BSRT Clinical Program Common Application

Transcription

1 BSRT Clinical Program Common Application Information on this form must be typed, and submitted with an original signature on the final page. APPLICANT INFORMATION Applicant Name: Last Name First Name MI Did you ever work or attend school under a different name than the one listed above?: Yes No If yes, please list: Current Street Address Apartment/Unit # City State ZIP Code Home (if different from above) Street Address Apartment/Unit # Telephone: City State ZIP Code Marian Are you a citizen of the U.S. or legally authorized to work in the U.S.?: Yes No Proof of authorization will be required upon acceptance into the program. Have you ever been employed by any facility connected to this site?: Yes No If yes, when?: Facility: Position(s) held: Do you have any relatives currently employed by this affiliate?: Yes No If yes, please list name(s) and relationship: Have you ever been convicted of a felony, misdemeanor or other criminal offense?: If yes, list dates and nature of offense: If yes, have your rights been restored?: Yes No Yes No Are you subject of any pending charges in a court of law?: Yes No If yes, list dates and nature of charges: If you have ever been convicted of a felony or misdemeanor, you are encouraged to contact the American Registry of Radiologic Technologists (ARRT) [(651) ; to inquire about your registry eligibility. BSRT Clinical Program Common Application Page 1

2 MILITARY RECORD Have you ever served in the United States Armed Forces?: Yes No Branch of Service: Dates of Service: Rank at Separation: Are you a member of an active reserve unit?: Yes No Please describe any related job training that you received: EDUCATION List the high school you graduated from and all post-secondary institutions (colleges and universities) you have attended in the table below. Please list in chronological order. Transcripts from each of these institutions must accompany your application to the program. High School/GED Program Name of School Location (City and State) Dates Attended Year Graduated (if applicable) Degree Earned (if applicable) EMPLOYMENT HISTORY In order to obtain a complete history, list all previous employers beginning with the most recent. Company: Job Title: Supervisor: Job Duties: Reason for leaving: May we contact this employer?: Yes No Company: Dates Employed: BSRT Clinical Program Common Application Page 2

3 Job Title: Supervisor: Job Duties: Reason for leaving: May we contact this employer?: Yes No Company: Job Title: Supervisor: Job Duties: Reason for leaving: May we contact this employer?: Yes No Company: Job Title: Supervisor: Job Duties: Reason for leaving: May we contact this employer?: Yes No Dates Employed: Dates Employed: Dates Employed: Please explain period(s) of unemployment, which may have occurred during your work history: PREVIOUS HEALTHCARE EXPERIENCE Include information about work, volunteer, and/or job shadowing experience here. If a job shadow was completed, attach a copy of the paperwork from the institution for verification. Capacity Dates of Experience/Hours Spent REFERENCES List the names and contact information of three persons you know professionally or through your BSRT Clinical Program Common Application Page 3

4 educational experiences. You may list recent or former teachers, counselors, or co-workers. Do not list personal friends, relatives, or neighbors. Name: Relationship: Name: Relationship: Name: Relationship: Phone Number: Length of Time Known: Phone Number: Length of Time Known: Phone Number: Length of Time Known: In case of an emergency, please notify: Contact Name: Last Name EMERGENCY CONTACT INFORMATION First Name Street City State ZIP Code APPLICANT S SIGNATURE This form must be completed in its entirety and signed by the student applicant. This document, along with all program-specific supplemental information, must be submitted to the Academic Advisor for Health Professions no later than the first Monday in December by 4:00pm. Applicant Signature Date BSRT Clinical Program Common Application Page 4

5 Marian University Mercy Medical Center Campus Radiologic Technology Program For more detailed information about the program and application requirements, please visit the Marian University Mercy Medical Center Campus Radiologic Technology Program website. APPLICATION SUBMISSION INSTRUCTIONS To apply to the School of Radiology, each of the following steps must be completed prior to the application deadline: 1. BSRT Clinical Program Common Application form and Marian University Mercy Medical Center Campus Supplemental Application form complete with all pertinent information. 2. Official transcripts from all post secondary colleges/universities. 3. Three Marian University Mercy Medical Center Campus Applicant Assessment Form documents are required. Two must come from educational references; the third may be a professional or educational reference (i.e. counselor, employer, supervisor, or professor). No personal references will be accepted. The forms should be submitted directly to the Academic Advisor for Health Professions in a sealed envelope with a signature over the seal. 4. The completion of a minimum of two (2), four (4) hour job shadow experiences in the Imaging (Radiology) Department at the hospital of your choice. It is your responsibility to coordinate the experience with the hospital. The two (2) experiences may not occur at the same hospital on the same day. In order to document the completion of the experiences, the applicant is required to submit two (2) of the Radiologic Technology Program Job Shadow Verification Forms completed by the facility. Only original copies of the completed form will be accepted. 5. A personal statement describing your interest in the field of Radiologic Technology, professional attributes as related to the field, and previous healthcare experience must be submitted. The applicant must include in the statement a description/explanation of their job shadow experiences. The statement should be 1 2 typed pages, and must be signed and dated by the applicant. 6. All applicants who meet program eligibility requirements must attend an informational meeting at the Mercy Medical Center campus; program faculty will notify applicants of eligibility to attend the informational meeting. This meeting is part of the application process and no interview will be granted unless the applicant has attended this informational meeting. CERTIFICATIONS (CPR, CNA, etc.) Please attach a copy of the certificate for verification. Certification Completed (month/year) Marian University Mercy Medical Center Supplemental Application Page 1

