north arkansas college...north arkansas college radiologic technology program 1515 pioneer drive...
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NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
1515 Pioneer Drive
Harrison, Arkansas 72601-5599
(870) 391-3318
PROGRAM APPLICATION FOR ADMISSION
Date of Application ____________________ Date of Birth____________________________
Northark Student ID ___________________ SS# ____________________________
Name _______________________________________________________________________________
Last First Middle Maiden
____________________________________________________________________________________
Mailing Address City State ZIP
Email Address __________________________________ Cell Phone (_____)_________________
Home Phone (____) ___________________ Business Phone (_____) _________________________
Spouse ______________________________________ Business Phone (____) ____________________
or
Parent ______________________________________ Business Phone (____) ____________________
Length of time in Arkansas _________________ Own transportation: Yes ____ No____
US Military Service: Yes_______ No_______ If yes, Branch ___________________________
High School _____________________________________________ Date of Graduation __________
Name of School
________________________________________________________________________
Address
If GED _________________________________________ Date of GED _____________________
Name of School
______________________________________________________________________________
Address
*Have you ever been convicted of : Misdemeanor ________ Felony ________
If yes, explain ________________________________________________________________________
_____________________________________________________________________________________
*Be advised that applicants convicted of a felony or misdemeanor involving moral turpitude will be
eligible to take the ARRT Registry examination when completing the program only if they have served
their entire sentence including probation and parole and have had their civil rights restored. Students may
Pre-Qualify by going to www.arrt.org and completing the Pre-Qualification Forms.
*Clinical Education Sites have the right to refuse students at their facilities.
Have you ever been dismissed (fired, terminated, etc.) from a health care facility? Yes_____ No____
Have you ever been dismissed from any health care educational program? Yes_____ No____
If yes, please explain and sign below (add additional page if needed):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I am allowing the Radiologic Technology Program at North Arkansas College to verify the information
stated above.
______________________________________________________ ___________________
Signature of Applicant Date
WORK EXPERIENCE
Employer Address Dates of
Employment
Position Reason for
Leaving
COLLEGES AND OTHER SCHOOLS ATTENDED
Name Address Dates Attended Credits Graduation
Date
Please read and sign the following:
I hereby certify that the information contained in this application is true and complete to the best of my
knowledge. I understand that any misrepresentation or falsification of information is cause for denial of
admission to the Radiologic Technology Program.
__________________________________________________ _________________________
Signature of Applicant Date
North Arkansas College does not discriminate on the basis of race, color, sex, religion, ethnic origin, or
handicap. Revised 7/3/13
Revised 6/29/15
RADIOLOGIC TECHNOLOGY PROGRAM
CLINICAL OBSERVATION PROCESS
Cox Medical Center-Branson, MO: 1. Contact the Radiology Department for a time frame on when they can accommodate your Clinical
Observation. (8:00am-12:00pm Monday-Friday) 2. Next contact Human Resources at 417-335-7268. You will need to provide:
Proof of enrollment at Northark, or previous school, or intent to attend Northark Immunizations:
2 MMR vaccinations or documentation of Rubella screening Hepatitis B vaccination-series of 3; Titer-screening; or waiver Varicella vaccination-series of 2; Titer-screening; or waiver Tetanus; Tdap within the last 10 years When in season—Influenza Vaccine (flu shot)
PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12 months)
Background Check—If student does not have a recent background check, Cox can provide this, but be aware that there is a delay in getting the results back, and this could delay your observation
3. Once the above has been completed, you will need to complete a mini Orientation with HR, and once that is complete they will make your badge and you can schedule the Observation.
Baxter Regional Medical Center, Mountain Home, AR:
1. Contact Alita Newberry or Cody Garrison at 870-508-1766 for an “Application to Shadow”. You will need to provide proof of:
2 MMR vaccinations or documentation of Rubella screening PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12
months) 2. Set up a 4 hour Hospital Orientation 3. Schedule the Clinical Observation
North Arkansas Regional Medical Center, Harrison, AR:
1. Contact the Education Department with the desired dates and times you are available to Shadow/Observe in Radiology (fill out form on next page & submit to Human Resources at NARMC)
Education Department will: notify student of Shadow/Observation approval and date scheduled provide student with “careLearning” student ID & password for online orientation
Student will provide documentation of: PPD; Tuberculin Skin Test (TB Skin Test); or Certificate of Health-within the last year (12
months) Hepatitis B vaccination-series of 3; Titer-screening; or waiver Varicella vaccination-series of 2; Titer-screening; or waiver 2 MMR vaccinations or documentation of Rubella screening Influenza Vaccine-flu shot (October-March)
Complete “careLearning” online modules Sign Confidentiality and Privacy Statement Pick up Badge After completing shadowing return badge to Education Department Revised 7/2015
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICANT CLINICAL OBSERVATION
An observation at a hospital is required for admission to the radiologic technology program. Please contact one of
the following clinical faculty for an appointment. You are expected to observe from 8:00 am - 12:00 noon on one
day during the week (Monday-Friday). Dress nicely but comfortably and enjoy your morning. Remember, though,
this is an observation only. Please have the clinical instructor complete this form and return to the address at the
bottom of the page.
