Santa Fe College Radiography Program Student Handbook

Fall 2017

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Foreword The admission of a student into the health field is in many ways the entrance into a world with practices and rules differing in many respects from those to which one is accustomed. The following overview of program requirements, ethical standards, and regulations has been formulated as a guide for the student. It is the student’s responsibility to carefully study this handbook to learn what is expected of the student and what can be expected from the Program. It is the responsibility of the college to provide instruction and to counsel students on program requirements, graduation, and eligibility requirements to sit for the national certification examination. It is the student’s responsibility to see that these requirements are met. Failure to meet these requirements may result in termination of a student from the program or delay of graduation and eligibility to take the credentialing examination.

Program policies must meet the requirements for accreditation at the professional, state, and institutional levels, and the rights of students and faculty, individually and collectively, must be respected. The Program curriculum is competency based and follows the Joint Review Committee on Education in Radiologic Technology (JRCERT) adopted curriculum guidelines published by the American Society of Radiologic Technologists (ASRT).

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Contents Foreword ................................................................................................................................................................................. 1

ACADEMIC ACHIEVEMENT STANDARDS .............................................................................................................................. 4

AMERICANS WITH DISABILITIES ACT (ADA) ......................................................................................................................... 4

ATTENDANCE POLICY .......................................................................................................................................................... 4

BACKGROUND CHECKS, NATIONAL AND STATE .................................................................................................................. 6

CHILDREN ON CAMPUS ....................................................................................................................................................... 6

CLINICAL ASSIGNMENTS ...................................................................................................................................................... 6

CODE OF CONDUCT ............................................................................................................................................................. 6

DIRECT AND INDIRECT SUPERVISION IN THE CLINICAL SETTING ......................................................................................... 6

DISCRIMINATION / HARASSMENT POLICY ........................................................................................................................... 7

DISHONESTY, ACADEMIC ..................................................................................................................................................... 7

DISMISSAL FROM PROGRAM ............................................................................................................................................... 7

DRESS CODE ........................................................................................................................................................................ 7

ELECTRONIC DEVICES .......................................................................................................................................................... 8

EMPLOYMENT POLICY ......................................................................................................................................................... 9

FOOD IN THE CLASSROOM .................................................................................................................................................. 9

GRIEVANCE /COMPLAINTS / APPEALS PROCESS .................................................................................................................. 9

HEALTH ................................................................................................................................................................................ 9

HIPAA/CONFIDENTIALITY .................................................................................................................................................... 9

HIV/AIDS EDUCATION ........................................................................................................................................................ 10

INJURIES /ACCIDENTS IN LABS OR CLINICAL SITES ............................................................................................................ 10

ORAL COMPETENCY .......................................................................................................................................................... 10

PREGNANCY ....................................................................................................................................................................... 10

RADIATION SAFETY / DOSIMETRY ...................................................................................................................................... 11

RESOURCES ....................................................................................................................................................................... 12

STUDENT RIGHTS AND RESPONSIBILITIES ......................................................................................................................... 13

SUBSTANCE ABUSE ............................................................................................................................................................ 13

TECHNICAL STANDARDS .................................................................................................................................................... 13

VACCINATIONS .................................................................................................................................................................. 13

WITHDRAWING FROM PROGRAM ..................................................................................................................................... 14

PROGRAM GOALS and LEARNING OUTCOMES .................................................................................................................. 15

HANDBOOK AGREEMENT .................................................................................................................................................. 16

PERFORMANCE STANDARDS ALLIED HEALTH PROGRAMS ................................................................................................ 17

PROGRAM FACULTY .............................................................................................................................................................. 19

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Radiography Program Course Sequence ........................................................................................................................... 20

ACCIDENT / INCIDENT REPORT .......................................................................................................................................... 21

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ACADEMIC ACHIEVEMENT STANDARDS Students must maintain a minimum of 2.0 grade point average each term in all professional courses to remain in an

Allied Health program.

Successful completion of a course is determined by a final grade of C or better. In the event a student does not

successfully complete a course, the student may repeat the course the next time it is offered, pending space available. A

withdrawal is deemed a failed attempt. Students must follow the Program course sequence and my not advance unless

all courses within the term are successfully completed.

A student has three course and or program attempts.

If the third attempt is in the same course, the student will be required to pay out of state tuition for the third attempt.

If a student fails any three professional program courses, or fails one course three time, the student will not be

readmitted to the Program due to Florida law. (Florida law requires that any college credit course that has been

repeated and taken for the third time should be regarded as the final attempt.)

If a student receives an “F” grade in a professional course, the student cannot remain in the program.

AMERICANS WITH DISABILITIES ACT (ADA) If you are a student with a disability: In compliance with Santa Fe College policy and equal access laws, a counselor is

available to discuss appropriate academic accommodations that you may requires as a student with a disability.

Requests for academic accommodations need to be made during the first week of the semester (except for unusual

circumstances) so arrangements can be made. You must be registered with the Disabilities Resource Center (DRC) in S-

229 for disability verification and determination of reasonable academic accommodations. For more information, see:

http://www.sfcollege.edu/student/drc/

ATTENDANCE POLICY

To receive credit for your courses, you must attend class, lab and clinical assignments. Because the exchange of ideas

between students and instructors is crucial to the course learning outcomes, students will fail to meet minimal course

requirements if they do not attend regularly. With that in mind, the Allied Health Programs require that you attend at

least 94% of the clinical and lab meetings for the scheduled courses. If you miss more than 6% of scheduled lab or

clinical meetings, you will fail the course.

Lab

Missing more than 6% of lab hours will result in failure of the lab component.

Coursework

Should it become necessary to miss a class, the student must notify the appropriate instructor prior to the start of the

class. Students must attend 94% of class meetings. If more than 6% of class time is missed, the student will fail the

course.

4 absences = reduction of final grade average by 4 points

5 absences = reduction of final grade average by 6 points

More than 5 absences or missing more than 6% of class meetings will result in failure of the course

3 tardies (late arrival to class) = 1 absence

Any exceptions to this policy will be determined by the Chair of the Allied Health Programs.

Arriving to class or lab late is unacceptable. Three late arrivals will equal one absence. Leaving class early will count as a

late arrival.

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Clinical rotations

Attendance is mandatory during all scheduled clinical hours.

Students will report to their clinical assignments early enough to be ready to begin clinical education at the

designated time (specifically, 8:00am).

A 30-minute lunch break will be scheduled by the clinical preceptors or their designee.

Students do not have the option of skipping lunch. You may work from 8am to 1pm without a lunch break, but

after 1pm you are required to take a lunch break.

Evening clinical assignments are scheduled approximately one evening per month beginning in the Spring Term

of the first year. Students will work an 8 hour shift that aligns with the clinical affiliate’s evening schedule.

Students must attend 94% of scheduled clinical hours.

For example, when students are assigned to clinic 3 days a week in a 16 week term, 48 days of clinical attendance is

scheduled. Should a student miss more than 2.88 days (23.04 hours) of clinic, the student would receive a failing

grade and be required to repeat the course the next time it is offered.

Time away from clinic may only be taken in a minimum of 4 or 8 hour blocks.

Late arrival to clinic up to 30 minutes = 4 hour time deduction

Late arrival to clinical > 30 minutes = 8 hour time deduction

Leaving clinic early up to 4 hours = 4 hour time deduction

Leaving clinic early > 4 hours = 8 hour time deduction The student will be notified if they have reached their established limit for absences, and that additional absences will jeopardize the successful completion of the course. If a student is going to be absent from a clinical assignment, he/she must do both of the following:

1. If a student is going to be absent from a clinical assignment, he/she must do both of the following: a. Call the Clinical Coordinator 10 minutes prior to the start of his/her clinical assignment. b. Call the assigned clinical instructor at the site at least 10 minutes prior to the start of his/her clinical

assignment. The student is to speak directly to a clinical instructor or supervising technologist or must obtain the name of the person taking the message. It is the responsibility of the student to make these calls – not parents, friends, or relatives.

