School of Kinesiology
Athletic Training Program
Application Packet
This packet must be completed in its entirety to be considered for admission to the Athletic Training Program at Southern Miss. The packet contains two parts (A and B). All materials in each part MUST be completed and turned in to Dr. Parr no later than their deadline. Missing either of the following deadlines will delay the student’s admission to the AT Program for one academic year.
- Part A contains materials that must be completed prior to participating in clinical observations at Southern Miss. The deadline for Part A is August 31.
- A mandatory meeting will be held on the second Thursday of September in KIN 105 at 4:00 p.m. to discuss the remainder of the application process.
- Part Bmust be completed when formally applying to the AT Program. The deadline for Part B is November 1.
*Should any deadline fall on a weekend or holiday, the deadline will be on the following business day.
AA /EOE/ADAI
AT ProgramApplication Packet
Part A
Documentation of each of the following items along with the corresponding documents from this packet must be received by August 31. Please complete the TB screening and physical exam between June 1 and the August 31 deadline so that they are current for the entire academic year.
_____ ITEM A1: Tuberculosis Screening*
_____ ITEM A2:Physical Examination*
_____ ITEM A3:Tetanus shot**
_____ ITEM A4:Hepatitis B Vaccination+
_____ ITEM A5: Confidentiality Policy Signature Form
_____ ITEM A6:Blood Borne Pathogens Training++
*TB Skin Tests are offered at the Southern Miss Campus Clinic for $12. Physical Exams are also available at the clinic for $40.
**Tetanus shots must be current (within the last 10 years) and you must show a shot record indicating the date of your last tetanus shot. The Southern Miss Campus Clinic offers updated Tetanus shots for $44.
+Hepatitis B Vaccinations are offered at the Southern Miss Campus Clinic for $60 per shot. The series of shots is 3-part and takes approximately 6 months to complete the series. You must show the completion of at least one of the three shots by the deadline above.
++BBP training will be provided in KIN 219 for those taking the course at USM. For those who do not take KIN 219 at USM during the application semester may receive BBP training through the American Red Cross Chapter or American Heart Association. BBP certification must be current through June 1 of the following year.
Prices are estimates not guaranteed for the Southern Miss Campus Clinic. Students can seek these services anywhere they are offered.
ITEM A1: Tuberculosis Screening
Instructions: Fill out ALL blank sections in the following statement and sign below. Medical documentation of the negative TB test must be placed immediately after this page in the application packet.
Negative Tuberculosis Screening
I, , verify that I completed the annual Tuberculosis screen
on.
Date
I understand that I will not be able to participate as an observation student at USM or apply to the Athletic Training Program until the TB Screen is complete with a negative result.
Athletic Training Student Signature Date
NOTE: Medical Documentation must accompany this form
ITEM A2: Physical Examination
Instructions: Students must have a physician or other authorized health care provider(MD, DO, NP, PA) complete a physical examination for them. Students must completely fill out the medical history form (page 5 and top of page 6) prior to having the physical examination. The physician may fill out the physical examination form found on the bottom of page 6 or submit an alternative that mirrors the information found on this form if they prefer. Students must also read and sign the statements on the Medical History Signature Form found on page 7.
Medical History and Physical Exam Form
NameDate of Birth
The University of Southern Mississippi complies with state and federal disability laws. To ensure opportunity for all qualified persons, the university will make reasonable accommodation for its students with qualified disabilities that might affect the application process or participation in the Southern Miss AT Program. To qualify for accommodation students must contact the Office of Disability Services. If this form is needed in an alternate format, please contact Dr. Jeffrey Parr at 601-266-6321.
