MCC-Penn Valley Surgical Technology Program Information/Admissions Booklet

MCC-Penn Valley Surgical Technology Program Information/Admissions Booklet 2014 MCC - Health Science Institute Campus 3444 Broadway Kansas City, Missouri, 64111 REV: 6/13 Page 1 of 22 RVM

Dear Applicant: The purpose of this admission booklet is to help you navigate through our procedures for applying to our limited selective enrollment program. Please read the entire booklet before applying for admission. It is your responsibility to make sure that all forms and information required for admission are provided to the Surgical Technology Program admissions office. We wish you success in achieving your educational goals. If we can assist you in any way, please contact our office. Surgical Technology Program Admissions Office, 410 Health Science Institute Campus 3444 Broadway Kansas City, Missouri 64111 816.604.4232 Sincerely, Roger V. Massey, CST Program Coordinator - Surgical Technology REV: 6/13 Page 2 of 22 RVM

Contact Names and Phone Numbers for Surgical Technology Program MCC - Health Science Institute Campus Surgical Technology Program Coordinator Roger Massey Surgical Technology Clinical Coordinator Shirley Musick Allied Health Division Administrative Assistant - Terry McDaniel 816.604.4664 816.805.2955 816.604.4232 MCC - Penn Valley Community College Penn Valley Main Campus 816.604.4000 Counseling Office 816.604.4079 Financial Aid Department 816.604.4006 PLACEMENT/COMPASS Testing Center Student Data Center 816.604.4433* 816.759.1421 * www.mcckc/pennvalley/testing Other important contact numbers : ACCESS OFFICE 816.604.4089 REV: 6/13 Page 3 of 22 RVM

Surgical Technology The MCC Surgical Technology Program provides clinical experience built upon classroom instruction in the basic sciences, patient care, aseptic techniques and surgical procedures. Instruction also includes an extensive clinical rotation to give students hands-on experience in the surgical environment. The surgical technologist works under medical supervision to facilitate the safe and effective conduct of surgical procedures. This individual works under the supervision of a surgeon to ensure that the operating room environment is safe, that equipment functions properly, and that the operative procedure is conducted under conditions that maximize patient safety. A surgical technologist possesses expertise in the theory and application of sterile and aseptic techniques and combines the knowledge of anatomy and physiology, microbiology, pharmacology, humanities, medical terminology, speech, college algebra and psychology. Other studies cover the care and safety of patients during surgery, and surgical procedures. Students also learn to sterilize instruments; prevent and control infection; handle special drugs, solutions, supplies and equipment, implement tools and technologies to facilitate a surgeon s performance of surgical procedures and diagnostic procedures. Career Path Well-trained Surgical Technologists are in high demand. You can expect to work in professional environments such as: Hospital operating rooms Surgeon s private practice Surgery centers Emergency departments Dental surgery offices Delivery rooms Advancement depends on personal goals of the individual. There are three basic channels for advancement, each requiring further education: Free-Lance Technologist, Registered Nurse and Surgical Assistant. Program Admission Requirements Acceptance into the Surgical Technology Program is based upon selective admission process. REV: 6/13 Page 4 of 22 RVM

Certifications/Degrees Earned MCC offers a one-year Certificate in Surgical Technology or Associate of Science degree and graduates are eligible to apply to the National Board of Surgical Technology and Surgical Assisting (NBSTSA) to sit for the Certified Surgical Technologist (CST) National Certification Exam. Location MCC's Surgical Technology courses are available at our Health Sciences Institute Campus location. Program Length The Surgical Technology Program is 3 semesters in length with a clinical externship beginning in the 2 nd semester. Classes meet between the hours of 8:00 a.m. to 4:00 p.m., Monday through Friday. Clinical settings, which include many of the area hospitals, may require a different schedule. The program offers no evenings or weekend courses at this time. Programmatic Accreditation Metropolitan Community College's Surgical Technology program is accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) in cooperation with the Accreditation Review Committee on Education in Surgical Technology (ARC-ST). Program Requirements for Students Academic Requirements Allow time for study to be successful in a challenging program. Receive a grade of C or better in all coursework. Students not receiving a minimum grade of C in any program course once admitted to the program will not be allowed to continue in the program. In order to achieve a C in surgical technology courses, a student must achieve a minimum score of 75% in both laboratory and lecture portions of the class in order to pass the course. If a student receives a D or below in a surgical technology course once in the program, the student must reapply to the program, enrolling in all previous surgical technology coursework. In addition, students will be required to maintain a 2.5 grade point average while in the program. Failure to do so will result in dismissal from the program. Students will perform practical examinations that will be graded according to a performance checklist and students must meet minimum standards in order to proceed to clinical rotations. The program has attendance policies that result in point deductions for absences. Attendance in class is required and continued absences may result in dismissal from the program. Students will be responsible for maintaining and completing a student clinical case log. For more detailed information about program policies, consult the Surgical Technology Program Handbook on-line at http://www.mcckc.edu/main.asp?p=dp_stnu. Students will be expected to participate in clinical rotations which are scheduled 24 hours/week. Students may be scheduled at a clinical rotation site within 50 miles radius. Transportation to and from the site is the responsibility of the student. Access to and responsibility for the cost of emergency services in off campus educational experiences is the responsibility of the student. REV: 6/13 Page 5 of 22 RVM