__________ Baxter Regional Medical Center, Mountain Home, AR (870) 508-1766, Alita Newberry
__________ Cox Medical Center Branson, Branson, MO (417) 335-7223, Deanna Halbert
__________ North Arkansas Regional Medical Center, Harrison, AR (870) 414-4098, Kim Morris
__________ Ozarks Medical Center, West Plains, MO (417) 257-9111, Danette Huber
__________ Stone County Medical Center, Mountain View, AR (870) 269-4361, ext. 153, Chuck Robinson
Student Name ___________________________________________ Date __________________________
Hospital ___________________________ Clinical Instructor ____________________________________
(Grading Criteria on Back Page)
Please Evaluate Unsatisfactory Needs Improvement
Average Above Average Excellent
6 7 8 9 10
Attendance
Punctuality
Appearance
Attitude
Communication Skills
Interest in Profession
Initiative
Motivation
Number of Questions Asked
Number of Areas Observed
BONUS: Would you recommend this student for the Radiologic Technology Program?
Yes ______ (+5 points) No _______ (-10 points)
Comments: _________________________________________________________________________________
Signature of Clinical Instructor or RT
PLEASE SEAL AND RETURN TO: RADIOLOGIC TECHNOLOGY PROGRAM
NORTH ARKANSAS COLLEGE
1515 PIONEER DRIVE
HARRISON, ARKANSAS 72601-5599
Revised 6/14
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
CLINICAL OBSERVATION CRITERIA
Unsatisfactory: Unacceptable performance
Needs Improvement: Below expectations
Average: Meets expectations
Above Average: Exceeds expectations
Excellent: Outstanding performance
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY
POLICY ON STUDENT PREGNANCIES
As a pregnant student radiographer you may be exposed to a minimal amount of radiation. The following
guidelines were made to protect you and your baby. Your gestational dose will be monitored closely and
will be limited to 500 millirem for the entire pregnancy. It is your choice to declare or not declare your
pregnancy.
1. Declaration of student pregnancy is voluntary. Students are advised to inform the program
director, IN WRITING, of their pregnancy as soon as possible and include the estimated
conception date and estimated due date.
2. General radiography assignments will be allowed. During pregnancy, the time spent in
fluoroscopy, surgery and on portables, will be carefully controlled.
3. Pregnant students will not be allowed to hold patients while exposures are made.
4. If the student declares the pregnancy, a second radiation monitor will be provided to be worn at
waist level under the lead apron. This monitor will be identified as the fetal dose monitor.
5. The student's radiation exposure will be continuously monitored to insure that the maximum
permissible dose of 500mR during the nine months is not exceeded.
6. When the program director is notified that the student is pregnant, the monthly radiation report
will be discussed by the program director and the student.
7. If the student exceeds the maximum gestational dose, she will be withdrawn from all clinical
courses for the remainder of her pregnancy. Students may receive an extension to complete the
requirements as outlined in the Policy for Student Extensions in the current Program Manual.
8. All attendance, absence, and make-up policies will be equally enforced among all students.
9. If the student must completely withdraw from the Radiologic Technology Program because of
pregnancy or delivery, the student may be readmitted into the Program according to the Re-
Admission Policy in the current Program Manual.
10. In compliance with Federal Law, students may undeclare their pregnancy at any time.
I, __________________________________, have read the pregnancy policies for radiologic technology
program applicants.
____________________________________________ __________________________
Signature of Student Date
Reviewed 7/3/13
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
DOCUMENTATION OF HEALTH-RELATED WORK EXPERIENCE
Student ____________________________________________ Date ________________________
The above named student has had the following health-related work experience:
(If “none,” please indicate and return form to Program)
NAME OF FACILITY
Hospital/Department____________________________________________________________________
Doctor's Office________________________________________________________________________
Veterinary Clinic______________________________________________________________________
Other________________________________________________________________________________
Duties (required)_______________________________________________________________________
______________________________________________________________________________
DATES
From To
Full-Time Employee ____________________ ____________________
Part-Time Employee ____________________ ____________________
Volunteer ____________________ ____________________
Name of Supervisor (Please Print)_________________________________________________________
Title________________________________________________________________________________
Facility______________________________________________________________________________
Address_____________________________________________________________________________
_____________________________________________________________________________
Phone ______________________________________________________________________________
___________________________________ ____________________
Signature of Supervisor Date
ALL OF THE ABOVE INFORMATION MUST BE COMPLETED FOR CONSIDERATION FOR
PROGRAM ADMISSION.
Reviewed 7/3/13
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICANT REFERENCE FORM
To: _________________________________ RETURN TO: Sondra Richards, M.S. RT(R)(M)
_________________________________ Radiologic Technology Program
_________________________________ Northark
_________________________________ 1515 Pioneer Drive
Harrison, AR 72601-5599
STUDENT:________________________________ has applied for admission to the Radiologic Technology Program.
