Surgical Technology Application Packet

For Spring 2018

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Welcome!!

I am excited you are considering the FVCC Surgical Technology Program! Making a

commitment to a healthcare career in Surgical Technology will prove to be more than a job, but a

lifelong learning endeavor. The program curriculum is both exciting and challenging; it offers

graduates the opportunity for employment in a wide variety of settings.

You will find that the FVCC instructors are very committed to the Surgical Technology

profession and community. During the course of this program, it is the goal of the faculty and

staff, to provide a solid foundation of professionalism, dedication, integrity and mutual respect

between instructors and students.

Program coursework and clinical rotations are challenging, demanding and time

consuming. It is your responsibility to take full benefit of your coursework and clinical education

by actively participating and dedicating your time and efforts to the program to be successful.

We encourage students to work hard, provide the highest level of quality patient care and

customer service possible to those you encounter, treat people with respect, and behave with

integrity. The effectiveness of your education and skill is determined not only by constant

practice and study, but also by your attitude and behavior. A sense of professionalism should be

incorporated into all classroom, laboratory, and clinical experiences.

Finally, this program is accredited, which means upon completion of the coursework, you

will be eligible to sit for the national certifying exam. Graduates often find a sense of pride in

their certification, as they have accomplished a challenging period in their life that has helped

shape them as a professional.

Congratulations on taking the next step toward serving patients! Good luck during the

process and don’t forget to ask questions.

Highest regards,

Rob Blackston, BS, CST, CSFA Program Director for Surgical Technology

406-756-4328

rblackston@fvcc.edu

mailto:rblackston@fvcc.edu

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Our Program

The Flathead Valley Community College Surgical Technology Associate in Applied Science

(AAS) degree is a 70-credit program designed to develop skills in all phases of operating room

procedures and techniques, including clinical experience in the operating room.

In addition to operating room techniques, surgical procedures, surgical instruments and equipment,

students study surgical microbiology, surgical pharmacology, medical terminology, anatomy and

physiology, asepsis (sterile technique), preparation of the patient for surgery and the physical

conditions that make it necessary for a person to have surgery.

A new class of ST students begins each year in January.

Why Surgical Technology?

As a Certified Surgical Technologist (CST), you will be directly involved in the outcome of a patients’

medical recovery. You will assist in the operating room by preparing instruments and supplies, passing

them to the surgeon, anticipating and meeting the surgeon’s needs, and ensuring patient safety throughout

the procedure. When the stakes are high and the job is stressful, you realize that you are making a

difference in that patient’s life and it is all worth the effort. The CST enables lives to be saved and

witnesses momentous changes in patients’ health every day.

Program Objectives

Graduates will consistently demonstrate the necessary training to assume responsibilities in the

operating room, including aseptic technique, instrument setup, assisting the surgeon, anticipating

the surgeon’s needs, and assisting with post-operative care.

Graduates will apply knowledge, skills, and demonstrate ability to perform as a surgical

technologist in the cognitive, psychomotor, and affective learning domains.

Graduates will provide to the community professional, competent, and knowledgeable individuals

who can provide surgeons and the surgical team quality assistance as a Surgical Technologist

utilizing ethical standards and integrity.

Graduates will display professionalism, be prepared to be a lifelong learner, and value the

professional attributes of the Surgical Technologist.

Graduates will possess the necessary didactic and clinical skills needed to pass the certification

exam and enter into the job arena as a competent entry-level Surgical Technologist.

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Program Accreditation and Approvals

The Surgical Technology Program is accredited by the Commission on Accreditation of Allied

Health Education Programs (www.caahep.org) upon the recommendation of the Accreditation

Review Committee on Education in Surgical Technology and Surgical Assisting (ARC/STSA)

(arcstsa.org).

Upon successful completion of the Surgical Technology Program, students will sit for the national

certification exam as administered through the National Board of Surgical Technology and Surgical

Assisting (www.nbstsa.org)

Demands of the Profession

The Surgical Technology student should have the maturity, individual motivation, conscience, good

interpersonal skills, and manual dexterity combined with a solid academic science background to

assume the professional responsibilities of the Surgical Technologist. Demands include but are not

limited to:

At times required to:

Assist in lifting and positioning patients weighing as much as 350+ pounds, repeatedly lift trays

of instruments weighing 25 pounds, stand, bend, stoop, and/or sit for long periods of time in one

location with minimum or no breaks, refrain from nourishment or restroom breaks for periods up

to 6 hours, maneuver large pieces of surgical equipment.

