SURGICAL TECHNOLOGY PROGRAM
APPLICATION CHECKLIST
Student Name: __________________________________ Student Number: _______________________
The application must include the following documentation. Your application will be disqualified if you fail to include any of the following items in your application packet.
Completed Program Application
Copy of High School Diploma (or GED equivalent)
Documentation of certifications in health care and/or prior work experience
Two completed reference forms (in sealed envelopes)
Letter of Intent
Signed DisclaimerApplications will be accepted during the week of: ____________________________________________ during the hours of 7:30 a.m. to 4:30 p.m., Monday through Friday.
Completed applications should be returned in person to: Student Services
Davis Applied Technology College 550 East 300 South
Kaysville, UT 84037
DATC USE ONLY:
Dear Student:
Thank you for your interest in the Davis Applied Technology College (DATC) Surgical Technology Program. Persons desiring to become Surgical Technologists can expect to enter a career field that presents many challenges, opportunities for professional growth, and much personal reward. Attached is the DATC Surgical Technology Program application. You should review the application guidelines and requirements carefully to ensure you meet the admission requirements, that your application is fully completed, and you have enclosed the required supporting documentation. Sign and date your application and return it to Student Services during the designated application period. Failure to complete the form correctly or return it with the required documentation within the designated timeframe will result in your application being denied.
Due to the limited number of slots available in the program, only the number of students that can be accommodated will be accepted. You will be notified of your acceptance status within approximately two weeks. If you are not selected, you are encouraged to reapply during the next application period.
If you have any questions concerning your application or the program, please do not hesitate to contact me.
Sincerely,
Pamela Carter, RN, M.Ed., CNOR
Surgical Technology Program Coordinator Tel: (801) 593-2330
E-mail: [email protected]
SURGICAL TECHNOLOGY PROGRAM
APPLICATION PROCESS
Due to the nature of this career, there are certain criteria that applicants must meet for entry into the Surgical Technology Program:
A Surgical Technologist must:
o Possess good critical thinking and problem solving skills. A surgical patient’s condition can change at any time, changing a “simple, routine procedure” into a life-threatening emergency.
o Be in good physical condition. Vision and hearing deficiencies must be corrected. One must be able to lift and move a minimum of 50 pounds and must be able to stand in one place for extended periods of time in the operating room.
o Be able to work under stressful conditions and be able to cooperate as a team player with others. This career field will demand long hours, nights, weekends, and holidays. Most emergency surgeries occur during these times.
It is your responsibility to meet the following requirements, complete the application correctly, and submit the necessary documentation. Failure to do so will result in your application being disqualified.
Admissions and Job RequirementsVerify that you meet the Surgical Technology program admissions and job requirements which are available for review on the DATC Website (www.datc.edu/surgical).
o Have a high school diploma or equivalent (GED). Please enclose a copy of your high school diploma or GED certificate.
o Score at required entry levels in reading, math, spelling, and language (or provide appropriate alternative documentation). If you score below these levels, you must complete academic skills upgrades before being able to apply to this program.
o Take the PSB Health Occupations Aptitude Examination.
Completed Application FormComplete all required information on the application form and sign and date it. Return it, along with all other required documents in this envelope, to student services prior to the application deadline.
Documentation of Prior Work Experience or Education in the Health Care FieldProvide documented prior work experience or education in the health care field that is “patient care” related, such as Nurse Aide, Medical Assistant, or Emergency Medical Technician. If you are unsure if your work experience or training meets these requirements, contact the program instructor. If you do not have health care experience, the DATC offers a Nurse Aide course that is relatively inexpensive and short in length. This will prepare you to take the Utah Nurse Aide written and skills certification exams. Prospective
students who are completing the Nurse Aide course are required to take and pass the CNA state certification written and skills exams before applying. Please provide a copy of your certification certificate or have related work
ReferencesProvide two completed reference forms from teachers, health professionals or employers that address your preparedness and strengths pertinent to employment as a health care professional. All information on the form, including the evaluator’s contact information, must be complete. Reference forms should be placed in a sealed envelope with the evaluator’s signature across the seal and included with your completed
application. Reference forms completed by family members will NOT be accepted.