Please give us your candid opinion of the applicant's suitability for the duties of a radiologic technologist. All information
will be kept confidential. It is not a kindness to recommend someone who is not suited for this type of work.
Please mail back AS SOON AS POSSIBLE to the above address. This applicant will not be considered for the
radiologic technology program until this reference form is returned. All forms are due before March 1.
How long have you known this person? _____________________________________________________
Describe your relationship (employer, teacher, etc.) ____________________________________________
Circle the appropriate number to rate this applicant's behavior from your experience with him/her.
(Grading Criteria on Back page)
Unsatisfactory Needs
Improvement
Average Above Average Excellent
1 2 3 4 5 Dependability
1 2 3 4 5 Judgment/decision making
1 2 3 4 5 Enthusiasm
1 2 3 4 5 Initiative/motivation
1 2 3 4 5 Maturity
1 2 3 4 5 Trustworthiness
1 2 3 4 5 Communication skills
1 2 3 4 5 Interpersonal skills
1 2 3 4 5 Copes with stress
1 2 3 4 5 Organization/work habits
Were you aware that this applicant was interested in a health care career?_____________________________
In your opinion, is this applicant well-suited for a career in health care?_______________________________
Why or why not?__________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Name (Please Print): ________________________________________________________________________
Title: ___________________________________ Phone:___________________________________
Place of Business:______________________________________________________________________________
Business Address: ______________________________________________________________________________
Signature ___________________________________ Date_________________________________ Revised 1/2011
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICANT REFERENCE FORM CRITERIA
Unsatisfactory: Unacceptable performance
Needs Improvement: Below expectations
Average: Meets expectations
Above Average: Exceeds expectations
Excellent: Outstanding performance
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICANT REFERENCE FORM
To: _________________________________ RETURN TO: Sondra Richards, M.S. RT(R)(M)
_________________________________ Radiologic Technology Program
_________________________________ Northark
_________________________________ 1515 Pioneer Drive
Harrison, AR 72601-5599
STUDENT:________________________________ has applied for admission to the Radiologic Technology Program.
Please give us your candid opinion of the applicant's suitability for the duties of a radiologic technologist. All information
will be kept confidential. It is not a kindness to recommend someone who is not suited for this type of work.
Please mail back AS SOON AS POSSIBLE to the above address. This applicant will not be considered for the
radiologic technology program until this reference form is returned. All forms are due before March 1.
How long have you known this person? _____________________________________________________
Describe your relationship (employer, teacher, etc.) ____________________________________________
Circle the appropriate number to rate this applicant's behavior from your experience with him/her.
(Grading Criteria on Back page)
Unsatisfactory Needs
Improvement
Average Above Average Excellent
1 2 3 4 5 Dependability
1 2 3 4 5 Judgment/decision making
1 2 3 4 5 Enthusiasm
1 2 3 4 5 Initiative/motivation
1 2 3 4 5 Maturity
1 2 3 4 5 Trustworthiness
1 2 3 4 5 Communication skills
1 2 3 4 5 Interpersonal skills
1 2 3 4 5 Copes with stress
1 2 3 4 5 Organization/work habits
Were you aware that this applicant was interested in a health care career?_____________________________
In your opinion, is this applicant well-suited for a career in health care?_______________________________
Why or why not?__________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Name (Please Print): ________________________________________________________________________
Title: ___________________________________ Phone:___________________________________
Place of Business:______________________________________________________________________________
Business Address: ______________________________________________________________________________
Signature ___________________________________ Date_________________________________ Revised 1/2011
NORTH ARKANSAS COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICANT REFERENCE FORM CRITERIA
Unsatisfactory: Unacceptable performance
Needs Improvement: Below expectations
Average: Meets expectations
Above Average: Exceeds expectations
Excellent: Outstanding performance
Date ________________________________
Please send an official transcript of my credits to:
Admissions
North Arkansas College
1515 Pioneer Drive
Harrison AR 72601
If any charge, please bill me at the address below.
_____________________________________________________________________________________
Last Name First Middle Maiden
_____________________________________________________________________________________
Mailing Address
_____________________________________________________________________________________
City State Zip Code
____________________________________________________________________________________
Date of Birth Dates of Attendance Social Security No.
__________________________________________ PLEASE ATTACH THIS FORM
Signature TO TRANSCRIPT
Date ________________________________
Please send an official transcript of my credits to:
Admissions
North Arkansas College
1515 Pioneer Drive
Harrison, AR 72601
If any charge, please bill me at the address below.
_____________________________________________________________________________________
Last Name First Middle Maiden
_____________________________________________________________________________________
Mailing Address
_____________________________________________________________________________________
City State Zip Code
____________________________________________________________________________________
Date of Birth Dates of Attendance Social Security No.
__________________________________________ PLEASE ATTACH THIS FORM
Signature TO TRANSCRIPT