Have the ability to:

Adapt to frequent changes in the work environment (from calm to extremely stressful),

concentrate and attend to detail amidst a variety of environmental distractions, process

information accurately, thoroughly, and quickly, carry out complex sequences of instructions,

prioritize tasks quickly, demonstrate sufficient peripheral vision to function while in the sterile

surgical environment, demonstrate positive coping skills in a stressful environment, learn and

apply new information regarding new procedures on an on-going basis, demonstrate prior

learning, demonstrate critical thinking skills, demonstrate professional behaviors and

accountability and manipulate and account for placement of very fine (11-0) suture with needle

holder (finer than a strand of hair).

Disability Statement

Upon admission, a candidate who requests accommodations due to a disability may be asked to

provide documentation of his or her disability for the purpose of determining appropriate and

reasonable accommodations. To continue in the curriculum, the candidate must be able to

perform all of the essential functions. Request for accommodations should be directed to:

Disabled Student Services Office

Tracy Sullivan

(406) 756-3881

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Program Curriculum

Pre-Surgical Technology Courses

These classes must be completed, or be currently enrolled in, in order to apply.

3 Credits M 120* Mathematics with Healthcare Applications

3 Credits AHMS 144* Medical Terminology

4 Credits BIOH 201NL* Human Anatomy and Physiology I

4 Credits BIOH 211NL* Human Anatomy and Physiology II

4 Credits PSYX 100A* Introduction to Psychology

3 Credits COMX 115* Interpersonal Relations/Communications

Or

3 Credits COMX 111C* Introduction to Public Speaking

3 Credits WRIT 101W* College Writing

3 Credits AHST 101 Introduction to Surgical Technology

27 Total Semester Credits

Spring Semester

4 Credits AHST 201 Surgical Procedures I

6 Credits AHST 116 Surgical Techniques I with Lab

4 Credits BIOM 250NL Microbiology for Health Sciences w/ Lab

14 Total Semester Credits

Fall Semester

5 Credits AHST 202 Surgical Procedures II

3 Credits AHST 216 Surgical Techniques II

4 Credits AHST 250 Surgical Clinical I

4 Credits BIOL 170 Disease Processes/Pharmacology

16 Total Semester Credits

Spring Semester

3 Credits AHST 207 Professional Development and Leadership

10 Credits AHST 255 Advanced Surgical Clinical

13 Total Semester Credits

70 Total Program Credits

*Students must earn a grade of C (2.0) or higher in all ST pre-requisite classes.

**Students are presumed to possess basic computer skills with the use of word processing and presentation software and the ability to use the internet and send/receive email. Students should enroll in the CAPP 131 computer class if they need introductory coursework in a computer class.

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Program Application Deadline

Applications may be obtained via the FVCC Surgical Technology website or picked up in the ST

Program Directors office, BC 126A anytime and must be returned no later than the first Friday in

October for Spring admission. Once applicants have met all the program criteria, selected students

will be interviewed by ST faculty, objectively assessed on a rubric, then notified of their admission

status into the ST Program by mid November.

Class Schedule

ST course work is offered days only. Students should be available M-F from 8:00 - 5:00.

Clinical Rotations

During clinical rotations, students are expected to work the schedule they are assigned by the

FVCC Clinical Coordinator which could vary according to patient care and student needs.

Weekend and evening call shifts will be required during a student’s last clinical rotation. Clinical

sites are local (within a 100-mile radius of FVCC).

Enrollment

Maximum of 8 students accepted each year with 2 put on a wait list.

Degree Awarded

Associate of Applied Science (AAS) in Surgical Technology

Program Costs

Costs are subject to change. Costs listed are estimates only. Costs include specific technical

courses and requirements after formal acceptance into the ST program. It does not include costs

associated with obtaining pre-requisite courses and/or courses taken during the ST program, that

are for a “second degree”. Transportation costs, room and board, relocation costs to the Flathead

Valley for class and other locations for clinical experiences are not included in the below costs.

