The application deadline is July 15th each year or until the class is full. The program begins in the fall semester of each year.

Transcription

1 Health Sciences Division Nuclear Medicine Technology Program Dear Prospective Student: Thank you for your interest in the Nuclear Medicine Technology Program at Gulf Coast State College. Enclosed is an application packet. The packet includes information you will need to read and forms you must complete to begin the application process. Enclosed you will also find a Checklist which gives you information on how to proceed, and the steps you will need to take in order to be considered for the Nuclear Medicine Technology Program. The application deadline is July 15th each year or until the class is full. The program begins in the fall semester of each year. If you should have any questions or concerns after reviewing the material, please don t hesitate to contact me at (850) , or me at dvanderschaaf@gulfcoast.edu. Good luck with your educational endeavors. Sincerely, DeeAnn VanDerSchaaf DeeAnn VanDerSchaaf, MS, RT (R) Medical Imaging Programs Coordinator Revised 7/2015

2 Nuclear Medicine Technology (NMT-CCC) AREA OF CONCENTRATION: The Nuclear Medicine Technology Technical Certificate is intended for Allied Health Professionals with an Associate s Degree and who hold a current allied health care professional license. A selective admissions policy with specific selection criteria is utilized in order to select the most qualified applicants. The strength of the applicant pool varies year to year, with the best qualified applicants receiving first consideration. It is the applicant s responsibility to inquire about these specific admission and selection criteria and to ensure that all required documents are received on campus prior to the deadline of July 15 of each year or until the class is full. The program begins in the fall of each year. Upon completion of the sixteen (16) months, full time program, the student may be eligible to take the American Registry of Radiologic Technologist Nuclear Medicine Examination and/or the Nuclear Medicine Technology Certification Board Examination. To apply for this program of study, students should obtain a program application packet from the Division of Health Sciences, containing a current listing of admission and course requirements. PRIMARY ADVISERS: DeeAnn VanDerSchaaf (ext. 3318) Admission Requirements: Application to Nuclear Medicine Technology Technical Certificate program which includes: 1. Apply for admission to Gulf Coast State College. 2. Submit program application form, including Technical Standards form. 3. Possess an Associate s Degree in an Allied Health Care Profession and hold a current allied health care professional license. 4. Completion of additional required General Education courses requirements with a C or better. 5. Submit official high school transcript or copy of GED scores to the Office of Admissions and Records. 6. Submit official college transcript and have evaluation completed by the Office of Admissions and Records. 7. Schedule a visit to or contact the Medical Imaging Programs Coordinator for an advisement session. Requirements after conditional acceptance: 1. Satisfactory fingerprint / criminal background check completed by Gulf Coast State College. 2. Copy of current CPR certification. Either the American Heart Association Health Care Provider Life Support Course or the American Red Cross CPR for the Professional Rescuer is acceptable. 3. Completion of physical examination with satisfactory results. 4. Copy of Immunization records to include Hepatitis B series or signed waiver. 5. Copy of a current TB skin test, completed within one year. 6. Satisfactory 10 panel urine drug screening scheduled by Gulf Coast State College.