Please complete the following Health History
Drug AllergiesOther Allergies
List any prescription medications that you take
Medical problems and chronic illnesses
Have you had any of the following in the past 6 months? / Yes / No / Please explain “yes” responses1. Weakness of the arms, hands, legs, or feet
2. Difficulty fully moving arms and/or legs
3. Pain or stiffness when you lean forward or backwards at the waist
4. Difficulty fully moving head up or down
5. Difficulty fully moving head side to side
6. Difficulty squatting to the ground
7. Difficulty climbing a flight of stairs
8. Difficulty carrying more than 25 pounds
9. Difficulty with vision or loss of an eye
10. Surgery, an illness, or injury in the past 2 months
11. Has a physician ever disqualified you from physical activity?
12. Please list any other health or physical problems that might
affect your duties as an athletic training student
Please use this space for additional explanation
Please check all of the following conditions that you have ever had
Lost consciousness / Asthma / Chest pain or discomfortConcussion / Lung problems / Heart murmur
A seizure / Tuberculosis / High blood pressure
Fainting spell / Exposure to tuberculosis / Irregular heart beat
Hernia / Shortness of breath with exercise / Rheumatic fever
Eating disorder / Fatigue with exercise / Heart problems
Please explain any items you checked above
Physical Examination
Height / Weight / Blood Pressure / PulseVisual Acuity / Right / 20 / ______ / Left / 20 / ______ / With / Without Correction / Pupils: L > = < R
Flexibility / CBC Drawn? / YES / NO
Grip Strength: / Right / Left
Heart Auscultation in Standing / Heart Auscultation in Supine
Femoral Pulses: / Right / Left / Marfanoid: / YES / NO
Lungs
Abdomen
Musculoskeletal: General Posture / Deformities
Neck / Back / Cervical Spine
Shoulder / Arm / Elbow / Wrist / Hand / Fingers
Hip / Thigh / Knee / Shin / Calf / Ankle / Feet / Toes
Additional Findings (skin, ENT, etc)
Assessment
Disposition / Not Cleared / Cleared with Concerns / Full Medical Clearance
Signature of Physician (MD, DO, NP, PA – NOT DC)
Date
Medical History Signature Form
Please read and sign both statements below.
I hereby state that I have fully and completely disclosed and described every part of my medical history of which I have knowledge. I have disclosed any medical conditions which would potentially cause me to be unable to perform as an athletic training student. As to anything which I have not disclosed, I hereby waive all my rights to any claims against The University of Southern Mississippi, the School of Human Performance and Recreation and their employees, and the physicians associated with The University of Southern Mississippi Athletics for medical expenses, and any or all other claims.
Athletic Training Student Signature Date
I authorize The University of Southern Mississippi and its designated medical facility to perform an evaluation as deemed necessary or requested to determine my ability to safely participate in The University of Southern Mississippi AT Program. I authorize the full release of the results of this evaluation to The University of Southern Mississippi to enable the Southern Miss AT Program Director to evaluate my ability to safely participate in the Southern Miss AT Program. I understand that incorrect information or omission of information could endanger my health and others by promoting a misinformed medical determination to The University of Southern Mississippi. I further understand that this evaluation is specific for my participation in The Southern Miss AT Program and is not meant to take the place of routine medical health evaluations.
Athletic Training Student Signature Date
ITEM A3: Tetanus shot
Instructions: Medical documentation of current (within the last 10 years) Tetanus shot must be placed immediately after this page in the application packet.
ITEM A4: Hepatitis B Vaccination
Instructions: The following pages (page 10 & 11) contain information about Hepatitis B. Students must read all information found on these pages. After reading this information, the student should make an informed decision about whether or not to begin the series of vaccinations (the Southern Miss AT Program strongly encouragethe vaccines). Students must sign ONE of the statements on page 12 indicating their decision regarding the Hepatitis B vaccinations. If the student does NOT decline the vaccinations, they should place the medical documentation of the shots immediately after page 12.
WHAT YOU NEED TO KNOW ABOUT HEPATITIS B
Why get vaccinated?
A.Hepatitis B Virus (HBV) is a serious disease.