Uniform, textbooks, background check, CPR, immunizations, etc. are all estimations from area

facilities. There may be other costs not included in this list.

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Estimated Program Costs

In-District Out of District Out of State

Program: Semester III (Spring Semester)

Course Tuition and Fees $1,982.60 $2,668.60 $5,552.60

Course Lab Fees $150.00 $150.00 $150.00

Textbooks (approximate cost) $794.00 $794.00 $794.00

Uniform¹ $210.00 $210.00 $210.00

Program: Semester IV (Fall Semester)

Course Tuition and Fees $1,982.60 $2,668.60 $5,552.60

Course Lab Fees² $322.00 $322.00 $322.00

Immunizations (This price varies depending on the facility)ᶟ $640.00 $640.00 $640.00

BLS Healthcare Provider (CPR) $10.00 $10.00 $10.00

Background Check $55.00 $55.00 $55.00

Program: Semester V (Spring Semester)

Course Tuition and Fees $1,844.20 $2,481.20 $5,159.20

Course Lab Fees $30.00 $30.00 $30.00

Total Program Tuition and Fees $8,020.40 $10,029.40 $18,475.40

¹ The uniform price is going to vary based on the dealer you choose. The uniform consists of: 2 - Plain Black Scrub Pants, 2 - Plain Black Scrub Tops, 1 - Plain Black Scrub Jacket, 1 - Pair of Operating Room Shoes (Non-marking athletic shoes or close-toed "Dansko's") and 2 - Surgical Technology Patches (purchased in the college Bookstore). Patches are to be sewn on the right sleeve of scrub tops.

² Course Lab Fees encompass costs for laboratory supplies, NBSTSA Certification Exam, Exam Review Book and AST membership for 1 year.

Based on the published FVCC 2015-2016 Tuition and Fee Schedule at:

http://www.fvcc.edu/about-fvcc/administration-governance/administrative-departments/business-services/tuition-fees.html

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Admission Guidelines and Criteria

Surgical Technology applicants must complete the FVCC Application for Admission (degree

seeking) and follow the steps for enrolling at Flathead Valley Community College. Admission to

Flathead Valley Community College does not guarantee acceptance into the Surgical

Technology Program. Students entering Flathead Valley Community College with the intent to

become an ST may declare an Associate of Science in ST upon admission, but are not accepted

into the ST Program until after a formal application, interview and selection process occurs.

In order to be considered for acceptance into the Surgical Technology Program, the student must

have:

Completion of the required prerequisite courses within 15 years with exception of Human A & P

Students need to earn a selective GPA of 2.75 or higher on ST pre-requisite courses Earn a grade of C (2.0) or higher in all ST pre-requisite classes Credits are accepted for prerequisites only if a letter grade appears on the official college

transcript. If a college grade is not assigned to the course, the course needs to be

completed to complete the prerequisite.

Completion of Human Anatomy and Physiology I & II must be within five (5) years of admission date and must contain a lab component. Unless approved by the program

director.

The FVCC ST program assumes that students applying for the program have had experience with basic computer skills and keyboarding. Students are responsible for

obtaining these skills independently if they do not meet this technical requirement.

Must be in degree status at FVCC with all records required on file. Once preliminary acceptance is received, students will need to complete a background

check to finalize the acceptance process.

Before the Fall Clinical Rotation, students are expected to receive an annual Influenza vaccination and provide all other immunizations.

Completed Surgical Observation Form Completed sealed Professional Recommendation forms (2) Completed Job History (If applicable) Completed Biographical Essay

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Fulfillment of the minimum requirements does not

guarantee acceptance into the Surgical Technology Program

All candidates who meet ST application requirements will be considered for acceptance. An objective point procedure using a rubric will include: completed application form, GPA,

essay, observation hours, health care related job verification, interview performance,

recommendation forms and prior education, etc. will be used to determine final placement in the

program.

Any discrepancies in application criteria must be discussed and signed off with the Program Director prior to assumption of meeting admission criteria.

The Program Director may accept courses that are older than the 5 years for Anatomy/Physiology and/or the 15 years for pre-requisite courses at their discretion.

For students who have taken courses more than one time, the highest grade will be used for GPA calculation.

