DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM APPLICATION FOR ADMISSION

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1 Date of application: Name (Last) (First) (Middle) (Maiden) VCC ID# Home Address City, State, Zip, County Telephone Number (Home/Day time): Male Female Race Birth Date Atlas Address: Are you a U.S. citizen? Yes No Are you a Florida resident? Yes No Have you been accepted to Valencia Community College? Yes No Please indicate by a check the college level courses that you have taken with C or better, and with an E if you are currently enrolled: College Algebra (MAC 1105) Humanities/Fine Arts Anatomy & Physiology II (BSC 2094C) Anatomy & Physiology I (BSC 2093C) Freshman Comp I (ENC 1101) General Psychology (PSY 1012) Medical Terminology (HSC 1531) Professions of Caring (HSC 1001) Have you taken any courses at another college or university regardless of the grades earned or their applicability toward this program s requirements? Yes No Name of College or University: Are your official college and high school transcripts on file with Valencia s records office? Yes No Excluding this application, how many times have you applied for admission to this program?

2 A $15 non refundable application fee to the program (check or money order payable to Valencia Community College) must be submitted to the Business Office with each application. Application and check must be together. Do not send separately. Please make payment to the Business Office before turning in your application. Valencia Community College Business Office SSB S. Kirkman Road Orlando, FL Finance Office Use Have you completed the following: Health care work experience documentation Yes No Currently enrolled in a course not at VCC Yes No Review of advisement information Yes No Professional license, certification, or registration documentation Yes No NET exam (copy of results) Yes No Name and telephone numbers of references Yes No Reviewed Radiography Program video Yes No Paid the $15 application fee for the Radiography Program Yes No SONOGRAPHY APPLICATION AND DOCUMENTATION MUST BE SUBMITTED BY MAY 1 ST TO BE CONSIDERED FOR ADMISSION TO THE SESSION 1 CLASS. I AFFIRM THAT ALL INFORMATION ON THIS APPLICATION IS TRUE. I ALSO UNDERSTAND THAT IT IS FRAUDULENT TO MISREPRESENT ANY INFORMATION ON THIS FORM. Signature

3 REFERENCES Name of Applicant: VCC ID# Please list the name, address, position and telephone number of three people you authorize us to contact for references. Include people who can evaluate you in regard to your work performance, relationships with other people, emotional maturity, and commitment to goal accomplishment. Name: Position: Telephone #: Address: Name: Position: Telephone #: Address: Reference #1 Reference #2 Name: Position: Telephone #: Address: Reference #3 Waiver of rights to reference information: I waive all my rights to the information submitted by the person serving as my reference, and I understand no one will have access to this information other than members of the Admission Committee. Signature of Applicant Date

4 HEALTH CARE WORK EXPERIENCE AND PROFESSIONAL CERTIFICATES Applicant s health care related work experience as well as health related professional license, registration and certification will be taken into consideration in the selection process. Please provide the following information (use additional pages if needed). 1. List all health care experience with direct patient contact and include the following: A. Positions held B. Paid or volunteer C. Length of time in position D. List of responsibilities E. What did you gain from this experience that will assist you in reaching your personal and professional goals? 2. List and enclose copies of health related professional license, registration, or certification certificates that you currently hold.

5 PERFORMANCE STANDARDS FOR ADMISSION AND PROGRESSION ISSUE STANDARD EXAMPLES OF REQUIRED ACTIVITIES (NOT ALL INCLUSIVE) Critical Thinking Interpersonal Communication Mobility Motor Skills Hearing Visual Tactile Critical Thinking ability sufficient for safe clinical judgment. Interpersonal abilities sufficient to interact with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds. Communication abilities sufficient for interaction with others in verbal and written form. Physical abilities sufficient to move from room to room and maneuver in small spaces. Gross and fine motor abilities sufficient to provide safe and effective care. Auditory abilities sufficient to monitor and assess patient needs, and to provide a safe environment. Visual ability sufficient for observation and assessment necessary in the operation of equipment and care of patients. Tactile ability sufficient for patient assessment and operation of equipment. * Identify cause effect relationships in clinical situations. * Evaluate radiographs to ascertain that they contain proper identification and are of diagnostic value. * Select exposure factors and accessory devices for all radiographic procedures with consideration of patient size, age, and extent of disease. * Assess patient s condition and needs from a distance of at least 20 feet. * Initiate proper emergency care protocols, including CPR, based on assessment data. * Establish rapport with patients, families, and colleagues. * Communicate in English to the patient in order to: converse, instruct the patient, relieve anxiety, gain their cooperation during procedures, understand the patient when communicating symptoms of a medical emergency. * Read the patient s medical chart and/or physician s orders. * Legibly write patient history. * Documents own actions and patient responses as indicated. * Assist all patients, according to individual needs and abilities, in moving, turning, transferring from transportation devices to the x ray table, etc. * Be able to push, pull, and lift 40 pounds. * Push a stretcher, wheelchair or other transportation device without injury to self, patient, or others. * Push a portable x ray machine from one location to another, including turning corners, getting on and off of an elevator, and manipulating it in a patient s room. * Manually move the x ray tube and position the tube at various angles at heights up to 7 feet. * Accurately draw up sterile contrast media and other solutions without contaminating the syringe and/or needle, etc. * Place cassettes in Bucky trays and spot film devices and properly manipulate all locks. * Physically be able to administer emergency care including performing CPR. * Be able to stand for periods as long as 2 hours wearing lead aprons and to walk a distance of 2 miles during a normal work day. * Hear a patient talk in a normal tone from a distance of 20 feet. * Hear monitor alarm, emergency signals, and cries for help. * Observe the patient in order to assess the patient s condition and/or needs from a distance of, at least, 20 feet. * Can see numbers, letters, calibrations, etc. of varying sizes located on equipment utilized by a radiographer. * Perform palpation, tactile assessment, and manipulation of body parts to insure proper body placement and alignment. * Manipulate dials, buttons, and switches. I have read and understand the performance standards necessary to be a competent radiographer. Signature: Date

6 MISSION STATEMENT It is the mission of the Diagnostic Medical Sonography Program to provide a learning environment that promotes student success in Abdominal/OB/GYN Diagnostic Medical Sonography. Facilitate student competence to: GOALS 1. Recognize normal and abnormal anatomy. 2. Produce high quality diagnostic images. 3. Provide appropriate patient care. 4. Maintain a safe environment. 5. Develop critical thinking and decision making skills. 6. Communicate effectively. 7. Develop ethical and professional values. 8. Demonstrate employability skills. INDIVIDUALS WITH A DISABILITY For the purpose of the Diagnostic Medical Sonography Program a Qualified individual with a disability is one who, with or without reasonable accommodation or modification, meets the essential eligibility requirements for participation in the program. Diagnostic Medical Sonography is a practice discipline with cognitive, sensory, affective, and psychomotor performance requirements. Based on these requirements a list of Performance Standards has been developed. Each standard has an example of an activity or activities which a student will be required to perform while enrolled in the Diagnostic Medical Sonography program. These standards are a part of a Sonographer s professional role expectation. These standards should be used to assist students in determining whether accommodations or modifications are necessary to meet performance standards. Students who identify potential difficulties with meeting the performance standards must communicate their concerns to the college counseling/advising staff and program director. The student has the obligation to identify and document the disabling condition and to ask for appropriate adjustments. The department of Health Related Programs at Valencia Community College makes no preadmission inquiries concerning an applicant s disabling condition. Information related to an applicant s disabilities is not a part of the information reviewed by the Admission Committee. Determination is made on a individual basis as to whether or not any accommodations or modifications can be reasonably made.

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