1515 Pioneer Drive Harrison, Arkansas 72601-5599 (870) 391-3318 PROGRAM APPLICATION FOR ADMISSION Date of Application Northark Student ID Date of Birth SS# Name Last First Middle Maiden Mailing Address City State ZIP Email Address Cell Phone ( ) Home Phone ( ) Business Phone ( ) Spouse Business Phone ( ) or Parent Business Phone ( ) Length of time in Arkansas Own transportation: Yes No US Military Service: Yes No If yes, Branch High School Date of Graduation Name of School Address If GED Name of School Date of GED Address *Have you ever been convicted of : Misdemeanor Felony If yes, explain *Be advised that applicants convicted of a felony or misdemeanor involving moral turpitude will be eligible to take the ARRT Registry examination when completing the program only if they have served their entire sentence including probation and parole and have had their civil rights restored. Students may Pre-Qualify by going to www.arrt.org and completing the Pre-Qualification Forms. *Clinical Education Sites have the right to refuse students at their facilities.
Have you ever been dismissed (fired, terminated, etc.) from a health care facility? Yes No Have you ever been dismissed from any health care educational program? Yes No If yes, please explain and sign below (add additional page if needed): I am allowing the Radiologic Technology Program at North Arkansas College to verify the information stated above. Signature of Applicant Date WORK EXPERIENCE Employer Address Dates of Employment Position Reason for Leaving
COLLEGES AND OTHER SCHOOLS ATTENDED Name Address Dates Attended Credits Graduation Date 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 or falsification of information is cause for denial of admission to the Radiologic Technology Program. Signature of Applicant Date North Arkansas College does not discriminate on the basis of race, color, sex, religion, ethnic origin, or handicap. Revised 7/3/13 Revised 6/29/15
CLINICAL OBSERVATION PROCESS Cox Medical Center-Branson, MO: 1. Contact the Radiology Department for a time frame on when they can accommodate your Clinical Observation. (8:00am-12:00pm Monday-Friday) 2. Next contact Human Resources at 417-335-7268. You will need to provide: Proof of enrollment at Northark, or previous school, or intent to attend Northark Immunizations: 2 MMR vaccinations or documentation of Rubella screening Hepatitis B vaccination-series of 3; Titer-screening; or waiver Varicella vaccination-series of 2; Titer-screening; or waiver Tetanus; Tdap within the last 10 years When in season Influenza Vaccine (flu shot) PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12 months) Background Check If student does not have a recent background check, Cox can provide this, but be aware that there is a delay in getting the results back, and this could delay your observation 3. Once the above has been completed, you will need to complete a mini Orientation with HR, and once that is complete they will make your badge and you can schedule the Observation. Baxter Regional Medical Center, Mountain Home, AR: 1. Contact Alita Newberry or Cody Garrison at 870-508-1766 for an Application to Shadow. You will need to provide proof of: 2 MMR vaccinations or documentation of Rubella screening PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12 months) 2. Set up a 4 hour Hospital Orientation 3. Schedule the Clinical Observation North Arkansas Regional Medical Center, Harrison, AR: 1. Contact the Education Department with the desired dates and times you are available to Shadow/Observe in Radiology (fill out form on next page & submit to Human Resources at NARMC) Education Department will: notify student of Shadow/Observation approval and date scheduled provide student with carelearning student ID & password for online orientation Student will provide documentation of: PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12 months) Hepatitis B vaccination-series of 3; Titer-screening; or waiver Varicella vaccination-series of 2; Titer-screening; or waiver 2 MMR vaccinations or documentation of Rubella screening Influenza Vaccine-flu shot (October-March) Complete carelearning online modules Sign Confidentiality and Privacy Statement Pick up Badge After completing shadowing return badge to Education Department Revised 7/2015