For students who have taken a higher level course than the pre-requisite course requirement, he/she may utilize the grade for that course for admission purposes if the grade is higher than

that of the required course and approved by the Program Director.

The number of students accepted into the Surgical Technology Program is limited to 8 students with 2 on the waiting list.

If the number of qualified applicants exceeds available spaces, not all qualified applicants will be accepted.

A tie will be broken down by combined rubric score of selective GPA and interview total followed by combined Anatomy and Physiology I and II GPA.

Students will be required to have a completed criminal background check and drug screen once they have been officially notified of acceptance into the program. This must be completed

before the first day of class Spring semester. Students whose background checks reveal issues

with drugs or alcohol, abusive behavior, theft, or fraud, to name some of the potential concerns,

will need to provide documentation of successful resolution and/or treatment before acceptance

into the program is complete. A thorough review of information will be conducted by the

program director and FVCC college administration to determine status of acceptance into the

FVCC ST program.

Prior to applying for the ST program

1. Obtain the most current information and application packet for the Surgical Technology Program either from the FVCC website, Program Director’s office or from the FVCC

Admissions and Records Office. Please be sure to use the most current application as updates

are made for each application session.

2. Review the application requirements for the Surgical Technology Program. 3. Compile all of the requested material. 4. Organize your application in a way that allows for easy identification and review of content

(separate tabs and/or table of contents are both very helpful for ease of content review)

5. DO NOT rush the application process. Your application can be denied if incomplete.

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FVCC Surgical Technology Program

Application Steps

REQUIRED APPLICATION MATERIALS:

1. Application Form: A completed Surgical Technology application form with your signature. (Page 11 & 12)

2. Biographical Essay - Submissions must be in a word-processed/typed format no more than 3 pages long, double spaced, no smaller than 11-point font. Applicants will be graded

upon the following content areas:

Content Includes: 1) Interests/goals in pursuing a career as a Surgical

Technologist, 2) Experiences in any health care field or in your life which directly

relates to your knowledge of and interest in Surgical Technology 3) Personal

strengths which will allow you to function effectively as a CST, 4) List 5 reasons

why you won’t quit, 5) Include a picture of yourself for your file.

Structure - spelling, grammar, punctuation & outline

Composition - theme, thought process, & expression

3. Transcripts and evaluation of transfer courses: Include copies of transcripts from other colleges or universities that you have attended and are requesting to be considered for

transfer of credit. If the official transcripts are on file with the FVCC registrar, you may

include copies that can be obtained through the student portal. Request official transcripts

early as this can take time. Official transcripts must be on file in the FVCC registrar’s office

for transfer of credit to be considered.

4. Surgery Observation Form contact program director for info on observation. 5. Medical Work Experience Verification Form: Please document your work experience

on the form in this packet. It should include all health care experience. All health care

experience is considered and is important in the selection process.

6. Proof of Education Degree or Certification, copies will be accepted. 7. Completed Professional Recommendation forms sealed in envelope. 8. Completed GPA calculations form. This is checked for accuracy. 9. Completed application and requested materials must be received by October 7th, 2016 by

4:00 pm. NO LATE APPLICATIONS WILL BE ACCEPTED.

10. Applications may be mailed or hand delivered to the FVCC Admission and Records Office. Please mail early to allow maximum opportunity for delivery before the deadline.

11. Please note that all applications will be date stamped upon receipt. Contact information will be entered into the tracking system. It is the individual’s responsibility to contact the

Surgical Technology Program Director with changes in address or phone number.

12. If you have any questions regarding the ST Admission process or forms, please contact the ST Program Director, Rob Blackston, BS, CST, CSFA at (406)-756-4328 or

rblackston@fvcc.edu

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FVCC Surgical Technology Application 2016

Please return your completed and signed application and all requested materials in a sealed

envelope to the following address:

FVCC Admissions Office/Surgical Technology Program

777 Grandview Drive

Kalispell, MT 59901

Please carefully read the application and review it for completeness before signing.