Requirements to Advance to Clinical Component of the Program Successful completion of prior coursework in the program with a minimum grade of C in both the lecture and laboratory portions of the course. Overall grade point averages no lower than 2.5. Successful completion of course written and practical skills examinations. Complete physical examination (prior to clinical). Verification of vaccinations or acquired immunity to specific disorders Annual TB test required. (information will be provided once in program) Carry health insurance or sign a waiver. Obtain Hepatitis B vaccination or sign a waiver. (information provided once in program) Purchase liability insurance through the college for clinical rotations. Students may be required to complete a drug screen for a clinical rotation and may be dismissed from the clinical site as a result of a positive drug screen. Criminal Background Check (CBC): Clinical sites require that only students with an acceptable consumer report, as it relates to criminal background, be allowed to participate in clinical rotations. Criminal background checks will be conducted prior to beginning clinical rotations. MCC shall not use the results of a background check as criteria for admission to any program or course. However, you should know that you will not be able to obtain a license to practice or be allowed to participate in clinical s should you have an unacceptable background as defined by state law regarding health care providers. An unacceptable background includes a felony and/or class A misdemeanor conviction. See documents: Listing of Criminal Offenses and Summary of Rights located in the program student handbook. REV: 6/13 Page 6 of 22 RVM

Program Performance Standards for Surgical Technology Students Applicants to this program should be aware of the technical standards required for completion of this program. These performance standards are provided to prospective students to assist them in determining whether they will be able to successfully complete the program. It is the policy of MCC-Penn Valley to provide reasonable accommodations for individuals with disabilities. If you need an accommodation due to a disability under the Americans with Disabilities Act, please contact the Access Resource Coordinator at http://www.mcckc.edu/main.asp?p=sadaoveriew Two to six weeks advance notice is required for some accommodations. Surgical Technology students should possess and be able to demonstrate the following: Surgical Technology students should possess critical thinking sufficient for clinical judgment. For 1. Critical Thinking example, students must be able to identify cause-effect relationship in clinical situations. Surgical Technology students should possess interpersonal abilities sufficient to interact with individuals, 2. Interpersonal groups, etc., from a variety of social, emotional, cultural and intellectual backgrounds. For example, student must be able to establish rapport with health care team members. Surgical Technology students should possess communication abilities sufficient for interaction with 3. Communication others in both verbal and written form. For example, the student should be able to explain surgical procedures and document when appropriate. Surgical Technology students should possess physical abilities sufficient to move from room to room and 4. Mobility maneuver in small places and stand for extensive periods of time. Surgical Technology students should possess gross and fine motor abilities sufficient to provide safe and 5. Motor Skills effective performance in the handling of equipment and instrumentation. 6. Hearing Surgical Technology students should possess sufficient auditory abilities to perform efficiently. 7. Visual Surgical Technology students should possess sufficient visual acuity for performance of required tasks. 8. Physical Surgical Technology students should be able to lift and manipulate/move 30 pounds of weight. Surgical Technology students may be exposed to communicable diseases and /or bodily fluids, toxic 9. Occupational Exposures substances, medicinal preparations and shall use appropriate precautions at all times. Surgical Technologists work in clean, brightly lit, relatively quiet, cool environments. At times they may be exposed to communicable diseases and unpleasant sights, odors, and materials. Most of their duties require standing, sometimes for a number of hours, and it is imperative that their attention be focused 10. Working Conditions closely on the task at hand. Most surgery is performed during the day, but many hospitals and surgicenters require 24-hour coverage. A 40-hour week is common, although most are required to periodic on-call hours available to work on short notice in case of emergency. REV: 6/13 Page 7 of 22 RVM

