School of Medical Laboratory Science Application Packet

Transcription

1 Application Packet Please mail completed application packet and required documents to Untied Regional HealthCare System Att; Asma Javed, Program Director School of Medical Laboratory Science th St, Bethania Building Wichita Falls, TX Revised 1/2009 1

2 An equal opportunity provider of education. Does not discriminate on the basis of race, religion, sex, national origin, age and disability to sexual orientation and gender identity. Dear Interested Applicant, Enclosed is an application form for the Medical Technology Program at URHCS. Academic Prerequisites for Medical Technology, Criterion for Student Selection, Description of lectures and rotation curriculum, and the Immunization policy are provided on the website at The Applicant must provide with the following along with the application o At least a 2.5 Overall and Science GPA o Official Transcripts from all schools attended (if degree not complete, unofficial copy is acceptable. Official copy will be required before the start of the rotation) o Three letters of reference; one personal, two academic o A Student letter of Intent explaining your interest in the field and why you should be accorded an interview o Immunization records In addition to your Application and Health Questionnaire, please sign and return the enclosed Essential Functional Tasks document. Please have your references sent directly to the MT school office. There is no form for the reference letter. To attend our school, you should be eligible for a Bachelors in Science from any of accredited in the United States or already have a Bachelor of Science with the necessary prerequisites and criteria for selection (lists are enclosed) from any accredited US institution of higher education. Foreign students would need to get their degrees equalized by an accredited institution. Revised 1/2009 2

3 The MLS School at United Regional is currently affiliated with the following Universities. Midwestern State University Wichita Falls, TX Texas Woman s University Denton, TX University of North Texas Denton, TX Northeastern State University Tahlequah, OK Southwestern Oklahoma State University Weatherford, OK Additional affiliation maybe setup if a student from a nonaffiliated university is accepted. If you have any questions, please do not hesitate to contact me. Sincerely, TáÅt ]täxw Asma Javed, MS, MT (ASCP) Program Director Ph; ; ajaved@unitedregional.org Please mail completed application packet and required documents to Untied Regional HealthCare System Att; Asma Javed, Program Director School of Medical Technology th St, Bethania Building Wichita Falls, TX Revised 1/2009 3

4 Essential Functional Tasks --- School of Medical Technology Applicants The ability to perform certain essential tasks is necessary for all students entering the United Regional Health Care System School of Medical Technology. The function of these tasks is essential for successfully completing the clinical education component of the Medical Technology Program. These essential functions are based upon the specialized nature of the work in the profession of medical technology, and are aligned with the job performance standards for an employed medical technologist. Reasonable effort will be made to accommodate any disabilities to allow for performance of these essential functional tasks. To meet the essential function requirements, the student shall: 1. Complete a pre-entry health history given by the Program Director and reviewed by the Medical Director. 2. Obtain or update all required immunizations as required by the school. 3. Complete visual testing and laboratory screening studies. These tests will be performed free of charge. In addition to completing the above, the student shall possess: 4. The ability to read and write. 5. Visual acuity in order to discriminate color in urine chemistry reactions, chemical reactions, and microscopic identification of cell morphology, special stains, etc. 6. Adequate motor skills in order to perform phlebotomy procedures; instrument calibration and maintenance; delicate sampling procedures; a variety of manual, semiautomated, and automated analytical procedures; and computer keyboarding. 7. Physical ability to tolerate long periods of standing. 8. Physical strength for light lifting of weights of 25 pounds or less from the floor to waist level. 9. Communication skills, to include appropriate telephone skills, necessary to interact effectively with instructors, patients, and other members of the health care team. 10. Demonstrated ability to function effectively under stress. A student who fails to meet the above essential functions may be denied admission to the program or be removed anytime during the rotation (Please retain pages 1-4 for your records) Revised 1/2009 4

5 Application Deadline; December 15 th APPLICATION TO THE SCHOOL OF MEDICAL TECHNOLOGY DATE OF APPLICATION SS# Expected entrance date Name Last First MI Gender: M F Are you a U.S. citizen or permanent resident? Yes No If no, please indicate type of visa and country of origin. Address Street Apt. # City State Zip-code Phone # Name of parent, nearest relative or guardian: Address Street Apt. # City State Zip-code Phone # Revised 1/2009 5

6 Education: Please start with High School Institution Dates attended Degree awarded Major Total GPA Science GPA If more institutions, please attach a typed sheet. Activities and Honors; List of three references; 1. Name address 2. Name address 3. Name address Revised 1/2009 6

7 Work and Volunteer Experience; Name of Company/Organization Type of Work Dates If more experience, please attach a typed sheet. Background check: Have you ever been convicted of a felony or misdemeanor, or received deferred adjudication? A conviction will not necessarily automatically disqualify you for admission. Rather, such factors such as date of conviction and seriousness and nature of the crime will be considered. However, false, misleading or incomplete information may likely result in rejection of your application or dismissal from MT school. NO YES, Explain Signature of the Applicant Date * Please attach a current passport style professional photograph to the application. Revised 1/2009 7

8 HEALTH REPORT FOR MT SCHOOL APPLICANTS Personal History: To be completed by applicant Name Family Health Record Father: Mother: Living Deceased Cause of Death Living Deceased Cause of Death Student/Employee Health Record Checks once (x) those conditions you have had. Double check (xx) those you now have. Acne Headaches, frequent Rheumatism/Arthritis AIDS Heart ailment Rheumatic fever Appendicitis Hay fever Scarlet fever Asthma Hepatitis Sinusitis, chronic Back complaints Hernia Smallpox Chickenpox High blood pressure Sore throat, frequent Cold, Frequent Kidney disorder Tonsillitis Diabetes Malaria Typhoid fever Digestive disturbances Measles Venereal disease Ear infections, frequent Meningitis Varicose veins Easily fatigued Pleurisy Whooping cough *Food Allergies Pneumonia *Other Allergies Polio *Allergies (food and other) Revised 1/2009 8

9 Illnesses, Injuries, Surgeries (Please be specific) Incident Date Degree of Recovery Handicaps Impediments (speech etc.) Attach your immunization record (see the immunization policy in the packet) Date of last Diphtheria / Tetanus The above data is true and correct to the best of my knowledge. I understand it is to be included as part of my application and student record. Student Signature Date Data obtained after enrollment Tuberculin Skin Test Color Blindness Test Survey 8 (Optional) CBC (Optional) Urinalysis (Optional) Revised 1/2009 9

10 Essential Functions Tasks: School of Medical Technology Applicants Please sign and return this page with the Application Packet and Health Report. DATE: Medical Advisor, School of Medical Technology DATE: Laboratory Director DATE: Program Director, School of Medical Technology I have read and do understand this document and agree to abide by its contents. Student Name DATE: Student Signature Revised 1/