1.The HBV can cause illness that leads to:
a.ACUTE: loss of appetite, diarrhea & vomiting, tiredness, jaundice (yellow skin or eyes), pain in muscles, joints, and stomach
b.CHRONIC: liver damage (cirrhosis), liver cancer, death
B.About 1.25 million people in the US have chronic HBV infection.
C.Each year it is estimated that:
1.200,000 people, mostly young adults, get infected with HBV
2.More than 11,000 people have to stay in the hospital because of HBV
3.4,000-5,000 people die from chronic HBV infection
D.Hepatitis B Vaccine can prevent HBV infection
1.It is the first anti-cancer vaccine because it can prevent a form of liver cancer.
II.How is HBV spread?
A.HBV is spread through contact with the blood and body fluids of an infected person. A person can get infected in several ways, such as:
1.During birth when the virus passes from an infected mother to her baby
2.Having sex with an infected person
3.Injecting illegal drugs
4.Being stuck with a used needle on the job
5.Sharing personal items, such as a razor or toothbrush with an infected person
B.People can get HBV infection without knowing how they got it.
C.About 1/3 of HBV cases in the US have an unknown source.
III.Who should get HBV vaccine?
A.Everyone 18 years of age and younger
B.Adults over 18 who are at risk
1.People who have more than one sex partner, men who have sex with other men, injection drug users, health care workers, and others who might be exposed to infected blood or body fluids
C.If you are not sure whether you are at risk, ask your doctor or nurse
IV.How should the HBV vaccine be administered?
A.People should get 3 doses of HBV vaccine according to the following schedule. If you miss a dose or get behind schedule, get the next dose as soon as possible. There is no need to start over.
B.The second dose must be given at least 1 month after the first dose
C.The third dose must be given at least 2 months after the second dose, and at least 4 months after the first
D.The third dose should NOT be given to infants younger than 6 months of age
E.All three doses are needed for full and lasting immunity
F.HBV Vaccine may be given at the same time as other vaccines
V.Some people should not get HBV vaccine or should wait
A.People should not get HBV vaccine if they have ever had a life-threatening allergic reaction to Baker’s yeast (the kind for making bread), or to a previous dose of HBV Vaccine
B.People who are moderately or severely ill at the time the shot is scheduled should usually wait until they recover before getting HBV vaccine
C.Ask your doctor or nurse for more information
VI.What are the risks from HBV Vaccine?
A.A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of HBV vaccine causing serious harm, or death, is extremely small
B.Getting HBV vaccine is much safer than getting HBV infection
C.Most people who get HBV vaccine do not have any problems with it
D.Mild Problems
1.Soreness where the shot was given, lasting a day or two (up to 1/11 children and adolescents, and about 1/4 adults)
2.Mild to moderate fever (up to 1/14 children and adolescents and 1/100 adults)
E.Severe Problems
1.Serious allergic reaction (very rare)
Hepatitis B Vaccination Schedule / WHO?Infant whose mother is infected with HBV / Infant whose mother is not infected with HBV / Older child, adolescent, or adult
W
H
E
N
? / First Dose / Within 12 hours of birth / Birth – 2 months of age / Any time
Second Dose / 1-2 months of age / 1-4 months of age (at least 1 month after first dose) / 1-2 months after first dose
Third Dose / 6 months of age / 6-18 months of age / 4-6 months after first dose
VII.What if there is a moderate or severe reaction?
A.What to look for:
1.Any unusual condition, such as a serious allergic reaction
a.May include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. If such a reaction were to occur, it would be within a few minutes to a few hours after the shot
B.What to do:
1.Call a doctor or get the person to a doctor right away
2.Tell your doctor what happened, the date and time it happened, and when the vaccination was given
3.Ask your doctor, nurse, or health department to file a Vaccine Adverse Event Reporting System (VAERS) form, or call VAERS yourself at
1-800-822-7967
VIII.The National Vaccine Injury Compensation Program
A.In the rare event that you or your child has a serious reaction to a vaccine, a federal program has been created to help you pay for the care of those who have been harmed
B.For details about the National Vaccine Injury Compensation Program, call 1-800-338-2382 or visit the program’s website at
IX.How can I learn more?