Surgical Technology Offered at MCC-Penn Valley Surgical Technology Certificate... 50-56 Credits This program leads to a certificate of proficiency and prepares students for entry-level jobs as operating room technicians. General Education Requirements Must be taken at one of the MCC Campuses Credits BIOL 100 Introduction to Cell Biology or CHEM 105 Introductory Chemistry for Health Sciences 3 5 BIOL 109 Anatomy and Physiology or BIOL 110 Human Anatomy and BIOL 210 Human Physiology 6 10 BIOL 150 Medical Terminology 2 BIOL 208 Microbiology 5 Specific Program Requirements Semester Taken Prerequisites MATH 20 or satisfactory score or placement test BIOL 100 or CHEM 105 BIOL 110 and either BIOL 100 or CHEM 105 BIOL 100 or CHEM 205 or higher, plus one of the Following course: BIOL 101, 104, 106, 108, 109, or 110 STNU 100 Introduction To Surgical Technology 2 BIOL 100 or CHEM 105, BIOL 109 or 110 and STNU 101 Care of the Surgical Patient 3 BIOL 210, 150, 208. Formal acceptance into the program BIOL 100 or CHEM 105, BIOL 109 or 110 and STNU 102 Principles of Surgical Technology I 5 BIOL 210, 150, 208. Formal acceptance into the program BIOL 100 or CHEM 105, BIOL 109 or 110 and STNU 103 Principles of Surgical Technology II 4 BIOL 210, 150, 208. Formal acceptance into the program STNU 105 Pharmacology for the Surgical Technologist 2 STNU 100, 101, 102, 103 STNU 120 Surgical Procedures I 4 STNU 100, 101, 102, 103 STNU 121 Clinical Experience I 2 STNU 100, 101, 102, 103 and concurrent enrollment in STNU 120 STNU 130 Surgical Procedures II 4 STNU 105, 120, 121 STNU 131 Clinical Experience II 2 STNU 105, 120, 121 and STNU concurrent enrollment in STNU 130 STNU 140 Surgical Procedures III 4 STNU 105, 120, 121 STNU 141 Clinical Experience III 2 STNU 105, 120, 121 and STNU concurrent enrollment in STNU 140 Total Credit Hours Required 50-56 REV: 6/13 Page 8 of 22 RVM

Surgical Technology Offered at MCC-Penn Valley A.A.S Surgical Technology.. 62-68 Credits This program leads to a certificate of proficiency and prepares students for entry-level jobs as operating room technicians. A.A.S. Surgical Technology General Education Requirements Must be taken at one of the MCC Campuses Credits BIOL 100 Introduction to Cell Biology or CHEM 105 Introductory Chemistry for Health Sciences 3-5 BIOL 109 Anatomy and Physiology or BIOL 110 Human Anatomy and BIOL 210 Human Physiology 6-10 BIOL 150 Medical Terminology 2 BIOL 208 Microbiology 5 Semester Taken Prerequisites MATH 20 or satisfactory score or placement test BIOL 100 or CHEM 105 BIOL 110 and either BIOL 100 or CHEM 105 BIOL 100 or CHEM 205 or higher, plus one of the Following course: BIOL 101, 104, 106, 108, 109, or 110 ENGL 101 Composition and Reading 3 HIST 120 United States History to 1865 or HIST 121 United States History Since 1865 or POLS 135 Introduction to Political Science or POLS 136 Introduction to American National Politics 3 POLS 137 Introduction to State and Local Politics PSYC 140 General Psychology 3 SPDR 100 Fundamentals of Speech or SPDR 102 Fundamentals of Human Communications 3 Specific Program Requirements STNU 100 Introduction to Surgical Technology 2 STNU 101 Care of the Surgical Patient 3 BIOL 100 or CHEM 105, BIOL 109 or 110 and BIOL 210, 150, 208. Formal acceptance into the program STNU 102 Principles of Surgical Technology I 5 BIOL 100 or CHEM 105, BIOL 109 or 110 and BIOL 210, 150, 208. Formal acceptance into the program STNU 103 Principles of Surgical Technology II 4 BIOL 100 or CHEM 105, BIOL 109 or 110 and BIOL 210, 150, 208. Formal acceptance into the program STNU 105 Pharmacology for the Surgical Technologist 2 STNU 100, 101, 102, 103 STNU 120 Surgical Procedures I 4 STNU 100, 101, 102, 103 STNU 121 Clinical Experience I 2 STNU 100, 101, 102, 103 and concurrent enrollment in STNU 120 STNU 130 Surgical Procedures II 4 STNU 105, 120, 121 STNU 131 Clinical Experience II 2 STNU 105, 120, 121 and STNU concurrent enrollment in STNU 130 STNU 140 Surgical Procedures III 4 STNU 105, 120, 121 STNU 141 Clinical Experience III 2 STNU 105, 120, 121 and STNU concurrent enrollment in STNU 140 Total Credit Hours Required 62-68 REV: 6/13 Page 9 of 22 RVM

