Radiologic Technology Admissions Checklist

Transcription

1 Radiologic Technology Admissions Checklist Utilize this RT admissions checklist as a guide for successfully completing your RT application process. All application materials must be postmarked on or before April 15 of each year for preferred consideration. Visit the N&AH website at to find program information and all forms needed for the Radiologic Technology program. Chattanooga State Checklist: Complete college application if not a current student. Provide official high school and college transcripts to the Chattanooga State Admissions Office. Important Note: If you are currently enrolled at another college, your transcripts will not be evaluated until Chattanooga State receives a complete and final transcript. Take the ACT, SAT or COMPASS, if applicable Submit vaccination requirements for Chattanooga State s Admission Office Radiologic Technology Program Checklist: Attend one required Radiologic Technology Program Information Session (2 ½ hours). Schedule an appointment with a N&AH Academic Advisor to create an academic plan. Applicant is in the process of completing all pre-requisite and all appropriate college credit courses. Learning Support Classes, if applicable. Preference will be given to students who have completed CHEM and Math 1710 (pre-requisite courses) and BIOL 2010 and BIOL 2020 (college credit courses) and other recommended preparatory courses noted in the Radiologic Technology brochure. Now you re ready to complete these important steps. Submit the Radiologic Technology application form and attach the following: *Submit a copy of your high school transcript (this is required). *Submit a copy ONLY of previous college transcript(s). Important Note: Spring grades and GPA are calculated in the point calculation process. Therefore, a copy of the final transcript from other colleges MUST BE submitted as soon as your grades are posted. Submit completed Student Academic History Form. Submit a copy of the American College Test (ACT) if not on high school transcript. **Attach a copy of your current TEAS results OR on the program application under TEAS Testing Information - be sure to post confirmed test date on when it is scheduled or date when you are retaking the test. *TRANSCRIPTS: Submit copies of transcript(s) by using the N&AH Transcript Request Form. Copies are only needed from previous college(s) - No transcripts are needed if attending Chattanooga State. NOTE: DO NOT REQUEST ANY COPIES OF TRANSCRIPTS FROM THE ADMISSION S OFFICE AT CHATTANOOGA STATE. **TEAS TEST: Register early to take the TEAS Test. Results of test must accompany application if taken at another college. The test must be taken on or before the RT deadline date. To get a copy of your results go to the ATI website Application, program materials, updates and inquiries: Chattanooga State Community College N&AH Application Coordinator, HSC Amnicola Hwy Chattanooga TN / Fax:

2 DENTAL HYGIENE Attendance: Strongly encouraged; but not required Need Reservation: NO Where: HSC Building, Room 2031 When: Dates and times below Length of Session: Approx. 1.5 hours Program Deadline Date: 2/3/ September 13 (Fri 1 pm) January 7 (Tues 9 am) October 10 (Thurs 5 pm) January 23 (Thurs 5 pm) November 12 (Tues. 1 pm) April 4 (Fri 1 pm) June 12 (Thurs 9 am) HEALTH INFORMATION MANAGEMENT Attendance: YES, REQUIRED Need Reservation: NO Where: HSC Building, Room 2106 When: TUESDAYS 5:30 pm SPECIAL TIME Length of Session: Approx. 1 hour Program Deadline Date: 5/5/ September 24 January 7 10 am October 29 February 25 March 25 April 22 IMPORTANT NOTES: * If a deadline date ends on a weekend, the following Monday will be considered the last day to turn in all materials. SPECIAL DAY AND/OR TIME N&AH Information Sessions for Degree Programs NURSING Attendance: Strongly encouraged; but not required Need Reservation: NO Where: HSC Building, Room 1083 When: TUESDAYS, 9 am & 5 pm Length of Session: Approx. 2 hours Program Deadline Date: Transition 1/15/14 & *RN 3/15/ August 6 January 7 September 10 February 11 October 1 *March 18 November 5 April 8 May 13 June 10 July 8 August 5 PHYSICAL THERAPIST ASSISTANT Attendance: Strongly encouraged; but not required Need Reservation: NO Where: HSC Building, Room 2029 When: WEDNESDAYS (times below) SPECIAL DAY Length of Session: Approx. 1.5 hours Program Deadline Date: 3/3/ October 2 (noon) January 7 Tues 9 am November 6 (3 pm) February 5 (3 pm) April 2 (3 pm) IMPORTANT TOPICS ARE DISCUSSED WHEN YOU ATTEND AN INFORMATION SESSION RADIOLOGIC TECHNOLOGY Attendance: YES, REQUIRED Need Reservation: NO Where: HSC Building. Room 2060 When: THURSDAYS, 5:30 PM SPECIAL DAY / TIME Length of Session: Approx. 2.5 hours Program Deadline Date: 4/15/ October 10 January 7 Tues 9 am November 14 February 6 Summer Sessions March 20 May 15 3:30 pm April 14 Mon July 10 3:30 pm RESPIRATORY CARE Attendance: Strongly encouraged; but not required Need Reservation: NO Where: HSC Building, Room 2117 When: WEDNESDAYS (times below) SPECIAL DAY Length of Session: Approx. 1.5 hours Program Deadline Date: 5/15/ September 11 (noon) January 7 Tues 10:30 am October 9 (3 pm) February 19 (3 pm) November 13 (noon) April 9 (3 pm) LOCATION AT THE MAIN CAMPUS - EASTERN TIME ZONE - Chattanooga State Community College Health Science Center Building (HSC) 4501 Amnicola Hwy Chattanooga TN (423) or for more information visit Division-wide information Application: Process/Admission Requirements/Selection Sessions January 7, 2014 Program: Overview/Curriculum/Details/Opportunities/Answers Pub. No /13/jc/bap*form#42*PDF*Chattanooga State Community College is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability or age in its program and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Director and Affirmative Action Officer, 4501 Amnicola Highway, Chattanooga, TN 37406,

3 First Name Last Name Nursing &Allied Health Division Radiologic Technology Application Form IMPORTANT NOTE: Refer to the Radiologic Technology Admission Checklist (on the last page of this application) to successfully complete the application process. Preferred application deadline is April 15 of each year. Personal Data: Date Social Security # ChSCC Banner A ID (if applicable) Name Street City Last First Middle Maiden State Zip Phone Number (Home) (Work) (Cell) Address In case of emergency please notify Phone In compliance with Title VI Civil Rights Act 1964 (Please check one in each area) Sex: M F Race: Asian/Pacific Islander American Indian Black Hispanic White Bi-racial Date of Birth: Month Day Year Education: Name of High School Year of Graduation Street Address City State Zip GED Year Completed GED Test Score Are you currently enrolled at a college? Yes No if Yes, where? Previous Colleges Attended: Address Dates Attended Degree Earned to to to Military Service: Branch of Service Where When Schooling (if applicable), type & ranking in school Testing Information: The TEAS is required for Radiologic Technology. Have you taken this test Yes No If yes, attach a copy of your current TEAS results or record date you took the test Note: To get a copy of your results, go to the ATI website If no, when are you scheduled to take the test The ACT is required for Radiologic Technology. Have you taken the ACT Yes No If yes, when? Total Composite If you have not taken any of the above tests, when is the expected date of testing? Information Sessions: One information session is required Have you attended an information session? Yes No if yes, when if no, when do you plan to attend? Prerequisites: 1. Did you have chemistry in high school with a C or better? Yes No If no, you must take CHEM 1010 prior to beginning the RT program. 2. You must take MATH 1710 prior to beginning the RT program. All applicants must attach a copy of their high school transcript to this application. PLEASE CONTINUE TO NEXT PAGE