2. “No show, no call” - Any student who does not call the clinical site supervisor, Clinical Coordinator and assigned clinical instructor before the start of the clinical assignment will be put on probation for the remainder of the program and will receive written warning of the violation. Two incidents of “no show, no call” will result in failure of the clinical course.

3. Students who leave the clinical site early without prior approval by the Clinical Coordinator will be considered absent for the entire day.

4. Tardiness: Tardy will be defined in the course syllabus and/or established by the course instructor. 1st offense: verbal warning 2nd offense: written warning 3rd offense: failure of the course

5. Up to 2 excused absences per semester may be made up, given this is acceptable to the clinical affiliates. In instances when more than 2 make up days are required, delay in graduation from the Program may result. An excused absence is granted by the Department Chair. An excused absence is defined as an absence that is unexpected and outside of the student’s control. Students must provide documentation within 48 hours of absence that indicates the absence was unexpected and out of the control of the student.

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6. Exceeding the allowed absences will be grounds for failure of the clinical course, which may also result in exit from the Program.

BACKGROUND CHECKS, NATIONAL AND STATE A federal and state criminal Level 2 and expanded background check was used as a tool to determine your eligibility to

enter and remain in SF Allied Health Programs. Further and/or additional clinical screenings may be required and

completed by clinical agencies. Dismissal from the program may result from additional screening results.

Acceptance into an Allied Health Program requires you to remain free of disqualifying charges or face dismissal from the

program. You are obligated to notify the Department Chair of Allied Health Programs of any arrests, incidents and/or

charges regardless of adjudication that occur after acceptance and during enrollment in an Allied Health Program.

Failure to promptly notify shall be grounds for immediate dismissal from the Program.

Students that are charged and/or arrested will be denied clinical access until the charges are completely resolved.

Missed clinical time must be completed. Students may continue to attend didactic courses while waiting for a

resolution.

Students may be subjected to additional background checks by various clinical agencies and must meet that agency’s

requirements for clinical attendance.

CHILDREN ON CAMPUS Children are not permitted in classrooms, labs or clinical sites.

CLINICAL ASSIGNMENTS Students will be supervised, instructed and assessed in the clinical affiliates by the clinical instructors/preceptors, staff

technologists and SF faculty. Attendance at the clinical affiliate facilities is a privilege as opposed to a right of the college

or students to use the facilities. Students are expected to seek out opportunities to participate in procedures. Students

are assigned to the Program’s clinical affiliates by faculty in an effort to provide a balanced and varied clinical

experience. Students must be prepared to attend any and all clinical sites, including those outside of Gainesville

(between Ocala and Lake City).

CODE OF CONDUCT Each student is expected to conform to professional standards of conduct that foster an environment of honesty, trust

and respect in the classroom, lab and in the clinical area. Students are expected to adhere to the SF College Student

Conduct Code, Rule 7.23 http://www.sfcollege.edu/Assets/sf/rules/pdfs/Rule_7/7_23.pdf

DIRECT AND INDIRECT SUPERVISION IN THE CLINICAL SETTING Direct supervision assures patient safety and proper education practices. Students must work under direct supervision

until the student is deemed competent performing specific procedures.

Direct Supervision is student supervision by a qualified radiographer who:

Reviews the procedure in relation to the student’s achievement,

Evaluates the condition of the patient in relation to the student’s knowledge,

Is physically present during the conduct of the procedure, and

Reviews and approves the procedure and/or image. Indirect supervision is defined as supervision provided by a qualified radiographer immediately available to assist

students regardless of the level of student achievement. “Immediately available” is interpreted as the physical presence

of a qualified radiographer adjacent to the room or location where a radiographic procedure is being performed. This

availability applies to all areas where ionizing radiation equipment is in use on patients. There is no situation, or level of

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clinical competency, which would allow a student to perform a radiologic exam without any form of supervision.

DISCRIMINATION / HARASSMENT POLICY Santa Fe College (SF) is committed to maintaining a work and educational environment that embraces diversity and where no member of the college community is excluded from participation in, denied the benefits of, or subject to discrimination in any college program or activity based on: their race, ethnicity, national origin, color, religion, age, disability, sex, pregnancy status, gender identity, sexual orientation, marital status, genetic information, political opinions or affiliations, or veteran status. This commitment applies to employees, volunteers, students, and, to the extent possible, to third parties, applicants for admission, applicants for employment, and the general public.

Inquiries regarding non-discrimination policies or concerns about discrimination or harassment, including concerns about sexual harassment or sexual violence under Title IX, should be directed to Jasmine Gibbs, Equity Officer and Title IX Coordinator, 3000 NW 83rd Street, R-Annex, Room 113, Gainesville, Florida 32606, 352-395-5950, equity.officer@sfcollege.edu.

DISHONESTY, ACADEMIC The Allied Health Programs require that any student found cheating or leveled with a charge of academic dishonesty in

any course requirement be counseled by the Department Chair of Allied Health Programs. Appropriate action will be

taken and will follow the guidelines as found in the SF Student Conduct Code: Rule 7.23.

Specific examples, in addition to those mentioned in the code, include, but are not limited to the following.

1. Falsifying time records of clinical attendance or procedure/competency logs

2. Violation of HIPAA regarding patient privileged information.

3. Copying or manipulating assessment material in any way at any time.

DISMISSAL FROM PROGRAM Students are expected to exhibit professional behavior while in program. Demonstration of unprofessional behavior is

unacceptable and may result in dismissal from the Program. The following list describes some, but not all reasons for

immediate dismissal from programs in the Allied Health department.

1. Violation of the Santa Fe College Student Conduct Code.

2. Violations of rules and regulations of the Program or the student’s assigned clinical education site.

3. Failing 3 professional courses.

4. Failing a clinical course. Clinical grades lower than a “C” are unacceptable and deemed an unsuccessful

attempt.

5. Habitual absence and/or tardiness.

6. Unprofessional or unethical conduct in the clinical setting, such as sleeping on a scheduled clinical education

assignment, exhibiting disrespectful behavior to patients or hospital staff.

7. Behavior that compromises patient safety.

8. Dismissal from a clinical assignment by a preceptor or hospital employee for violations of hospital or

departmental regulations or procedures, student actions are affecting work flow in the department or aberrant

behavior that is offensive to department personnel.

9. Two incidents of “no show, no call” to a clinical assignment will result in exit from the program.

DRESS CODE A professional appearance is mandatory at all times. Patients and healthcare workers view students as members of a

professional team, therefore students are expected to present themselves in a professional manner. All students are

expected to conform to the Program’s standards of dress and grooming.

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1. A specific uniform color has been established by the Program. The uniforms are supplied and laundered by the

students.

2. Uniforms must be the appropriate size and pants must fit correctly at the waist. No over-sized pants or sagging

at the waistline is permitted. Pants must also be of the appropriate length.

3. The uniform is to be non-revealing and free of ornamentation.

4. Cloth shoes are not acceptable. Athletic shoes are acceptable. All shoes must have an enclosed heel and toe.

5. Solid color Croc-style shoes are acceptable but holes or vents are not allowed. Straps must be worn on heels

appropriately.