3 CRIMINAL BACKGROUND CHECKS Gulf Coast State College (GCSC) students who are granted conditional acceptance into a Health Sciences program must receive a satisfactory criminal background check prior to final acceptance into the program. The background check will be scheduled and performed at the discretion of the Division of Health Sciences at GCSC. Information and instructions on how to complete the background check will be sent by the program coordinator. Criminal background checks performed through other agencies will not be accepted. The student must also be aware that clinical agencies may require an additional background check prior to clinical access. It is possible to graduate from a program at GCSC but be denied the opportunity for licensure because of an unfavorable background check. An applicant must consider how his / her personal history may affect the ability to meet clinical requirements, sit for various licensure exams, and ultimately gain employment. Most healthcare boards in the State of Florida make decisions about licensure on an individual basis. You may visit the Florida Department of Health website ( for more information regarding licensure. We offer this information so that you can make an informed decision regarding your future. Please read the following information carefully: Any student who has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to, any offense under the provision of (see below) may be disqualified from admission to any Health Sciences program. In addition to these specific convictions, there are other crimes which may disqualify applicants from entering into the Health Sciences programs and / or clinical rotations. The statute can be found online at: Health care fraud; disqualification for license, certificate, or registration. (1) Health care fraud in the practice of a health care profession is prohibited. (2) Each board within the jurisdiction of the department, or the department if there is no board, shall refuse to admit a candidate to any examination and refuse to issue a license, certificate, or registration to any applicant if the candidate or applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant: (a) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, or chapter 893, or a similar felony offense committed in another state or jurisdiction, unless the candidate or applicant has successfully completed a drug court program for that felony and provides proof that the plea has been withdrawn or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, or registration unless the sentence and any subsequent period of probation for such conviction or plea ended: 1. For felonies of the first or second degree, more than 15 years before the date of application. 2. For felonies of the third degree, more than 10 years before the date of application, except for felonies of the third degree under s (6)(a). 3. For felonies of the third degree under s (6)(a), more than 5 years before the date of application; (b) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss , or 42 U.S.C. ss , unless the sentence and any subsequent period of probation for such conviction or plea ended more than 15 years before the date of the application; (c) Has been terminated for cause from the Florida Medicaid program pursuant to s , unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent 5 years; (d) Has been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the candidate or applicant has been in good standing with a state Medicaid program for the most recent 5 years and the termination occurred at least 20 years before the date of the application; or (e) Is currently listed on the United States Department of Health and Human Services Office of Inspector General s List of Excluded Individuals and Entities.

4 Nuclear Medicine Technology Program (NMT CCC) ATION COURSE All courses must be completed with a "C" or better. +* BSC2086, Anatomy and Physiology II 3 +* BSC2086L, Anatomy and Physiology II Lab 1 +* CHM 1032 General Organic Biochemistry 3 +* PHY XXXX Approved Physics (contact advisor) 3 10 Suggested Physics Courses PHY1001, PHY1007, PHY1020, PHY1023, PHY2023, or PHY2053 MAJOR NUCLEAR MEDICINE COURSES MAJOR COURSES +*# NMT 1613 Nuclear Medicine Physics 3 +*# NMT 1713 Nuclear Medicine Methodology I 3 +*# NMT 1804 Clinical Education I 3 +*# NMT 1723 Nuclear Medicine Methodology II 3 +*# NMT 1814 Clinical Education II 3 +*# NMT 1733 Nuclear Medicine Methodology III 3 +*# NMT 1824 Clinical Education III 3 +*# NMT 1834 Clinical Education IV 3 +*# NMT 1312 Radiation Safety, Protection and Regulations 3 +*# NMT 2061 Nuclear Medicine Seminar 2 +*# NMT 2130 Radiopharmacy and Radiochemistry 3 +*# NMT 2534C Nuclear Medicine Instrumentation 3 +*# NMT 2430 Nuclear Medicine Radiation Biology 3 38 ATION COURSES H TOTAL CERTIFICATE HOURS 48 C * Minimum grade of "C" required. + Prerequisites required. # Applies only to A.S. degree, A.A.S. degree, and certificate programs.

5 Nuclear Medicine Technology Program Program Checklist All items must be completed and received by the July 15th deadline each year or until class is full It is the applicant s responsibility to make sure their application folder is complete and received by the application deadline. 1. New students should apply for General Admission to GCSC. Applications are available at the Enrollment Services Office or online at: 2. Returning students who have not attended GCSC in 2 years or more must also re apply for admission. New students must pay the $20 non refundable college application fee online, at the Bookstore, or at the GCSC Business Office (in person or by phone). If the application fee is not paid, you cannot get registered for courses. Returning students who have not attended GCSC in 2 years or more must pay a $10 non refundable college application fee online, at the Bookstore, or at the Business Office. 3. New students must complete a free online College Orientation which must be completed prior to course registration, otherwise a "hold" will be placed on the student's account. Follow the registration steps via the GCSC website for free online college orientation at: Complete and submit the Nuclear Medicine Technology Program application (including the signed Technical Standards Form) to the Health Sciences Building, Room 200, by the application deadline of July 15th. Provide High School and College transcripts. Applicant must request official transcripts from high school or GED with scores, and all colleges attended be sent to GCSC Enrollment Services. Transcripts must be received by Enrollment Services prior to the admission deadline date. It is your responsibility to ensure all transcripts have arrived and been evaluated by Enrollment Services prior to the deadline. Note: If you are enrolled in classes at another institution that will not be completed prior to the deadline, and you want these uncompleted classes to be considered in selection, your documentation of enrollment must be received in the Health Sciences Division prior to the deadline. 6. Transfer transcripts must be evaluated. All college credits granted by another institution must be evaluated by GCSC Enrollment Services prior to admission deadline date. 7. Completion of BSC 2086 and BSC 2086L Anatomy and Physiology II with Lab, CHM1032 General Organic Chemistry, and Approved Physics; a minimum grade of "C" must be achieved. 8. Cumulative GPA of at least Possess an Associate s Degree in an Allied Health Care Profession and hold a current allied health care professional license.