Letter of IntentThe ability to communicate clearly is an important characteristic for those working in the health care profession. Prepare a typed or neatly handwritten, grammatically correct letter of intent describing:
o Your reasons for selecting Surgical Technology as a career o Accomplishments that have given you the greatest satisfaction o Your plans and aspirations for the future
Pre-requisite CoursesStudents may choose to start taking pre-requisite courses prior to applying to the program, or you may wait to begin these courses after being accepted into the program. Many of these courses are available during evening hours, as well as during the day. These pre-requisite courses must all be completed prior to advancing into the program’s core courses. The pre-requisite courses are:
BTEC 1110 Computer Literacy BTEC 1510 Business English MATH 1000 Math I
MEDA 1100 Medical Terminology MEDA 1200 Medical Law and Ethics
MEDA 1300 Psychology for Healthcare Professionals WKSK 1400 Workplace Relations
WKSK 1500 Job Seeking Skills
Any courses completed prior to the time of application will be reviewed for grades and/or progress and attendance, and given consideration accordingly.
Completion of the pre-requisite courses, does not guarantee acceptance into the program.
DisclaimerCarefully review, check off, and sign the disclaimer form.
Post Admission RequirementsFollowing acceptance into the program, you must meet the following post admission requirements. o Submit to and pass a urine drug screen
o Submit to and pass a federal background check
o Obtain a physical exam performed by a physician and provide documentation of all required vaccinations
SURGICAL TECHNOLOGY PROGRAM APPLICATION
Student Name: ______________________________________________________________________________________________
Last First Middle Initial
Address: ___________________________________________________________________________________________________
Number and Street
_________________________
City State Zip
Personal Information: ________________________________________________________________________________________
Social Security Number DATC Student Number
Phone Number:
Home Cell
Email Address:
Emergency Contact : _________________________________________________________________________________________
Name Relationship Phone
1. Education
Please provide information concerning high school, college, technical school, or other schools attended. Include any schools you have or are currently attending. College transcripts may be included in your application for consideration.
2. Health Care Experience
List health care employment experience, starting with your most recent position. DO NOT include experience that was part of your training for an educational program.
Name of Employer City and
State Full-Time (months) Part-Time (months) Position Held
3. Other Employment
Name of Employer Dates Type of Work Position Held
I HEREBY certify the statements in this application are true and complete to the best of my knowledge. I understand that falsifying information on this application may be grounds for dismissal from the program.
Signature: ____________________________________________________________________ Date: _______________________
Completed applications should be returned to: Student Services
Davis Applied Technology College 550 East 300 South
SCHOOL OF HEALTH PROFESSIONS
SURGICAL TECHNOLOGY PROGRAM REFERENCE FORM
PART 1: APPLICANT: Complete Part 1 of this form and forward it to two identified references who should complete the
remainder of the form.
Name of Applicant: ____________Signature: _____________________________________
PART 2: REFERENCE: The above named applicant has selected you to as a reference in support of an application to the
Surgical Technology program at the Davis Applied Technology College. Your thorough and candid evaluation is appreciated. If admitted and enrolled in the program, this form will become part of the student’s file and will be available to him/her should a request be made as guaranteed by the Family Educational Rights and Privacy Act of 1974 and its amendments. Name: ____________________ Title: ______________________________________
Address: __________________________________________________________________________________ Tel: __________________________________________ E-mail: _____________________________________
Length of time you have known the applicant: Years: ______________________ Months: __________________ Relationship to the applicant:
Teacher Supervisor Employer Coworker Other (specify) _____________________________
PART 3: EVALUATION: Rate the applicant in each of the following categories as it relates to their potential as a health care
professional. Comments in each area are helpful.