6. Lab coats may be worn during clinical assignments, but they are not mandatory. Acceptable lab coats are short

(mid-hip style), scrub type with banding at the neck and wrists, and standard (mid-thigh) with a collar. Snaps or

buttons are acceptable. Hoodies or sweat-type jackets are not acceptable. Lab coats are to be white or one of

the designated colors.

7. Grooming:

a. Hair must be clean and long hair must be pulled back from the face. Hair color must be within the

natural range of shades of human hair.

b. Fingernails must be clean and reasonably short. Polish must be light in color.

c. Artificial nails are not allowed while students are assigned to clinical affiliate facilities.

d. NO heavy make-up, perfume or cologne is allowed.

e. No chewing gum while assigned to clinical facilities.

f. No more than two small stud earrings may be worn in each ear. No other jewelry may be visible in parts

of the body that have been pierced, including the face and tongue.

g. Ear lobe gauges must not be visible.

h. Beards and mustaches must be clean and well groomed.

i. Tattoos that are visible when students are dressed in the prescribed clinical uniform must be covered by

appropriate clothing. Tattoos on arms must be covered by a solid color tee-shirt worn under the scrub

uniform top. Tattoos on forearms may require a long sleeve solid color tee-shirt. Under no

circumstances are students permitted in the clinical affiliates with visible tattoos.

j. Students who smoke cigarettes must take measures to avoid the smell of smoke on their clothes, breath

and body, or they will be sent home to change clothes. Personal leave time will be applied for their

absence until they return.

k. NAME TAGS MUST BE VISIBLE AT ALL TIMES WHEN IN CLINICAL FACILITIES.

Students may be asked to leave their clinical assignment for a violation of the dress code. Upon the first occurrence of

such an event, leave time will be deducted from the student’s balance and the student will be placed on probation. A

second violation of the dress code will lead to a failing grade assigned to the clinical course.

ELECTRONIC DEVICES Each instructor will disclose whether or not it is permissible for students to audio record lectures. Videotaping is NOT

permitted. Audio recordings are for personal use only and may not be published or distributed over the internet.

Transcripts of recordings are not to be distributed or posted in any format. Failure to follow these rules will be

considered an act of academic dishonesty and subject to the same consequences.

Recordings made by representative of the Disability Resource Center are exempt from the policy stated above.

Cell phone usage is not permitted in the classroom unless clearly stated by the instructor. Students will be dismissed

from the classroom or lab and counted as absent if caught using their cellphone without permission.

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EMPLOYMENT POLICY Students in the Radiography Program are enrolled in a course load that is deemed full time. It is highly recommended

that students abstain from working full time during their tenure in the Program. Students are expected to spend ample

time outside of the prescribed class schedule researching, reading and studying course materials.

FOOD IN THE CLASSROOM Food is not allowed in SF classrooms and labs.

GRIEVANCE /COMPLAINTS / APPEALS PROCESS Allied Health Programs Grievance Policy Students are directed to meet with their instructor first to resolve course issues. Should the issue remain unresolved after the meeting with the instructor, students may discuss the matter with the Department Chair. If the student is unsatisfied with the Chair response, the student may submit an email statement of less than 500 words to the Associate Vice President (AVP) of Health Sciences for review. The AVP will respond via email to the student within two days of receiving the appeal (Example: received appeal on Friday and responds to student by Tuesday at the end of business day). If the student is unsatisfied with the AVP response, the previously submitted appeal documents should be submitted via email within 24 hours to the Provost for review. Provost responds via e-mail as quickly as schedule allows. The decision of the Provost is final.

College Grievance Policy

See rules Manual, Rule 7.36, Student Complaint Procedure: Students and Administration

http://www.sfcollege.edu/Assets/sf/rules/pdfs/Rule_7/7_36.pdf

HEALTH CPR: A current CPR certification card with expiration date stated is required prior to orientation for all Allied Health

Programs. Students must keep their CPR certification active until graduating from the Program.

Health and Accident Insurance: All students are strongly encouraged to carry some form of personal health and accident

insurance for the duration of their enrollment in their program. Any medical accidents that occur in class, lab or

assigned clinical work must be reported to the program clinical coordinator or the Department Chair of Allied Health

Programs within 24 hours. The SF incident report must be submitted to the Program Director the following school day

following the incident/injury.

Health Status Change: It is the student’s responsibility to contact the program clinical coordinator or the Department

Chair of Allied Health Programs if their health status changes during the Program. A change in health status may require

a release statement form a physician stating students may return “without restrictions in class, lab or clinical area.”

The status of students having long term absences beyond their control will be individually evaluated by the Department Chair of the Allied Health Programs and faculty based upon how realistically a viable education can be provided under existing conditions. Conditions which prevent students from participating in clinical and/or didactic education may result in the student’s total withdrawal from the Program. Physical Examination: The completed physical examination form is due on the date given in orientation. This includes

required immunizations.

HIPAA/CONFIDENTIALITY Federal Law, 45 CFR Parts 160-164 requires specialized training regarding client privacy and security. All healthcare

providers must complete HIPAA privacy training. The student healthcare provider in SF Allied Health Programs will

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complete initial HIPAA training prior to initial clinical rotations and will continue to receive education related to HIPAA

integrated in the Program’s curricula. Specific clinical affiliates may also require additional HIPAA training.

No patient data may be photocopied.

HIPAA violations – Professional standards and norms for all health care providers include areas of: professional

behavior, confidentiality, patient’s rights, informed consent, privileged communication and health care settings

standards and norms. Additionally, federal laws (including HIPAA and FERPA), state regulations, licensure requirements

and practice acts detail use of specific information related to health care settings and professional behavior. As a

student in the SF Allied Health Programs, it is the student’s responsibility to adhere to any and all of these standards and

regulations. The relaying, discussion, transferring or use of any privileged information or knowledge of events, or

actions, via any verbal, written, electronic, computer and/or other technology form(s) concerning identifying patient

information, health care agency information (institution or staff), SF College faculty and staff, fellow SF College students

or any other like information is strictly prohibited.

Failure to comply with this directive in any way will result in disciplinary action and can include dismissal from the

Program.

HIV/AIDS EDUCATION The State of Florida Department of Education requires that all Allied Health Programs include within the program

curriculum approved training on HIV/Aids. This course must be completed prior to graduation.

INJURIES /ACCIDENTS IN LABS OR CLINICAL SITES If a student incurs or is involved in an activity resulting in an injury or potential injury, including but not limited to needle sticks, the student is responsible for notifying their instructor and the clinical coordinator whether in the classroom, lab or clinical affiliate within 24 hours. The SF instructor will advise the student of the appropriate procedures and direct the student to complete appropriate paperwork and SF incident report.

ORAL COMPETENCY The Florida Department of Education dictates that students meet an oral competency standard. Students must

demonstrate the ability to effectively convey material in an organized manner, use understandable language and

respond to questions in an appropriate dialogue. Students will be evaluated on delivery, content and presentation of

material, the use of verbal and non-verbal communication, effective listening and responding to the audience. Students

must demonstrate minimum competency to enter the clinical setting and ultimately graduate from the Program.

PREGNANCY Pregnancy Policy: October 2013: Students should be aware that the Nuclear Regulatory Commission (NRC) and the State of Florida require instruction of occupational workers in the hazards associated with radioactive material and radiation, and in the precautions and safety measures to be followed to minimize radiation exposure according to ALARA (as low as reasonable achievable). ALARA I and II levels document states "Florida law states that a female radiation worker may voluntarily inform her employer in writing of her pregnancy," therefore your declaration of pregnancy is entirely VOLUNTARY. Pregnant students have 3 options:

1. Make a written voluntary declaration of your pregnancy and continue in the Program without modification of clinic or classroom scheduling. 2. Decide not to declare your pregnancy. 3. Withdraw your written voluntary pregnancy declaration at any time.

