CLT/MLT Program Application CLINICAL LABORATORY TECHNICIAN APPLICATION Packet 2015

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1 CLINICAL LABORATORY TECHNICIAN APPLICATION Packet

2 Checklist 1. Prior to CLT application the following must be completed and Submitted to Calhoun Community College ADMISSIONS OFFICE: Calhoun Community College Application for Admission Official transcripts from all colleges previously attended ACT reading score of 17 or higher OR comparable COMPASS Reading score of 76 or higher (Calhoun Admissions department will place acceptable coursework into the students Calhoun transcript. Applicant must submit updated CALHOUN transcript as listed below) 2. Submit Completed CLT Application and required documention to the Allied Health Department office (pages 1,2, 3 are not necessary to submit) CLT Program Application (page 4) Acknowledgement Signature Page (page 5) Clinical Laboratory Observation Form, documenting a minimum of 3 hours of clinical laboratory observation (page 6) Written summary stating why you would like a career in Laboratory Medicine Transcript from Calhoun Community College with all applicable coursework HIGHLIGHTED ACT, SAT, COMPASS Reading documentation Keyboarding/computer course indicated on transcript or unofficial typing documentation of >24 wpm (see Documentation of Phlebotomy or Previous Lab experience Separately mail 2 pages of reference (page 9,10) Sealed Professional Evaluation/Recommendation form (pages 9-10). A checklist of your professional characteristics is to be mailed separately by that person. This form is the last 2 pages of this packet; print one double sided form and give to the person you listed to complete your Professional Evaluation. This form must be received by the same deadline of Jun 4. Be sure to provide them a stamped addressed envelope: Calhoun Community College PO Box 2216 Decatur, AL ATTN: Allied Health/CLT ALL information requested must be completed and included for your application packet to be considered acceptable. Incomplete or missing documentation may result in the application NOT being considered for admission. Application packets MUST be delivered in person or received by mail by the deadline date. Information will NOT be accepted via fax. Upon acceptance into the CLT program at a designated deadline and prior to clinical rotations, CLT students are required to submit preclinical requirements documentation including but not limited to Health Screen, Hepatitis B vaccination, tuberculosis screening, seasonal flu vaccination, drug screen, and background check at the students expense. 2

3 Applicant to keep for your records CLT/MLT Program Application 2015 CLT Applicant RANKING CRITERIA Use the following worksheet with appropriate information for your own use. Acceptance into the CLT Program is a selective multi-step process. Applicants are ranked by points using information provided by the applicant with Application pages 4,5,6. Missing or incomplete documentation will result in applicants lower ranking scores. ITEM Phlebotomy Training Documentation Course Grade for Science/Math General Education courses: -BIO103, -CHM104, -MTH100 A=10 B=5 Course Grade for non- Science/Math General Education courses: 5 points for C or higher: -ENG101, -ENG102 or HUM, -SPH, -PSY Additional Course completion with grade of B or higher: 5 points each course up to limit of 3 courses Biology, Chemistry Math, Advanced level Medical Terminology Previous LAB employment Documentation Placement Testing Compass Reading, TEAS, ACT, SAT prorated Reference from separately submitted forms TOTAL APPLICANT POINTS Maximum Record your Submitted Information here Points 10 Facility DATE 30 GRADE: BIO 103 CHM 104 MTH ENG101 ENG102/HUM SPH PSY GRADES: BIOLOGY CHEMISTRY MATH MED TERMS 5 Facility DATE 10 Type of TEST DATE 10 Name of Reference Relationship Contact Info Each applicant will be evaluated using this criteria. 100 The highest 18 ranked students will be accepted and notified by letter. 3

4 Return completed application pages 4,5,6 in person to Health Science Center, Decatur Campus OR Mail to Address: For Calhoun Entry Only Calhoun Community College Date Received Allied Health Division CLT Date Contact PO Box 2216 Decatur AL CLINICAL/MEDICAL LABORATORY TECHNICIAN REQUIRED INFORMATION (PRINT LEGIBLY) NAME CALHOUN Student C# Mailing Address City State Zip Primary Phone ( ) EDUCATIONAL INFORMATION: specific requirements highlighted Attach Calhoun transcript and test scores with Name and contact information of person providing your Professional Reference which is to be submitted separately from this application: APPLICANT Signature DATE CLT APPLICATION Pg 1 of 3 4

5 ACKNOWLEDGEMENT SIGNATURES Please read and initial the boxes CRIMINAL BACKGROUND If you have ever been convicted of a crime, other than minor traffic violations, you are advised to consult with the Medical Laboratory Technician licensing board regarding your licensing eligibility: American Society for Clinical Pathology Board of Registry, Phone (800) Website: I understand any conviction of illegal activity may render me ineligible for clinical rotations and completion of the CLT program. I understand I will be required to submit acceptable Criminal Background check prior to any clinical assignments. HEALTH and CHEMICAL DEPENDANCY I understand Students admitted to the program are expected to have & maintain a satisfactory level of health, including freedom from chemical dependency and communicable diseases. I understand Students progressing to clinical semesters of the CLT clinical experience must provide health requirements prior to entry into the laboratory clinical rotation. I understand I will be required to submit acceptable Drug Screen check prior to any clinical assignments ESSENTIAL FUNCTIONS The Essential Functions requirements for students entering and participating in the CLT Program include but are not limited to the ability to: 1. Accurately observe demonstrations and exercises in which biological fluids are being tested (Normal functional use of the senses: speech, smell, hear, vision, and touch). 2. Use sufficient motor function to perform all tasks that are normally expected within the scope of practice for the practitioner in the workplace (standing, walking, hand-eye coordination, lift, reach, or transport supplies, patients, and equipment). 3. Measure, calculate, analyze, synthesize, integrate and apply information (critical thinking skills). 4. Possess the emotional health required to use their intellectual abilities fully, such as exercising sound judgment, promptly completing all responsibilities, being able to work in a changing and stressful environment, displaying flexibility and functioning independently in the face of uncertainties or problems that might arise. 5. Demonstrate professional demeanor and behavior and must perform in an ethical manner in dealing with peers, faculty, staff and patients; able to participate collaboratively and flexibly as a professional team member. 6. Obtain relevant information from lectures, seminars, laboratory sessions and exercises, computer documentation, clinical laboratory practicums and independent study assignments using the English language. I certify that to the best of my knowledge I have the ability to perform these essential functions. I understand that a further evaluation of my ability may be required and conducted by the CLT faculty if deemed necessary to evaluate my ability prior to admission to the program and for retention and progression through the program. I have read and understand the requirements for submitting program application and the procedure for selection and notification of applicants as stated in the CCC catalog. I understand that my academic records will be reviewed by the admissions committee. I understand that all application materials, including test scores, college transcripts, and clinical laboratory department observation visit form must be submitted to the Allied Health office. APPLICANT Signature DATE CLT APPLICATION Pg 2 of 3 5

6 CLINICAL LABORATORY OBSERVATION FORM Print Applicant Name: Clinical Laboratory Visited: PLEASE READ AND SIGN THE FOLLOWING STATEMENTS prior to Observation: CONFIDENTIALITY STATEMENT: I understand and agree that in the performance of my Clinical Laboratory observation as a student at the above listed medical center I must hold medical information in confidence. I understand that any violation of this policy will result in legal action. NON-DISCRIMINATION STATEMENT: I understand and agree that in the performance of my Clinical Laboratory observation as a student at above medical center I will not harass the employees or visitors nor discriminate against any patient in rendering patient care (including, but not limited to the equality and quantity of patient care) because of race, color, national origin, sex, age, marital status, religion, veteran s status, financial status, or mental or physical handicap. I understand that any violation of this policy will result in legal action. Applicant SIGNATURE DATE Clinical Staff: Please initial the appropriate areas listed and sign below. Hematology Chemistry Blood Bank Microbiology Phlebotomy or Processing Serology Urinalysis Other-list: Date of Visit Time IN/OUT Clinical Staff Signature POSITION CLT APPLICATION Pg 3 of 3 6

7 OBSERVATION VISIT INFORMATION An integral part of your application to the CLT program is the completion of an Observation Visit in a hospital Clinical Laboratory Department. This visit will serve to increase your knowledge and awareness of the field of Clinical Laboratory Technology. You are required to complete one Observation Visit, a minimum of three hours in length, and it should be scheduled between the hours of 7:00 AM 11:00 AM. It is the responsibility of the applicant to schedule the Observation Visit. Below is a list of clinical sites and contact information. Observation Visits are not limited to these sites, and applicants may choose to visit a hospital not listed by contacting that facility s Clinical Laboratory Department to request a scheduled Observation Visit. IMPORTANT POINTS TO REMEMBER Observation visits MUST be scheduled in advance and completed prior to the application deadlines. Please dress appropriately for the OBSERVATION VISIT. (No open-toed shoes, blue jeans, short skirts, or caps are to be worn.) Take the CLINICAL LABORATORY OBSERVATION FORM with you to the Observation Visit and present it to the technologist at that facility. Complete the top portion prior to arriving; the technologist will check the appropriate areas observed, sign, and return this form to you. The technologist at the facility will not turn the form in to the college. You MUST submit the completed form with application to the CLT program by the posted deadline. Suggested Clinical Sites (Other accredited Medical Laboratories are acceptable) Athens Limestone Hospital, Athens, AL Venita Chaney Decatur General Hospital, Decatur, AL Barbara McDonnell Huntsville Hospital, Huntsville, AL Ruby Glover Marshall Medical Center South, Guntersville, AL Vanessa Williams This page not to be submitted with application 7

8 Applicant to keep for your records CLT/MLT CURRICULUM 2015 TOTAL CREDIT HOURS 74 GENERAL EDUCATION Coursework COURSE ID Course Name CREDITS ORI 101 ORIENTATION to COLLEGE 1 MTH 100 Intermediate College Algebra 3 ENG 101 ENGLISH COMPOSITION I 3 ENG 102 OR HUM ENGLISH COMPOSITION II OR HUMANITIES ELECTIVE 3 BIO 103 PRINCIPLES OF BIOLOGY 4 CHM 104 Intro to Inorganic CHEMISTRY 4 SPH 106/107/116 SPEECH ELECTIVE 3 PSY 200 GENERAL PSYCHOLOGY 3 24 CLINICAL LABORATORY TECHNICIAN Program Coursework to be completed in Five Sequential Semesters COURSE ID Course Name CREDITS CLT 111 Clinical Urine/Body Fluids 4 CLT 121 Clinical HEMATOLOGY 5 CLT 131 Clinical Laboratory Techniques 4 CLT 141 Clinical MICROBIOLOGY I 5 CLT 142 Clinical MICROBIOLOGY II 4 CLT 151 Clinical CHEMISTRY 5 CLT 161 Laboratory SIMULATIONS 2 CLT 181 Clinical IMMUNOLOGY 2 CLT 191 Clinical IMMUNOHEMATOLOGY 5 CLT 293 Clinical SEMINAR 2 CLT 294 Clinical Practicum Hematology 3 CLT 295 Clinical Practicum Microbiology 3 CLT 296 Clinical Practicum Immunohematology 3 CLT 297 Clinical Practicum Chemistry 3 50 This page not to be submitted with application 8

9 CLT PROGRAM APPLICANT 2015 PROFESSIONAL CHARACTERISTICS REFERENCE FORM Page 1 of 2 The Calhoun Community College CLT Program requires a reference concerning professional characteristics as a portion of the student application process. Please indicate the following listed traits about the CLT Program Applicant checking the most appropriate response. All information is kept in confidence to be accessible only to the CLT Program faculty. Once completed, please seal document into a business labeled envelope, initial, and date the seal, and mail to the listed address below. These 2 reference pages are NOT to be submitted with application. Mail both pages in sealed envelope: Calhoun Community College PO Box 2216 Decatur, AL ALLIED HEALTH-CLT Applicant Thank you for your assistance. Questions may be directed to Allied Health Secretary, or the CLT Program Director, NAME OF CLT Program APPLICANT NAME of Person Completing POSITION/Place of Employment Relationship to Applicant Contact Information (phone and , please) SIGNATURE DATE 9

10 Calhoun Community College CLT PROGRAM APPLICANT 2015 PROFESSIONAL CHARACTERISTICS REFERENCE FORM Page 2 of 2 CLT Program APPLICANT NAME: Length of relationship with applicant: Less than 3 months 3 months- 1 year 1-3 Years More than 3 years Please rate the applicant using the following scale: 3-Above Average 2-Average 1-Below Average Ability to function in a critical thinking scenario, working through problems Professional and Ethical behaviors demonstrated appropriately Attire, hygiene appropriate for situation Ability to receive constructive criticism with a desire to learn Recommendation for this applicant into CLT Program Please check one line that best describes your observation of this applicant experiencing a stressful situation in a work setting: Able to handle the situation having no problems Able to handle the situation with some issues, but worked through difficulties Able to handle the situation only with management assistance Any further comments may be listed here: Mail both pages in sealed envelope 10

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