A.Ask your doctor or nurse. They can give you the vaccine package insert or suggest other sources of information
B.Call your local or state health department’s immunization program
C.Contact the Centers for Disease Control and Prevention (CDC):
1.1-800-232-2522 (English)
2.1-800-232-0233 (Spanish)
3.Visit the National Immunization Program’s website at or CDC’s hepatitis Branch website at
Hepatitis B Documentation
Please sign under ONE of the Hepatitis B statements either verifying that you have started or completed the vaccination series, or that you are exercising your right to decline the Hepatitis B vaccination.
I, , verify that I began / completed (circle one) the Hepatitis B vaccination
series on .
Date
Athletic Training Student Signature Date
I, , verify that I have read the Hepatitis B information located in this packet, and hereby exercise my right to decline Hepatitis B vaccination.
Athletic Training Student Signature Date
ITEM A5: Confidentiality Policy Signature Form
Instructions:Students are required to read and sign the following confidentiality statement.
Confidentiality Policy
Athletic Training is an allied health care profession. Athletic Trainers and athletic training students in the AT Program,by nature of the profession, come in contact with medical histories, medical records, injury reports, insurance information and other information related to student-athletes.
Athletic Training Students are to discuss confidential information regarding an athlete’s medical history, injury, rehabilitation progress, or playing/practice status only with individuals associated with the AT Program, Athletic Training Staff, or Medical Staff involved with athlete patient care.
Athletic Training Students are not to discuss injuries or talk to the news media (reporters) regarding an athlete’s medical history, injury rehabilitation progress, or playing/practice status.
This policy relates to all Athletic Training Students who are assigned on- or off-campus affiliated clinical sites.
Students who violate this policy will be suspended or dismissed from the AT Program. Students suspected of violating this policy will be brought before the AT Program Director and preceptor associated with the clinical site to discuss disciplinary action.
I understand the Confidentiality Policy, and agree to abide by the guidelines listed above, and in the HIPAA Information (Appendices of the Southern Miss AT Program Policies and Procedures Manual).
Athletic Training Student SignatureDate
ITEM A6: Blood Borne Pathogens Training
Instructions:Blood Borne Pathogens Training will be provided in KIN 219 before August 31. Students who do not take KIN 219 during the application semester are required to have a current certification through either the American Red Cross or the American Heart Association in Blood Borne Pathogens Training. Students must have completed the certification and received the cards prior to turning in this application. Copies of the cards should be placed immediately following this page in the packet. Do not turn in the original cards, only copies please.
AT ProgramApplication Packet
Part B
Documentation of all of the following items along with the corresponding sheets from this packet must be received by November 1.
_____ ITEM B1: Application Cover Letter
_____ ITEM B2: Five Essays
_____ ITEM B3: Technical Standards Signature Form
_____ ITEM B4: Documentation of 40 Hours of Supervised Clinical Observation*
_____ ITEM B5: Official Transcripts of all College or University Courses
_____ ITEM B6: Two Letters of Recommendation**
*Must be approved by at least one certified athletic trainer
**Sent directly to AT Program Director or enclosed in sealed envelopes, signed across seal by reference, and submitted with the application
Letters of recommendation may be sent to:
Jeffrey Parr PhD, ATC, LAT
Athletic TrainingProgram Director
School of Kinesiology
118 College Dr. #5142
Hattiesburg, MS 39406
ITEM B1: Application Cover Letter
Instructions: Students are expected to write a professional cover letter for the AT Program Application. There are no specific requirements but you are encouraged to include any information that would make you a more suitable candidate such as additional observation or clinical experience and CPR or First Aid certification. You can also highlight strengths within your application or provide information about those who have recommended you for the program.
ITEM B2: Five Essays
Athletic Training Essays