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If you choose to declare your pregnancy, you must do so in writing. The declaration may be performed at any time during the pregnancy. If the student decides to declare her pregnancy then she is required to meet with the Radiation Safety Officer (RSO) and complete the Voluntary Declaration Form and receive counseling concerning radiation exposure to the fetus. The Voluntary Declaration Form must be completed, signed and returned to the RSO and Program Director. By signing this form you state that you have been advised of the potential health risks to the embryo/fetus associated with radiation exposure and have been advised of the NRC requirements to limit the dose to the embryo/fetus. Before signing and returning the form you should have any questions concerning this information answered to your satisfaction. The Nuclear Regulatory Commission (NRC) and State of Florida Department of Health (DOH) advise that such counseling include special instructions to females of childbearing potential, regarding the risks to the unborn fetus associated with prenatal radiation exposure. In addition to the instruction requirement, the NRC Regulatory Guide 8.13 – Instructions Concerning Prenatal Radiation Exposure (http://pbadupws.nrc.gov/docs/ML0037/ML003739505.pdf ) and State of Florida regulations, section 64E-5.311, FL Administrative Code (‘Dose to an Embryo or Fetus”) require that special efforts be made to limit any radiation exposure to the developing fetus. Voluntarily declaring your pregnancy is the most prudent course of action. It provides maximum protection for the developing embryo/fetus. All female students are required to complete/sign a form stating that they have read and understand the Pregnancy Policy. Forms available from the RSO include:

1. Instructions for Declared Pregnant Women 2. Declaration of Pregnancy 3. Declaration of Pregnancy Withdrawal

Any information provided to Program and / or the RSO regarding your pregnancy will be kept confidential. Consideration must be given to the student’s welfare during pregnancy as well as the policies of the clinical sites to which she is assigned. Students returning to their clinical assignments following a leave of absence due to pregnancy must provide documentation from their physician stating they are able to resume their clinical duties “without restriction in class, labs and clinical settings.”

RADIATION SAFETY / DOSIMETRY Students in the Radiography Program are not allowed to make exposures in the SF labs without an instructor present.

While in the clinical setting, a radiation dosimeter issued by SF must be worn by the student at all times on the student’s

collar, outside of lead protective garb. SF will monitor and archive records of each student’s radiation exposure.

Students reporting to clinic without their assigned dosimeter must leave immediately until the proper current dosimeter

is obtained. Personal leave will be charged for time away from clinic until the student arrives to the clinical site with

their assigned dosimeter. Charges incurred for dosimeters and the associated monitoring are included in the students’

lab fees. Badges are inspected upon receipt and again when put on the badge board in W-15. It is the student’s

responsibility to notify their Clinical Coordinator and lab manager, Jennifer Weeks, if their badge or clip is damaged upon

receipt or anytime during the month of use.

Dosimeter exchange must take place within three (3) business days of notification but should be as close to new

dosimeter start date as possible.

If a student loses or damages a radiation dosimeter, he/she must complete the radiation dosimeter incident

report. A "spare" dosimeter will be issued as a replacement in the case of loss or damage and the student will

receive a three (3) point deduction from their final grade for each lost or damaged dosimeter. The Clinical

Coordinator reserves the right to require the student(s) to orally present a radiation safety topic to the class.

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Students are required to read and initial the radiation exposure report. Questions about the report should be

addressed by the SF Radiation Safety Officer, Sara Smith (sara.smith@sfcollege.edu), office W-22C, phone

number 352.395.5673.

The following radiation safety rules must be followed by all students.

1. Doors to radiographic rooms are to be closed when patient is in the room to protect passersby from radiation exposure.

2. Exposures are never made with anyone in the room except the patient. Exceptions will be made in cases of medical necessity; however, it is not the student’s role to determine medical necessity in this case.

3. Patients shall be provided with appropriate radiation shielding. 4. Collimation of the x-ray beam shall be to the size of the image receptor and smaller when possible.

Student Radiation Exposure Limits

Radiation dosimetry reports which show personnel monitoring results on current students will be evaluated

regularly by the Radiation Safety Officer and/or her designee. The student radiation exposure reports will also be

reviewed by the Radiation Safety Committee according to the current ALARA investigational levels.

ALARA Investigational Levels

NOTE: Level I: 10% TEDE Level II: 25% TEDE (Re: 30%)

MONTHLY: LEVEL I LEVEL II

Whole Body 40 mrem 100 mrem

Hands 400 mrem 1000 mrem

QUARTERLY: LEVEL I LEVEL II

Whole Body 125 mrem 315 mrem

Hands 1250 mrem 3125 mrem

Warranted Action:

Levels < I No Action

Levels > I But < II RSO reviews and reports to the RSC with comparisons of other

personnel results at the same tasks.

Levels > II RSO investigates the results with the student, assesses the

situation, takes action, and reviews the report with the RSC.

Special Note: Declared Pregnancy: Effective January 1, 1994, federal and Florida law state that a female radiation worker

may voluntarily inform her employer in writing of her pregnancy and estimated conception date. This then requires the

employer to monitor the embryo/fetus if there is a probability to receive 50 mrem during the gestation period. A fetal

dosimeter will be issued and the records/results will be kept confidential.

Students are to know and adhere to these program policies as they are based both on NRC Federal laws and the state of

Florida DOH laws.

RESOURCES TLC (Teaching Learning Center) is a Health Sciences Resource Center for students. It is located in room W-233.

Computers, learning software, study rooms and printers are available.

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TEAM Health is a resource through which students can schedule tutors when available. The Santa Fe College Library has copies of required texts. Librarians are available to assist with learning needs.

STUDENT RIGHTS AND RESPONSIBILITIES Student rights and responsibilities are posted at the following site, http://www.sfcollege.edu/studentaffairs/?section=policies/student_rights . The purpose of this document is to provide students with a general overview of both their rights and responsibilities as members of the Santa Fe College community.

SUBSTANCE ABUSE Alcoholic beverages, illegal or controlled substances or drug paraphernalia are not permitted in the classroom, laboratories or clinical settings. Students enrolled in the Allied Health Programs are prohibited from attending class, lab or clinical assignments under the influence of alcohol or drugs. Observed impairment of a student may be evidenced and identified by many factors, including but not limited to reasonable suspicion and/or bizarre and unusual behavior. It is the faculty’s responsibility to identify students who display physical and/or emotional conditions which may impede clinical judgement and/or practice in class, lab or clinical setting. Upon identification, the student will be excused from class, lab or clinical assignment and will be required to submit to a blood and/or urinalysis test at the student’s expense. The student must notify faculty if he/she is required to take medically prescribed drugs which could impair his/her ability to function safely in the clinical setting or lab. Documentation of the student’s ability to function safely in the capacity as a technologist may be required of any student for whom medication has been prescribed. Clinical evidence of the use of illegal substances or alcohol in the clinical setting may lead to dismissal from the program.

TECHNICAL STANDARDS The student must have:

•Sufficient eyesight to observe patients, manipulate equipment and evaluate radiographic quality.

•Sufficient hearing to assess patient needs and communicate verbally with other health care providers.

•Sufficient verbal and writing skills to communicate needs promptly and effectively in English.

•Sufficient gross and fine motor coordination to respond promptly to the patients’ needs, manipulate equipment,

lift a minimum of 30 pounds, participate as a team member of four in moving a 150 pound incapacitated patient,

and ensure overall patient safety.

•Satisfactory intellectual and emotional functions to exercise independent judgment and discretion in the safe

technical performance of medical imaging procedures.

