Allied Health Admissions, CA TEB 103 Fax: N. Killingsworth St. Phone: Portland, OR Cell Phone: Other Phone: Yes

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1 Medical Laboratory Technology Program Application Received (office use only): Return completed application and all documentation to: Portland Community College Allied Health Admissions, CA TEB 103 Fax: N. Killingsworth St. Phone: Portland, OR NOTE: Students are encouraged to attend an information session or meet with the Admissions Coordinator before applying. Admission is competitive. Generally 24 students are chosen each year for the Medical Laboratory Technology Program. More students apply than we are able to place in the program. Students are encouraged to get health related experience and to get the best grades possible on all prerequisite coursework see Advising Guide It is your responsibility to ensure all contact information is current and correct, if you change addresses or phone numbers please contact admissions with the correct information. Applicant Information Please Type or Print Clearly PCC ID # G Name: Last First MI Maiden Home Address: City State Zip Cell Phone: Other Phone: PCC Do you have a prior degree? No Yes Previous college attended: College College Have you applied to the MLT program before: No Yes If yes: Year Optional - In case of emergency, please notify: Name: Relationship Address: Home Phone: Work Phone: STUDENT SIGNATURE DATE Medical Laboratory Technology Program Application Page 1 of 8

2 Important Information for Applying Prerequisite Requirements Must pass with a C or better These classes must be completed or concurrently enrolled in during the term applications are being accepted. WR 121 English Composition MTH 95 Intermediate Algebra (or a higher level math) BI 121 Introduction to Human Anatomy and Physiology I (or BI 231 & 232 or BI 211 & 212) BI 122 Introduction to Human Anatomy and Physiology II (or BI 233 or BI 213) CH 104 Allied Health Chemistry I (or CH 221) CH 105 Allied Health Chemistry II (or CH 222) CH 106 Allied Health Chemistry III (or CH 223) MLT 110 Introduction to Medical Lab Technology NOTE: All BI and CH classes must be taken as the complete series. In the event you wish to substitute a course taken at another school for a PCC program requirement please contact the Admissions Coordinator to ensure that this course is an acceptable substitute. In some cases you may need to provide a course description or syllabus for the course. All BI and CH classes need to be taken within the past seven years unless approval is granted by the MLT department chair. Requirements for Application Complete all prerequisite requirements by the end of Spring Term You may turn in your application prior to the completion of prerequisite classes but you will need to pass all classes with a C or better by the end of Spring Term Your application will not be considered complete until all documents have been turned in. Complete the Supplemental Experience Questions on pages 4, 5 and 6. Complete the Supplemental Essays on page 6 Submit two Recommendation Forms filled out by counselors, instructors or supervisors and placed in a sealed envelope that is signed across the seal on pages 7 and 8. If more than two are received, only the first two we receive will be scored. Provide unofficial transcripts from all colleges that you have attended other than Portland Community College. If you are currently enrolled in any prerequisite coursework at another college you must provide proof of enrollment with your application. Application Timeline All application materials listed above will be accepted Monday, April 09, 2018 through Friday, June 22, 2018, and all materials must be turned in by 5:00 on June 22nd. The application due date is firm, and all required documents must be in the Allied Health Admission office by that date or the application will not be processed. o All grades from in-progress prerequisite classes taken at other schools must be in the Admission office by one week after grades have posted. Applicants will be notified within a month of the close of the application period of their acceptance status, and applicants with the top points will be conditionally accepted and invited to a mandatory MLT new student orientation. Official acceptance will be sent after the MLT new student orientation has been successfully completed. At that time, any students who have taken MLT program coursework at a college other than Portland Community College will need to order official transcripts and have them evaluated by Student Records. Application Evaluation Applicants will be given points using the point system and rubrics listed on the Advising Guide In the event applicants have the same number of admission points, ties will be broken based on the date and time of application, so it is to your advantage to get your application turned in as early as possible. Two or more people will read all supplemental experience questions and essays for evaluation purposes and the points given will be the average of these evaluations. Medical Laboratory Technology Program Application Page 2 of 8

3 STATEMENTS OF UNDERSTANDING Please initial each of the statements below and sign I understand that the experiences listed in the work, volunteer and public service experience sections must be verifiable. Applicants may have the experiences listed verified prior to acceptance into the Medical Laboratory Technology program. Any misinformation may result in disqualification of the application. I understand that I must earn at least a C in all MLT program related courses. I understand that if I earn less than a C in any program related course, I will be dismissed from the program. I understand that after admission to the program I will be required to complete some or all of the following: criminal background check, proof of immunizations, physical examination and a ten-panel drug screening. I also understand that laws and clinical site requirements are subject to change, and that PCC may have very little to no influence on this process. If I am unable to pass the background check and drug screen required by the sites at the time I am scheduled for directed practice, or provide proof of immunizations this may limit my ability to complete my clinical rotations and graduate from the program. There will be a cost associated with completing this requirement If understand that, if admitted, I am required to attend a mandatory Program Orientation dates to be announced. Student Signature Medical Laboratory Technology Program Application Page 3 of 8