SURGICAL TECHNOLOGY PROGRAM ESTIMATED PROJECTED COSTS FOR ACADEMIC 2013 Item(s) Cost Tuition In-District: $92.00/Credit Hour = Certificate (50 Credit Hours) In-District: $92.00/Credit Hour = A.A.S. (62 Credit Hours) Out of District Total: $172.00/Credit Hour = Certificate (50 Credit Hours) Out of District Total: $172.00/Credit Hour = A.A.S. (62 Credit Hours) Out of State Total : $226.00/Credit Hour = Certificate (50 Credit Hours) Out of State Total : $226.00/Credit Hour = A.A.S. (62 Credit Hours) International Total: $226.00/Credit Hour = Certificate (50 Credit Hours) International Total: $226.00/Credit Hour = A.A.S. (62 Credit Hours) $ 4,350.00 $ 5,394.00 $ 8,600.00 $ 10,664.00 $ 11,300.00 $ 14,012.00 $ 11,300.00 $ 14,012.00 Program Costs Allied Health Fee ($20.00/Per Credit Hour) x 44 $ 880.00 Programs Fees $ 2,340.00 Lab Fees $ 108.00 Liability Insurance $ 80.00 AST Membership $ 45.00 Background check/urine drug screen $ 51.00 Program Text Books $ 850.00 Graduation Fee $ 30.00 CPR certification (2 year) $ 50.00 CST Exam $ 300.00 USB External Drive $ 20.00 Program Costs Total $ 4,554.00 REV: 6/13 Page 10 of 22 RVM

Application Surgical Technology Program Application & Admissions Applications are due February 15 th. Applicants applying for this program must be at least 18 years of age and should not have an aversion to the sight of blood. Considerable physical stamina is also a requirement due to the necessity of lifting, walking, and standing for long periods of time. Visit our MCC program web page and download our program information/admission booklet. Submit application from program information/admission booklet. Fill out the application exactly as directed. Complete both sides of the program admission application in ink. Be sure to sign it. The preliminary deadline for applications is February 15 th. Submit the Surgical Technology Program application in person to the Allied Health Division office, 4 th Floor, 410B) or mail to: MCC Health Science Institute ATTEN: Roger Massey Surgical Technology Program 3444 Broadway Kansas City, Missouri 64111 Selection Process MCC - Surgical Technology Program is a selective admission program with a limited number of openings each year. To be accepted, you must meet the basic program admission requirements. You will be ranked for admission based on points awarded according to admission criteria. The number of admissions is limited to the available spaces in the next class (maximum of 25). Applications will be reviewed and applicants will be notified for interview 2-3 weeks following the application deadline. To qualify for interview, applicants must have completed prerequisites with a grade point average of 2.5 or above and minimum grade of "C" in all biological courses completed for the degree. The applicants are notified beginning in May preceding the start of class in June. Included in the acceptance letter is a date for orientation to the program. This orientation is mandatory. Students not attending orientation may not attend the class starting that program year at the discretion of the coordinator. If the number of qualified individuals applying exceeds slots in the program, the best qualified applicants will be selected based on: Academic performance ( including, but not limited to: GPA in courses for degree, Intro to ST and biology grades, degrees, history of repeated coursework) Volunteer or work experience in health care Written communication Reference questionnaires Interview REV: 6/13 Page 11 of 22 RVM