AN INCOMPLETE AND/OR UNSIGNED APPLICATION WILL NOT BE PROCESSED. Please Print

______________________________________________________________________________ Last Name First Name MI DOB Student ID #

______________________________________________________________________________

Mailing Address **Notification of acceptance/non-acceptance will be sent to this address**

______________________________________________________________________________ City State Zip Telephone Number Email

PLEASE CAREFULLY READ THE FOLLOWING INFORMATION *PLEASE INITIAL EACH ITEM

AND SIGN YOUR NAME

I understand that I must submit the following by the Fall Semester Clinical course (AHST 250): Proof of Hepatitis B Series including antibody titer results. (you must show proof that

you have at least started the series)

Proof of two doses of measles, mumps, rubella (MMR) immunization, or lab titer for each; either by dates of two vaccinations after your first birthday, a physician diagnosis

of disease history or laboratory verification of positive antibody titer, (need only one

of these methods of verification).

Proof of chicken pox immunity by statement verifying year and age that student had chickenpox, or vaccination dates, or lab titer (need only one of these methods of

verification).

Proof of one dose of Tdap: Tetanus/ pertussis (whooping cough) vaccination as an adult.

Proof of current (infant through adult) Basic Life Support (BLS) Healthcare Provider CPR certification that will not expire prior to completion of program.

I understand that I will be notified by email after November 17th, 2017 whether or not I have received placement in the ST Program for Spring Semester 2018. Students will need to respond

to the FVCC ST Program Director in writing of their choice (email or letter) to accept or

decline admission into the ST program. Students who are put on the waiting list will be offered

a placement assignment if and only if an opening occurs. The wait list is maintained only until

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the first week of Spring Semester 2018. Students who are not accepted may reapply for

placement into a following year program during the open application process.

I understand that all placements in the Flathead Valley Community College ST Program are dependent upon sufficient financial, faculty and clinical resources.

Please list college/universities you have attended:

Name of Institution Dates of Attendance (month/year) Degrees earned (if applicable)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

I have submitted transcripts from all colleges/universities listed above. If official copies of transcripts are on file in the FVCC Admission Office, photocopies are acceptable to include

with this application. (These are available to download and print from your student portal.)

I have evaluated my transcript(s) and academic standing and I am confident that I can complete or have completed, with a grade of “C” or higher, all of the required prerequisite courses for

the Surgical Technology Program placement by the end of Fall Semester 2017. My selective

GPA in these courses is at least 2.75 (on 4.0 scale).

I have provided proof of current professional certifications (if applicable) such as Certified Nursing Assistant (C.N.A), Emergency Medical Technician, Certified Medical Assistant, etc.

Professional certifications will need to be approved by the program director as related to the

health profession prior to submission.

I have included the completed selective GPA worksheet. I have included my completed Surgical Observation Form. I have included my completed Medical Work Experience and Verification Form I have included my Biographical Essay (no more than 3 pages, double spaced, minimum of

11-point font) and a picture for my file.

I have included my 2 Professional Recommendation forms which are unopened, sealed in a standard letter-size envelope, and signed across the seal by the person who completed the

recommendation form.

I understand that upon withdrawal from the program for any reason, re-entry into the program is not guaranteed.

I understand that my final admission to the program is contingent upon completing a successful criminal background check.

I have retained a copy of this application for my records (it is my responsibility to make my own copy).

Student Signature _________________________________________Date__________________

Printed Name of Applicant _______________________________________________________

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Selective GPA Calculation Worksheet EXAMPLE

Please fill in the information requested below and calculate your own GPA. If you are currently

enrolled in pre-requisite courses listed below, simply indicate the semester you are taking the

course and do not fill in a grade.

Instructions for calculating selective GPA:

1. Insert grade earned for classes taken through spring 2015.

2. Enter points based on grade as follows: A = 4; A– = 3.7; B+ = 3.3; B = 3; B– = 2.7; C+ = 2.3; C = 2

3. Multiply points by credits for each class and enter in last column.

4. Total number of credits completed.

5. Total last column.

6. Divide last column by total credits to find GPA.

Course Name Grade Points Credits Points x

Credits

M 120 Mathematics with Healthcare

Applications

A

4

3

4x3=12

AHMS

144

Medical Terminology

B

3

3

3x3=9

AHST

101

Introduction to Surgical Technology

A

4

3

4x3=12

BIOH

201NL

Human Anatomy and Physiology I

B+

3.3

4

3.3x4=13.2

BIOH

211NL

Human Anatomy and Physiology II

B

3

4

3x4=12

COMX

115C

Introduction to Interpersonal

Communication

A-

3.7

3

3.7x3=11.1

PSYX

100A

Introduction to Psychology

A

4

4

4x4=16

WRIT

101W

College Writing I

A

4

3

4x3=12

Total

27

97.3

GPA (Total Points/ Total Credits)

97.3/27

3.60

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Selective GPA Calculation Worksheet

Please fill in the information requested below and calculate your own GPA. If you are currently

enrolled in pre-requisite courses listed below, simply indicate the semester you are taking the

course and do not fill in a grade (attach the Grade Inquiry Form).