4 SUPPLEMENTAL QUESTIONS Work Experience Provide as much information as possible below. If you need more space for these questions, please attach a supplemental document, and title it SUPPLEMENTAL QUESTIONS ADDENDUM. This information must be verifiable. Worth up to 3 points each question see Advising Guide for rubrics. 1. What experiences have you had working in a health related area? s of Experience Total Hours Worked: or more s of Experience Total Hours Worked: or more 2. What experiences have you had working in a laboratory environment? (This could be at the same site as listed in question 1) s of Experience Total Hours Worked: or more s of Experience Total Hours Worked: or more Medical Laboratory Technology Program Application Page 4 of 8

5 SUPPLEMENTAL EXPERIENCE Volunteer Experience Provide as much information as possible below. If you need more space for these questions, please attach a supplemental document, and title it SUPPLEMENTAL QUESTIONS ADDENDUM. This information must be verifiable. Up to 3 points each see Advising Guide for rubrics. 3. What experiences have you had volunteering in a health related area? s of Experience Total Hours Volunteered: or or more s of Experience Total Hours Volunteered: or or more 4. What experiences have you had volunteering in a laboratory environment? (This could be at the same site as listed in question 3) s of Experience Total Hours Volunteered: or or more s of Experience Total Hours Volunteered: or or more Medical Laboratory Technology Program Application Page 5 of 8

6 SUPPLEMENTAL EXPERIENCE Public Service Experience 5. What experiences have you had serving your community in the Public Service sector? This could include military service, AmeriCorps service, holding a public office, fire fighter, police officer, or other public service occupations. Please attach documents proving your service, such as discharge papers. s of Experience Was this: Paid or Volunteer Total Hours Worked/Volunteered: s of Experience Was this: Paid or Volunteer Total Hours Worked/Volunteered: SUPPLEMENTAL ESSAYS: words each Answer the following questions on supplemental paper and attach to your packet: Worth up to 5 pts each. 1. Why are you interested in becoming a Medical Laboratory Technician? 2. What role do you imagine diversity plays in the Medical Laboratory field? Tell us about experience you have had treating people equally and including all people. Medical Laboratory Technology Program Application Page 6 of 8

7 PCC Cascade Campus Allied Health Medical Laboratory Technology Program Recommendation Form To be completed by an employer, volunteer supervisor, counselor or teacher. This student is seeking admissions to an Allied Health program at Portland Community College, Cascade Campus. Please fill the evaluation form out completely. You may be contacted to verify the information provided. Please place in a sealed envelope and sign across the closure. Applicant can include sealed envelopes with the Allied Health application or you can mail to the following address separately. Thank you. Portland Community College Allied Health Admissions, CA TEB N. Killingsworth St. Portland, OR Student Information Student Name Evaluator s Name Evaluator s How do you know this student Ratings Evaluator s Phone Number How long have you known this student No Basis for Comment 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent Knowledge/Preparation Work Quality/Organizational Skills Attendance/Punctuality Initiative Communication/Listening Skills Dependability/Reliability Emotional Maturity/Stability Judgment/Analytical Ability Evaluation Additional Verification of Recommendation Evaluator s Signature Medical Laboratory Technology Program Application Page 7 of 8

8 PCC Cascade Campus Allied Health Medical Laboratory Technology Program Recommendation Form To be completed by an employer, volunteer supervisor, counselor or teacher. This student is seeking admissions to an Allied Health program at Portland Community College, Cascade Campus. Please fill the evaluation form out completely. You may be contacted to verify the information provided. Please place in a sealed envelope and sign across the closure. Applicant can include sealed envelopes with the Allied Health application or you can mail to the following address separately. Thank you. Portland Community College Allied Health Admissions, CA TEB N. Killingsworth St. Portland, OR Student Information Student Name Evaluator s Name Evaluator s How do you know this student Ratings Evaluator s Phone Number How long have you known this student No Basis for Comment 1 = Poor 2 = Fair 3 = Satisfactory 4 = Good 5 = Excellent Knowledge/Preparation Work Quality/Organizational Skills Attendance/Punctuality Initiative Communication/Listening Skills Dependability/Reliability Emotional Maturity/Stability Judgment/Analytical Ability Evaluation Additional Verification of Recommendation Evaluator s Signature Medical Laboratory Technology Program Application Page 8 of 8