical setting. Behavioral Sufficient motivation, responsibility Adapts to assignment of patient and/or and flexibility to function in new, clinical/lab area in a manner that allows ever-changing and stressful students to meet objectives while providing environments. Adapts appropriately a safe, adequate patient care. Accountable to ever changing needs of clients. for clinical preparation and independent study and performs athletic training functions in a safe responsible manner. Ability to recognize the need for further research and respond accordingly based on changes in patient/client status since clinical assignment was made. Signature Page for Core Performance Standards for Admission and Progression into the Master of Athletic Training Program APPLICANT COMPLETES I (Print Your Name) ______________________ have read the Core Performance Standards for Admission and Progression into Master of Athletic Training Program and presented them to my physician. _____________________ ______ Applicants Signature Date PHYSICIAN COMPLETES Per my physical examination of (Print Applicant Name)_______________________, I confer that he/she is able to perform the technical/performance standards as I have answered below. ____________________________ _______ Physician Signature Date Please answer one of the following by placing an X in the space provided. _____ 1. Yes, the applicant can perform the above listed technical/performance standards as described above without reasonable dependence on technology or intermediaries. _____ 2. No, the applicant cannot perform the listed technical/performance standards as described without using some form of reasonable dependence on technology or intermediaries. If you checked response #2 then complete the following section: The following reasonable technological or intermediaries are needed for admission and progression into the Master of Athletic Training Program: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (Attach other statements or documents as needed) Medical History Form Name:_______________________________ 91Ƶ Student ID.: __________________ Date of Birth: ________________________ Gender: ________ Have you had or do you currently have any of the following? Respond by circling yes or no. Explain yes responses on the back of this page. Positive responses do not imply denial of entrance into the Master of Athletic Training Program. Visual Defects yes no Hearing Defects yes no Speech Defects yes no Cardiac Disease/Disorder yes no High Blood Pressure yes no Family History of Cardiac Disease yes no Tuberculosis, Lung, or Respiratory Problems yes no Hepatitis, Liver Disease yes no Sexually Transmitted Disease yes no Fainting Spells, Epilepsy or Convulsions yes no Diabetes yes no Kidney or Bladder Disease yes no Cancer yes no Back Injuries yes no Joint Injuries yes no Any Previous Surgeries yes no Immunosuppressive Therapy yes no Currently Under Chemical Dependency Treatment yes no Do you Smoke yes no Do you have Allergies yes no Do you have any communicable diseases? yes no Do you have a Disability that would prevent you yes no from meeting the Core Performance Standards for the Master of Athletic Training Progam? I have read the above and declare that I have no injury or illnesses other than as specifically herein noted. Any falsification or misrepresentation will be sufficient grounds for my release from the Master of Athletic Training Program. Signature________________________________ Date:______________ (Applicant) Physical