Selection Process The point system was implemented as an objective means for evaluating Surgical Technology applicants. Surgical Technology applicants will be ranked based upon points earned, and the students with the highest number of points will be selected. If two or more students have the identical point count total, the date that the "Application" was completed and submitted to our program admission s office will be the determining factor. POINTS FOR GRADES EARNED IN HIGH SCHOOL OR COLLEGE LEVEL COURSES Surgical Technology applicants may earn points for the completion of related courses in MCC's Surgical Technology program. In order to earn points for courses, applicants must have achieved grades of "C" or higher. See Point Count Form for point values. SPECIAL NOTES: BIO 108 or (BIO 109), BIOL 150 and BIO 208, must have been taken in the last five (5) years. First attempt with a letter grade of "C" or better will be considered for the point count.. POINTS FOR PREVIOUS WORK EXPERIENCE Students may earn 10 points for previous work experience within the last 5 years as an Operating Room Transportation Assistant or as an Operating Room Attendant, Medical Assistant or Anesthesia Technician. Any other related profession will need to be approved by the program director for inclusion of points. Applicants must submit proper documentation on official letterhead, signed and dated by supervisor or personnel/human resource officer and include: the beginning and ending dates of employment; average number of hours worked per week; description of job duties and applicant s current employment status. (Acceptable experience is at the discretion of the Director of the Program). POINTS FOR INFORMATION SESSION Ten (10) points will be awarded for attending one Information Session. Certificates of attendance must be filled out (by student) and submitted to Terry McDaniel immediately following the information session in order for points to be awarded. (Observation sessions will be conducted twice monthly, please make arrangements to attend an information session through Terry McDaniel via Terry.McDaniel@mcckc.edu) POINTS FOR SURGERY OBSERVATION SHEET Ten (10) points will be awarded for attending one observation session of a surgical procedure and submit a one page report outlining observations. Include what you saw, if your impression of ST has changed and if the experience has influenced your decision to become a ST. (Please contact Program Clinical Coordinator via Shirley.Musick@mcckc.edu for additional details regarding observation arrangements) POINTS FOR REFERENCE QUESTIONNAIRES Ten (10) points will be awarded for submitting (2) reference questionnaires. These individuals should know you professionally: an employment supervisor, a previous instructor or other professional relationship. In 2010, approximately 70% of qualified applicants were admitted to the program. The goal class size is approximately 20 students. Of applicants offered a position in the class during 2011, the majority of students had a GPA of 3.0 or better and nearly ½ had a GPA of 3.5 or above (in courses required for the degree), and approximately 40% had some experience in a medical or surgical technology field. NOTE: AN APPLICANT'S POINT COUNT IS CONFIDENTIAL; PLEASE DO NOT CALL TO INQUIRE ABOUT YOUR POINT COUNT. TO PROTECT YOUR PRIVACY, POINT COUNT TOTALS WILL NOT BE DISCUSSED ON THE TELEPHONE REV: 6/13 Page 12 of 22 RVM

Admissions Process You may find it helpful to use this section as a checklist to mark off the steps as you complete them: Apply to MCC on-line by filling out an application at http://www.mcckc.edu and click on Get Started and follow those steps. Contact the Penn Valley Campus Placement Testing Office to take the COMPASS test or CELSA test if non English speaking at your earliest convenience. The Placement/COMPASS test is the Metropolitan Community College placement test. There is no cost for taking the test. The program s minimum required scores are: Writing 70 Reading 85 Intermediate Algebra 50 If your scores on the Placement/COMPASS test do not meet the minimum scores as listed above, you will need to schedule recommended courses and complete the course with a grade of C or better before continuing with the enrollment process for Surgical Technology Program. Contact the Penn Valley Counseling Department (759-4077) for advice on enrollment in those classes. Request a copy of your scores be sent to the ST Program office or bring a copy of your scores to the Program office. Have formal transcripts sent to the Surgical Technology Program and the Student Data Center, 3200 Broadway, Kansas City, Missouri, 64111. Your transcript will be evaluated by the Student Data Center. The college will mail you a student ID number that will allow you to access your transcript information and determine what classes have transferred from other schools. Contact your high school to request they send an official copy of your high school transcript to the Program Or If you have a GED, contact the certifying agency to submit an official GED transcript. (These Transcripts become an official part of your application file) Or If you have been home schooled, please supply the statement of course work. Complete each of the following program required prerequisite courses: BIOL 109 Anatomy and Physiology (3 credits) or BIOL 110, 210 Human A & P (5 credits) (JCCC: CHEM 122, 5 credits) BIOL 150 Medical Terminology (2 credits) (JCCC: AAC 130, 3 credits) BIOL 208 Microbiology (5 credits) (JCCC: BIOL 230 (3credits) & BIOL 231(2 credits) As part of the application process, you will be required to arrange for a two hour observation at area operating rooms or surgery centers. Observation should be at an inpatient facility (hospital) or a outpatient surgery center facility. Have the supervising nurse sign the Observation Sheet and return it with your other paperwork. Type a one page report outlining your observations. Include what you saw, if your impression of ST has changed and if the experience has influenced your decision to become a ST. Fill out the Curriculum Checklist by highlighting those classes you have completed, indicating your grade for the course as well as the number of credit hours earned. Ask two individuals to serve as personal references for you. These individuals should know you professionally: an employment supervisor, a previous instructor or other professional relationship. REV: 6/13 Page 13 of 22 RVM