4 Finances: Numerous types of financial aid are readily available at Chattanooga State. The Student Aid Office is eager to help applicants complete the forms. The key to receiving aid is to apply early. Call the Student Aid Office at (423) for more details. Will you have to work while in school? Yes No If yes, how many hours per week do you plan on working? Employment Record: (Start with most recent) Employer Address Dates: From To Position Reason for Leaving Employer Address Dates: From To Position Reason for Leaving Employer Address Dates: From To Position Reason for Leaving Medical/Legal Information: Have you ever been convicted of a crime other than a minor traffic violation? Yes No If yes, Date: Describe Have you previously been accepted into a Nursing/Allied Health program at Chattanooga State? Yes No If yes, When: Which program Are you now or have you ever been licensed/credentialed in a health care career? Yes No If yes, are you currently licensed/credentialed in a health care career? Please give license number, state, and health care career and attach a copy of all valid state/national licenses/certificates. Have you ever applied for a license/credential in a health care career and been denied? Yes No If yes, please explain Has your license/credential ever been suspended, revoked, or put on probation? Yes No If you are not currently licensed but have previously been licensed/credentialed in a health care career, indicate the status and reason for the status of licensure /credentialed: Suspension (please explain) Probation Revoked Inactive (please explain) (please explain) (please explain) PLEASE CONTINUE TO NEXT PAGE

5 Please answer these important questions: What are your hobbies or other outside interests, in addition to work and school? How did you find out about the Radiologic Technology program at Chattanooga State? Why are you interested in the Radiologic Technology program at Chattanooga State? What do you know of the job responsibilities required of Radiologic Technologists? (You may attach additional sheets to complete your answers, if necessary.) Criminal Background: Following acceptance and prior to entering the first career course in designated healthcare programs, each student must undergo a criminal background check in order to comply with policies of affiliating clinical practice agencies. It shall be the student s responsibility to comply with instructions provided upon acceptance and provide the results by a designated date. The check will be at the expense of the student. Students who do not meet this requirement in a timely manner or whose background does not meet agency standards will not be able to successfully complete the program. Additionally, a criminal background may preclude licensure or employment. Individuals with a question concerning this should schedule an appointment with the Program Director. PLEASE CONTINUE TO NEXT PAGE

6 Certificate of Application: I affirm, agree, and/or understand that all statements on this form are true and accurate; any misrepresentation or omission of material facts may result in my expulsion from any Allied Health program. I hereby authorize Chattanooga State or other appropriate State investigative agencies to make all necessary investigations concerning me, my work habits, character, or my action in any transaction. I further authorize and request each former employer, person given as a reference, educational institution, or organization to provide all information that may be sought in connection with this application. I understand it is my responsibility to read the program brochure and follow the RT admission checklist in order to successfully complete the program admissions process. Copies of your high school and all previous college transcripts (other than Chattanooga State transcript) should accompany the RT application. The student s program file should be received and complete on or before the preferred RT deadline date of April 15 of each year. It is also the student s responsibility to notify the application coordinator of any changes (such as in address, name change, etc.) so the program file will remain up-to-date. Print Name Signature Date Radiologic Technology Admission Checklist to successfully complete the application process. All RT program forms and important information are available on the RT website. Attend one required RT information session Turn in RT program application and attach the following: 1) Copy of high school transcript 2) Copy of all college transcripts with the exception of Chattanooga State 3) RT Student Academic History Form 4) Copy of ACT test if not on high school transcript 5) Attach a copy of your current TEAS results or record date you took it The TEAS test should be taken on or before the preferred deadline date of April 15 of each year. Important Note: Spring grades and GPA are used in the point calculations. Therefore, a copy of the final transcript from other colleges MUST be submitted as soon as your spring grades are posted. (A faxed copy is acceptable.) Program application, materials, updates and inquiries: Chattanooga State Community College N&AH Application Coordinator, HSC Amnicola Highway Chattanooga, TN Telephone: (423) Fax: (423)