While enrolled in an Allied Health Program, students must notify the Program Director if they encounter a change

in the status of their health. Failing to notify the Program Director may result in exit from the Program.

VACCINATIONS All clinical affiliates require immunizations, so all students must be immunized to participate in clinical education. Prior to the first scheduled day of clinical education in the affiliates, students MUST show proof of:

1. Two (2) immunizations for measles and/or two MMR’S. 2. Varicella (chicken pox) vaccination, serologic proof of immunity or verification from a health care provider

of a history of varicella 3. Proof of a tetanus booster within past 10 years 4. Negative Tuberculin skin test and physical examination. Students must provide proof of a second negative

tuberculin skin test approximately one year after the date of the original test that was provided to the Program.

14

5. Proof of an annual Flu Vaccination is required by clinical sites. 6. The first and second of the three Heptivac (Hepatitis-B series) immunizations must be obtained and

documented prior to entering the clinical setting. Immunizations are available at the Alachua County Health Department (ACHD). Students who have questions regarding cost or hours of operation may call the ACHD at (352) 334-7900.

Santa Fe College students are eligible to receive certain immunizations and other healthcare assistance from the college’s Student Health Care Center located in S-120, for a nominal fee. Students should communicate directly with the Student Health Care Center regarding the costs and availability of immunizations and other services.

WITHDRAWING FROM PROGRAM Students considering withdrawing from the Program are advised to discuss their reasons with the Department Chair of Allied Health Programs before terminating their clinical or classroom attendance. Students who decide to withdraw from the Program must complete an exit form to remain in good standings within the Health Sciences Department of the College. Students can then withdraw from classes through their eSantaFe account.

PROGRAM ACCREDITATION The Radiography Program is accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT).

The JRCERT Standards for an Accredited Educational Program in Radiography are designed to promote academic

excellence, patient safety, and quality healthcare. The JRCERT accreditation process offers a means of providing assurance

to the public that a program meets specific quality standards. The process helps to maintain program quality and

stimulates program improvement through program assessment.

Students can find additional information about the JRCERT standards at the following website,

https://www.jrcert.org/students/ . Students of a JRCERT accredited program have the right to pursue allegations of

non-compliance of the standards. More information about the process can be found at

https://www.jrcert.org/students/process-for-reporting-allegations/ . JRCERT: 20 N. Wacker Drive, Suite 2850, Chicago, IL 60606-3182, phone 312.704.5300 mail@jrcert.org

15

PROGRAM GOALS and LEARNING OUTCOMES Goal: Students/graduates will be clinically competent.

Learning Outcomes:

Students/graduates will apply appropriate positioning skills.

Students/graduates will produce images that are of diagnostic quality.

Students/graduates will demonstrate appropriate radiation safety practices.

Goal: Students/graduates will apply critical thinking skills.

Learning Outcomes:

Students/graduates will analyze radiographic images for accuracy.

Students/graduates will adapt positioning and technical factors for non-routine situations.

Goal: Students/graduates will communicate effectively.

Learning Outcomes:

Students/graduates will demonstrate appropriate oral communication skills in the clinical setting.

Students/graduates will demonstrate adequate written and oral presentation skills.

Goal: Students/graduates will demonstrate professionalism.

Learning Outcomes:

Students/graduates will demonstrate professional and ethical behavior.

Students/graduates will demonstrate evidence of lifelong learning.

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HANDBOOK AGREEMENT

I certify that I have received a copy of the Santa Fe College Radiography Student Handbook. I further certify that I have read and agree to follow the standards outlined in the Handbook and realize that any deviation from these standards will be cause for counseling procedures to be implemented. I understand that these standards apply to each and every course within the Radiography Program. I understand that I am responsible for providing my own medical insurance, which is recommended, maintaining a current CPR certification, proof of a second negative tuberculin skin test (PPD), proof of annual Flu vaccine (required by clinical sites) by the first day of the Fall Term Second Year, and acquiring the series of Hepatitis B vaccinations.

I have completed a HIPAA instructional module, and I have submitted the appropriate certificate of completion to the program

Printed Name

__________________ ____ ________________________

Student’s Signature Date

Additionally, I give my permission to be photographed by the Program/College for faculty and/or clinical affiliate purposes of identification. If needed, I agree to participate in College/Program promotional activities, which might include a photograph or video to be posted on the college or program website.

________________________________ ___________________________

Student’s Signature Date

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PERFORMANCE STANDARDS ALLIED HEALTH PROGRAMS Health Sciences program applicants should:

Possess sufficient physical, motor, intellectual, emotional and social/communication skills to provide for patient care and safety, and

the utilization of equipment. Performance standards for Allied Health Programs are outlined below.

In the event, a student is unable to fulfill these technical standards, with or without “reasonable accommodation” (according to the

Americans with Disabilities Act), the student will not be admitted into the program or be permitted to continue in the program.

Compliance with the program’s technical standards does not guarantee a student’s eligibility for selection in the Program.

ISSUE STANDARD EXAMPLE

Critical Thinking Critical thinking sufficient for clinical

judgment.

Handle multiple priorities in stressful situations. Make accurate independent

decisions. Concentrate and focus attention for prolonged periods of time to

attain precise testing results. Ability to work alone as well as a member of a

team. Apply reasoning and evaluation skills necessary in the safe technical

performance of imaging procedures.

Interpersonal Interpersonal abilities sufficient to

interact with individuals, families, and

groups from a variety of social,

emotional, cultural, and intellectual

backgrounds.

Display compassion, empathy and concern for others. Effectively deal with

anger/fear/hostility of others in a calm manner. Demonstrate a high degree of

patience. Work with other health care providers in stressful situations, such as

life and death situations.

Communication Communication abilities sufficient for

interaction with others in verbal and

written form.

Communicate needs in a prompt, clear and concise manner. Accurately

record/document pertinent information. Follow verbal and/or written

instructions. Interact with patients and other health care providers in a

professional manner.

Mobility Physical abilities sufficient to move from

room to room and maneuver in small

spaces.

Respond promptly to the patient's needs, manipulate equipment, lift a

minimum of 30 pounds, exert a sustained force of 20 pound, push/pull mobile

equipment weighing up to 300 pounds, stand for prolonged periods wearing a

12-20 pound lead apron, walk an equivalent of 5 miles per day, ability to sit for

periods of 1 hour at a time, participate as a team member of four to move a

150 pound incapacitated person, and provide for patient safety at all times.

Motor Skills Gross and fine motor abilities sufficient

to safely and effectively perform

Program appropriate skills.

Ability to seize, grasp, grip, hold, turn or otherwise work with hands. Work

with fingers to manipulate switches, dials and other equipment controls. Input

data into computer.

Hearing Auditory ability sufficient to monitor and

assess health needs.

Auditory ability sufficient to monitor and assess health needs.

Visual Visual ability sufficient for observation

and assessment necessary in

radiographic technology.

Observe and monitor patients in full and dimmed light. Visual near acuity of

20 inches or less with clarity. Distinguish depth, color and spatial attributes of

images.

Tactile Tactile ability sufficient for physical

assessment.

Perceive attributes of an object via touch. Palpate.