6 NUCLEAR MEDICINE TECHNOLOGY Curriculum Sequence Fall 12 credits +#NMT contact hrs., 3 crs Nuclear Medicine Physics Prerequisite: Approved physics. This course will develop the understanding of radioactive decay, structure of the atom, atomic nomenclature. The student will be able to discuss the different types of radiation; the characteristics of each and how each react with matter. The student will also be able to calculate: radioactive decay, decay equations, decay factors, effective half life, biological half life, half value layers, standard deviation, and in the presence of background. +#NMT contact hrs., 3 crs. Nuclear Medicine Methodology I Co-requisite: None. This course covers nuclear medicine diagnostic procedures, including anatomy and physiology, pathophysiology, and protocols for routine and non-routine nuclear medicine procedures, bone imaging, cardiovascular system, central nervous system, digestive system and endocrine system. +#NMT contact hrs., 3 crs. Nuclear Medicine Clinical Education I $89.00 lab fee Corequisite: The course allows nuclear medicine students the opportunity to apply the skills necessary for patient care, administrative duties, and to apply the knowledge and skills of diagnostic procedures, and protocols for routine and non routine nuclear medicine procedures, bone imaging, cardiovascular system, central nervous system, digestive system and endocrine system in the NMT1713 course. +#NMT2430 Nuclear Medicine Radiation Biology 45 contact hrs., 3 crs. Prerequisite: None. The course involves a detailed study of the effects of radiation exposure on biological systems. Typical medical exposure levels, methods for measuring and monitoring radiation, and methods for protecting personnel and patients from excessive exposure. Spring 12 credits +#NMT contact hrs., 3 crs. Nuclear Medicine Methodology II Prerequisite: NMT1713. This course covers diagnostic procedures, including anatomy and physiology, pathophysiology, and protocols for routine and non routine nuclear medicine procedures, genitourinary system procedures, respiratory system imaging, hematology and in vitro studies, and PET/CT imaging specifics. +#NMT2534C 45 contact hrs,. 3 crs. Nuclear Medicine Instrumentation Prerequisite: None. This course covers the principles of operation and quality control for non imaging instruments, including monitoring equipment, dose calibrators, well counters, uptake probes, liquid scintillation systems, laboratory equipment, and the gamma probe. This course also includes the principles and applications of statistics as they relate to nuclear medicine instrumentation, the configuration, function, and application of computers and networks in nuclear medicine. Students should have extensive laboratory and clinical experience performing data acquisition, manipulation, and processing. Laboratory and clinical experience should be included in the learning process. +#NMT contact hrs., 3 crs. Radiation Protection and Safety Prerequisite: CHM1032. This course will teach methods of radiation protection, safety procedures and regulations according to the NRC, DOT and DOH; differentiate monitoring devices and detectors; dose and exposure limits; institutional licensing; possession limits; patient protection; receiving and disposing of radioactive material and packages; decontamination procedures; therapy procedures; as well as knowledge of regulatory agencies.

