APPLICATION DEADLINE: March 31

For Admissions use only. Return this form to: Admissions and Advising Services, Wynn Center (Building 10), room 10-200 Durham Technical Community College Surgical Technology Program Received By: Date: First Name: Last Name: Durham Tech Student ID Number: Date:: ConnectMail* Email Address: *NOTE: All official communication from the college is delivered via ConnectMail, including Health Technology admissions decisions. APPLICATION DEADLINE: March 31 Submit Completed paper application packets to Admissions and Enrollment Services beginning November 1 through March 31. Questions? banksa@durhamtech.edu No Faxed or Emailed applications accepted. Please submit application to: Wynn (Building 10), room 10-200 (Admissions and Enrollment Office) CHECKLIST: All steps below are REQUIRED. Please initial that each item is completed. I am currently admitted to Durham Tech. Note: If you have not been enrolled with Durham Tech within the last 12 months, you must reapply to Durham Tech using the CFNC application. I have attended a Surgical Technology information session within the past year: Date: I meet Multiple Measures (See page 2). I understand placement tests (NCDAP, Compass, Accuplacer, ASSET, SAT/ACT, scores) are required if I do not meet Multiple Measures. I have completed the placement tests within the past 5 years regardless of my educational history (See page 2). I have completed all developmental courses as indicated by my placement test results, for example, RED 090, ENG 090/090A, or DRE 098 and MAT 070 or DMA s 010-060 (See page 2). I have completed ONE of the below (see page 2): BIO 092 and CHM 094 in high school (within 10 years old) CHM 130 and 130A College level CHM 094 BIO 111 and CHM 151 I have attached a signed Clinical Training Form (See page 4). I have attached a signed English Language Requirement Form (See page 5 and 6). I have attached a signed Essential Skills Form (See page 7) NAME DURHAM TECH ID # Page 1 of 6

PLACEMENT AND DEVELOPMENTAL EDUCATION VERIFICATION: Print out (from Self-Service) high school courses completed/transferred Please initial below that each item is completed: I meet Multiple Measures: **High School graduates with an unweighted GPA of 2.6 or higher AND qualifying fourth math within the last five years will be exempt from placement testing. If you do not meet the above: Print out (from Self-Service) your placement test scores showing successful completion and/or testing out of required developmental education courses. I have attached documentation showing that I have completed the required placement test(s) (NCDAP, COMPASS, ASSET, ACCUPLACER, SAT or ACT, COMPASS ESL & Versant) within the past five years or I have been continuously enrolled since I completed the exam(s). I have attached documentation that I have completed the following required developmental courses within the past 5 years or I have been continuously enrolled since I have completed the classes. ENG 070and RED 070 or DRE 096 ENG 080 and RED 080 or DRE 097 ENG 090 and RED 090 or DRE 098 MAT 050, MAT 060, MAT 070, or DMA 010-060 Important: Test scores and developmental education coursework more than five years old will not be accepted unless you have been continuously enrolled in college (i.e. not missing three or more consecutive semesters of enrollment in classes including summer semester). Course Completion *I have completed one of the below: One biology and one chemistry course at the high school level within the past 10 years (passing with a grade of C or better or numeric grade of 77) college level CHM 094 OR CHM130 and CHM130A OR BIO 111 and CHM 151 Notes: Students who have taken BIO 168 or have transfer credit for BIO 168 (with a grade of C or better) meet this requirement. If CHM130 is taken at another community college, it must have the lab component CHM130A in order to meet the science requirement. NAME DURHAM TECH ID # Page 2 of 6

STATEMENT OF STUDENT RESPONSIBILITY I verify that I have read all the information regarding admissions to the Surgical Technology Program, and understand the steps I must take to qualify for admissions. I understand that it is my responsibility to notify the Student Information and Records office regarding changes in name, address, or phone number. I understand that all official communication from the college is delivered via ConnectMail, including Health Technology admissions decisions. I understand that my Surgical Technology application will not be accepted unless everything is completed. I understand that Students who register for Surgical Technology classes after acceptance into the program and then withdraw before classes begin or during the first semester will be given the opportunity to apply ONLY ONCE MORE. Note: Once an applicant has accepted a seat within the Surgical Technology program, this is considered their first admittance. Students are only allowed to be accepted into the Surgical Technology program twice (this also applies to returning students only allowed to return once). Signature Date Page 3 of 6