I have read and understand the aforementioned Performance Standards for Allied Health Programs. ________________________________________________ ________________________________ (Student signature) (Date)

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Pregnancy Policy Form*

To be completed by all female students

I, ________________________ have read and understand the Radiography Program Pregnancy Policy. I am aware that disclosure of pregnancy is totally voluntary on my part. I also understand that I can go the RSO to express any radiation protection concerns and have my questions answered fully, completely, and confidentially ____________________________________________ Student signature / Date _________________________ Clinical Coordinator Revised: October 2013

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PROGRAM FACULTY

Michael Fugate, M. Ed., R.T. (R) W017 395-5668 Program Director and Professor David DiSalvo, B.S., R.T. (R) W018 395-5667 Clinical Coordinator Michelle Hammond, A.S., R.T. (R) W018 395-5789 Adjunct Assistant Professor Todd Hargis, A.S., R.T. (R) W018 395-5789 Adjunct Assistant Professor June Martin, A.S., R.T. (R) W018 395-5789 Adjunct Assistant Professor Elias Garcia, A.S., R.T. (R) W018 395-5789 Adjunct Assistant Professor Sara Smith (N), CNMT W022C 395-5673 Radiation Safety Officer Sharon Whitcraft, M.A. RVT RVS RCS W201 395-5702 Department Chair of Allied Health Programs Jodi Long, Ph.D. W201 395-5680 Associate Vice President for Academic Affairs Health Sciences

20

Radiography Program Course Sequence

Radiology Professional Core hours required: 61.0

FALL – 13 credit hours

RTE1000 Intro Radiologic techniques – 3.0 hours

RTE1418C Radio Techniques 1 – 4.0 hours

RTE1503C Radiologic Procedures 1 – 4.0 hours

RTE1804 Radio Clinical Ed 1 – 2.0 hours

SPRING – 14 credit hours

RTE1457C Radio Techniques 2 – 4.0 hours RTE1513 Radiologic Procedures 2 – 3.0 hours RTE1513L Radiologic Procedures 2 Lab – 1.0 hours RTE1613 Radio Physics – 4.0 hours RTE1814 Radio Clinical Ed 2 - 2.0 hours

SUMMER – 7 credit hours

RTE1824 Radio Clinical Ed 3 – 1.0 hour SUMMER A RTE1834 Radio Clinical Ed 4 – 3.0 hours SUMMER B RTE2563 Rad Procedures 3 – 3.0 hours SUMMER A

FALL – 12 credit hours

RTE2385C Radiation Bio – 3.0 hours RTE2573C Spec Imagining modalities – 3.0 hours RTE2782 Pathology – 1.0 hours RTE2910 Directed Research – 1.0 hours RTE2844 Advanced Rad Clinical Ed 5 – 4.0 hours

SPRING – 15 credit hours

RTE2202 Admin Prof Conn – 3.0 hours RTE2473C Radiology Techniques 3 – 4.0 hours

RTE2061 Radiography Seminar – 3.0 hours

RTE2854 Advanced Rad Clinical Ed 6 – 4.0 hours – SPRING A RTE2864 Advanced Rad Clinical Ed 7 -1.0 hours – SPRING B

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Florida College System Risk Management Consortium

ACCIDENT – INCIDENT REPORT(A copy of this report is NOT authorization for medical treatment)

INSTRUCTIONS:If loss/occurrence/injury is to a college employee, please complete sections: 1, 2, 5, 6, 7 and 8.If loss/occurrence is to college owned property please complete sections: 1, 3, 5, 6, 7 and 8.If loss/occurrence/injury is to a non college employee or non college owned property, please complete sections: 1, 4, 5, 6, 7 and 8.

1. LOCATION AND DATE OF INCIDENT/OCCURRENCECOLLEGE: (Check One)� BreCC� BC� CC� CCF� DSC

� ESC� FGC� FKCC� GCSC� HCC

� IRSC� LSCC� MDC� NFCC� NWFSC

� PBSC� PHCC� PeSC� PSC� SJRSC

� SPC� SFC� SSC� SFSC� SCFMS

� TCC� VC

CAMPUS/LOCATION CODE:

DATE OF OCCURRENCE: TIME OF OCCURRENCE:AM PM

LOCATION OF OCCURRENCE (BE SPECIFIC):

2. INJURED EMPLOYEE (INJURY/LOSS TO COLLEGE EMPLOYEE)NAME OF EMPLOYEE: AGE: OCCUPATION & DEPARTMENT: EMPLOYEE #:

ADDRESS: CITY: ST: ZIP:

PHONE:( )

PART OF BODY INJURED: TYPE OF INJURY (CUT, STING, BUMP, BRUISE ETC.):

DOES EMPLOYEE WISH TO SEEK MEDICALATTENTION TODAY:

� YES � NO*

WILL EMPLOYEE REQUIRE TIME OFFFROMWORK:

� YES � NO

DATE INJURY FIRST REPORTED: TIME INJURY FIRST REPORTED:

* A “no” answer does not waive the employee’s right to request medical attention at a later date.

3. PROPERTY (COLLEGE OWNED)IDENTIFY THE DAMAGED/LOST PROPERTY: ESTIMATED COST OF DAMAGED/LOST PROPERTY:

$4. INJURED PARTY/PROPERTY (PERSONS NOT EMPLOYEED BY COLLEGE AND/OR PROPERTY NOT OWNED BY COLLEGE)NAME: AGE: PHONE:

( )

ADDRESS: CITY: ST: ZIP:

IDENTIFY THE INJURY OR THE DAMAGED/LOST PROPERTY: STUDENT ID #(If Injured Party is Admitted Student):

5. WITNESS(ES)NAME: PHONE:

( )

ADDRESS: CITY: ST: ZIP:

NAME: PHONE:( )

ADDRESS: CITY: ST: ZIP:

Revised: 09/12

2 of 2

6. DESCRIBE THE LOSS/OCCURRENCE/INJURY (To be completed by Injured Employee/Party, if at all possible):

7. SIGNATURESINJURED EMPLOYEE/PARTY’S SIGNATURE: DATE:

DEPARTMENT CONTACT’S SIGNATURE: DATE:

8. RISK MANAGEMENT COORDINATOR REVIEW (To be completed by the College’s Risk Management Coordinator):TYPE OF CLAIM (Please Check One):� GENERAL LIABILITY� COLLEGE PROPERTY DAMAGE/THEFT� EQUIPMENT BREAKDOWN� WORKER’S COMPENSATION**

� STUDENT ACCIDENT� ATHLETIC� FACILITIES USE� ALLIED HEALTH (Please Attach Allied Health Incident Form)

** Please do not send Work Comp A/I forms to the Consortium. The College WC coordinator should submit all WC claims through the call center.RISK MANAGEMENT REVIEW STATEMENTS (Initial ONLY those statements that apply):

_____ THIS A/I IS FYI ONLY. NO CLAIM IS BEING SUBMITTED AT THIS TIME.

_____ THIS A/I HAS BEEN SUBMITTED TO FRINGE BENEFITS, FOR CLAIM REVIEW (Student Accident Coverage).

_____ THIS A/I HAS BEEN SUBMITTED TO SUMMIT AMERICA, FOR CLAIM REVIEW (Athletic Coverage).

RISK MANAGEMENT COORDINATOR’S SIGNATURE: DATE:

Revised: 09/12

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ACCIDENT – INCIDENT REPORT INSTRUCTIONS

This form is used to notify the Florida College System Risk Management Consortium (FCSRMC) ofaccidents/incidents/occurrences for review as possible claims. This form should be used to document the followingtypes of occurrences: Accidents, Injuries, Crimes/Theft, Property Damage (College Owned), Property Damage (NonCollege Owned), Internet Crisis (stolen, lost, or hacked personal information), Equipment Breakdown (fka Boiler andMachinery), Student Accidents, Athletic Injuries, and Allied Health (Professional Liability Claims). Please note, Worker’sCompensation claims are not reported to the FCSRMC using this form. The College’s Worker’s CompensationCoordinator should submit all claims via the dedicated reporting line: 877 842 6843.