7 Nursing &Allied Health Division Radiologic Technology Student Academic History Form Name Social Security Number or Banner ID Address City State Zip Code HIGH SCHOOL DATA: Attended High School during the years from: to: City State Graduated Grade Point Average year Check courses completed in high school: Check Grade Received Basic Science Basic Math Algebra I Algebra II Geometry Trigonometry Advanced Math Courses Biology Advanced Biology Chemistry Physics Typing COLLEGE DATA: Attended City State Zip Code Graduated Major Grade Point Average year In the last five years have you attended or are you presently attending college? If yes, what subjects have you completed: Check Grade Received High School Chemistry or Principles of Chemistry (CHEM 1010) MATH 1710 *Anatomy and Physiology I (BIOL 2010) *Anatomy and Physiology II (BIOL 2020) Composition I (ENGL 1010) Behavioral or Social Science Elective Humanities Elective *BIOL 2010 and BIOL 2020 must have been taken within the past 5 years. ENTRANCE EXAMS: TEAS Score: % ACT Scores: Composite English Math Reading Science Reasoning IMPORTANT NOTE: PLEASE RECORD OTHER EXTRA CREDIT COURSES ON THE BACK.

8 Transcript Request Form Nursing & Allied Health Division IMPORTANT NOTES TO STUDENT: The school registrar(s) will be sending your transcript to your current address. The student is to keep the official transcript and submit only a copy with your program application; or self-printed transcripts will also be accepted by this division. The N&AH transcript request form should be sent to your high school and all colleges previously attended. No transcripts are needed if attending Chattanooga State or if your transfer credits are showing on the Chattanooga State transcript. A copy of your high school transcript is required for RT applicants; and for PTA applicants who do not have college level courses completed. If you are using high school credit for chemistry for RN, RC or DH, a copy of high school transcripts are required. Important Note: High School and/or other College Transcripts previously submitted to Chattanooga State s Admissions Office cannot be copied and forwarded to the Nursing & Allied Health Division. Do not request the ChSCC Admissions Office to send a copy to Nursing & Allied Health. To obtain N&AH Transcript Request forms go to the N&AH website STUDENT FILL OUT CLEARLY & COMPLETELY FOR REGISTRAR: School Registrar s Mailing Address I last attended your school in. For identification purposes, the name under which I attended your school was. My birth date is and my Social Security Number is. SCHOOL REGISTRAR: The N&AH Division would like to request that the complete official transcript of Academic Record be sent to the student s current address below. Note to Registrar: If there is any charge for this service, please bill the student at the address above: Questions: contact the N&AH Application Coordinator at (Student - Please Print Clearly for Registrar) Student s Name: Current Address: City/State/Zip: Student Phone Number(s): Respectfully, Student Print Name Student Signature Date Pub. No /13/jc/bap*form#43*PDF*Chattanooga State Community College is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability or age in its program and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Director and Affirmative Action Officer, 4501 Amnicola Highway, Chattanooga, TN 37406,