Instructions for calculating selective GPA:

1. Insert grade earned for classes taken through spring 2015.

2. Enter points based on grade as follows: A = 4; A– = 3.7; B+ = 3.3; B = 3; B– = 2.7; C+ = 2.3; C = 2

3. Multiply points by credits for each class and enter in last column.

4. Total number of credits completed.

5. Total last column.

6. Divide last column by total credits to find GPA.

Course Name Grade Points Credits Points

x

Credits

M 120 Mathematics with Healthcare

Applications

3

AHMS

144

Medical Terminology

3

AHST

101

Introduction to Surgical Technology 3

BIOH

201NL

Human Anatomy and Physiology I 4

BIOH

211NL

Human Anatomy and Physiology II 4

COMX

115C

Introduction to Interpersonal

Communication

3

PSYX

100A

Introduction to Psychology 4

WRIT

101W

College Writing I 3

Total

27

GPA (Total Points/ Total Credits)

/27

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FVCC Surgical Technology Application Rubric Categories Score Application Application Completed

fully and on time,

organized and easy to

process.

(10 points)

Completed fully and on time, content present but

not as well organized.

(8 points)

Submitted on time but content not complete.

Average organization

that required frequent verifications of content.

(6 points)

Submitted on time and not complete with poor

organization or

submitted late and complete.

(4 points)

Not submitted on time, application

not complete, errors

in calculations of GPA, etc.

(0 - 2 points)

Max 10 pts

Biographical Essay:

Content Addresses: 1.

Interests/goals in pursuing a career as a ST.

2. Experiences in any

health care field/ life which directly relates to

knowledge of ST. 3.

Personal strengths which

allow you to function

effectively as ST. 4. List

5 reasons why you won’t quit 5. Include a picture

for your file.

Excellent Good Structure (no spelling or

grammar errors);

Composition (well thought out and good

expression); Content

(addressed all 5 areas)

(26 - 30 points)

Average Average Structure (1- 2 grammar

or spelling errors);

Addresses 2 of the 3 content components;

essay is clear in most

paragraphs, but has minor flow or organizational

issues.

(16 – 25 points)

Below Average Less than Average Structure

(3-4 grammar or

spelling errors); Addresses 1 of the 3

content components;

Essay is confusing or disjointed.

(6 – 15 points)

Poor Informally written note, Addresses none of

the content components,

5-6 grammar or spelling errors; Essay lacks

discernible organization

(1- 5 points)

No Essay Submitted

(0 points)

Max 30 pts

Interview –

Candidate is observed

upon interpersonal communication skills,

knowledge and

commitment to the ST field; Professionalism and

Self-Confidence

Excellent

Excellent interpersonal

communication skills, professionalism in

behavior and dress, self-

confidence, knowledge and commitment to the

ST field, highly ranked

by panel.

(41 – 50 points)

Above Average

Above average

interpersonal communication skills,

professionalism in

behavior and dress, self- confidence, knowledge

and commitment to the

ST field, moderately high ranking by panel.

(26 – 40 points)

Average

Average interpersonal

communication skills, professionalism in

behavior and dress, self-

confidence, knowledge and commitment to the

ST field, average

ranking by panel

(16 – 25 points)

Below Average

Below average

interpersonal communication skills,

professionalism in

behavior and dress, self- confidence, knowledge

and commitment to the

ST field, below average ranking by panel

(6– 15 points)

Not Acceptable

Poor interpersonal

skills, behavior, professionalism,

inappropriate dress,

poor attitude and self-confidence,

poor knowledge and

commitment to ST field. Ranked

poorly by panel

(0 –5 points)

Max 50 pts

Surgical Observation (Documented)

Documented through

process with Clinical

Coordinator

(20 points)

