Associate of Applied Science Degree Surgical Technology Application Fall 2016

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1 Moving Mountains Transforming Lives Building Communities Surgical Technology Application Fall 2016 Open date: Monday, January 4, 2016 Applicants can begin submitting program applications. Close date: Friday, March 25, 2016 All required documentation listed on the application checklist must be received by the Admissions, Registration and Records office no later than 5 p.m. No postmark date allowed. No Exceptions. Please note: This application is for a restricted entry program, and must be filled out by hand and submitted, along with supporting documents and payment to Mt. Hood Community College s Admissions, Registration and Records Office, SE Stark St, Gresham OR If you need assistance with filling out this application or require accommodations, please contact at or

2 APPLICATION PACKET CHECKLIST Applicant Name ( ) MHCC ID Every item on this checklist needs to be received by the application deadline March 25, 2016, 5PM. Only completed applications containing all the required documents will be considered for review. You will not be given notification if items are missing. It is the applicant s responsibility to make sure everything is received by the deadline. By signing below, I am confirming each item below is included with my application or I have confirmed they are already on file at MHCC. I understand it is my sole responsibility to submit the required documents, and I will not be given notice if my application is incomplete until after the deadline, at which time it will be too late to submit missing documents. Item 1. Online General Admissions Form (my.mhcc.edu/ics/admissions) 2. Application Packet Checklist Page 2 3. Allied Health Division Application Page 3 4. Admission Criteria Worksheet Page 4 5. Two Written Exercises: Surgical Technologist Job Descriptions Page 5 Student Survey Page $25 Application Fee Make check payable to MHCC. Bank card/cash is only payable in person in Student Services (Room AC2253) 7. Official (in a sealed envelope) College Transcript(s) (Do not include MHCC transcript.) List name of schools you are using course work from to meet the prerequisite requirement. Official Transcripts from: Being Mailed Included On File at MHCC (This includes MHCC coursework.) Being Mailed Included On File at MHCC (This includes MHCC coursework.) Being Mailed Included On File at MHCC (This includes MHCC coursework.) 1. MHCC s Admissions, Registration and Records office will send all application notification by . It is your responsibility to set your spam filter system to accept mail addresses Do this even if you are currently receiving s from MHCC. We cannot be responsible for notices which are not received due to spam or junk mail handling. Make sure to add MHCC to your safe senders list. Applicants should be checking their on a computer and NOT on a smart phone. Provide the address that was submitted with your online admission form: 2. I understand it is my responsibility to ensure all items are received by the application deadline and that only complete applications will be evaluated for admission. Furthermore, I have read and understand the admission requirements and procedures for applying. I understand that withholding information or giving untruthful answers to questions on this application could be cause for non-acceptance or dismissal from the program. Signature Date Date Received: For Office Use Only Received By: (Rev 10/30/2015) p. 2 of 8

3 SURGICAL TECHNOLOGY ALLIED HEALTH DIVISION APPLICATION Please print and fill out the form in its entirety, do not leave blank. Attach extra paper if needed. Surgical Technology Program Name: SSN or MHCC ID: Previous Last Name(s): ALL notifications will go out via to this address Current Mailing Address: Street City State Zip Phone Number and Alternate Phone: ( ) ( ) Home Cell Name of Nearest Relative and Their Relationship to You: Name Relationship (i.e.) Mother Address of Named Relative Education Record: List ALL colleges attended. College: Street City State Zip Major: Degree earned or number of credits completed: Date of completion: Previous Applications: List all Allied Health programs you have previously applied to. Program Title: Application year(s): College: Were you accepted? Have you withdrawn or been dismissed from this or any other Allied Health program from MHCC or any other school? YES No If yes, please list below Program Title Which Year (s) did you apply? Name of School References: List two personal/professional references non-relatives Name: Address: Phone: Work Experience: In the grid below, list the position and the name of the company/organization. Note any certifications. Related: Unrelated: Volunteer: (Rev 10/30/2015) p. 3 of 8

4 ADMISSION CRITERIA WORKSHEET Applicant Name ( ) MHCC ID This Form Must Be Filled Out Completely and Submitted as Part of a Completed Application. Guidelines: Courses must be completed by the end of Winter term 2016 to apply into the Surgical Technology program. College courses taken as pass/fail, satisfactory/unsatisfactory or audit do not fulfill admission criteria for the Surgical Technology program. List the courses as they appear on your transcript. Do not use the MHCC equivalency or convert to quarter credits if not taken at MHCC. Fill out this form in its entirety. No points will be awarded if the class is not fully documented below. If the class is currently in progress, put IP in the term/year box. Submit updated transcripts documenting your grade once the class is completed. You may submit your application with coursework in progress for Winter term Requirement A: MINIMUM SKILLS PROFICIENCY (No points awarded): Applicants must demonstrate proficiency in the areas outlined below by one of the options listed. Subject OPTION 1 CPT placement into OPTION 2 Completion of Reading ^ RD117 OR RD115 or higher with a C grade or better Writing WR121 OR WR115 or higher with a C grade or better I have met the READING requirement by completing (check one box only): MHCC college placement test Placement test scores submitted from: score with placement into RD117 Completion of a college-level reading course (RD115 or higher). List course below: ^Regardless of coursework completed, students MUST meet the reading proficiency by Option 1 or 2 listed above. MAKE SURE YOU MEET THIS REQUIREMENT! I have met the WRITING requirement by completing (check one box only): MHCC college placement test Placement test scores submitted from: score with placement into WR121 Completion of a college-level writing course (WR115 or higher). List course below: Requirement B: Prerequisite Coursework for Academic Performance (up to 20 points awarded based on cumulative GPA): Applicants must complete the Mathematics and Biology prerequisites by one of the two choices listed below. Applicant must have at least a 2.5 GPA in the below prerequisite coursework Required Coursework Course Term/Year Grade Credits Institution EXAMPLE: BI234 BI231 WI/11 B 4 MHCC MTH065 Beginning Algebra ll Must be completed with a C grade or higher, coursework does not expire. BI112 Biology for Allied Health OR BI231 Human Anatomy & Physiology 1 Must be completed with a C grade or higher, no earlier than Spring BI234 Microbiology Must be completed with a C grade or higher, no earlier than Spring (Rev 10/30/2015) p. 4 of 8

5 WRITTEN EXERCISE: SURGICAL TECHNOLOGIST JOB DESCRIPTION Applicants are REQUIRED to complete the written requirements outlined below. Submissions must be in a wordprocessed/typed format and must be written in your own words. A. Demonstrate that they have researched the profession of Surgical Technology by creating a job description for the Surgical Technologist. The job description must include the following categories: Job Title Required Qualifications Required Personal Characteristics Wages Work Hours Examples of Places of Employment Description of the Working Environment/Conditions Duties/Roles and Responsibilities Requirements for Obtaining and Maintaining National Certification Description of Physical Demands B. Please explain. Why you feel that Surgical Technology would be the right profession for you. Describe how you meet the required demands of the program and the career for a Surgical Technologist. Please provide examples. C. Cite at least three resources (required) - resources may include employment ads, online resources such as olmis.org; ast.org; nbstsa.org; mhcc.edu/surgicaltech.aspx?id=1756 or interviews with surgical technologists. (Rev 10/30/2015) p. 5 of 8

6 WRITTEN EXERCISE: STUDENT SURVEY Applicant Name ( ) MHCC ID This survey is designed to assist us in assessing and planning for improving student success and promoting our program. Please complete both pages in its entirety. This information is confidential and will be shared with program faculty only. 1. How did you find out about the MHCC Surgical Technology program? 2. Do you have any experience in the health care field? If so, please describe. 3. List any specific skills, abilities and qualities you possess that will contribute to your success in the Surgical Technology program and profession. 4. What are the 3 most important things you are looking for in a career? How will a career in Surgical Technology meet those goals? 5. What leads you to choose Surgical Technology over other health care careers? 6. Do you live outside of the Portland/Gresham Metro area? If so, where? 7. Are you planning to work while in school? (See Work Limitations while in the program in the application) Yes No If yes, please tell us: Type of work: Shift times: Number of hours per week: (Rev 10/30/2015) p. 6 of 8

7 WRITTEN EXERCISE: STUDENT SURVEY (continued) What particular challenges do you see for yourself while you are a student in the Surgical Technology program? How do you plan to address these challenges? Please answer each section. Do not leave this blank. Work Hours Verbal and Written English Language Skills Financial Plan Childcare Family Obligations Study Time and/or Time Management Transportation Other (tell us what the challenge is and how you will address it) (Rev 10/30/2015) p. 7 of 8

8 SURGICAL TECHNOLOGY PROGRAM RELATED WORK EXPERIENCE FORM Fill out this form completely and submit it with your application materials by the deadline: March 25, 2016 at 5 p.m. Name of applicant: (Please Print) Please describe any work related experience you have had: (Examples may include experience in sterile processing, operating room or perioperative services, or in any other area of health care, vet tech, volunteer work in health care) Facility: Department: Address: Dates: Start End Total Number of Hours (Years if Employed): Supervisor s Name: Supervisor s or phone Role/Job Title: Brief Description of Role and Experience: (Rev 10/30/2015) p. 8 of 8

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