Application Packet

MATC PHARMACY TECHNICIAN PROGRAM
MOUNTAINLAND
APPLIED TECHNOLOGY COLLEGE
American Fork
Orem
Spanish Fork
Thanksgiving Point
Wasatch
FALL 2015
Pharmacy Technician Program
Mountainland Applied Technology College
PH A R M A C Y TE CH NICIAN RE G IST RAT ION PACK E T
Please read through this entire packet very carefully and fill out all forms completely. Incomplete forms will not be
accepted. Packets must be received by August 14, 2015
Please read the following information carefully.
1.
Registration Check List for the
Pharmacy Technician Program
The Utah Department of Occupational and Professional Licensing
(DOPL) has strict guidelines about who is allowed in a pharmacy
and who can dispense medications. Prior to starting the pharmacy
technician program students must get a Pharmacy Technician
Trainee License through the Department of Public Licensing
(DOPL).
The application to receive this license is attached to this packet.
Please read through it very carefully and make sure you fill out
all parts of the application. Page 2 of the application requires a
signature from a “program representative”. Before mailing in the
application to DOPL, please have either a Pharmacy Technician
Instructor or an MATC Student Services representative sign the
application.
2.
Application for Trainee
License mailed to DOPL
(background check included) for
adult students.
All adult and high school students are required to do a 9 panel
drug screen. The information on the drug screen is included in this
packet.
4.
Copy of immunizations
attached.
Copy of TB test results
attached.
The DOPL application for adult students (18 years or older)
requires a background check. The form and directions to receive
this background check are included in this packet. Any student 18
years or older needs to include the background check results with
the Trainee License Application.
3.
Drug Screen completed. Copy
of Work Med form/receipt
attached.
Students are required to provide the MATC with a copy of their
current immunization record and recent TB test results. A list of the
required immunizations are attached. This is a requirement to be
eligible to do training hours inside of a healthcare facility.
You, the student, are required to cover all the costs related to
the registration process. Tuition and fees through the MATC do
not cover these expenses.
If you have any questions or concerns,
please feel free to contact any of the
Pharmacy Technician Instructors:
Sandi Boren - Daytime Instructor
Thanksgiving Point Campus
[email protected]
Mandi Connelly - Evening Instructor
Thanksgiving Point Campus
[email protected]
Sadie Torgerson - Daytime Instructor
Spanish Fork Campus
[email protected]
PHARMACY TECHNICIAN APPLICATION PACKET
MOUNTAINLAND APPLIED TECHNOLOGY COLLEGE
American Fork
Orem
Spanish Fork
Thanksgiving Point
Wasatch
2015
Pharmacy Technician Program
Mountainland Applied Technology College
Immunization Requirements Information
MATC Pharmacy Technician Program
These requirements may be revised as mandated by the Centers for Disease Control and Prevention (“CDC”) or
Intermountain Healthcare. Such revised requirements shall become binding upon and adhered to by the parties on and
after the effective date as designated by the CDC or Intermountain Healthcare.
1.
2.
3.
Tuberculosis screening requirements. One of the following is required:
(a)
2-step TST (two separate Tuberculin Skin Tests, aka PPD tests) within twelve months of each other.
The last TST should be completed at the time the student/worker begins their training/work assignment
at an Intermountain Healthcare Facility.
(b)
One (1) QuantiFERON Gold blood test with negative result.
(c)
One (1) T-SPOT blood test with negative result.
(d)
If previously positive to any TB test, student/worker must complete a symptom questionnaire and have a
chest x-ray read by a radiologist with a normal result. If chest x-ray is abnormal, the student/worker
needs to be cleared by their physician or local health department before beginning their training/work
assignment at an Intermountain Healthcare Facility.
Measles (Rubeola), Mumps and Rubella requirement. One of the following is required:
(a)
Proof of two (2) MMR vaccinations.
(b)
Proof of immunity to Measles (Rubeola), Mumps, Rubella through a blood test.
Tdap requirement:
(a)
4.
5.
Proof of one (1) Tdap vaccination after age ten.
Varicella (Chicken Pox) requirement. One of the following is required:
(a)
Proof of two (2) Varicella vaccinations.
(b)
Proof of immunity to Varicella through a blood test.
(c)
Healthcare Provider documentation of Varicella disease.
Flu Vaccination requirement:
(a)
6.
Proof of current, annual influenza vaccination.
Hepatitis B. The Hepatitis B series should be offered to anyone who is at risk for an occupational exposure,
which is defined as someone with a reasonably anticipated skin, eye, mucous membrane, or parenteral contact
with blood or other potentially infectious materials that may result from the performance of their duties. One
of the following should be performed:
(a)
Documentation of three (3) Hepatitis B vaccinations and blood test with “Reactive” result.
(b)
Documentation of three (3) Hepatitis B vaccinations given more than 8 weeks prior to start date with no
documented blood test results (no blood test is required, but a baseline titer should be run immediately if
the person has a significant exposure to blood or body fluids).
(c)
Blood test with “Reactive” result.
(d)
Documentation of six (6) Hepatitis B Vaccinations with blood test result of “Not Reactive” (this person
is considered a “Non-Responder”).
Documentation must be provided upon request by Intermountain Healthcare.
PHARMACY TECHNICIAN APPLICATION PACKET
MOUNTAINLAND APPLIED TECHNOLOGY COLLEGE
American Fork
Orem
Spanish Fork
Thanksgiving Point
Wasatch
2015
Pharmacy Technician Program
Mountainland Applied Technology College
Drug Screen Information
MATC Pharmacy Technician Program
Students need to get a 9 panel drug screen before they
register for the Pharmacy Technician Program. Students
must pay for the drug screen and have the results
sent to the MATC. A release form must be completed to
get the results sent to the MATC. Please have Work Med
send the results to:
MATC-Attention Pauline Day
2301 W. Ashton Blvd.,
Lehi, UT 84043
or by email at:
[email protected]
Locations:
Orem IHC Work Med
830 North 980 West
Orem, UT 84057
801-724-4000
Hours: M - F, 7am - 5pm
Springville IHC Work Med
385 South 400 East
Springville, UT 84663
801-491-6400
Hours: M - Th, 8am - 5pm
Murry IHC Work Med
201 East 5900 South #100
Murry, UT 84107
801-288-4900
Hours: M - F, 8am - 5pm
Salt Lake City IHC Work Med
1685 West 2200 South
Salt Lake City, UT 84119
801-972-8850
Hours: M - F, 7:30am - 5:30pm
PHARMACY TECHNICIAN APPLICATION PACKET
MOUNTAINLAND APPLIED TECHNOLOGY COLLEGE
American Fork
Orem
Spanish Fork
Thanksgiving Point
Wasatch
2015
Official Use Only
State of Utah
Department of Commerce
Division of Occupational and Professional Licensing
Number: ___________________________________
Date Approved/Denied:________________________
Approved/Denied By: _________________________
Pharmacy Technician Trainee
APPLICANT INFORMATION
Full Legal Name:
First
Middle
Last
All Previous Legal Names:
Other DOPL Licenses Held:
SSN:
Date of Birth:
Male
Gender:
Female
Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
Phone:
ZIP Code
Email:
Please Select ONE:
I am a United States citizen OR a non-citizen of the United States who is lawfully present.
I am a foreign national not physically present in the United States.
None of the above, please explain:
Driver License
or State ID Card:
State of
Issue
License Number
Expiration Date
NOTE: If you do not hold a US Driver License or a US State ID, you must present a legible copy of your current and
valid government issued document(s) showing evidence of authorization to work in the United States.
AFFIDAVIT AND RELEASE
1.
I certify that I am qualified in all respects for the license for which I am applying in this application.
2.
I certify that to the best of my knowledge, the information contained in the application and all supporting
document(s) are true and correct, discloses all material facts regarding the applicant, and that I will update or
correct the application as necessary, prior to any action on my application.