Have each individual complete the Reference Questionnaire and send it directly to our department. Sign the Informed Consent statements and return. Drug Free Workplace, Campus and Community Drug Screen Policy. Student Responsibilities: The applicant is responsible for: Informing the Program admission office of any changes in name, address, and/or telephone number. Completing the program application process Following up with program admission s coordinator on application status. The applicant s file is deleted: If applicant s file is placed on inactive status if a mailed communication is returned. If there is no recent activity within the previous one (1) year. If there is only an application on file after one year. Prior Students Seeking Readmission Must: If it has been more than two (2) years since their participation in the Program, the student seeking readmission requests a review of their academic file in writing from the Program Coordinator and then if accepted, follow the admission process. If the prior student is seeking readmission following suspension from the program, the suspended student writes a letter requesting that the student be considered for readmission to the program. The letter will be placed in the student s file and reviewed when the next available class is selected. If the student has failed one course of the Surgical Technology Program, the student must reapply and request re-enrollment in writing to the Coordinator of the Program. Addendum to Curriculum Checklist Biology coursework more than five (5) years old is non-transferable towards attainment of the Surgical Technology Program certificate/degree. To remain in the program all Surgical Technology courses must be completed with a grade of C or greater. Metropolitan Community College is committed to a policy of nondiscrimination on the basis of age, color, creed, disability, marital or parental status, national origin, race, religion, or gender in admissions, educational programs or activities, and employment, as specified by federal laws Title IX of the Education Amendments of 1972, Titles VI and VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1997, the Americans with Disabilities Act, and state laws and regulations. REV: 6/13 Page 14 of 22 RVM

MCC HEALTH SCIENCE INSTITUTE SURGICAL TECHNOLOGY PROGRAM STUDENT APPLICATION Send Completed Application to: Roger V. Massey, Program Coordinator Surgical Technology Program Health Science Institute - Penn Valley Community College 3444 Broadway Kansas City, MO 64114 Final Deadline: February 15 th, 2014 (Ms/Mr) Last First MI Name(s) that will appear on previous educational records if different from above: (Ms/Mr) Last First MI Mailing Address: Street Address City State Zip Permanent Address: Street Address City State Zip Home Phone Work Phone Cell Phone E-Mail Address Name of person to be notified in case of emergency Phone: (Relationship) REV: 6/13 Page 15 of 22 RVM

Academic Record High School: Address, Dates Attended, and Graduation Date or Date of GED Colleges Attended: Beginning with the most recent, list all colleges you have attended. Request that official transcripts be sent to: Surgical Technology Program, 3444 Broadway, Kansas City, MO 64111. NOTE: Even if you took classes within the Metropolitan Community College system, you must send transcripts of all college work to the Surgical Technology Program as part of your application. College City/State Dates Attended Degree Received Work Experience: (note any experience in the health care field. Include dates of your employment and indicate whether the work was full-time or part-time.) Volunteer Experience: Please note any volunteer experience you have in the health care field. Identify the nature of the volunteer experience as well as the dates and total hours of the experience. How did you hear about our program? Signature and Date of Applicant REV: 6/13 Page 16 of 22 RVM