APPLICANT CLINICAL OBSERVATION An observation at a hospital is required for admission to the radiologic technology program. Please contact one of the following clinical faculty for an appointment. You are expected to observe from 8:00 am - 12:00 noon on one day during the week (Monday-Friday). Dress nicely but comfortably and enjoy your morning. Remember, though, this is an observation only. Please have the clinical instructor complete this form and return to the address at the bottom of the page. Baxter Regional Medical Center, Mountain Home, AR (870) 508-1766, Alita Newberry Cox Medical Center Branson, Branson, MO (417) 335-7223, Deanna Halbert North Arkansas Regional Medical Center, Harrison, AR (870) 414-4098, Kim Morris Ozarks Medical Center, West Plains, MO (417) 257-9111, Danette Huber Stone County Medical Center, Mountain View, AR (870) 269-4361, ext. 153, Chuck Robinson Student Name Date Hospital Clinical Instructor (Grading Criteria on Back Page) Please Evaluate Unsatisfactory Needs Average Above Average Excellent Improvement 6 7 8 9 10 Attendance Punctuality Appearance Attitude Communication Skills Interest in Profession Initiative Motivation Number of Questions Asked Number of Areas Observed BONUS: Would you recommend this student for the Radiologic Technology Program? Yes (+5 points) No (-10 points) Comments: Signature of Clinical Instructor or RT PLEASE SEAL AND RETURN TO: NORTH ARKANSAS COLLEGE 1515 PIONEER DRIVE HARRISON, ARKANSAS 72601-5599 Revised 6/14
CLINICAL OBSERVATION CRITERIA Unsatisfactory: Needs Improvement: Average: Above Average: Excellent: Unacceptable performance Below expectations Meets expectations Exceeds expectations Outstanding performance
RADIOLOGIC TECHNOLOGY POLICY ON STUDENT PREGNANCIES As a pregnant student radiographer you may be exposed to a minimal amount of radiation. The following guidelines were made to protect you and your baby. Your gestational dose will be monitored closely and will be limited to 500 millirem for the entire pregnancy. It is your choice to declare or not declare your pregnancy. 1. Declaration of student pregnancy is voluntary. Students are advised to inform the program director, IN WRITING, of their pregnancy as soon as possible and include the estimated conception date and estimated due date. 2. General radiography assignments will be allowed. During pregnancy, the time spent in fluoroscopy, surgery and on portables, will be carefully controlled. 3. Pregnant students will not be allowed to hold patients while exposures are made. 4. If the student declares the pregnancy, a second radiation monitor will be provided to be worn at waist level under the lead apron. This monitor will be identified as the fetal dose monitor. 5. The student's radiation exposure will be continuously monitored to insure that the maximum permissible dose of 500mR during the nine months is not exceeded. 6. When the program director is notified that the student is pregnant, the monthly radiation report will be discussed by the program director and the student. 7. If the student exceeds the maximum gestational dose, she will be withdrawn from all clinical courses for the remainder of her pregnancy. Students may receive an extension to complete the requirements as outlined in the Policy for Student Extensions in the current Program Manual. 8. All attendance, absence, and make-up policies will be equally enforced among all students. 9. If the student must completely withdraw from the Radiologic Technology Program because of pregnancy or delivery, the student may be readmitted into the Program according to the Re- Admission Policy in the current Program Manual. 10. In compliance with Federal Law, students may undeclare their pregnancy at any time. I,, have read the pregnancy policies for radiologic technology program applicants. Signature of Student Date Reviewed 7/3/13
DOCUMENTATION OF HEALTH-RELATED WORK EXPERIENCE Student Date The above named student has had the following health-related work experience: (If none, please indicate and return form to Program) NAME OF FACILITY Hospital/Department Doctor's Office Veterinary Clinic Other Duties (required) From DATES To Full-Time Employee Part-Time Employee Volunteer Name of Supervisor (Please Print) Title Facility Address Phone Signature of Supervisor Date ALL OF THE ABOVE INFORMATION MUST BE COMPLETED FOR CONSIDERATION FOR PROGRAM ADMISSION. Reviewed 7/3/13