Examination Form Name:________________________________ (Print Applicants Name) SKIN  EYES  VISION  EARS  HEARING  NOSE/THROAT  NECK  CHEST  HEART  ABDOMEN  HERNIA  EXTREMITIES  NEUROLOGICAL  MENSTRUAL HISTORY   BP T R P COMMENTS  I hereby certify that I have reviewed this patients information. I have examined this patient and have found them to be free of communicable diseases. I have reviewed their records and find them current on all required immunizations. Signature: _____ (Original Signature) Date Documentation of Vaccination Status and TB Skin Test TB SKIN TEST Proof of TB Skin Testing Date: ___________ Attach a copy of entry into applicants record at MD office Vaccination Status 1. Proof of Tetanus Immunization: Date: ___________ Attach on of the following below to provide proof a. copy of entry into applicants record at MD office b. copy of bill for Tetanus Injection c. copy of Immunization Record Proof of Rubella Immunization: Date:___________ Attach on of the following below to provide proof a. copy of entry into applicants record at MD office b. copy of bill for Rubella Injection c. copy of Immunization Record Proof of Measles Immunization: Date:___________ Attach on of the following below to provide proof a. copy of entry into applicants record at MD office b. copy of bill for Measles Injection c. copy of Immunization Record Proof of Mumps Immunization: Date:___________ Attach one of the following below to provide proof: a. copy of entry into applicants record at MD office b. copy of bill for Mumps injection c. copy of immunization Record 5. Proof of Hepatitis B Vaccination: or Waiver Date:___________ Attach one of the following below to provide proof: a. copy of entry into applicants record at MD office b. copy of bill for Hepatitis B injections c. copy of immunization Record MANDATORY HEPATITIS B VACCINATION DECLINATION FORM I understand that due to my occupational exposure to blood or other potentially infectious material. I may be at risk of acquiring the Hepatitis B virus (HBV) infections. I understand that I must either provide evidence of immunization (3 injection series) or sign this waiver releasing the University and clinical agencies from any responsibility should I contract Hepatitis B. I release 91Ƶ, Master of Athletic Training Program or any agency in which I attend clinical experiences of any responsibility for any consequences of this decision. 91Ƶ Student ID # ____________________________________________ ___________ Signature Date ____________________________________________ ___________ Witness Date Permission to Review Health Screening Information I (print your name)______________________ give the Director of the Master of Athletic Training Program my permission to review my medical records as required by the Master of Athletic Training Program for purposes of my application for admission and progression into the Master of Athletic Training Program. I am aware that they will be placed in a secured location. _____________________________ ________ Applicant Signature Date     PAGE  PAGE 1 -PQS\ajl~0 ? { | H I { 5 6 H I J { |   F c ¹汩橱枱hK CJaJ hK 5\ h15\ h5\h 5CJ\aJh1CJaJh=CJaJh >*CJaJh15>*CJ\aJh 5>*CJ\aJh-5>*CJ\aJh CJaJh  h;5\ h 5\2-QRSklc d   6 7 ``^``$a$   3yp`p$a$gd1|]|gd1  y}HVWz{_lm{56|}efRS 678_`#%&נh15CJ\aJhK h5CJ\aJhK 5CJ\aJhK hCJaJhK CJaJhK h CJaJhK h 5CJ\aJhK h 5>*CJ\aJ>'GH-D^_^@D1{ `^`p`p `p UM5 `^`` `^` `^` `P^`Pp`p ,-$%qr  YZi|}01Rbh*/`czƿƸ͙͕ͩ͊͡wƸh1CJaJh 6CJ]aJh16CJ]aJhK h CJaJh 5>*\h15>*\ h15\ hK 5\ h5\ h 5\h hK h 5CJ\aJhK CJaJhK h CJaJ j=hK h CJaJ.ijklmnopqrstuvwxyz{|}~$a$^2 ` ^` `^`$a$23+-./{&'2 u -! & F `pp^p^` ``^`` ` ^` `^`z{'Aj +!.!0!1!E!F!l!!9"h"""A$B$&#&&'T']'`'j''''''''''''''''' ( (((!("(h5CJ\aJh15CJ\aJh 5CJ\aJhCJaJh1CJaJhK CJaJh CJaJh CJaJh 5CJ$\aJ$h=t5CJ$\aJ$h 6CJ]aJ h 5\h1h 5-!.!/!0!1!F!G!!!!!"""""##>#\####$4$I$l$$$$a$$$$$,%D%d%%%%%%&&&'&''S'_'`'a'b'c'd'e'f'g'h'$a$` `P^`Ph'i'j'''''''''''''''Ekd$$Ifx0>TP&4 xa:$If$If $:$Ifa$ d$If`$a$''''''''''QEkd$$Ifx0>TP&4 xa $:$Ifa$ d$IfEkdk$$Ifx0>TP&4 xa:$If$If ''''''''''''EkdA$$Ifx0>TP&4 xa:$If$If $:$Ifa$ d$If ''' ( ( ( ( (((QEkd$$Ifx0>TP&4 xa:$If$If $:$Ifa$ d$IfEkd$$Ifx0>TP&4 xa (((((((( (!( $:$Ifa$Ekd$$Ifx0>TP&4 xa:$If$If d$If !("(#()(*(+(,(-(.(6(QEkdX$$Ifx0>TP&4 xa:$If$If $:$Ifa$ d$IfEkd$$Ifx0>TP&4 xa "(,(-(9(:(E(F(V(W(h(i(((((((()))))))))3*>*M*R*T*Y*Z*e*f*******ujh1h1CJaJh1h 5>*CJ\aJh1h:CJ\aJh1h CJ\aJh1hCJaJh1h CJaJh1h 5CJ\aJh:5CJ\aJh 5>*CJ\aJhK 5CJ\aJh CJaJh5CJ\aJh 5CJ\aJ)6(7(8(9(:(;(B(C(D(E( $:$Ifa$Ekd$$Ifx0>TP&4 xa:$If$If d$If E(F(G(S(T(U(V(W(X(e(QEkd$$Ifx0>TP&4 xa:$If$If $:$Ifa$ d$IfEkd.$$Ifx0>TP&4 xa e(f(g(h(i(j(|(}(~(( $:$Ifa$Ekd$$Ifx0>TP&4 xa:$If$If d$If ((((((((((((+$If $+$Ifa$ d$IfEkdo$$Ifx0>TP&4 xa ((((((((wlwff^:$If$If $:$Ifa$ d$If~kd$$Ifxr>T [P&y? 4 xa((())))))&*'*4*5*f***$a$ ^`gd:gd:` `P^`PEkdo$$Ifx0>TP&4 xa****"+X+~++++,:,`,,,,,-C-b-c----$.C.D.. ``  *****"+C++++++++++,%,~,,,,,,,,-b-c-l-------#.$.B.C.P.s.u.v...//:/;/*\h1CJaJh1h 5>*CJ\aJh15CJ\aJh1h 5CJ\aJh1h1CJaJh1h:CJaJh1hCJaJh1h CJaJ5.../;//?/@/A/B/C/D/E/F/G/H/I/J/}/~/1111111$a$`J/|/}/~/111$1'16111111*2+222222222233/3u3333j4s4444444444444444444h{%uh=t h=t0Jjh=t0JUhjhUh 5CJ\aJhuq5CJ\aJh 6CJ]aJ huq5\ h:5\ h5\hh>* h>*hK hh  h 5\412021222l22222222222222222222222$a$ `^`22222222222@4A4B4j44444444444 &`#$gd{%u ` ^` ^gd:gd:$a$44444444 ` ^` &`#$gd{%u444444444h hh{%uh=t h=t0Jhuq0JmHnHujh=t0JU50P/ =!"#$% Dp8 00P/ =!"#$% Dp8 00P/ =!"#$% Dp8 00P/ =!"#$% Dp8 00P/ =!"#$% Dp8 00P/ =!"#$v%v Dp8 00P/ =!"#$v%v Dp> 00P:p / =!"#$v%v Dpi$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xai$$If!vh#v#v:V x55/ 44 xa$$If!vh#v#v#vy#v? #v:V x555y5? 5/ 44 xai$$If!vh#v#v:V x55/ 44 xa^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH L`L Normal1$7$8$H$CJ_HaJmH sH tH DA`D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List <& < Footnote ReferenceLOL Level 1# & F h0@&^`04 @4 =tFooter  !.)@!. =t Page NumberPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] }0i!*,z7zqzzz{Y{{ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$' z"(*J/44!%.68< 2-!$h''''(!(6(E(e((((*.1244 "#$&'()*+,-/01234579:;  '!!8@0(  B S  ?\g#j,s,,,,,,,,,,,,ltdl7?3=y'2-5DP^ g @ I D H 1 7 { ` j pr UWMP57Z]/3gi{'/KMCE"###X#Y#~##$$:$;$`$a$$$%%C%D%%%%&$&%&z&|&&&&&''j,,,,,,,,,,,,,33333333333333333333333333333333333333333333333333333333333333333333333333#T]""8#C###$%$$$$%%%%%u&v&&&G'J'**j,s,,,,,,,,,,#T]""8#C###$%$$$$%%%%%u&v&&&G'J'**j,s,,,,,,,,,,,,,,................0.1.2.@3.4.5.@6.7.@0.@1.2.3.@4.5.6.7. AutoList1 AutoList1-=K X  =t{%uuq\1;:,,@,p@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialkWP TypographicSymbolsCourier NewA$BCambria Math"A hu[gc % P% P! xx2p,p,3 P? 2!xx Health ScreeningYellen, Joshua BYellen, Joshua B  Oh+'0   @ L X dpxHealth ScreeningYellen, Joshua BNormalYellen, Joshua B4Microsoft Office Word@d@'E@" @Vr %՜.+,0 hpx  Pp, Health Screening Title91Ƶ  !"#$%&'()*+,-./0123456789:;<=?@ABCDEGHIJKLMNOPQRSTUVWXYZ\]^_`abmRoot Entry F<ғoData >1TableF(WordDocument{SummaryInformation([DocumentSummaryInformation8@CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q՜.+,0 hpx  Pp, Health Screening Title91Ƶ