MCC Health Science Institute Surgical Technology Program - Curriculum Checklist Name: Student ID#: Please consult the Program Coordinator, Roger Massey, for any changes in curriculum sequencing PROGRAM PREQUISITES Hours Grade Hours Earned Grade Points BIOL 109 Anatomy and Physiology (JCCC: BIOL 140 & 144 5 BIOL 150 Medical Terminology (JCCC: AAC 130) 2 BIOL 208 Microbiology (JCCC: BIOL 230 & BIOL 231) 5 FIRST SEMESTER TOTAL 12 STNU 100 Introduction to Surgical Technology 2 STNU 101 Care of the Surgical Patient 3 STNU 102 Principles of Surgical Technology I 5 SECOND SEMESTER TOTAL 10 STNU 103 Principles of Surgical Technology II 4 STNU 105 Pharmacology for the Surgical Technologist 2 STNU 120 Surgical Procedures I 4 STNU 121 Clinical Experience I 2 THIRD SEMESTER TOTAL 12 STNU 130 Surgical Procedures II 4 STNU 131 Clinical Experience II 2 STNU 140 Surgical Procedures III 4 STNU 141 Clinical Experience III 2 TOTAL 12 TOTAL PROGRAM CREDIT HOURS 46 General education courses can be sequenced in any manner, however, should be completed prior to the summer semester. For PVCC BIOL 109 Anatomy & Physiology requirement, two JCCC options are available: Option 1 - BIOL 144 Human Anatomy & Physiology (5 cr) AND BIOL 145 Human Anatomy/Physiology Dissection (1 cr). (NOTE: BIOL 144 must be taken before BIOL 145.) Option 2 - BIOL 140 Human Anatomy (4 cr) AND BIOL 225 Human Physiology (4 cr). (NOTE: CHEM 122 and BIOL 140 must be taken before BIOL 225.) REV: 6/13 Page 17 of 22 RVM

Dear Director of Surgical Services: As part of the application process at the Metropolitan Community College-Penn Valley, prospective surgical technology students are required to spend 2 hours in a surgical setting to observe a surgical procedure. The student is to complete this form and submit to the Surgical Technology Coordinator at MCC-Health Science Institute. Thank you for your assistance and time in allowing the student to make an informed decision regarding surgical technology as a career. Respectfully, Roger V. Massey Roger Massey, CST Director, Surgical Technology Program Surgical Technology Program Health Science Institute, 410L 816-604-4664 Roger.Massey@mcckc.edu Student's Name Facility where observation was completed Surgical Staff Signature/Title/Date Surgical Staff Print/Title/Date Prospective ST Candidate Signature/Date Prospective ST Candidate Print/Date REV: 6/13 Page 18 of 22 RVM

Surgical Technology Program Reference Questionnaire This form is to be completed by a Work Supervisor who has knowledge of the applicant's integrity, dedication and communication skills. Applicant: Last First MI To the evaluator: The above individual is applying for admission to the Surgical Technology Program at MCC- Penn Valley. Once you have completed this reference questionnaire, seal the envelope and sign over the seal. Mail to: MCC-Penn Valley, Surgical Technology Program, Health Science Institute, 410L, 3444 Broadway, Kansas City, MO 64111 Please rate the applicant on the following: (If unable to assess, please leave blank.) 1 IS THE LOWEST, 10 IS THE HIGHEST Communicate effectively Interacts effectively with co-workers Interacts effectively with clients Demonstrates initiative & self-discipline Utilizes constructive criticism Demonstrates appropriate self-confidence Demonstrates non-judgmental behavior toward others Demonstrates flexibility for unexpected events Shows consideration for others Follows instructions well Is punctual Demonstrates good time management skills Appears well-groomed & dress appropriately Demonstrates ability to evaluate own strengths & weaknesses Exhibits good judgment Exhibits tact Handles stressful situations Behaves ethically Attends regularly 1 10 Relationship to Applicant Name Date REV: 6/13 Page 19 of 22 RVM

Surgical Technology Program Reference Questionnaire This form is to be completed by a Work Supervisor who has knowledge of the applicant's integrity, dedication and communication skills. Applicant: Last First MI To the evaluator: The above individual is applying for admission to the Surgical Technology Program at MCC- Penn Valley. Once you have completed this reference questionnaire, seal the envelope and sign over the seal. Mail to: MCC-Penn Valley, Surgical Technology Program, Health Science Institute, 410L, 3444 Broadway, Kansas City, MO 64111 Please rate the applicant on the following: (If unable to assess, please leave blank.) Communicate effectively Interacts effectively with co-workers Interacts effectively with clients Demonstrates initiative & self-discipline Utilizes constructive criticism Demonstrates appropriate self-confidence Demonstrates non-judgmental behavior toward others Demonstrates flexibility for unexpected events Shows consideration for others Follows instructions well Is punctual Demonstrates good time management skills Appears well-groomed & dress appropriately Demonstrates ability to evaluate own strengths & weaknesses Exhibits good judgment Exhibits tact Handles stressful situations Behaves ethically Attends regularly 1 IS THE LOWEST, 10 IS THE HIGHEST 1 10 Relationship to Applicant Name Date REV: 6/13 Page 20 of 22 RVM