APPLICANT REFERENCE FORM To: RETURN TO: Sondra Richards, M.S. RT(R)(M) Radiologic Technology Program Northark 1515 Pioneer Drive Harrison, AR 72601-5599 STUDENT: has applied for admission to the Radiologic Technology Program. Please give us your candid opinion of the applicant's suitability for the duties of a radiologic technologist. All information will be kept confidential. It is not a kindness to recommend someone who is not suited for this type of work. Please mail back AS SOON AS POSSIBLE to the above address. This applicant will not be considered for the radiologic technology program until this reference form is returned. All forms are due before March 1. How long have you known this person? Describe your relationship (employer, teacher, etc.) Circle the appropriate number to rate this applicant's behavior from your experience with him/her. Unsatisfactory (Grading Criteria on Back page) Needs Improvement Average Above Average Excellent 1 2 3 4 5 Dependability 1 2 3 4 5 Judgment/decision making 1 2 3 4 5 Enthusiasm 1 2 3 4 5 Initiative/motivation 1 2 3 4 5 Maturity 1 2 3 4 5 Trustworthiness 1 2 3 4 5 Communication skills 1 2 3 4 5 Interpersonal skills 1 2 3 4 5 Copes with stress 1 2 3 4 5 Organization/work habits Were you aware that this applicant was interested in a health care career? In your opinion, is this applicant well-suited for a career in health care? Why or why not? Name (Please Print): Title: Phone: Place of Business: Business Address: Signature Date Revised 1/2011
APPLICANT REFERENCE FORM CRITERIA Unsatisfactory: Needs Improvement: Average: Above Average: Excellent: Unacceptable performance Below expectations Meets expectations Exceeds expectations Outstanding performance
APPLICANT REFERENCE FORM To: RETURN TO: Sondra Richards, M.S. RT(R)(M) Radiologic Technology Program Northark 1515 Pioneer Drive Harrison, AR 72601-5599 STUDENT: has applied for admission to the Radiologic Technology Program. Please give us your candid opinion of the applicant's suitability for the duties of a radiologic technologist. All information will be kept confidential. It is not a kindness to recommend someone who is not suited for this type of work. Please mail back AS SOON AS POSSIBLE to the above address. This applicant will not be considered for the radiologic technology program until this reference form is returned. All forms are due before March 1. How long have you known this person? Describe your relationship (employer, teacher, etc.) Circle the appropriate number to rate this applicant's behavior from your experience with him/her. Unsatisfactory (Grading Criteria on Back page) Needs Improvement Average Above Average Excellent 1 2 3 4 5 Dependability 1 2 3 4 5 Judgment/decision making 1 2 3 4 5 Enthusiasm 1 2 3 4 5 Initiative/motivation 1 2 3 4 5 Maturity 1 2 3 4 5 Trustworthiness 1 2 3 4 5 Communication skills 1 2 3 4 5 Interpersonal skills 1 2 3 4 5 Copes with stress 1 2 3 4 5 Organization/work habits Were you aware that this applicant was interested in a health care career? In your opinion, is this applicant well-suited for a career in health care? Why or why not? Name (Please Print): Title: Phone: Place of Business: Business Address: Signature Date Revised 1/2011
APPLICANT REFERENCE FORM CRITERIA Unsatisfactory: Needs Improvement: Average: Above Average: Excellent: Unacceptable performance Below expectations Meets expectations Exceeds expectations Outstanding performance
Date Please send an official transcript of my credits to: Admissions North Arkansas College 1515 Pioneer Drive Harrison AR 72601 If any charge, please bill me at the address below. Last Name First Middle Maiden Mailing Address City State Zip Code Date of Birth Dates of Attendance Social Security No. Signature PLEASE ATTACH THIS FORM TO TRANSCRIPT Date Please send an official transcript of my credits to: Admissions North Arkansas College 1515 Pioneer Drive Harrison, AR 72601 If any charge, please bill me at the address below. Last Name First Middle Maiden Mailing Address City State Zip Code Date of Birth Dates of Attendance Social Security No. Signature PLEASE ATTACH THIS FORM TO TRANSCRIPT