Documented by other

means

(15 points)

NA

(0 points)

NA

(0 points)

NA

(0 points)

Max 20 pts

Professional

Recommendation forms

(2)

2 excellent

recommendations

(20 points)

2 above average

recommendations

(15 points)

2 average

recommendations

(10 points)

2 below average

recommendations

(5 points)

2 unsealed, poor,

not included

(0 points)

Max 20 pts

GPA in Selective ST

prerequisites (see form)

Range 3.5 - 4.0

(40 - 50 points)

Range 3.25-3.49

(30 - 39 points)

Range 3.0-3.24

(20 - 29 points)

Range 2.75 - 2.99

(10 – 19 points)

Less than 2.75

(0 - 9 points)

Max 50 pts

GPA in Human A & P I

and II

Range 3.5 - 4.0

(40-50 points)

Range 3.25-3.49

(30-39 points)

Range 3.0-3.24

(20 - 29 points)

Range 2.75 - 2.99

(10-19 points)

Less than 2.75

(0 - 9 points)

Max 50 pts

Previous Degrees or

Health related

Certifications (C.N.A., EMT, CMA, etc.

Bachelors, Master's

Degree or higher

(30 points)

AAS in Health Care

Related Field

(25 points)

AA, AS in Non-Health

Care Related Field or

Health Related Certification C.N.A.,

EMT, CMA, etc.)

(20 points)

High School Degree

Graduate with proof of

graduation with Honors

(15 points)

High School Degree

(10 points)

Max 30 pts

Work Experience in

Healthcare Field

Paid experience in health care setting

greater than 12 months

in last 5 yrs.

(30 points)

Paid experience in health care setting; 6-12 months

in last 5 years

(20 points)

Paid experience in health care setting; < 6

months in last 5 years

(10 points)

Paid experience in health care setting, but

none in last 5 years

(5 points)

No experience

(0 points)

Max 30 pts

Applied to FVCC ST

Program within last 2

years

Yes, placed on waiting

list

(10 points)

Yes, not placed on

waiting list

(5 points)

Yes, but withdraw

application

(2 points)

NA

(0 points)

NA

(0 points)

Max 10 pts

TOTAL 300 pts

_____/300

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Medical Work Experience Verification Form

LIST PLACES OF EMPLOYMENT MOST RECENT TO LEAST RECENT:

Facility Name: Phone: ( )

Address:

Supervisor:

Job Title:

Responsibilities:

From: (Mo/Yr) To:

Facility Name: Phone: ( )

Address:

Supervisor:

Job Title:

Responsibilities:

From: (Mo/Yr) To:

Facility Name: Phone: ( )

Address:

Supervisor:

Job Title:

Responsibilities:

From: (Mo/Yr) To:

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Surgical Technology Observation Form

Student Name_______________________________________ Date__________________

Surgeon Name ___________________________

Surgical Procedure_____________________________________________

What type of surgery is it?

Describe what you observed before the procedure:

Describe what you observed during the procedure? What was the Surgical Tech doing?

Describe what you observed after the procedure:

Student Signature_______________________________________________________Date_______________

Hospital Staff Signature__________________________________________________Date_______________

Circle One

Orthopedic

Obstetrics/Gynecology

Neurosurgery

General

Cardio/Thoracic

Ear, Nose and Throat

Ophthalmic

Urologic

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Professional Reference for Applicants

Surgical Technology Program

Name of applicant _______________________________________ Date_________

The above named applicant is a candidate for admission to the Flathead Valley Community

College Surgical Technology Program. Please answer the following questions to the best

of your ability and submit the reference to the applicant in a signed and sealed envelope.

After sealing the envelope please sign your name across the seal to ensure confidentiality.

Feel free to use additional paper if you require extra space.

1. How long have you known the applicant and in what capacity?

2. Describe the applicant’s ability to perform effectively in stressful and emergency situations. Please give an example.

3. Describe the applicant’s ability to perform effectively and harmoniously as a team member.

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4. Describe the applicant’s leadership qualities.

5. Do you endorse this applicant as a suitable candidate for this program? Please comment

6. Do you have any other information you feel would be relevant to an employer (program)?

Printed Name: ____________________________________________ Date: ____________

Signature: _______________________________________________