Name: _______________________________ Date: _______________________________

Page 1 of 11

Department of Pathology & Laboratory Medicine

Application UC Irvine Medical Center Clinical Laboratory Scientist Training Program Last Name First Name Middle Name/Initial

Mailing Address: Street City State Zip Code

Permanent Address (if different from above) Street City State Zip Code

Cell Phone Alternate Phone

E-mail

Emergency Contact: Name

Relationship Cell Phone

Are you a US Citizen? Yes No

If no, then are you: Permanent Resident (green card) Yes No

DACA Yes No If PR or DACA you will need to bring a copy of your documents should you be interviewed.

Have you applied for or have a California Clinical Laboratory Scientist Trainee License?

Yes No

If yes then: License Number Expiration Date If pending, date initiated

Date of Birth Are you a reapplicant?Yes No

Name: _______________________________ Date: _______________________________

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COLLEGE EDUCATION

School State Country Dates

Attended Major Degree &

Date Cum GPA

______________________________________________________________________________

LETTERS OF REFERENCE Please list the names, relationship (e.g., professor, supervisor, etc.) and contact information for the three individuals you have asked to send a letter of recommendation.

Name Relationship Affiliation Email Phone Number

Units

Name: _______________________________ Date: _______________________________

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ACADEMICS In chronological order (earliest to most recent) list all Biological Sciences, Chemistry, Physics and Mathematics courses. The five required courses are listed at the top in red.

Units

Course Institution Year Semester Quarter Grade In Progress

(X) Planned

(X)

Biochemistry

Analytical (Quant.) Chem

Medical Microbiology

Hematology

Immunology

Name: _______________________________ Date: _______________________________

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ACADEMICS - CONTINUED In chronological order (earliest to most recent) list all Biological Sciences, Chemistry, Physics and Mathematics courses. The five required courses are listed at the top in red.

Units

Course Institution Year Semester Quarter Grade In Progress

(X) Planned

(X)

Name: _______________________________ Date: _______________________________

Page 5 of 11

ACADEMICS - CONTINUED In chronological order (earliest to most recent) list all Biological Sciences, Chemistry, Physics and Mathematics courses. The five required courses are listed at the top in red.

Units

Course Institution Year Semester Quarter Grade In Progress

(X) Planned

(X)

Name: _______________________________ Date: _______________________________

Page 6 of 11

ACADEMICS - CONTINUED In chronological order (earliest to most recent) list all Biological Sciences, Chemistry, Physics and Mathematics courses. The five required courses are listed at the top in red.

Units

Course Institution Year Semester Quarter Grade In Progress

(X) Planned

(X)

Name: _______________________________ Date: _______________________________

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EXTRACURRICULAR ACTIVITIES: List your three main research, clinical, community and school activities, and employment.

ACTIVITY LOCATION DATES

From -To Total Hrs RESEARCH

CLINICAL

COMMUNITY

SCHOOL

EMPLOYMENT

Name: _______________________________ Date: _______________________________

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PERSONAL STATEMENT

In this section please tell the admissions committee your motivation for applying to the CLS training program and your future career goals. The limit is 3,000 characters including spaces.

Name: ___________________________ Date: ___________________________

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ESSENTIAL FUNCTIONS Clinical Laboratory Scientist Training Program

Essential functions represent the non-academic requirements of the Clinical Laboratory Scientist Program at UCI Medical Center. The demonstrated ability to perform these functions is necessary for the successful completion of training and achievement of entry-level competency.

Carefully read the information provided about essential functions and at the end of the document indicate that you understand these requirements.

GENERAL Tasks that a student is expected to successfully perform at the laboratory bench in each different area of the laboratory. In general, one would expect a CLS or student to:

1. Follow a written protocol, produce an accurate result, and notice and confirm anyunusual findings.

2. Follow quality control protocols and follow through with problem situations by notifyingthe instructor and working out the problem.

3. Perform all work in the laboratory following all established safety guidelines.

4. Organize, prioritize and efficiently complete the assigned work.

5. Adapt readily to changes in the work environment.

6. Communicate effectively, via the telephone or in person, with instructors, laboratory andhospital staff and patients

Certain psychomotor skills are required to achieve an acceptable level of performance. Some examples of these skills are:

1. Ability to read procedures, thermometers, instrument indicators and read-outs, andcomputer video terminals.

2. Ability to distinguish variations in color and shape both macroscopically andmicroscopically.

3. Ability to hear and respond to instrument alarms and beeps.

4. Capability of carrying supplies to the work bench or storage areas.

5. Ability to reach instruments at varying heights or reach behind/under instruments,printers, etc.

6. Ability to perform a number of manual functions such as pipetting, using a computerkeyboard, handling test tubes, media plates or tools.