1. Communication: Verbal & Nonverbal Comments: Poor 1 2 Average 3 4 Very Good 5 6 Outstanding 7 2. Interpersonal Relationships: Comments: Poor 1 2 Satisfactory 3 4 Above Average 5 6 Outstanding 7 3. Appearance/Grooming: Comments: Untidy 1 2 Usually Tidy 3 4 Clean & Neat 5 6 Always Well-groomed 7 4. Motivation: Comments: Poor 1 2 Fair 3 4 Good 5 6 Excellent 7
5. Integrity: Comments: Questionable 1 2 Usually Honest 3 4 Honest; Truthful 5 6 Always Honest; Trustworthy 7 6. Punctuality/Absenteeism: Comments: Often Late or Absent 1 2 Usually Present Punctual 3 4 Good/Very Punctual 5 6 Excellent/ Always Punctual 7 7. Dependability/Responsibility/ Maturity: Comments: Immature; Undependable 1 2 Usually 3 4 Very Responsible 5 6 Always Dependable 7 8. Problem Solving/Decision Making/Critical Thinking: Comments: Poor 1 2 Satisfactory 3 4 Very Good 5 6 Excellent 7 9. Anxiety Level: Comments: Very Stressed & Anxious 1 2 Average; Somewhat Anxious 3 4 Deals With Stress Well 5 6 Calm During Stressful Situations 7 10. Caring Attitude: Comments: Rarely Considers Other’s Needs 1 2 Usually Positive & Caring 3 4 Very Positive 5 6 Exceptional 7 ADDITIONAL COMMENTS:
HEALTH CARE EXPERIENCE: Has the applicant worked in a healthcare facility or environment for 6 months or
longer in a position providing direct patient care?? Yes No (If yes, please provide details)
Job Title: _____________________________________________ Dates: ____________________________ Name of Employer/Organization: ____________________________________________________________
RECOMMENDATION: Indicate your overall recommendation of this candidate as a future Surgical Technology
student. Highly Recommended Recommended Not Recommended
Signed __________________________________________________________ Date ___________________
Thank you for your assistance. Please seal the completed form in an envelope, signing on the sealed area and return it to the applicant in a timely manner. Your recommendation is part of a packet the applicant must submit to the College to be considered for acceptance into the Surgical Technology Program. If you have any questions, please
SURGICAL TECHNOLOGY PROGRAM DISCLAIMER
Name: ______________________________________________________________________________
Application Date: __________________ Student Number: _____________________________________ After you have reviewed the Surgical Technology Program Admission Requirements and Application, please read the following statements carefully and check each box to state you have read, understood and
acknowledge these requirements in order to apply for acceptance into the program.
I have read and understand the admission requirements, post admission requirements, and job requirements as detailed under the “Admissions and Job Requirements” on the Surgical Technology web page on the DATC website (www.datc.edu/surgical).
I have read and understand the following program attendance requirements and confirm I will be able to commit to the prescribed hours for training:o Satisfactory progress during Surgical Technology training requires regular attendance. You will be expected to complete the program within 12 – 15 months and must be enrolled at least 18 hours per week during the first half of the program and attend assigned lab days according to your lab schedule.
o You will be required to maintain a cumulative progress and attendance of at least 85% throughout the program.
o Clinical externship hours are at least 8 hour shifts (usually 7:00 a.m. to 3:30 p.m. with some variations), for a minimum of 4 days per week.
I understand that due to the availability of clinical extern slots, there may be an unavoidable delay before I am able to begin the clinical practicum portion of the program.
If accepted into the program, I understand, as part of the mandatory requirements set forth by the clinical facilities for all health professions students, I am required to:o Submit to and pass a urine drug screen test by the required date.
o Submit to and pass a federal criminal background check by the required date. o Obtain a physical examination prior to scheduling classes with clinical observation.
o Provide documentation of all required immunizations prior to scheduling classes with clinical observation.
I understand that failure to submit to or pass any of these items by the required dates may result in my immediate withdrawal from the program.