9 Page TEAS INFORMATION SHEET FACTS TO KNOW ABOUT THE TEAS (TEST OF ESSENTIAL ACADEMIC SKILLS): Chattanooga State only gives the reading and math sections of the TEAS. The TEAS includes multiple-choice questions divided into 2 subsections: Mathematics and Reading. The test used is Version 5 and we do not give the Science and English sections of the TEAS. Reading paragraph comprehension, passage comprehension, and inference/conclusions (58 minutes, 42 questions) Math whole numbers, metric conversion, fractions, decimals, algebraic equations, percentages, and ratio/proportion (51 minutes, 30 questions) Study Manuals for the TEAS-V are available for purchase at the Chattanooga State Bookstore -. Also, online from ATI at are purchases that include learning strategies, TEAS Pre-Test Study Manual, TEAS Online Practice Assessments and TEAS Transcripts. Other sources of test review materials include the reading comprehension and mathematics (basic math up to intermediate algebra) sections of any GED, ACT or SAT prep manual. Study Manuals are also on reserve at the Chattanooga State Library. Calculators are NOT ALLOWED. The test will be taken on the computer. There is no paper and pencil option. In order to be a valid test, it must have been taken within two (2) years of the program application deadline. Only one test every six (6) months is valid. ADVANCED REGISTRATION is required due to limited seating. DON T WAIT! Pre-register at least 4-6 weeks before the program deadline date. Remember: The test has to be taken on or before the program deadline date. RESULTS OF TEAS: After you take the test, keep a copy of your TEAS results. You will be attaching a copy and/or posting the test date information on your program application. The student can at any time access their results under their account at ATI testing visit or contact ATI at If the TEAS is retaken, the higher score total from one test will be used SCORING THE TEAS: Don t forget to view the TEAS Sample Score Sheet Individual Performance Profile, which is available on the N&AH website. This will help you understand how the TEAS is scored. The adjusted individual scores of the two tests are averaged to the nearest tenth (i.e. 63.8) for a composite score. Remember, each N&AH program calculates the formula points differently. Attend a program information session to go over this important process. TESTING CENTER POLICIES PLEASE READ IMPORTANT! CANCELLATION POLICY: A 24 hour notice is required if you have to cancel - call To reschedule once without penalty of repayment: Present documentation/note from doctor, courts, etc. stating your emergency to cancel If no documentation (as stated above), you ll be required to repay the fee. Student must show picture ID or driver s license at time of testing. IMPORTANT: KEEP Pages 1 & 2 FOR REFERENCE PROGRAM S THAT REQUIRE THE TEAS TEAS test must be taken on or before the program deadline date for Don t wait until the last minute to register. Important: Don t take the TEAS test after the deadline date unless approved by the Program Director. Program Deadline Date for 2014: Physical Therapist Assistant March 3 Dental Hygiene February 3 Health Information Management May 5 LPN to RN Transition January 15 Paramedic to RN Transition January 15 Radiologic Technology April 15 Registered Nursing March 15 (RN: Must be registered by 3/1/14, call (423) if questions) Since RN s deadline ends on a weekend, the following Monday will be considered the last day to turn in all materials which means the deadline will be March 17. Respiratory Care May 15 *Veterinary Technology May 1 *Veterinary Technology (Vet Tech) is a program offered through the Math & Science Division at Chattanooga State.

10 Page 2 TEAS SAMPLE SCORE SHEET Individual Performance Profile Test of Essential Academic Skills V - Form A Individual Name: Student Number: Institution: Chattanooga State TEAS ADN Program Type: ADN Test Date: 3/25/2011 # of Questions: 72 Attempt: 1 of 1 Days since last attempt: 0 ati Scores # Adjusted Individual Mean Percentile Rank Adjusted Individual Score (% correct) Sub-Scale Items Score National Program National Program TEAS Reading % 69.7% 71.3% Paragraph and Passage % 69.5% 71.1% Comprehension Informational Source % 71.7% 73.5% Comprehension TEAS Mathematics % 68.0% 69.4% Numbers and Operations % 70.1% 71.4% Algebraic Applications % 67.6% 68.6% Data Interpretation % 63.3% 64.9% Measurement % 63.1% 64.9% Adjusted Individual Score Means Percentile Rank Bar Graph Percent scores based on the number of questions answered correctly divided by total number of questions for each component of the test. The bolded and enlarged Reading and Math % scores are averaged together when calculating class selection points. Each program calculates the formula points differently. The other scores provide information as to how you did in each component in the reading and math sections. Compares your % score to national and program averages for student who took the test. A comparison score that shows how you ranked compared with others who have taken the test. If you scored 34, that means you scored better than 34% of the people who took the test. This is a presentation of your % scores. This is a good way to see your strengths and areas for improvement if you plan to take the test again.