Name: ___________________________ Date: ___________________________

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PHLEBOTOMY Examples of essential functions expected in Phlebotomy would include:

1. Mastery of proper specimen collection in inpatient and outpatient environments, whichincludes patient preparation and the labeling, handling, processing, transportation, andstorage of specimens.

2. Mastery of skills required for collection of blood specimens by using various techniques,such as syringes, evacuated tubes and butterflies, on patients of varying age and physicalcondition.

BLOOD BANK Examples of essential functions expected in Blood Bank would include:

1. Demonstration of the ability to perform the standard Blood Bank procedures includinganswering phones, issuing and ordering blood and components, processing and preparingblood components, and inventory of blood components.

2. Performing the required technical skills including pipetting, making cell suspensions,centrifuging, washing cells, and making eluates.

3. Demonstrating proper operation of the instruments utilized in the performance of theseprocedures and performing appropriate quality control measures.

4. Demonstration of the ability to work in the Donor Center in areas such as obtaining donorhistories, phlebotomy and component preparation.

CHEMISTRY Examples of essential functions in Chemistry would include:

1. Demonstration of the ability to perform the procedures in the Chemistry sections withproper use of the instruments in those areas. Required technical skills may includepipetting, preparation of dilutions and reagents, calibration techniques, sample loading,and touch screen sample programming.

2. Performing preventive maintenance, calibration and troubleshooting procedures, as wellas the incorporation of quality control measures, for each procedure and relatedinstrument. System maintenance would include replacement and cleaning of suchcomponents as sample and reagent supply, incubators and photometers.

3. Demonstration of the ability to perform procedures in Special Chemistry and Toxicologyincluding operation of instruments such as: a spectrophotometer, nephelometry,electrophoresis equipment, densitometer, gas chromatograph (GC), atomic absorptionspectrophotometer (AA), high performance liquid chromatograph (HPLC), and variousimmunochemistry analyzers. These instruments have very diverse operational andtechnical requirements. Procedures may involve the quantitation of analytes at thenanogram level.

4. Demonstration of the ability to perform procedures in Urinalysis and Automated Chemistry including the use of a refractometer, centrifuge, microscope, osmometer, automatedurinalysis system, and a variety of automated chemistry analyzers.

Name: ___________________________ Date: ___________________________

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HEMATOLOGY Examples of essential functions in Hematology would include:

1. Demonstration of the ability to perform the procedures in the Hematology lab with theproper use of the instruments in this section such as automated hematology analyzers,automated coagulation analyzers, slide stainer, and spectrophotometer.

2. Performing the necessary preventive maintenance, calibration and troubleshootingprocedures for each procedure and the related instruments.

3. Performing required technical skills including centrifugation, preparation of reagents andcontrols, pipetting, preparation of dilutions, manual counting methods, and preparationof peripheral blood, bone marrow and body fluid smears.

4. Identifying both normal and abnormal cells on bone marrow, blood and body fluidsmears, and differentiating cells according to stage of development and cellularmorphology with the utilization of various staining techniques. Performance ofimmunofluorescent procedures requires fluorescent microscopy skills.

MICROBIOLOGY Examples of essential functions in Microbiology would include:

1. Demonstration of the ability to perform the various procedures in bacteriology,susceptibility testing, mycology, mycobacteriology, parasitology, immunoserology, andvirology. Students must demonstrate the ability to work with the instrumentation,equipment and/or materials associated with the different procedures including varioustypes of incubators, anaerobic jars, culture media, centrifuges, automatedinstrumentation, molecular technology, fluorescent microscopes and standard lightmicroscopes.

2. Demonstration of the ability to perform immunoserological procedures which includeindirect hemagglutination (IHA), neutralization, latex agglutination, complement fixation,immunodiffusion, latex particle agglutination (LPA), enzyme immunoassay (EIA), indirectfluorescent assay (IFA) assay, and counterimmunoelectrophoresis assay. Students mustalso demonstrate the ability to observe and interpret final readings for these procedures.

3. Processing specimens in each area of Microbiology by centrifugation, inoculation ofmedia, and staining of smears.

4. Performing testing procedures involving sterile technique, pipetting, diluting andpreparing of reagents while incorporating the appropriate quality control measures.

5. Identifying different organisms through the examination of stained smears, culturegrowth characteristics, biochemical reactions, proteomics, nucleic acid analysis, andimmunoserological typing of organisms.

6. Performing various antimicrobial susceptibility test procedures and demonstrating theability to interpret test results.

By checking this box, I attest that I have read and understood all essential functions required of the CLS training program and believe I can meet these requirements.

Name:_________________________________________ Date:_____________

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