6 SUPPLEMENTAL APPLICATION INFORMATION Has it ever been determined by any county that you have abused or neglected a child? Yes No If yes, please explain: In the past three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician? Yes No If yes, please explain: Do you have any physical or mental disabilities which may interfere with your performance in the program? Yes No If yes, please explain: Indicate the other medical imaging programs to which you have applied: Aurora St. Luke s Medical Center, School of Radiologic Technology Froedtert Hospital, School of Radiologic Technology Ministry St. Joseph s Hospital, School of Radiography UW Hospital and Clinics, School of Radiologic Technology Wheaton Franciscan All Saints Hospital, School of Radiologic Technology Wheaton Franciscan St. Joseph, School of Radiologic Technology Aurora St. Luke s Medical Center, School of Diagnostic Medical Sonography UW Hospital and Clinics, School of Diagnostic Medical Sonography Please rank (1 3) your desired placement for clinical practicum (NOTE: If the applicant is accepted into the program, faculty will attempt to assign the first choice; however, this is not guaranteed): St. Elizabeth Hospital; Appleton, Wis. Mercy Medical Center; Oshkosh, Wis. St. Agnes Hospital; Fond du Lac, Wis. APPLICANT S STATEMENT In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, creed, sex, national origin, age, marital status, disability (if otherwise qualified), sexual orientation, ancestry, or other class protected by law. I acknowledge that the information I have supplied in this application is correct and understand that any falsification of information on this form may be cause for rejection as an applicant. I understand that this application is not legally binding on me in any way. I consent to and also understand that admission to the program is contingent upon the satisfactory results of a physical examination, including drug screen and criminal background check. I further understand that acceptance by the clinical site will require me to obey all regulations affecting personnel within both the hospital and University settings. I understand that after enrollment as a student, I have the right to withdraw voluntarily from the program for personal reasons. I also understand that, if accepted and enrolled as a student, I shall be subject to dismissal from the program for poor scholastic and/or clinical performance, criminal acts or proven charges of unprofessional conduct. Applicant Signature Date Marian University Mercy Medical Center Supplemental Application Page 2

7 Radiologic Technology Program Job Shadow Verification Form I verify that completed a minimum of four (4) hours Student s Printed Name of job-shadowing experience on. Month, Day, Year This experience included shadowing in the following Imaging Department area(s): Student s Signature Date Job Shadow Supervisor s Printed Name Title Job Shadow Supervisor s Signature Date Facility Phone Number of Facility

8 Marian University Mercy Medical Center Campus Radiologic Technology Program Applicant Assessment Form Applicant Name: Date: The above named individual has applied for admission to the Marian University Mercy Medical Center Campus Radiologic Technology Program. We are requesting information that will aid us in selecting the most qualified students. The applicant has selected you as someone who can give an objective and candid evaluation of their qualifications. Please provide an assessment based on your observations of and/or interactions with the applicant. In what capacity do you know this applicant? How long have you known this applicant? To the best of your ability, please answer the following questions which will give the Admissions Committee a more complete picture of the applicant s academic and professional abilities. 1. What do you believe to be the applicant s positive traits? Please explain. 2. Where do you believe the applicant needs some improvement? Please explain. 3. Why do you believe the applicant is a strong candidate to work specifically in the health care field? Be specific. 4. How does the applicant deal with conflict?

9 Please rate the applicant on the following areas. Characteristic Adaptability Significant Strength Fully Competent Needs Development Not Observed Ability to follow instructions Ability to work under pressure Attitude Communication skills oral & written Emotional stability & maturity Initiative and motivation Integrity Interpersonal skills Punctuality and dependability Quality of work Please indicate your overall endorsement of this applicant: Recommend highly Recommend Recommend with reservation Do Not Recommend Thank you in advance for your candid responses to this assessment. Please feel free to include an additional letter outlining your recommendation of this student, if desired. Reference Name: Title: Signed: Date: Completed forms should be submitted directly to Marian University (address below) for inclusion in the student s application packet. Forms should be mailed in a sealed envelope with your signature across the closure no later than no later than December 1 st. Marian University School of Nursing and Health Professions Attention: Teri Durkin 45 South National Avenue Fond du Lac, WI 54935