7 +#NMT contact hrs., 3 crs. Nuclear Medicine Clinical Education II $64.00 lab fee Prerequisite: NMT1804. Corerequisite: NMT1733. A continuation of NMT1804, this course allows nuclear medicine students the opportunity to apply the skills necessary for patient care, administrative duties, and to apply the knowledge and skills of diagnostic procedures, and protocol for genitourinary system procedures, respiratory system imaging, hematology and in vitro studies, and PET/CT imaging specifics. Clinical experience may include rotations through general, cardiac, pediatric, positron emission tomography and positron emission tomography/computed tomography, single photon emission computed tomography, and singlephoton emission computed tomography/computed tomography. Summer 9 credits +#NMT contact hrs., 3 crs. Nuclear Medicine Methodology III Prerequisite: NMT1723. This course covers diagnostic procedures, and protocols for oncology/inflammation procedures, and radionuclide procedures. +#NMT contact hrs., 3 crs. Nuclear Medicine Clinical Education III $89.00 lab fee Prerequisite: NMT A continuation of NMT 1814, this course allows nuclear medicine students the opportunity to apply the skills necessary for patient care, administrative duties, and to apply the knowledge and skills of diagnostic procedures, and protocol for diagnostic procedures, and protocols for oncology/inflammation procedures, and radionuclide procedures. +#NMT contact hrs., 3 crs. Radiopharmacy and Radiochemistry Prerequisite: CHM1032. This course covers the theory and practice of radiopharmacy, including preparation and calculation of the dose to be administered, quality control, radiation safety, and applicable regulations. In addition, it deals with nonradioactive interventional drugs and contrast media that are used as part of nuclear medicine procedures. For all administered materials, it addresses the routes of administration, biodistribution mechanisms, interfering agents, contraindications, and adverse effects. Fall 5 credits +#NMT contact hrs., 2 crs. Nuclear Medicine Seminar Prerequisite: NMT1733. This course involves comprehensive testing, discussions and refinement of knowledge of all aspects of Nuclear Medicine technology complementary to national and state certification and professional competency. +#NMT contact hrs., 3 crs. Nuclear Medicine Clinical Education IV Prerequisite: NMT 1824 The course allows nuclear medicine students the opportunity to apply and enhance their skills of diagnostic procedures, and protocol for all diagnostic procedures. During this clinical education, students shall be under the supervision of certified or licensed nuclear medicine technologists. Clinical experience should include rotations through general, cardiac, pediatric, positron emission tomography and positron emission tomography/computed tomography, single-photon emission computed tomography, and single-photon emission computed tomography/computed tomography. Ancillary rotations in magnetic resonance imaging and computed tomography to include the administration of contrast media may be included.

8 GULF COAST STATE COLLEGE - HEALTH SCIENCES DIVISION APPLICATION FOR PROGRAM ADMISSION Application 5230 West U.S. Highway 98 deadline July 15 of Panama City, FL each year or until (850) or Toll Free: Fax: (850) the class is full. Answer ALL Questions: Please TYPE or PRINT (Please submit form as soon as possible) Name: First Middle Last Maiden Name Home Address: Street & Number City State Zip County Student ID: Social Security # Male Female (absolutely must have this!) Permanent or Mailing Address (If different from above): Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) EDUCATION OFFICIAL TRANSCRIPT(s) must be received by GCSC Enrollment Services. ALL schools and colleges attended must be listed for the application to be complete. Use additional sheets if necessary. Name of School Location of School From (Month/ Year) To (Month/ Year) Did you Receive Diploma, Degree, or Certificate? What was your Major / Minor? High School or GED: Vocational / Other Technical Program College or University:

9 College or University: LICENSES AND CERTIFICATIONS Type Issued by Which State or Agency? License / Cert. Number Date Issued/Expired CONTACT INFORMATION Please provide information about three people who will always know where to locate you: Name 1. Mailing Address Telephone Number HEALTH RELATED WORK EXPERIENCE and / or VOLUNTEER EXPERIENCE Use additional sheets if necessary 1. EMPLOYER: Address Phone: Extension Street & Number City State Supervisor s Name Title Dates employed: From To Nature of your Job Duties: Mo./Yr. Mo./Yr. Reason for Leaving Full-Time Part-Time

