MMAC PROGRAM APPLICATION

For assistance with this application or for any questions and/or additional information, please email mmac@dvs.virginia.gov or call 804-482-8528

To complete this application, you will need your DD214 and a resume. Both must be in PDF format. Please ensure you complete the entire application. It should take no longer than 15 minutes.

Fields marked with red asterisk (*) are required.

Date*

First Name*

Middle

Last Name*

Hidden

Name - HIDDEN

First Middle Last

Address*

Address Line 2

City*

State / Province*

ZIP / Postal Code*

Country*

Telephones*

Email (Your Email)*

Are you a spouse of an active duty service member?*

Yes
No

Home of Record

Affiliated Branch of Service

Discharge Date*

If on Terminal Leave, Place Separation Date Here

Available Date*

MOS / RATING / AFSC*

Are you a Medic, Corpsman or Medical Technician that has performed hands-on Patient Care in a Clinical or Field Setting Within the Last 12 Months?*

Yes, I have performed hands-on Patient Care in a Clinical or Field Setting Within the Last 12 Months
No, I have not performed hands-on Patient Care in a Clinical or Field Setting Within the Last 12 Months

Geographic Location Preferred. Check All That Apply:

Statewide/No Preference
Region 1 - Central
Region 2 - Northern
Region 3 - Tidewater
Region 4 - Southwestern

Are you currently enrolled in an educational or credentialing program or planning to enroll within the next 12 months?*

Yes
No

Please Attach Your Resume*

PDF Only | Maximum file size: 20MB

Accepted file types: pdf, Max. file size: 20 MB.

Discharge Status Acknowledgement/DD214 REQUIRED

The Code of Virginia requires all MMAC Applicants to affirm their discharge status. Please attach a .pdf copy of your DD214 below. The form is stored in our secure applicant database.

If ETS pending check here

DD214 Form Upload*

PDF Only | Maximum file size: 20MB

Accepted file types: pdf, Max. file size: 20 MB.

How Did You Learn About the MMAC Program?*

If an MMAC Program participant referred you, enter their name in the box below. If you are hired by one of our MMAC Partner Healthcare Systems, the MMAC Program participant is eligible for our MMAC Recruitment Rewards Program.

Would you like information about the benefits of joining the Virginia National Guard?

Yes
No

MMAC General Scope Of Practice (GSOP) Acknowledgement

If you are a former 68W, Corpsman or a 4N0X and it hasn't been more than 12 months since you practiced the majority of the skills in the GSOP, you might be MMAC Qualified. The MMAC GSOP provides critically important details of your clinical skills and experience. We use it to determine if you are MMAC Qualified and then match your skills with the healthcare employer that allows you the maximum opportunity to apply those skills. Before starting please review the Are You MMAC Qualified? and MMAC General Scope of Practice sections of the MMAC Applicant Action Guide. CLICK HERE to download. Have your DD214 JST, METC or VMET transcript handy. Plan on about 15 minutes of uninterrupted time to complete the GSOP form.

Instructions: Indicate whether or not you performed the skill/procedure. Then enter the month and year you last preformed the skill/procedure in the box below each skill/procedure. Note: the skill/procedure must be performed on a live patient in a clinical care role.

1.) Obtain patient health history, chief complaints, medication history, and identification of health related conditions that may impact the patient’s health status.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

2.) Evaluate patients for emergency medical conditions, order appropriate diagnostic studies and perform a wide range of treatment procedures under the direction of the supervising physician/nurse.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

3.) Assess patient status to keep the supervising physician/nurse informed of any change or need for additional treatment.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

4.) Assist in behavioral/psychiatric situations to include crisis intervention, management of aggressive or suicidal psychiatric patients, and one-to-one observations.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

5.) Recognize life threatening situations and act to correct these according to established national or facility protocols. Able to operate specialized medical equipment such as defibrillators, electrocardiographs, and oxygen apparatus.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

6.) Assist physician/nurse with complex, specialized, and potentially life threatening procedures such as defibrillation, cardioversions, insertion of chest drainage tubes, or initiation of mechanical ventilation.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

7.) Perform triage duties as assigned. Have expertise in the use of specific triage tools, the Emergency Severity Index (ESI) triage tool, or be trained in its use prior to conducting triage evaluations.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

8.) Conduct or assist with the training of personnel in CPR, basic, and advanced emergency medical care techniques, if appropriately trained and qualified.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

9.) Conduct or assist with community health programs, blood pressure and glucose screenings, flu immunizations, etc.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

10.) Transport patients monitored and unmonitored patients to diagnostic procedures and/or inpatient units in the facility.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

Skilled Care:

11.) Perform airway management using Bi Level Positive Airway Pressure (BIPAP) and advanced airway techniques, to include the use of Laryngeal Mask Airway (LMA) and oral intubations using laryngoscope, if properly trained, credentialed and privileged. Understanding in the use of pulse oximetry, capnometry, capnography, or other secondary confirmation methods to ensure correct placement of emergency advanced airway devices.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

12.) Perform dressing changes, wound management, suture removal, repair of simple lacerations, Foley catheter insertion, splint, binder and bandage applications, and performance of tracheotomy care.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

13.) Conduct specimen collection, preparation and transfer to the lab for processing of blood, tissue, urine, stool and sputum.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

14.) Monitor and obtain test results as soon as available and informs physicians/podiatrist promptly to facilitate patient care.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

15.) Start peripheral IVs.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

16.) Perform venipuncture.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

17.) Perform ear irrigation.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

18.) Perform nasogastric lavage.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

19.) Perform incision and drainage of abscesses.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

20.) Administer enemas.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

21.) Perform splinting.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

Simple Wound Care:

22.) Provide suture removal.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

23.) Perform nail removal.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

24.) Conduct suturing of simple one-layer lacerations not on face, neck, or hands.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

25.) Perform skin stapling - scalp lacerations.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

26.) Apply Steristrips™.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

27.) Apply Dermabond™.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

Diagnostics:

28.) Obtain vital signs.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

29.) Perform EKG.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

30.) Apply rapid strep swabs.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

31.) Perform urine dip.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

32.) Perform urine pregnancy test.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

33.) Perform visual acuity test.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

Medication Administration:

34.) Administer Oxygen.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

35.) Administer basic IV fluids.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

36.) Administer nebulizer medications.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

37.) Administer limited PO meds.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

38.) Administer IM meds.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

39.) Administer IM Immunizations/vaccines.*

Have Performed
Have Not Performed

Date MM/YY & Notes*

Notes:

GSOP Acknowledgement:

Check box to acknowledge*

I confirm that the information in my GSOP listing to be true and correct to the best of my knowledge. I affirm that providing false information may lead to disqualification from participating in the Military Medics and Corpsman Program and may lead to termination of offer or employment by the healthcare system to which I may be referred.

Date:*

Education, Transition & Employment

MMAC Candidate Application Portal

MMAC PROGRAM APPLICATION

MMAC General Scope Of Practice (GSOP) Acknowledgement

Skilled Care:

Simple Wound Care:

Diagnostics:

Medication Administration:

GSOP Acknowledgement: