Medical Laboratory Technician Admission Application Spring 2015 Cohort

Transcription

1 Medical Laboratory Technician Admission Application Spring 2015 Cohort Students wishing to enter the Medical Laboratory Technician Program Major must complete the following Admission Application. Name: Date: Address: City State Zip address: Telephone: Home Work Cell Preferred method for contact: Emergency Contact Information Name Telephone: Home Work Cell Relationship to you: I am applying to the MLT Program: (please check) For the first time Re-entering after a leave of absence from an earlier admission date Transferring from another MLT program (Give name of program and attach a copy of your transcript) Other (Explain) Have you ever been dismissed from a professional program or academically withdrawn from a professional program? Yes No If yes, complete the following information: School Name and Location: _ Dates of Attendance: to Type of Program: Are you in good standing and eligible to return to the program? Yes No If no, please explain. SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,

2 Community Residency Are you resident of San Juan County, New Mexico? Yes No If your answer is no please continue. Do you reside in one of the following counties in Colorado Yes No Montezuma, Archuleta, Dolores or San Juan? If your answer is no please continue. Are you enrolled as a member of the Navajo Nation? Yes No Employment History Employer Address Dates of Employment Supervisor Name Supervisor Phone Job Title and Description of Tasks May we contact this supervisor? Yes No Employer Address Dates of Employment Supervisor Name Supervisor Phone Job Title and Description of Tasks May we contact this supervisor? Yes No List two references other than family members who can address your work ethic and personal characteristics. Do not use a family member. Please have these references fill out the reference form attached and send to Mary Doshi, San Juan College, MLT Program, 4601 College Blvd., Farmington, New Mexico Name Telephone Number: Adress Relationship to you Name Telephone Number: Address Relationship to you SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,

3 Please fill out the Prerequisite and General Education Courses you have completed, in the table chart below. Us IP for in progress My Cumulative GPA at this time is Pre - Requisite Courses Final Grade Semester/Year Course Completed or in Progress If not taken at SJC list the institution where taken and grade earned Course Equivalent (to be filled out by SJC staff) MLTS 120 Introduction to Medical Laboratory MLTS 160 Theory of Phlebotomy BIOL 252* Human Anatomy & Physiology I BIOL 253* Human Anatomy & Physiology II BIOL 224* Microbiology MATH 115 Intermediate Algebra OR HIGHER ENGL 111 Freshman Composition ENGL 211 Advanced Composition COMM 111 or 110 Interpersonal Communication CHEM 110 or CHEM 111 Introductory Chemistry CHEM 210 Organic Chemistry Survey PSYC 120 Introduction to Psychology * The science courses of *Introductory Biology I, Anatomy and Physiology I, II, and Microbiology should not be older than 10 years to be accepted. If CHEM 110 was taken in high school, you must include a copy of your official high school transcripts for credit to be given. Eligibility of courses that are older than 10 years will be determined on a case by case basis by Medical Laboratory Technician Faculty.* If you have transfer courses, please attach a transcript from that college (unofficial is accepted) In Progress Courses: If you currently have prerequisite courses in progress at another institution at the time of this application, please list contact information for your instructor for verification purposes. SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,

4 The selection committee would like to know a little more about you. Please write a short essay that will give the committee a description of you. Include your background, interests, achievements and make sure you include why you have chosen laboratory medicine for your career goal. Additional Directions: 1. Limit the description to one page. 2. Type essay using an 11 or larger font size. 3. You may single or double space as needed. 4. Do not put your name on this page. Staple your story to the back of your application and it will be given a number that corresponds to your application for identification after the review process. I certify this application is true. Any false statements knowingly submitted will result in expulsion from the program. I understand that taking prerequisite courses in the MLT Program does not guarantee acceptance into the major. All applicants will be required to complete a federal background check prior to acceptance into their clinical component at their expense. The background checks must be current. In addition, all students must complete the required inoculations and health clearances required for the clinical affiliates at their expense. This may include a drug screen. Individuals who have been convicted of a felony may have limited employment opportunities and are not gauranted employment after graduation. I understand that admission to the MLT program is competitive and applicants are ranked. The following criteria will be used in the selection process. 60% GPA in prerequisite courses 20% Self Description (See rubric for scoring) 20 % Reference Recommendations In keeping with the Community Mission of San Juan College, those applicants that meet Residency and/or Special Residency Status will be given 2% preference in the application process. Applicants who have all prerequisite courses including Chemistry 210 or equivalent will also be given a 2% preference. Signature of Applicant Date Return completed application to: Mary L. Doshi MLT Program Director Or Devonna Coolidge, Administrative Assistant San Juan College 4601 College Boulevard Farmington, New Mexico Phone: or doshim@sanjuancollege.edu Due date 3 rd Friday of October by 17:00 SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,

5 The Medical Laboratory Program is affiliated with the following clinical sites. You will be assigned to one of them to do your clinical practicum rotation. Please rank them in the order by placing a 1 by the site you would most like to complete your practicum, 2 for your second choice and so on. If you have no preference, rank them all as 1. Each of the clinical affiliates will be ranking student choices and matches will be made on mutual preference. You are not guaranteed of being placed at your highest ranking sites. If for some unforeseen circumstances arise that there are more students than available sites, the students with highest GPA will be placed first. San Juan Regional Medical Center is a modern, acute-care hospital located in one of the most rural areas of the American southwest, the Four Corners. As a sole community provider of hospital services in San Juan County, New Mexico, the hospital delivers range of healthcare services not only to to the people of the entire Four Corners Region. The hospital itself has a 260 bed capacity. San Juan Regional Medical Center is designated a Level III trauma center and provides air ambulance service with a helicopter and a fixed wing aircraft. The laboratory is located on the second floor of the hospital. The total gross square footage is 11,000. This hospital laboratory has the second busiest blood bank in the state. Mercy Regional Medical Center is southwest Colorado's largest and most technologically advanced hospital. Mercy Regional Medical Center is an 82-bed acute care hospital designated a level III. More than 120 physicians and nearly 40 mid-level medical providers on staff represent more than 35 medical specialties. The new Mercy Regional Medical Center opened in Durango in June, It includes state-of-the-art medical technology in an environment designed to promote a sense wellness and healing. The hospital laboratory is new and has about 10,000 square feet and also has a very busy immunohematology section. The Northern Navajo Medical Center in Shiprock, New Mexico is the largest unit serving The Navajo Nation. The facility has 55 beds. Approximately 45,500 Native Americans are enrolled in the Service Unit. The daily inpatient load is 40, and the daily outpatient volume averages 400 a day. Annual ED cases average 15,000-16,000. Field clinics are open various times per week. Southwest Memorial Hospital is in Cortez, Colorado. This 61-bed acute care facility, is a progressive hospital driven by Continuous Quality Improvement. The laboratory occupies just under 5000 square feet and offers a wide variety of laboratory testing. Western Slope to include Moab and others as contracted Other Site suggested by student see director to see if practicum can be arranged. All sites subject to change until time of assignment. Name Signature SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,

6 The following rubric will be used to score your description Scale Score Description Organization (Overall order, flow, and transitions) Quality of Information Grammar & Spelling Very limited Details and examples are not organized, are hard to follow and understand. Unable to find specific details. Numerous grammatical and/or spelling errors. Somewhat helpful Information is scattered and needs further development. Details are somewhat sketchy. Three to five grammatical or spelling errors. More relevant Very much to the point Information is logically ordered with paragraphs and transitions. Some details don t support the topic. Fewer than 3 grammatical or spelling errors. Information is presented in effective order. Excellent structure of paragraphs and transitions enhances readability and understandability. Supporting details are specific to topic and provide the necessary information. No spelling or grammatical errors. Total SJC Medical Laboratory Technology/APPLICATION/DoshiM 2009, 2011,2012,