10 2. EMPLOYER: Address Phone: Extension Street & Number City State Supervisor s Name Title Dates employed: From To Nature of your Job Duties: Mo./Yr. Mo./Yr. Reason for Leaving Full-Time Part-Time PLEASE READ AND SIGN THE FOLLOWING I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation, omission or falsification of information is cause for denial of admission from the program. I understand that illegal use, possession, and/or misuse of drugs are reasons for immediate dismissal from any of the programs in the Health Sciences Division. I further understand that background checks and drug screening are routinely required at most clinical facilities prior to the students clinical placement. Signature of Applicant Date RETURN APPLICATION TO: Gulf Coast State College Health Sciences Division Room W. U.S. Highway 98 Panama City, FL IN CASE OF EMERGENCY NOTIFY: Name: Address: Phone:

11 Gulf Coast State College Nuclear Medicine Technology Program TECHNICAL STANDARDS TECHNICAL STANDARD DEFINITION EXAMPLES OF REQUIRED ACTIVITIES (not all inclusive) Cognitive Qualifications Critical Thinking Interpersonal Communication Mobility Motor Skills Sufficient Reading, Language and Math Skills; intellectual and emotional functions necessary to plan and implement patient care for individuals Critical thinking ability sufficient for clinical judgment; synthesize information from written material and apply knowledge to clinical situations Interpersonal abilities sufficient to interact with individuals, families, and groups from a variety of social, educational, cultural, and intellectual backgrounds Communication abilities sufficient for interaction with others in verbal and non verbal form (speech, reading, and writing) Physical abilities sufficient to move from room to room, to maneuver in small spaces and to perform procedures necessary for emergency intervention Gross and fine motor abilities sufficient to provide safe and effective care Ability to comprehend and interpret written material Follow and deliver written and oral direction Identify cause effect relationships in clinical situations Develop order of multiple imaging exams Make rapid decisions under pressure Handle multiple priorities in stressful situations Assist with problem solving Establish rapport with patients and colleagues Function effectively under stress Cope with anger, fear, hostility of others in calm manner Cope with confrontation Demonstrate high degree of patience Display compassion, professionalism, empathy, integrity, concern for others with interest and motivation Explain imaging procedures Document patient history and incident reports Write legibly Communicate clearly and effectively (oral, written) with patients, co workers, and other health care providers by use of the English language and medical terminology Move around in clinical operatories, workspaces, classrooms, laboratories and other treatment areas Administer cardio pulmonary resuscitation procedures Assist all patients, according to the individual s needs and abilities in moving, turning, transferring from transportation devices to the x ray table, etc. Push a stretcher or wheelchair without injury to self, patient, or others Push mobile x ray equipment from one location to another, including turning corners, getting on and off elevator, and manipulating equipment around patient rooms and in small spaces Calibrate and manipulate x ray equipment and supplies Position patients Perform repetitive tasks Able to grip Bend at knee and squat. Reach above shoulder level Lift with assistance 150 pounds Exert pounds of force (pushing, pulling) Complete a CPR Healthcare Provider certification course Climb stairs Remain in standing position for 3 5 hour periods

