Medical Laboratory Technician
Admission Application
Spring 2015 Cohort
Students wishing to enter the Medical Laboratory Technician Program Major must complete the
following Admission Application.
Name: ______________________________________ Date: _______________________
Address: ________________________________________________________________
City
State
Zip _____________
Email address: ___________________________________________________________
Telephone: Home ________________ Work ______________ Cell _________________
Preferred method for contact: _______________________________________________
Emergency Contact Information
Name ___________________________________________________________________
Telephone: Home __________________Work ______________Cell_________________
Relationship to you: ________________________________________________________
I am applying to the MLT Program: (please check)
_______
For the first time
_______
Re-entering after a leave of absence from an earlier admission date
_______
Transferring from another MLT program (Give name of program and
attach a copy of your transcript)_____________________________
_______
Other (Explain)__________________________________________
Have you ever been dismissed from a professional program or academically withdrawn from a
professional program? Yes
No
If yes, complete the following information: School Name and Location:
______________________________________________________________________________
Dates of Attendance: ______________ to ______________
Type of Program: __________________________________
Are you in good standing and eligible to return to the program?
Yes
No
If no, please explain. ____________________________________________________________
_____________________________________________________________________________________________
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Community Residency
Are you resident of San Juan County, New Mexico?
Yes
No
Yes
No
Yes
No
If your answer is no please continue.
Do you reside in one of the following counties in Colorado
Montezuma, Archuleta, Dolores or San Juan?
If your answer is no please continue.
Are you enrolled as a member of the Navajo Nation?
Employment History
Employer ____________________________________________________________________
Address _____________________________________________________________________
Dates of Employment____________________________________________________________
Supervisor Name __________________________________Supervisor Phone_______________
Job Title and Description of Tasks _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
May we contact this supervisor? ________Yes _______ No
Employer ____________________________________________________________________
Address _____________________________________________________________________
Dates of Employment____________________________________________________________
Supervisor Name __________________________________Supervisor Phone_______________
Job Title and Description of Tasks _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
May we contact this supervisor? ________Yes _______ No
List two references other than family members who can address your work ethic and personal
characteristics. Do not use a family member. Please have these references fill out the reference
form attached and send to Mary Doshi, San Juan College, MLT Program, 4601 College Blvd.,
Farmington, New Mexico 87402.
Name __________________________________ Telephone Number: _____________________
Adress________________________________________________________________________
Relationship to you _____________________________________________________________
Name __________________________________ Telephone Number: ____________________
Address ______________________________________________________________________
Relationship to you _____________________________________________________________
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Please fill out the Prerequisite and General Education Courses you have completed, in
the table chart below. Us IP for in progress
My Cumulative GPA at this time is ______________
Pre - Requisite Courses
Final
Grade
Semester/Year
Course
Completed or in
Progress
If not taken at SJC
list the institution
where taken and
grade earned
Course
Equivalent
(to be filled out
by SJC staff)
MLTS 120
Introduction to Medical Laboratory
MLTS 160
Theory of Phlebotomy
BIOL 252*
Human Anatomy & Physiology I
BIOL 253*
Human Anatomy & Physiology II
BIOL 224*
Microbiology
MATH 115
Intermediate Algebra OR HIGHER
ENGL 111
Freshman Composition
ENGL 211
Advanced Composition
COMM 111 or 110
Interpersonal Communication
CHEM 110 or CHEM 111
Introductory Chemistry
CHEM 210
Organic Chemistry Survey
PSYC 120
Introduction to Psychology
* The science courses of *Introductory Biology I, Anatomy and Physiology I, II, and Microbiology should not be older than 10
years to be accepted. If CHEM 110 was taken in high school, you must include a copy of your official high school transcripts for
credit to be given. Eligibility of courses that are older than 10 years will be determined on a case by case basis by Medical
Laboratory Technician Faculty.* If you have transfer courses, please attach a transcript from that college (unofficial is accepted)
In Progress Courses:
If you currently have prerequisite courses in progress at another institution at the time of this
application, please list contact information for your instructor for verification purposes.
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The selection committee would like to know a little more about you. Please write a short
essay that will give the committee a description of you. Include your background,
interests, achievements and make sure you include why you have chosen laboratory
medicine for your career goal.
Additional Directions:
1.
Limit the description to one page.
2.
Type essay using an 11 or larger font size.
3.
You may single or double space as needed.
4.
Do not put your name on this page. Staple your story to the back of your
application and it will be given a number that corresponds to your
application for identification after the review process.