Prospective Student Information Packet I have read the Program Information Booklet MCC Health Science Institute Surgical Technology Program Informed Consent Page Name Date Use of Application and Transcript Information I understand that information provided in the program application and college transcripts will be utilized for purposes of determining eligibility to the program and for academic advising and counseling by program faculty. Information contained within the application will be provided to academic counselors/advisers for purposes of advisement and counseling. Name Date Program Admission I understand that the program capacity is limited and therefore, the application process is competitive. As such, if the number of applicants exceeds the number of positions in the program, the best qualified applicants will be determined based on: Academic performance, including but not limited to: calculated grade point average of any course taken towards the degree, grades in Intro to ST and/or biology courses, history of repeated coursework and dropped courses, degree attainment, and demonstrated ability to handle a full academic load, volunteer or work experience related to health care, written paperwork, references and interview Name Date Program Policies 1. The program is time consuming and it would be difficult for an individual to work more than 24 hours/week after the first academic semester. 2. The program requires a commitment to attendance and study time that is more rigorous generally than many other courses of study. 3. The program has a set of policies that includes the following: a. Students must receive a minimum grade of 75% or greater in each surgical technology course in order to successfully pass the course. If a student fails to achieve a 75% in a surgical technology course than they would not be permitted to participate in subsequent sequence of surgical technology courses. That student would need to reapply to the surgical technology program. b. Students must demonstrate minimum competency on certain skills to pass a course. c. The program has attendance policies that include point deductions for tardiness and absences d. Students must adhere to clinical guidelines of affiliated health care institutions that will require students to undergo criminal background checks. Individuals with felony convictions or class A misdemeanors may be unable to complete clinical rotations or obtain employment in certain health care settings. For more information on criminal background checks see the Prospective Student Packet. e. Students may be required to undergo a drug screen when participating in clinical rotations and may be dismissed from a clinical as a result of a positive drug screen. f. Students may be exposed to blood and body fluids on clinical rotations, however, the risk should be minimal if standard precautions are observed. g. Students will be required to show proof of current vaccination and/or titer results, and undergo a physical examination prior to clinical rotations. Students may be required to undergo certain vaccinations in order to advance to the clinical portion of the program because of current hospital policy. I have read and agree to abide by the policies of the Surgical Technology Program. Name Date REV: 6/13 Page 21 of 22 RVM

MCC Health Science Institute Drug-Free Workplace, Campus and Community Drug Screen Policy MCC Penn Valley is committed to maintaining high standards in all programs including allied health and nursing education and practice. Safe practice includes efficient, reliable, and unimpaired student performance at all times including in the classroom and in a clinical setting. Being under the influence of drugs or alcohol poses serious safety and health risks not only to the user but also to all persons who come in contact with the user. Students are required to perform all education related activities in appropriate mental and physical condition MCC-PV has adopted the Federal Drug-Free Workplace Act of 1988 and Drug-Free Schools and Communities Act Amendments of 1989. The policy is one of zero tolerance. Together with the college s Drug-Free policy, the Code of Student Conduct imposes prohibited conduct and possible disciplinary action. If in violation of these policies, students subject themselves to disciplinary actions up to and including suspension or expulsion from the college and its programs. Clinical facilities are committed to providing a safe environment in order to protect its patients, residents, employees and visitors; to provide the highest level of service; and to minimize the potential for accidents and injuries. Therefore, many of the clinical contracts between MCC PV and hospitals, clinics, and other facilities have a component requiring drug screening for allied health and/or nursing students. The clinical site might require that an MCC PV allied health and/or nursing student complete and pass a drug screen prior to being admitted into the facility as a student. Additionally, some clinical facilities require random drug testing during the duration of a clinical rotation. Refusal to submit to a drug screen or testing positive can make a student ineligible to participate in clinical training. The cost for a drug screen may be covered by the clinical facility. If not, the student is responsible for the cost. I understand the policy as outlined above and agree to abide by this policy. Student s Name Date REV: 6/13 Page 22 of 22 RVM