APPLICATION FOR ADMISSION BS in Medical Laboratory Science Part A: MLS Online Application

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1 SOUTH DAKOTA STATE UNIVERSITY MEDICAL LABORATORY SCIENCE UPWARD MOBILITY DISTANCE LEARNING PROGRAM APPLICATION FOR ADMISSION BS in Medical Laboratory Science Part A: MLS Online Application To The Student: The Medical Laboratory Science Program accepts only 24 students per class to into the Medical Laboratory Science Upward Mobility Program. Selection will be determined by the Medical Laboratory Science Program Director in consultation with the MLS/MLT Program Clinical Coordinator. You will be notified of the decision in writing as soon as decisions have been made. Applications are due in the MLS Program Office by FEBRUARY 1st, to be eligible for the program the following September. Admission Criteria: Students MUST be admitted to SDSU in order to be Eligible for Admission to the Upward Mobility Program Consideration for admission to the Upward Mobility Distance Learning Program for Medical Laboratory Science the student successfully meeting all admission criteria listed. Completion of an associate degree and certified as a CLT/MLT or equivalent Minimum cumulative GPA of 2.8 on a 4.0 in all college work attempted. Grade of C or 70% minimum in all prerequisite courses. Completion of a minimum of 20 college level credits in biology and chemistry to include general biology, Anatomy and Physiology, General Microbiology, statistics and two courses in chemistry to include general/ organic and biochemistry or equivalencies. All courses must contain a lab component. Employed in a JACHO/CAP/COLA/CLIA laboratory, capable of providing a multidisciplinary laboratory experience. Statement of support from current laboratory employer (Laboratory Director). Minimum of 2 years clinical laboratory bench experience. Student must have access to a computer and the internet (preferably high speed access); including Microsoft Office for word=-processing, spreadsheet and database needs. 1

2 Directions for Applying: The applicants must submit the following items: 1. Application Form Type or print legibly using ink. 2. Letters of Recommendation 2 letters of recommendation using the forms provided 3. Admission completed to SDSU, submission of all official transcripts 4. Statement of Support from employer and any additional sponsors required for the completion of the clinical competency portion within the program. Application Deadline: Complete applications must be received by February 1 st. Applications received after February 1 st will be evaluated if there are any remaining positions left to fill. 2

3 South Dakota State University Medical Laboratory Science Program Department of Chemistry and Biochemistry Box 2202, SAV 131, Brookings, SD DIRECTIONS: Complete this application and return it to the Medical Laboratory Science Program at the address above. Evaluation and recommendation for acceptance to the Upward Mobility Program will be made by the MLS Program Director in consultation with the MLS faculty. You will be notified whether or not you are accepted. Some students may be accepted on a probationary status. If you are accepted on a probationary status, you will receive further information about additional requirements. Full Name (Last, First, Middle) Telephone # SSN: - - SDSU ID: Address address: Emergency Contact Name Emergency Contact Address Emergency Contact Telephone # 3

4 EDUCATIONAL HISTORY Name of Institution Dates Attended: Address: (City/State) High School to University/College to University/College to Have you already earned a AA degree? degree was obtained? If yes, please state from where the Cumulative GPA: Honors (Honorary and professional organizations, scholarships and prizes): College/university activities (list offices held): 4

5 EMPLOYMENT HISTORY Employer and Address Position Held Dates of Employment 5

6 STATEMENT OF SUPPORT Part B: MLS Online Application Prospective Online Student: Facility Name: Address: City/State/Zip Code: The information below is to be completed by the laboratory director and/or manager: Please indicate on-site departments: (all departments do not need to be present, however the student is responsible for finding a site to sponsor them if employment facility cannot support: MLS program faculty may be able to assist; Specialized Training Sessions may be available at SDSU) If additional sites are required, each site must complete a statement of support to be included with students application. Phlebotomy: Hematology/Hemostasis: Microbiology: (Bacteriology) Chemistry: Immunohematology: Basic ABORH typing UA/Serology: Other/Specify: Laboratory Accreditation: (CAP, JCAHO, COLA, CLIA, other): The aforementioned individual has expressed a great interest in participating in South Dakota State University Medical Laboratory Science Upward Mobility Distance Learning Program. This program, which is accredited by NAACLS allows a valued employee the opportunity to further their educational status and obtain national certification required 6

