The following information must be completed prior to June 15 th. No exceptions!

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1 DIXIE STATE UNIVERSITY SURGICAL TECHNOLOGY PROGRAM CHECKLIST DUE DATE: JUNE 15 th The fllwing infrmatin must be cmpleted prir t June 15 th. N exceptins! DIXIE STATE UNIVERSITY ADMISSION PROCESS COMPLETED Currently a student in gd standing OR have cmpleted the admissin prcess. COMPLETE THE PREREQUISITE COURSES WITH A C OR HIGHER ENGL 1010 Intrductin t Writing MATH 1010 Intermediate Algebra HLOC 1000 Medical Terminlgy BIOL 2320/2325 Human Anatmy/Lab BIOL 2420/2425 Human Physilgy/Lab COMPLETE SURGICAL TECH PROGRAM APPLICATION COMPLETE THE PSB HEALTH OCCUPATIONS APTITUDE EXAM Taken at the testing center $40.00 fee. Submit a cpy f results with applicatin. (Cntact testing center fr details.) TWO RECOMMENDATION FORMS Sealed in envelpes accrding t instructins. $25 APPLICATION FEE RECEIPT Paid t the cashiers ffice CURRENT RESUME Shw related health care wrk experience (if any) PREVIOUS ACADEMIC RECORDS Official transcripts required fr curses transferred. Unfficial transcripts frm DSU with applicatin, but must submit fficial transcripts shwing curses cmpleted upn acceptance int prgram. PERSONAL LETTER Why d yu want t be a surgical technlgist Why yu feel yu wuld be a gd surgical technlgist Yur perceptin f yurself in regards t yur ability t handle stress Yur perceptin f yur persnal integrity A persnal analysis f yur ability t listen and receive cnstructive criticism Yur feelings regarding yur ptential success in the Surgical Technlgy prgram Any ther pertinent infrmatin such as medical prblems, drugs, etc. PERSONAL INTERVIEW Successful applicants will be cntacted fr an appintment. Fr Questins Cntact: Dixie State University Chris Giffrd Surgical Tech Advisr Thank yu fr yur interest in the Surgical Tech Prgram at Dixie State University!

2 Dixie State University Surgical Technlgist Prgram Applicatin fr Admissins First Time Applicant Re- Applicant Semester 1. Persnal Infrmatin DSU Student Number Dmail Username Preferred Name Date f Birth First Name Last Name MI Address City State Zip Cell Phne Other Phne 2. Emergency Cntact Name Relatinship Phne Address City State 3. Prgram Applicatin Requirements I am a student in gd standing OR I am a transfer student and have cmpleted the DSU admissins prcess I have enclsed OFFICIAL transcripts frm all institutins I have included the $25 applicatin fee receipt I have enclsed my typed persnal letter I have enclsed a cpy f my PSB HOAE test results I haven enclsed my resume shwing related healthcare wrk experience (if any) I have attached 2 SEALED persnal recmmendatin frms 4. Academic Histry (Pst high schl) Institutin Lcatin Dates Attended Majr Degree

3 PREREQUISITE COURSE COMPLETION Be sure and include Cllege r University name. D NOT use MIDTERM grades. Required Curses DSU Curse # (Circle class taken) MOST RECENT ATTEMPT Semester Grade Cllege r University Anticipated Cmpletin Date Human Anatmy BIOL 2320 Human Anatmy Lab BIOL 2325 Human Physilgy BIOL 2420 Human Physilgy Lab BIOL 2425 GENERAL EDUCATION PREREQUISITES Intr t Writing ENGL 1010 Transitinal Mathematics II MATH 1000 r higher Medical Terminlgy HLOC 1000 Applicants must have excellent interpersnal skills and a strng interest in the health care field. I certify that all f the statements in this applicatin are true and accurate t the best f my knwledge. I have carefully cnsidered the mental and physical demands f the prgram and the pressure invlved in undertaking respnsibilities f being a full time student in this prgram, and I am willing t arrange my life s I can successfully adapt t the demands f a rigrus Surgical Technlgy prgram. I have enclsed all f the requirements with the applicatin. I am willing t participate in a persnal interview with members f the selectin cmmittee. I will be cntacted fr details. Print name f Applicant Signature f Applicant Date

