I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B
virus (HBV) infection. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk
of acquiring hepatitis B, a serious disease.
Should I become exposed to or contract any of the aforementioned diseases I agree to hold harmless the Facility, Faculty and Midlands
Technical College from any and all liability.
Student Signature Date
Applicants and students should be able to perform essential functions, or with reasonable accommodations (such as with the help of
compensatory techniques and/or assistive devices), be able to demonstrate ability to be proﬁcient in these essential functions. Based on the
health assessment which you performed, please indicate whether you noted conditions which might limit the student’s ability to perform the
essential functions, or for which they will need reasonable accommodation to perform the functions:
Technical Standard Examples of
(Not all inclusive)
If yes, list the
Critical Thinking Critical thinking ability sucient
for clinical judgment
Identify cause-eect relationships in clinical
situations; evaluate patient or instrument
responses: synthesize data: draw sound
Interpersonal Interpersonal abilities sucient to
interact with individuals, families,
and groups from a variety of
social, emotional, cultural and
Establish rapport with patients and
colleagues. Use therapeutic communication
(attending, clarifying, coaching, facilitating,
and teaching. Function (consult, negotiate,
share) as a part of a team.
Communication abilities sucient
for eective interaction with
others. in spoken and written
Explain treatment procedures; initiate health
teaching; document and interpret instructions.
Mobility Physical abilities sucient to
move from room to room and
maneuver in small spaces; full
range of motion; manual and
ﬁnger dexterity; and handeye
Move around in work area and treatment
Motor Skills Gross and ﬁne motor skills
sucient to provide safe patient
care and operate equipment.
Use equipment and instruments with
Hearing Ability Auditory ability sucient to
monitor and assess health needs.
Ability to hear alarms, emergency signals,
auscultatory sounds and cries for help.
Tactile Ability Tactile ability sucient for
Perform palpation, functions of physical
examination and/or those related to
Olfactory Ability Olfactory senses (smell)sucient
for maintaining environmental
and patient safety.
Distinguish smells, which are contributory to
assessing and/or maintaining the patient’s
health status or environmental safety.
Ability to present professional
appearance and implement
measures to maintain one’s own
physical and mental health and
Work under stressful conditions. Be exposed
to communicable diseases and contaminated
bodily ﬂuids. React calmly in emergency
situations. Demonstrate ﬂexibility. Show
concern for others.
Return completed form and all copies of requested documents to:
Corporate & Continuing Education
Midlands Technical College
PO Box 2408
Columbia, SC 29202