12 Hearing Normal, corrected, or audible Auditory ability sufficient to interpret verbal communication from patients and health care team members and to monitor and assess health needs Hear monitor alarms, emergency signals, cries for help Hear telephone interactions Hear audible stethoscope signals during blood pressure screenings Hear patient speaking from a 20 ft distance Visual Normal, corrected Visual acuity sufficient for observation and patient assessment and equipment operations and departmental protocols. Observe patient condition and needs from a 20 ft distance Identify and distinguish colors Accurately read radiation exposure readings on x ray equipment View radiographic images and medical reports Assess direction of and correctly direct the central ray to anatomical part being imaged and align image receptor Read departmental protocol for imaging procedures, the radiographic examination request and physician orders Tactile Tactile ability sufficient for patient assessment and operation of equipment. Perform palpation, tactile assessment, and manipulate body parts to ensure proper body placement alignment Manipulate dials, buttons, and switches of various sizes Environmental Ability to tolerate environmental stressors Be able to tolerate risks or discomforts in the clinical setting that require special safety precautions, additional safety education and health risk monitoring (i.e. ionizing radiation, chemicals), working with sharps, chemicals and infectious diseases. Student may be required to use protective clothing or gear such as masks, goggles, gloves, and lead aprons. Work with chemicals and detergents Tolerate exposure to fumes and odors Work in areas that are close and crowded Adapt to shift work Gulf Coast State College s mission is to assist students in reaching their academic potential and achieving their educational goals. A "qualified individual with a disability is one who, with or without reasonable accommodation or modification, meets the essential eligibility requirements for participation in the program." Radiography is a practice discipline with cognitive, affective, and psychomotor performance requirements. Based on those requirements, a list of "Technical Standards" has been developed. Each standard has an example of an activity or activities that a potential student will be required to perform while enrolled in the Radiography program. These standards are a part of a radiographer s professional role expectation. These standards should be used to assist students in determining whether accommodations or modifications are necessary to meet performance standards. Students who identify potential difficulties with meeting the Technical Standards must communicate their concerns to the program Coordinator. I have read the above Technical Standards. I feel it is within my ability to carry out the duties and responsibilities of a Nuclear Medicine Technologist. If I ever have any change in my ability to meet these standards, I will inform the Medical Imaging Programs Coordinator without fail. Printed Name Student Signature Date

13 GULF COAST STATE COLLEGE Health Sciences Nuclear Medicine Technology Program Letter of Recommendation Name of Applicant: (Last) (First) (Middle) (Maiden Name) What Medical Imaging Program? To Applicant: This Letter of Recommendation should be given to a College Professor, Academic Counselor, employment supervisor, or medical mentor who is familiar with your academic ability and/or can speak to personal qualities such as motivation, maturity and capacity for growth. To be completed by the Applicant: I, give permission to to complete this personal reference for me. I appreciate their candor and understand that this form is confidential. However, under Federal Law entitled the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their records including recommendation forms. I do do not waive my rights to review the content of this form. I release them from any liability regarding their completion of this form. I have supplied the person completing this form with a stamped addressed envelope to the following address. To Referent: Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850) Gulf Coast State College Medical Imaging Programs appreciates your responding to the following areas of information. 1. How long have you been acquainted with the applicant and in what capacity? 2. What impresses you most about the applicant?

14 3. In the healthcare field, healthcare personnel have access to confidential information from charts and files and are required to handle drugs and/or controlled substances. Are there any factors that may interfere with the applicant s integrity? 4. To your knowledge, is there anything that might interfere with or limit the success of this applicant in the healthcare field? 5. Please rate the applicant on the following Personal Factors. Personal Factors Above Average Average Below Average No Basis to Judge Applicant Communication Skills Sociability, Cooperation Courtesy Dependability, Reliability Motivated Honesty, Integrity Initiative Maturity Organization Skills Intellectual Ability Critical Thinking Self Accountability Responsibility Seeks help when needed 6. Please mark the appropriate response regarding your recommendation of this candidate for medical imaging career. Highly recommend Recommend Recommend with reservation Do not recommend Signature of Person Completing Recommendation: Date Print Name: Position/Title: Address: Phone Number: Thank you for completing this Letter of Recommendation. Please mail directly to below address. Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850)

15 GULF COAST STATE COLLEGE Health Sciences Nuclear Medicine Technology Program Letter of Recommendation Name of Applicant: (Last) (First) (Middle) (Maiden Name) What Medical Imaging Program? To Applicant: This Letter of Recommendation should be given to a College Professor, Academic Counselor, employment supervisor, or medical mentor who is familiar with your academic ability and/or can speak to personal qualities such as motivation, maturity and capacity for growth. To be completed by Applicant: I, give permission to to complete this personal reference for me. I appreciate their candor and understand that this form is confidential. However, under Federal Law entitled the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their records including recommendation forms. I do do not waive my rights to review the content of this form. I release them from any liability regarding their completion of this form. I have supplied the person completing this form with a stamped addressed envelope to the following address. To Referent: Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850) Gulf Coast State College Medical Imaging Programs appreciates your responding to the following areas of information. 1. How long have you been acquainted with the applicant and in what capacity? 2. What impresses you most about the applicant?