7 for different levels of laboratory work. The student will complete a series of didactic courses delivered utilizing the Desire to Learn (D2L) delivery format. Access to D2L provides 24/7 access. Coursework will be completed according to the timeline included in each course syllabus. Students must complete a class within the designated timeframe. Following successful completion of the didactic component, the student will be required to spend an average number of hours in the specified department working with a qualified mentor in order to complete the competency checklist for that discipline. The laboratory component of the program must be completed at the student's work facility or other approved clinical site. For this to take place, the assistance of a mentor or other facilitator is required. The facilitator will NOT serve as a full-time clinical instructor, but should be able to answer questions, evaluate core laboratory competencies, and give valuable assistance as needed. Various mentors maybe utilized dependent upon the organization and size of your facility. Dependent on the applicant's skill level and work experience the time involved for mentors will vary for each course. Students enrolled in this program may complete various projects emphasizing workload recording, test method validation, procedure manual evaluation, CAP and CLIA requirements, and instrument selection. To complete these projects, the student will need to access procedure manuals, laboratory data, instrument validation data, and utilize laboratory instruments. Students should NOT work on these projects as part of their regular work duties. Prior to being accepted into the SDSU Upward Mobility Distance Learning Program in Medical Laboratory Science the student must obtain a statement of support indicating the employers understanding and agreement with the responsibilities outlined in this document and complete any additional University required documentation (volunteer work agreements, test and resource menu, faculty fact sheet, facility fact sheet, student assessment forms). In addition, if the facility is NOT a regular affiliate of the MLS program, an affiliation agreement must also be completed prior to student acceptance in the Upward Mobility Program. Laboratory Director/Manager Signature Date 7

8 Your signature above indicates your willingness to provide the required support for your employee to participate in this innovative program. Laboratory Director/Manager: Office Phone: Facility Name: Address: City/State/Zip Code; Any questions please contact: MLS Upward Mobility Clinical Coordinator TBD Pat Tille Ph.D. MT(ASCP) Program Director Medical Laboratory Science Office:

9 RECOMMENDATION SOUTH DAKOTA STATE UNIVERSITY MEDICAL LABORATORY SCIENCE PROGRAM To the Student: This recommendation form is required for a complete application and must be returned with your application in a sealed, signed envelope. Please complete the Applicant s Waiver of Right to Access for each recommendation and give the form to the person who will write a recommendation on your behalf. To the Evaluator: Please provide a written assessment, preferably on letterhead, of the applicant s strengths, weaknesses and any characteristics that would help the admissions committee evaluate his/her potential to succeed in an independently directed online medical laboratory science program. Attach it to this form. Additionally, give your impression of the applicant by placing a in the most appropriate boxes in the chart below. Please sign the form. NAME OF APPLICANT (First) (Middle) (Last) Applicant s Waiver to Right of Access: The Family Educational Rights and Privacy Act of 1974, as amended, (PL ), allows a candidate for admission to waive his or her right of access to confidential statements written on his or her behalf if the recommendation is used solely for the purposes of admission and if the candidate, upon request, is notified of the names of all persons making such recommendations on his or her behalf. The admissions committee does not require that your make such a waiver as a condition for admission. Under the legislation, you have the option of signing such as waiver as follows: I hereby voluntarily waive, do not waive my right to examine this confidential evaluation. Applicant s Signature Date How long have you known the applicant? In what capacity have you known the applicant? How well do you know the applicant? Very well Fairly well Slightly 9

10 Analytical ability Breadth of General Knowledge Ability of Express Self Orally Writing Ability Perseverance Emotional Maturity/Judgment Organizational Skills Manual Dexterity Overall Academic Potential Excellent (Top 10%) Above Average (Top 10 25%) Average (Top 25 50%) Below Average (Bottom 50%) The MLS Program faculty would appreciate other comments regarding the character, ability or background of this applicant. Please attach comments on a separate page. Place the completed reference form in an envelope and seal and sign the flap. Thank you providing a reference for this student. EVALUATOR Signature Title Address Date: 10

11 UPWARD MOBILITY COURSE SEQUENCE University Proficiency Examination: All upward mobility students will be required to complete the SDSU Proficiency Examination. Students are required to identify a proctor. The exam will be mailed to the proctor via registered mail. Instructions will be provided to the student upon acceptance into the MLS Upward Mobility Program. Semester 1 (Fall 2012) MLS412 - Laboratory Methods - 2 credits MLS321-Hemostasis - 1 credit MLS401-Hematology II - 2 credits Semester 2 (Spring 2013) MLS341- Diagnostic Microbiology II - 2 credits MLS403- Diagnostic Immunology - 3 credits MLS461- Management and Education - 2 credits Semester 3 (Fall 2013) MLS411- Clinical Chemistry II - 3 credits MLS441- Diagnostic Microbiology II - 2 credits MLS451- Immunohematology II- 2 credits Semester 4 (Spring 2014) MLS468- Advanced Supervised Clinical Experience I - 5 credits MLS483- Senior Capstone Clinical Practice - 1 credit Semester 5 (Summer 2014) MLS469- Advanced Supervised Clinical Experience II- 5 credits MLS471- Advanced Medical Diagnostics - 2 credits NOTE: Registration per semester is required as outlined. Courses will be presented in a modular format, in other words during semester 1, you will register for all three classes at the beginning of the semester, but will proceed through the courses one at a time throughout the entire semester. This allows you to concentrate on one subject before moving on to the next course. 11

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