3.
I authorize all persons, organizations, governmental agencies, or any others not specifically listed, which are set
forth directly or by reference in this application, to release to the Division of Occupational and Professional
Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division to
properly evaluate my qualifications for licensure/certification/registration by the State of Utah.
4.
I understand that it is the continuing responsibility of applicants and licensees to read, understand, and apply the
requirements contained in all statutes and rules pertaining to the occupation or profession for which I am applying,
and that failure to do so may result in civil, administrative, or criminal sanctions.
5.
I certify that I do not currently pose a direct threat to myself, to my clients, or to the public health, safety or welfare
because of any circumstance or condition.
6.
I understand that I am responsible to update the Division of any changes relating to my
license/certification/registration.
Signature of Applicant: ______________________________________________ Date: _________________________
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
QUALIFYING QUESTIONNAIRE
Read thoroughly, and answer each question. Do not leave any question blank.
A “yes” answer does not necessarily mean you will not be granted a license; however, DOPL may request additional documentation if the
information submitted is insufficient.
1.
Yes
No
2.
Yes
No
3.
Yes
No
4.
Yes
No
5.
Yes
No
6.
Yes
No
7.
Yes
No
8.
Yes
No
9.
Yes
No
10.
Yes
No
11.
Yes
No
12.
Yes
No
Have you ever had a license, certificate, permit, or registration to practice a regulated profession
denied, conditioned, curtailed, limited, restricted, suspended, revoked, reprimanded, or
disciplined in any way?
Have you ever been permitted to resign or surrender your license, certificate, permit, or
registration to practice in a regulated profession while under investigation or while action was
pending against you by any professional licensing agency or criminal or administrative
jurisdiction?
Are you currently under investigation or is any disciplinary action pending against you now by
any local, state or federal licensing, enforcement or regulatory agency?
Have you ever been declared by any court to be incompetent by reason of mental defect or
disease and not restored?
Have you ever had a documented case in which you were involved as the abuser in any incident
of verbal, physical, mental, or sexual abuse?
Have you been terminated, suspended, reprimanded, sanctioned, or asked to leave voluntarily
from a position because of drug or alcohol use or abuse within the past five (5) years?
Are you currently using or have you recently (within 90 days) used any drugs (including
recreational drugs) without a valid prescription, the possession or distribution of which is unlawful
under applicable state or federal laws?
Have you ever unlawfully used any drugs for which you have not successfully completed, or are
not now participating in a supervised drug rehabilitation program, or for which you have not
otherwise been successfully rehabilitated?
Do you currently have any criminal action pending?*
Have you pled guilty to, no contest to, entered into a plea in abeyance or been convicted of a
misdemeanor in any jurisdiction within the past ten (10) years? *
Have you ever pled guilty to, no contest to, or been convicted of a felony in any jurisdiction?*
Have you ever been incarcerated for any reason in any correctional facility (domestic or foreign)
in any jurisdiction or on probation/parole in any jurisdiction?*
*NOTE: Charges that were later dismissed and motor vehicle offenses such as driving while impaired or intoxicated
must be disclosed; however, minor traffic offenses such as parking or speeding violations need not be listed.
If you answered “Yes” to any of the above questions, enclose with this application complete information with respect to all
circumstances and the final result, if such has been reached.
If you answered “Yes” to Questions 9,10,11 or 12 you must submit the following for EACH and EVERY incident:

Personal account of the incident

police report(s)

court record(s)

probation/parole officer report(s)
If you are unable to obtain any of the records required above, you must submit documentation on official letterhead from the
police department and/or court indicating that the information is no longer available.
TRAINING PROGRAM
To be completed by the Program Representative:
Applicant’s Name:
Name of Education Program:
Telephone Number:
Email:
By signing below, I certify that the applicant named above is enrolled in a program of education outlined in 58-17b-305
(1)(f) and R156-17b-303a (3) and (4).
Signature of Program Representative:
Printed Name:
Date:
Title:
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
MEDICAL QUALIFYING QUESTIONNAIRE
Read thoroughly, and answer each question. Do not leave any question blank.
A “yes” answer does not necessarily mean you will not be granted a license; however, DOPL may request additional documentation if the
information submitted is insufficient.
1.
2.
3.
Have your rights, privileges, and/or participation ever been denied, conditioned, curtailed, limited, restricted,
suspended or revoked in any way by:
Yes
No
a hospital or health care facility
Yes
No
Medicaid, Medicare or any other state or federal health care payment reimbursement program
Yes
No
the Federal Drug Enforcement Administration or any state drug enforcement agency
Yes
No
malpractice insurance coverage
Yes
No
other entity: _____________________________________________________________________
Have you ever been permitted to resign or surrender any rights, privileges and/or participation while under
investigation or while action was pending against you from:
Yes
No
a hospital or health care facility
Yes
No
Medicaid, Medicare or any other state or federal health care payment reimbursement program
Yes
No
the Federal Drug Enforcement Administration or any state drug enforcement agency
Yes
No
malpractice insurance coverage
Yes
No
other entity: _____________________________________________________________________
Is any action pending against you now by:
Yes
No
a hospital or health care facility
Yes
No
Medicaid, Medicare or any other state or federal health care payment reimbursement program
Yes
No
the Federal Drug Enforcement Administration or any state drug enforcement agency
Yes
No
malpractice insurance coverage
Yes
No
other entity: _____________________________________________________________________
4.
Yes
No
Have you been named as a defendant in a malpractice suit?
5.
Yes
No
Have you ever had office monitoring, practice curtailments, individual surcharge assessments based
upon specific claims history, or other limitation, restrictions or conditions imposed by any malpractice
carrier?
If you answered “Yes” to question 4 you must submit a complete narrative of the circumstances and a National Practitioner
Data Bank report outlining all professional liability claims made against your license and any settlements paid by or on your
behalf. NPDB website: http://www/npdb.hrsa.gov.
If you answered “Yes” to any of the above questions, enclose with this application complete information with respect to all
circumstances and the final result, if such has been reached.
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
APPLICATION CHECKLIST AND INSTRUCTIONS
This checklist is for your convenience, you do not need to include it with your application.
NOTE: Incomplete applications will be denied.
Your application is classified as a public record and may be available for inspection by the public, except with
regard to the release of information which is sub-classified as controlled, private, or protected under the
Government Records Access and Management Act or restricted by other law.
The following items are required to complete your application:
 $50.00 non-refundable application-processing fee, made payable to “DOPL”.
 Supporting documentation for any “yes” answers provided on either of the qualifying questionnaires. See
pages 2 and 3 of the application for more information.
 If 18 or older on the date submitting this application, submit an original “Criminal History Report” from the
Utah Bureau of Criminal History. For information on how to obtain this report, please see
http://www.publicsafety.utah.gov/bci/crimrecords.html .
Please Note: There have been recent changes to the approval of Pharmacy Technician Training Programs. It is
important that you read and understand these changes prior to submitting your application. Applicants who are
not enrolled in acceptable programs will be denied.
To qualify for a trainee license, you must be enrolled in one of the following pharmacy technician training
programs:

Program approved by Division on or before April 30, 2014;

Program accredited by the American Society of Health System Pharmacists (ASHP) or that was in ASHP
candidate status on the day you completed the program;

National Pharmacy Technician Association (NPTA) Online Program;

Pharmacy Technicians University; or

Program conducted by a branch of the Armed Forces of the United States.
Submit the above items with your completed application to:
In person or via express delivery:
Division of Occupational and Professional Licensing
Heber M Wells Building, 1st Floor Lobby
160 E 300 S
Salt Lake City, UT 84111
US Postal Service:
Division of Occupational and Professional Licensing
PO BOX 146741
Salt Lake City, UT 84114-6741
If you have questions, please contact the Division via our direct email address, [email protected], or via the
phone or fax listed below.
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
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