16 3. In the healthcare field, healthcare personnel have access to confidential information from charts and files and are required to handle drugs and/or controlled substances. Are there any factors that may interfere with the applicant s integrity? 4. To your knowledge, is there anything that might interfere with or limit the success of this applicant in the healthcare field? 5. Please rate the applicant on the following Personal Factors. Personal Factors Above Average Average Below Average No Basis to Judge Applicant Communication Skills Sociability, Cooperation Courtesy Dependability, Reliability Motivated Honesty, Integrity Initiative Maturity Organization Skills Intellectual Ability Critical Thinking Self Accountability Responsibility Seeks help when needed 6. Please mark the appropriate response regarding your recommendation of this candidate for medical imaging career. Highly recommend Recommend Recommend with reservation Do not recommend Signature of Person Completing Recommendation: Date Print Name: Position/Title: Address: Phone Number: Thank you for completing this Letter of Recommendation. Please mail directly to below address. Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850)

17 GULF COAST STATE COLLEGE Health Sciences Nuclear Medicine Technology Program Letter of Recommendation Name of Applicant: (Last) (First) (Middle) (Maiden Name) What Medical Imaging Program? To Applicant: This Letter of Recommendation should be given to a College Professor, Academic Counselor, employment supervisor, or medical mentor who is familiar with your academic ability and/or can speak to personal qualities such as motivation, maturity and capacity for growth. To be completed by the Applicant: I, give permission to to complete this personal reference for me. I appreciate their candor and understand that this form is confidential. However, under Federal Law entitled the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their records including recommendation forms. I do do not waive my rights to review the content of this form. I release them from any liability regarding their completion of this form. I have supplied the person completing this form with a stamped addressed envelope to the following address. To Referent: Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850) Gulf Coast State College Medical Imaging Programs appreciates your responding to the following areas of information. 1. How long have you been acquainted with the applicant and in what capacity? 2. What impresses you most about the applicant?

18 3. In the healthcare field, healthcare personnel have access to confidential information from charts and files and are required to handle drugs and/or controlled substances. Are there any factors that may interfere with the applicant s integrity? 4. To your knowledge, is there anything that might interfere with or limit the success of this applicant in the healthcare field? 5. Please rate the applicant on the following Personal Factors. Personal Factors Above Average Average Below Average No Basis to Judge Applicant Communication Skills Sociability, Cooperation Courtesy Dependability, Reliability Motivated Honesty, Integrity Initiative Maturity Organization Skills Intellectual Ability Critical Thinking Self Accountability Responsibility Seeks help when needed 6. Please mark the appropriate response regarding your recommendation of this candidate for medical imaging career. Highly recommend Recommend with reservation Recommend Do not recommend Signature of Person Completing Recommendation: Date Print Name: Position/Title: Address: Phone Number: Thank you for completing this Letter of Recommendation. Please mail directly to below address. Gulf Coast State College Health Sciences Division Medical Imaging Programs Coordinator 5230 West U.S. Hwy 98 Room 317 Panama City, Florida or fax to: (850)

19 NMT Clinical Site Request Nuclear Medicine Students preferring to perform their clinical rotations within their geographical area must make contact with the intended medical facility and get approval from the imaging director. Once the student has gained approval from the imaging director, the student will need to the medical facility contact information to begin the contractual process. More than one clinical site may be submitted. Students will also need to have a Radiopharmacy and PET facility selected as part of their clinical rotation. The Gulf Coast State College has the final approval for a site selection and may assign a student to a particular site to ensure achievement of goals and objectives. Preferred Site #1 Institution Address Contact Person Contact Person s Telephone Number Contact Person s Preferred Site #2 Institution Address Contact Person Contact Person s Telephone Number Contact Person s Preferred Site #3 Institution Address Contact Person Contact Person s Telephone Number Contact Person s

20 Radiopharmacy Site #1 Institution Address Contact Person Contact Person s Telephone Number Contact Person s Radiopharmacy Site #2 Institution Address Contact Person Contact Person s Telephone Number Contact Person s PET Scan Site #1 Institution Address Contact Person Contact Person s Telephone Number Contact Person s PET Scan Site #2 Institution Address Contact Person Contact Person s Telephone Number Contact Person s

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