11 Page 3 How to Register: Mail or bring the TEAS Registration Form to the Chattanooga State Testing Center. There is a $55.00 test fee that is due at the time of registration. They will accept cash or checks; checks made payable to Chattanooga State. No telephone reservations are accepted. Location of Chattanooga State Testing Center: 4501 Amnicola Hwy, IMC Building Room 122, Chattanooga, TN Important Note if Registering by Mail.. Before mailing to the Testing Center, make sure these are included: the TEAS Registration Form $55.00 check for test fee made payable to Chattanooga State include a self-addressed and stamped envelope that will be used to return confirmation of your test date, reporting time and test location. NOTE: If an envelope is not included, an attempt to confirm by phone will be made 3 times. After that, all materials will be returned or put in a file marked unconfirmed. TEAS REGISTRATION FORM Read all important information from page 1. If mailing, include the 3 important items mentioned above. If Rescheduled: Date: Time: Please Print NAME: (as on driver s license) Soc. Sec or A # ADDRESS City State Zip Daytime phone # Cell # address Check here if you have educational, psychological and/or physical disabilities and may be eligible for accommodations. Information is available in the Disabilities Support Services Office. Please Explain: The TEAS test is scheduled on Mondays, unless specified below with an asterisk (*). DIRECTIONS: For your 1 st choice - place #1 next to a date and a time. For your 2 nd choice - place #2 next to a date and a time. NOTE: No TEAS testing in August due to entrance testing. JULY 2013 SEPTEMBER 2013 OCTOBER 2013 NOVEMBER 2013 DECEMBER 2013 JANUARY 2014 DATE/(TIMES) 15 (2:30) 22 (5:00) 29 (11:00) 9 ( 11:00 2:30 5:00) 14 * Sat ( 8:30 11:00) 16 (8:30) 23 (11:00) 7 (2:30) 21 (8:30) 28 (11:00) 4 (2:30) 9* Sat ( 8:30 11:00) 11 (5:00) 25 ( 8:30 11:00) 16 ( 8:30 11:00 2:30 5:00) 6 ( 8:30 11:00 2:30 5:00) 11* Sat ( 8:30 11:00) 13 ( 8:30 11:00 2:30 5:00) 27 ( 8:30 11:00 2:30 5:00) FEBRUARY 2014 MARCH 2014 APRIL 2014 MAY 2014 JUNE 2014 JULY * Sat ( 8:30 11:00) 3 ( 8:30 11:00 2:30 5:00) 10 ( 8:30 11:00 2:30) 17 ( 8:30 11:00 2:30 5:00) 24 ( 8:30 11:00 2:30) 1* Sat ( 8:30 11:00) 3 ( 8:30 11:00 2:30 5:00) 10 ( 8:30 11:00 2:30 5:00) 11* Tues (8:30) 12* Wed. (11:00) 13* Thurs. ( 8:30 2:30) 17 ( 8:30 11:00 2:30 5:00) 24 ( 2:30 5:00) 7 ( 8:30 11:00 2:30 5:00) 12* Sat ( 8:30 11:00) 14 ( 8:30 11:00 2:30 5:00) 5 ( 11:00 2:30) 12 ( 11:00 2:30) 19 (11:00) FOR OFFICE USE ONLY 1 st Date: Time: 9 (11:00) 16 (2:30) 23 (5:00) 14 (2:30) 21 (5:00) 28 (11:00) Pub. No /13/jc/bap*form#46*PDF*Chattanooga State Community College is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability or age in its program and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Director and Affirmative Action Officer, 4501 Amnicola Highway, Chattanooga, TN 37406,

12 Radiologic Technology Admission Points Additional Credit may be given for students who have successfully completed the following courses with a grade of C or above. Highlighted courses are encouraged. ENGL 1020 Composition II INFS 1010 Computer Science (EC for 1 only) SPCH 1010 Speech required for sonography HE 103 HS 111 Medical Terminology Introductions to Healthcare Professions SPAN 1002 Medical Spanish I and SPAN 1003 Medical Spanish II BIOL 1430 BIOL 1110 BIOL 1120 BIOL 2230 Nutrition General Biology I General Biology II Microbiology MATH above 1710 CHEM 1030 Integrated Chemistry CHEM 1110 General Chemistry I CHEM 1210 General Chemistry II CHEM 2020 Organic Chemistry PHYS 1030 Integrated Physics PHYS 2010 Physics I PHYS 2020 Physics II PHYS 2110 Calculus Based Physics I PHYS 2120 Calculus Based Physics II 40 hours or more observation at a full service radiology department