1. LOCATION AND DATE OF INCIDENT/OCCURRENCE

COLLEGE: Clearly check the FCSRMC abbreviation for your college.

CAMPUS/LOCATION CODE: Please use the campus codes as noted on the College’s Property Listings on file with theFCSRMC.

LOCATION OF OCCURRENCE (BE SPECIFIC): Provide campus name and building name or number. If accident occurred offcampus, provide street address and city.

2. INJURED EMPLOYEE

OCCUPATION & DEPARTMENT: List the occupation and department in which the employee is primarily employed.

PART OF BODY INJURED: Loosely identify the part of the Employee’s body which has been injured (i.e. wrist, ankle, backetc.)

TYPE OF INJURY: Loosely identify the manner in which the Employee has been injured (i.e. cut, sting, bruise etc.)

DATE INJURY FIRST REPORTED: If the injury was originally reported on a date different from the date of completing theA/I, please list the original date the injury was reported.

3. PROPERTY (COLLEGE OWNED)

IDENTIFY THE DAMAGED/LOST PROPERTY: Describe the damaged or stolen college owned property. Enter informationsuch as: “Flood damage to 1st floor of Building K; or 1998 white Mercedes driver side door; or Glass broken in classroomwindow; or IBM Pentium II computer, monitor, keyboard, and Hewlett Packard LaserJet printer.”

ESTIMATED COST OF DAMAGED/LOST PROPERTY: Enter your best guess of the value. This figure will not be used inevaluating the claim. It will be an indication of whether or not it falls within the college deductible and whether or not itneeds to be submitted to the servicing office.

4. INJURED PARTY/PROPERTY (INJURY/LOSS TO PERSONS NOT EMPLOYEED BY COLLEGE AND/OR PROPERTY NOT OWNED BY COLLEGE)

NAME: Report the name of the impacted person, such as, students who are not employees of the college at the time ofinjury, visitors, or owners of property that is stolen or damaged while at the college, including art exhibits.

IDENTIFY THE INJURY OR THE DAMAGED/LOST PROPERTY: Enter information such as “Twisted knee; or 1989 whiteMercedes convertible; or blue backpack with 4 textbooks; or Walkman radio/tape player; etc.”

Revised: 09/12

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5. WITNESS(ES)

This information is extremely valuable in adjusting the claims or if suits are filed later. Please supply the information if itis available.

6. DESCRIBE THE LOSS/OCCURRENCE/INJURY (To be completed by the injured person, if at all possible):

Please do not write “SEE ATTACHED.” Please give a brief description of accident using words such as: “College ownedvehicle was hit by vehicle owned by student; or Employee tripped over phone cord; or Student left backpack on librarysteps for 10 minutes; or Vehicle 1 (student owned) hit vehicle 2 (student owned) while backing out of parking space.”

If additional space is required, feel free to attach a second A/I form.

It is extremely important to remember that those of us reading the accident/incident reports after they have left yourcollege have no idea who the involved people are, whether they are college employees , students or visitors, and wehave some difficulty determining whether or not damaged property is college owned or non college owned.

7. SIGNATURES

Where possible, please get the signature of the Injured Employee/Party and a Department Contact.

8. RISK MANAGEMENT COORDINATOR REVIEW (To be completed by the College’s Risk Management Coordinator):

Review by the Risk Management Coordinator or his/her designee are extremely important. Our belief is every incidentshould be submitted through the Coordinator’s office for review and that office should accept responsibility forsubmitting the report to the Consortium office. It is important for loss control purposes to have one person at thecollege coordinating incident information and taking responsibility to make sure areas in need of repair are reported tothe proper people for this to be accomplished.

GENERAL LIABILITY: Check this block when incident involves students, visitors, property of students or visitors.

COLLEGE PROPERTY: Check this block when incident involves property owned by the college.

EQUIPMENT BREAKDOWN: Check this block only when incident involves your college owned boiler and/or refrigerationequipment.

STUDENT ACCIDENT: Check this block if the injured party is enrolled in a covered curriculum.

ATHLETIC: Check if claimant was participating in an enrolled sport.

FACILITIES USE: Check this block when incident involves visitors to an event for which Facilities Use coverage has beenpurchased.

ALLIED HEALTH: Check this block when incident involves patients of students enrolled in the Allied Health Program. Besure to attach an Allied Health Incident Form found at http://fcsrmc.com/attachments/Allied_Heath_Incident_Form.pdf

RISK MANAGEMENT REVIEW STATEMENTS: Initial the appropriate statements to let the FCSRMC staff know that theRisk Management Coordinator has reviewed the claim and determined that the A/I is for FYI purposes only, is a StudentAccident claim that has been forwarded to Fringe Benefits, OR is an Athletic claim which has been submitted to SummitAmerica. By initialing the appropriate statements, we hope to make the notification process more efficient and limit thenumber of follow up calls the FCSRMC has to make to the College Risk Coordinator.

Revised: 09/12

Florida College System Risk Management Consortium

How to File a Medical Claim

Florida College System Risk Management Consortium

Attached is a Blanket Lines Notice of Claim (Claim Form) for your accident policy.

Please forward claims and questions to the following address:

Fringe Benefit Coordinators, Inc.

P. O. Box 5249 Gainesville, FL 32627-5249

Toll Free Number (800) 654-1452

Fax Number (352) 372-9805

Policy underwritten by Hartford Life and Hartford Life and Accident Insurance Company

Claimant administration handled by Fringe Benefit Coordinators, Inc.

Step 1 - Submit a completed Notice of Claim (claim form) to our office either by fax or mail.

The Policyholder (not the Parent, Claimant or Agent) should:

• Fully answer/sign each item in the Policyholder Certification section.

• Read and sign the Fraud Warning Certification statement located on the reverse side of the Notice of

Claim.

The Parent/Guardian or Adult Claimant should:

• Fully answer/sign each item in the Claimant Certification section (choose either the Parent/Guardian

column or the Adult Claimant column; whichever is applicable).

• Read and sign the Fraud Warning Certification statement located on the reverse side of the Notice of

Claim.

Step 2 - Submit itemized medical bills for payment consideration to our office. This policy is

Excess, so please also include any other insurance carrier’s corresponding Explanation of Benefits

(EOBs) as outlined in the helpful information bullet listed below.

Helpful information for submitting claims and expediting payment

• A fully completed Notice of Claim is required for each accident/injury a Claimant incurs. Claims

submitted with incomplete information will be denied pending receipt of the missing data.

• Release of claim forms by an insurance company is not an admission of coverage. In addition, information on the form is subject to audit by the insurance company.

• Providers may wish to bill us directly for their services. If they do, please ensure a Notice of Claim

has first been submitted to our office.

• Itemized medical bills (including claimant name, date of service, diagnosis, procedure codes, amount

charged, and provider information) should be submitted for processing. “Balance Due” statements

and/or incomplete bills do not provide enough claim detail to process the charges. In order to ensure

we receive complete claim information, we suggest providers submit standardized billing statements

(called “UB-04” for hospital charges and/or a “CMS-1500” for physician charges).

• Unless proof of payment is submitted with the medical bill (a copy of check, a medical bill that

indicates the claimant has made all or partial payment or zero balance information) claim payment is

generally sent directly to the medical providers.

Please detach this page and forward the completed Notice of Claim (and medical bills if you are submitting expenses for payment) to the address listed above. We recommend you keep copies of the correspondence you are submitting to use for future reference.