I certify this application is true. Any false statements knowingly submitted will result in expulsion from
the program. I understand that taking prerequisite courses in the MLT Program does not guarantee
acceptance into the major. All applicants will be required to complete a federal background check prior
to acceptance into their clinical component at their expense. The background checks must be current. In
addition, all students must complete the required inoculations and health clearances required for the
clinical affiliates at their expense. This may include a drug screen.
Individuals who have been convicted of a felony
may have limited employment opportunities and are not gauranted
employment after graduation.
I understand that admission to the MLT program is competitive and applicants are ranked. The following
criteria will be used in the selection process.
60% GPA in prerequisite courses
20%
Self Description (See rubric for scoring)
20 % Reference Recommendations
In keeping with the Community Mission of San Juan College, those applicants that meet Residency
and/or Special Residency Status will be given 2% preference in the application process. Applicants who
have all prerequisite courses including Chemistry 210 or equivalent will also be given a 2% preference.
Signature of Applicant
Date
Return completed application to:
Mary L. Doshi
MLT Program Director
Or Devonna Coolidge, Administrative Assistant
San Juan College
4601 College Boulevard
Farmington, New Mexico 87402
Phone: 505.566.3855 or 505.566-3853
Email: [email protected]
Due date 3rd Friday of October by 17:00
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The Medical Laboratory Program is affiliated with the following clinical sites. You will be
assigned to one of them to do your clinical practicum rotation. Please rank them in the order by
placing a 1 by the site you would most like to complete your practicum, 2 for your second choice
and so on. If you have no preference, rank them all as 1. Each of the clinical affiliates will be
ranking student choices and matches will be made on mutual preference. You are not guaranteed
of being placed at your highest ranking sites. If for some unforeseen circumstances arise that
there are more students than available sites, the students with highest GPA will be placed first.
______ San Juan Regional Medical Center is a modern, acute-care hospital located in one of the most
rural areas of the American southwest, the Four Corners. As a sole community provider of
hospital services in San Juan County, New Mexico, the hospital delivers range of healthcare
services not only to to the people of the entire Four Corners Region. The hospital itself has a 260
bed capacity. San Juan Regional Medical Center is designated a Level III trauma center and
provides air ambulance service with a helicopter and a fixed wing aircraft. The laboratory is
located on the second floor of the hospital. The total gross square footage is 11,000. This hospital
laboratory has the second busiest blood bank in the state.
______ Mercy Regional Medical Center is southwest Colorado's largest and most technologically
advanced hospital. Mercy Regional Medical Center is an 82-bed acute care hospital designated a
level III. More than 120 physicians and nearly 40 mid-level medical providers on staff represent
more than 35 medical specialties. The new Mercy Regional Medical Center opened in Durango in
June, 2006. It includes state-of-the-art medical technology in an environment designed to promote
a sense wellness and healing. The hospital laboratory is new and has about 10,000 square feet and
also has a very busy immunohematology section.
______The Northern Navajo Medical Center in Shiprock, New Mexico is the largest unit serving The
Navajo Nation. The facility has 55 beds. Approximately 45,500 Native Americans are enrolled in
the Service Unit. The daily inpatient load is 40, and the daily outpatient volume averages 400 a
day. Annual ED cases average 15,000-16,000. Field clinics are open various times per week.
______ Southwest Memorial Hospital is in Cortez, Colorado. This 61-bed acute care facility, is a
progressive hospital driven by Continuous Quality Improvement. The laboratory occupies just
under 5000 square feet and offers a wide variety of laboratory testing.
______ Western Slope to include Moab and others as contracted
______Other Site suggested by student see director to see if practicum can be arranged.
All sites subject to change until time of assignment.
Name ___________________________
Signature_________________________
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The following rubric will be used to score your description
Scale
1
2
Description
Very limited
Somewhat
helpful
Organization
(Overall
order, flow,
and
transitions)
Quality of
Information
Grammar &
Spelling
3
4
Score
More relevant Very much to the point
Information is
Details and
Information is presented in effective
examples are Information is
logically
order. Excellent
not organized, scattered and
ordered with structure of paragraphs
are hard to
needs further
paragraphs and
and transitions
follow and
development.
transitions.
enhances readability
understand.
and understandability.
Supporting details are
Details are
Some details
Unable to find
specific to topic and
somewhat
don’t support
specific details.
provide the necessary
sketchy.
the topic.
information.
Numerous
Three to five Fewer than 3
grammatical
No spelling or
grammatical or grammatical or
and/or spelling
grammatical errors.
spelling errors. spelling errors.
errors.
Total
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