13 Radiologic Technology Estimated Costs These are estimated program costs. Actual costs may vary due to changes in tuition and/or fee increases as determined by the Tennessee Board of Regents. This cost will also be reduced for students since some of the required course work is completed prior to acceptance into the program. These general and support courses taken before the program is to lessen course load in a given semester. Note: College fees are included in the maintenance cost. To view current calculation table, go to Bursar s Office on Chattanooga State website. This website will also give you information on refund policies, fee payments and the refund calendar. Maintenance Fees In-State Out-of-State Pre-Admission Costs: College one time application fee TEAS Admission test First Semester (17 hours) (fall) Maintenance fee 1, , Truescreen: myrecord Tracker Fee: Upload documentation for: Physical examination and required test Hepatitis B (estimate) Fit test CPR Right, left and upright markers Liability insurance Radiation monitoring receipts Truescreen Criminal Background Check Truescreen Drug Screen (10 panel) Textbooks 1, , Second Semester (14 hours) (spring) Maintenance fee 1, , Uniforms, lab coats, etc Textbooks Parking-Hospitals Third Semester (4 hours) (summer) Maintenance fee , Fourth Semester (17 hours) (fall) Maintenance fee 1, , Truescreen: myrecord Tracker Fee: Upload documentation for: Fit Test TB Skin Test Liability insurance Radiation monitoring receipt Uniforms, lab coats, etc Textbooks Fifth Semester (17 hours) (spring) Maintenance fee 1, , Textbooks Sixth Semester (6 hours) (summer) Maintenance fee ,549.00

14 Nursing & Allied Health Division Chattanooga State Community College 4501 Amnicola Highway Chattanooga, TN Request for Waiver of 5-Year Limit Lab Science Courses Name (Please Print): Date: Last Name First Name Address: Street/PO Box City State Zip Phone Number: Home: Cell: address (please print clearly): Student ID Number: Year you plan to enter program? Program: Dental Health Information Physical Therapist Radiologic Respiratory Hygiene Management Assistant Technology Care PLEASE READ CAREFULLY: A waiver of the 5-year limit for Anatomy & Physiology and/or Microbiology will only be considered if the applicant Has applied for admission to Chattanooga State and submitted an application to the Allied Health program. Is currently licensed or certified in a healthcare career or can provide evidence as to why knowledge of the biology subject is current. Has a grade of B or better in the biology course(s.). A waiver request for courses with a grade of C will not be considered. Provides documentation that the courses were completed within no more than 8 years of the date of entry into the first program course. It is the student s responsibility to submit all requested information at the time the waiver form is submitted. Anatomy and Physiology I, II and Microbiology must have been completed no more than 5 years from enrollment in major courses. To request a waiver of the 5-year limit, provide ALL of the following information and submit completed form to the appropriate program director prior to the application deadline: Semester/Year Taken Grade Requesting Waiver Anatomy and Physiology I Anatomy and Physiology II Microbiology Concepts of Physics NOTE: Attach a copy of your Chattanooga State transcript verifying this information. If these courses were taken elsewhere and do not appear on your transcript in Banner Self Service attach a copy of the appropriate transcript(s). Incomplete applications will not be considered. Describe in detail: Why do you believe a 5-year waiver should be granted? (Use back of the page or attach a typed document.) Keep in mind that the content included in these courses is not taught during your major courses. It is assumed that students have current knowledge of the sciences upon which to build knowledge in your chosen healthcare field. Explain why you believe your knowledge is current enough to be granted a waiver of the 5-year limit. Include in this explanation such things as: Do you have prior health career education? What career? When were you enrolled? Are your currently certified or licensed in a health profession? Describe any work experience since completion of the biology course(s) related to maintaining current knowledge. Student Signature: Committee Action: Date: Approved (list any conditions: ) Denied