LC-7580-4 Page 1 of 3 08/2016

HARTFORD LIFE INSURANCE COMPANY

Florida College System Risk Management Consortium

HARTFORD LIFE & ACCIDENT INSURANCE COMPANY

Notice of Claim

Florida College System Risk Management Consortium

Fringe Benefit Coordinators, Inc. P. O. Box 5249, Gainesville, FL 32627-5249

Toll Free Number (800) 654-1452 Fax Number (352) 372-9805

POLICYHOLDER CERTIFICATION - To be completed by Policyholder Official

Policyholder Number

08SR2131

Policyholder Name

Florida College System Risk Management Consortium

College Name College Phone Number ( )

Policyholder Address (Street, City, State & Zip Code)

4500 NW 27th Avenue, Suite D2, Gainesville, FL 32606

Program Name

Claimant (Injured Party) Name Time of Accident (hh:mm)

AM PM

Date of Accident: (mm/dd/yyyy) Place of Accident Cause of Accident

Indicate injured body p art(s) Nature of Sickness (if applicable) Date Sickness first commenced

Policyholder Certification Signature Required:

I hereby certify the Claimant is a member of the group insured under the above Policy and the injury/sickness was sustained under adequate supervision while p articipating in an official Covered Activity. I further certify I have read

and signed the Fraud Warning statement located on the reverse side of this form.

Title of Policyholder Official Signature of Policyholder Official Date

CLAIMANT/STUDENT CERTIFICATION - To be completed by Parent/Guardian or Adult Claimant

*Due to new government regulations, claims submitted without this data will be returned.

Parent/Guardian completes for dependent child Adult Claimant completes

Claimant (Dependent Child) Name Claimant Gender

Male Female

Claimant Name Claimant Gender

Male Female

*Is the Claimant a Medicare Beneficiary? No Yes

If yes, please provide Claimant's Social Security Number or

Health Identification Claim Number

*Is the Claimant a Medicare Beneficiary? No Yes

If yes, please provide Claimant's Social Security Number or

Health Identification Claim Number

Claimant Date of Birth Daytime Phone Number

( )

Claimant Date of Birth

Daytime Phone Number

( )

Claimant Address (Street Number, City, State, Zip) Claimant Address (Street Number, City, State, Zip)

Does the Claimant have medical coverage through?

Do you have medical coverage through?

Mother’’s employers policy* Yes No

Father's employers policy* Yes No Your employer* Yes No

Guardian’s employers policy* Yes No Spouse’s employer* Yes No

Medicare policy Yes No Medicare policy Yes No

Medicaid policy Yes No

Any other medical policy* Yes No

Medicaid policy

Any other medical policy*

Yes No

Yes No

This Policy is Excess, please include the other insurance

carrier ’s Explanation of Benefits (EOBs) for each medical

bill submitted.

This Policy is Excess, please include the other insurance

carrier’s Explanation of Benefits (EOBs) for each medical

bill submitted.

Parent/Guardian or Adult Claimant Certification Signature Required:

I certify the above information to be true and accurate to the best of my knowledge. I further certify I have read and

signed the Fraud Warning Certification statement located on the reverse side of this form. I also authorize any physician /

hospital that has attended me or my dependent child to disclose information acquired for claim payment purposes.

Printed Name Parent/Guardian or Adult Claimant

Signature of Parent/Guardian or Adult Claimant Date

LC-7580-4 Page 2 of 3 08/2016

Page 3 of 3 Florida College System Risk Management Consortium 08/2016 LC-7580-4

Signature - Please read the statement that applies to your state of residence and sign the bottom of the page.

With the exception of any source(s) of income reported above in this form, I certify by my signature that I have not received and am not

eligible to receive any source of income, except for my disability benefits from this plan. Further, I understand that should I receive

income of any kind or perform work of any kind during any period The Hartford has approved my disability claim, I must report all details

to The Hartford, immediately. If I receive disability income benefits greater than those which should have been paid, I understand that

I will be required to provide a lump sum repayment to the Plan. The Hartford has the option to reduce or eliminate future disability

payments in order to recover any overpayment balance that is not reimbursed.

For residents of all states EXCEPT Arizona, California, Colorado, Florida, Kentucky, Maine, Maryland, New Jersey, New

York, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: Any person who knowingly presents a false

or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty

of a crime and may be subject to fines and confinement in prison.

F o r R e s i d e n t s o f Ar i z o n a: F o r y o u r p r o t e c t i o n A r i z o n a l a w r e q u i r e s t h e f o l l o w i n g s t a t e m e n t t o a p p e a r o n t h i s f o r m . A n y p e r s o n w h o k n o w i n g l y p r e s e n t s a f a l s e o r f r a u d u l e n t c l a i m f o r p a y m e n t o f a l o s s i s s u b j e c t t o c r i m i n a l a n d c i v i l p e n a l t i e s . For Residents of California: For your protection, California law requires the following to appear on this form: Any person who

knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance

company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of

insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete,

or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder

or claimant with regard to a settlement award payable from insurance proceeds shall be reported to the Colorado Division of

Insurance within the Department of Regulatory Agencies.

For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of

claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a

statement of claim or an application for insurance containing any materially false information or conceals, for the purpose of

misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

For residents of Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or

misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,

fines and denial of insurance benefits.

For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit and who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading

information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an

application for insurance policy is subject to criminal and civil penalties.

For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a

civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For residents of Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto that the insurer relied upon is subject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available.

For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance or statement of claim containing any materially false information or conceals for the purpose

of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and subjects

such person to criminal and civil penalties.

For residents of Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an

insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other

benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be

sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars

($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,

the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

The statements contained in this form are true and complete to the best of my knowledge and belief.

Signature of Policyholder Official Date

Signature of Parent/Guardian or Adult Claimant Date

Electronic Funds Transfer (EFT) is our standard method of payment. When making our claim decision we may contact you to obtain your banking information.

STUDENT ACCIDENT (EDUCATION / TRAINING)

Summary of Coverage:

This is a fully insured program underwritten by Hartford Life and Accident Insurance Company (Hartford). This policy provides coverage for registered students in the named education/training courses on file with Hartford while the student is:

o Participating in college courses, labs or clinical training : Sponsored by the college; and On the premises designated and supervised by the College; or

o On the premises used for classes, labs or clinical training as designated by the college; or

o Traveling with a group in connection with the activities under the direct supervision of the college

Once the course or program of study ends, coverage ends. The policy does not

provide for any returning students who wishes to take agility tests, re-certifications, etc. unless they are enrolled in a class.

Student must incur first medical expense within 26 weeks after the accident for

coverage to apply for Accident Medical Benefit

Accidental Death Benefit and Accidental Dismemberment Benefit—loss of life or limb (per policy) must occur within 365 days after the date of accident

The college has no deductible

The policy provides limits of:

Accident Medical Expense Maximum $15,000 Accidental Death Principal Sum $25,000 Dental Maximum $15,000 Accidental Dismemberment Principal Sum $25,000 Benefit Period 104 Weeks

This policy provides EXCESS coverage – any coverage available to the student

would be primary including Health Insurance. Claims reporting:

College must file Accident / Incident report to the Consortium indicating at the top of the form “Student Accident Claim-Hartford form sent directly to Fringe Benefits Coordinators”.

Complete Hartford Claims Form within 30 days of date of injury to comply with policy

provisions (these forms can be found on Fringe Benefits Coordinators website: www.fbc-inc.com). Forward the Hartford Claims Form to Fringe Benefits Coordinators, Inc. along with any medical bills or other supporting documentation to gzinger@fbc-inc.com. Please include the student’s / claimant’s social security number, claims will NOT be processed without it.

Example of claim: Student suffers a laceration requiring medical attention while participating in a clinical experience as part of his/her education/training coursework.