4 CONFIDENTIAL RECOMMENDATION FORM DIXIE STATE UNIVERSITY HEALTH SCIENCES PROGRAMS ATTENTION APPLICANT!! The evaluatr MUST cmplete this frm and seal it in the envelpe prvided. Instruct the evaluatr t sign the sealed flap f the envelpe and return it t yu prmptly. Please allw sufficient time fr the evaluatr t cmplete this frm. TO THE APPLICANT: Please cmplete this area ONLY!!! (Please Print) Applicant s Name: Year Prgram: (please circle) ADN BSN PHLB SURG TECH RAD TECH EMS Address: Phne: The Family Educatinal Rights and Privacy Act f 1974 and its amendments guarantee student access t educatinal recrds cncerning them. Students are als permitted t waive their rights t access t recmmendatins. The fllwing signed statement indicates the applicant s wish regarding this recmmendatin: I waive, r d nt waive my right t see this frm r any supplementary ntes r letters pertaining t this reference frm. Applicant Signature Date: ***************************************APPLICANT: DO NOT WRITE BELOW THIS LINE************************************** TO THE EVALUATOR: Yu have been chsen as a reference in supprt f the applicant fr ne f the Dixie State University Health Sciences Prgrams. We are particularly interested in yur appraisal f the applicant s abilities and ptential fr educatin in a rigrus training prgram. Circle the number that is mst characteristic f the applicant. Make any additinal cmments that yu feel wuld be helpful in ur evaluatin. Seal it in the envelpe prvided. Sign yur name acrss the flap and return it t the applicant prmptly. 1. Prblem Slving: Ability t identify and slve prblems. Very Pr Satisfactry Excellent 2. Sense f Respnsibility: Ability t cmplete tasks, duties, and hnrs cmmitments. Desn t Cmplete Satisfactrily Cmpletes Always Cmpletes Avids Respnsibility Will Accept Respnsibility Accepts Respnsibility 3. Maturity: Cnducts self in a mature, adult manner. Immature/Childish Average Mature/Adult Behavir 4. Attitude: Based upn yur experience, what type f attitude des the applicant prject tward life, schl, jb, etc.? Very Negative Average Very Psitive 5. Caring Attitude: Des the applicant shw genuine cncern and care fr thers? Very Little Average Exceptinal

5 6. Anxiety Level: Ability t deal with stressful, anxiety-prducing situatins. Prly/Ineffective Average Excellent 7. Mtivatin: Extent t which individual applies self. Uninspired Average Self-Starter/Hard Wrker 8. Appearance: Extent t which the applicant s standard f appearance is met. Untidy Average Well Grmed Appearance 9. Cnfidence/Flexibility: Extent t which the applicant accepts cnstructive critique and cnsiders thers pints f view. Resents/Rejects Average Seeks, Utilizes & Respnds Effectively 10. Cmmunicatin Skills: Ability t cmmunicate with peers, c-wrkers, teachers, etc. Expresses Self Prly Average Excellent Expressin/Fluent 11. Integrity: Extent t which the applicant displays an ethical cde. Cheats/Untruthful Average Always Hnest/Trustwrthy 12. Interpersnal Relatinships: Ability t cperate and get alng with peers, c-wrkers, teachers, emplyers, etc. Inapprpriate Behavir Satisfactry Outstanding Ability T Wrk Well With Others 13. Absenteeism/Punctuality: Extent t which the applicant s absenteeism and punctuality affects perfrmance. Interferes With Perfrmance Average Almst Never Interferes *********************************************************************************** OVERALL RECOMMENDATION: I highly recmmend this applicant fr the prgram being applied fr. I recmmend this applicant fr the prgram being applied fr. I d nt recmmend this applicant fr the prgram being applied fr. *********************************************************************************** COMMENTS: (Please Print) May attach additinal page(s) if necessary. EVALUATOR INFORMATION: (Please Print) Evaluatr s Name/Title: Phne: Length f time yu have knwn applicant: Capacity: Signature: Date: Thank yu fr yur participatin. Please return this frm t the applicant prmptly in a sealed and signed envelpe. This signature will be used t verify yur riginal signature n the envelpe.

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