Statement of Policy Regarding Acceptance for Clinical Training in the Following Programs at Durham Technical Community College Associate Degree Nursing Clinical Trials Research Associate Occupational Therapy Assistant Pharmacy Technology Practical Nursing Respiratory Therapy Surgical Technology Medical Assisting Students accepted into the above programs must meet the standards of both the College and the affiliated clinical site in order to participate in the appropriate clinical training for the program. Each clinical site where a student receives training reserves the right to refuse clinical training to any student found to be unacceptable according to that site s policies and regulations. Clinical sites require a Criminal Background Check prior to the student s placement for training at that site. Reasons for refusal could include, among other considerations, a documented police record indicating convictions for drug or alcohol related charges, child abuse or molestation, burglary, larceny, or other convictions deemed inappropriate to the particular clinical setting. The student must confirm to and be subject to all policies and regulations of the assigned clinical site. The site reserves the right to end clinical training of any student whose performance violates rules, policies, procedures, or professional standards expected by the agency. Written justification from the clinical site must be provided to the College for such suspension. The clinical site and college personnel reserve the right to take appropriate immediate action, when necessary, to maintain the proper and safe operation of its facilities and the safety of clients in the clinical setting. Criminal Background Check: A Criminal Background Check form will be sent to students at the time they are accepted into the clinical portion of their health program. The background check will include reports from all states where the student has lived within the past ten (10) years or from the date that the student turned eighteen (18) years of age, whichever is shorter. Students will pay a fee directly to a designated vendor for this background check. View additional information on the Criminal Background Check requirement. I verify that I have read and fully understand the Statement of Policy Regarding Acceptance for Clinical Training at Durham Technical Community College. I also understand that a Criminal Background Check is required for placement in clinical training sites for Durham Technical Community College. NAME (Print) DURHAM TECH ID # PROGRAM OF STUDY SIGNATURE DATE Page 4 of 6

English Language Requirement Form All health care workers (native and non-native US English speakers alike) are expected to use clear communication skills in the workplace. Students whose native language is not US English are expected to demonstrate "near native" US English language abilities. To confirm this ability, all students entering a Health Technologies program are required to meet the English language requirement. All students should submit this form to Admissions, Advising, and Enrollment Support to verify how he/she meets the English language requirement. Students meeting the following criteria must comply with this revised requirement: 1. Students who applied to a Health Technologies program on or after January 1, 2016, OR 2. Students who applied to a Health Technologies program before January 1, 2016, but have not yet met the previous English language requirement. Please check the ONE that applies: 1. I have only attended a US high school, and my first language is US English. 2. I have attended school outside the United States. 3. My first language is not US English. If you checked number 1, please sign here. There is nothing further that you need to do. I understand that this is an official Durham Technical Community College document and that any falsification on this document may result in disciplinary action according to the Student Code of Conduct. My signature below indicates that I am responding truthfully. Student Name (Print): Student ID: Student Signature: Date: If you checked number 2 or number 3, you must meet the English Language Requirement by successfully completing one of the following options: Option 1: Take the Accuplacer ESL Listening Test (obtain a score of 106 or above) AND complete a personal interview with the EFL Coordinator in order to assess your speaking skills (obtain a score of 70 or above). Option 2: Take the Test of English as a Foreign Language (TOEFL), ibt version (obtain a score of 22 in listening and above 26 in speaking. Option 3: Complete EFL 055 and/or EFL 064 and other EFL courses as recommended or required by placement testing (obtain a score of 80 percent or above). *Note: Scores for the above tests and classes are valid for up to 5 years. Page 5 of 6

If you have any further questions or need clarification, contact EFL Director Paula Wilder for additional information. I understand that this is an official Durham Technical Community College document and that any falsification on this document may result in disciplinary action according to the Student Code of Conduct. I answered no to questions number 2 and/or number 3; however, I have met the English Language Proficiency Requirement as follows: 1. I scored a 106 or above on the Accuplacer ESL Listening and a 70 or above on my personal interview to assess my speaking skills. 2. I took the Test of English as a Foreign Language (TOEFL), ibt version and scored above 22 in listening and above 26 in speaking. 3. I have completed one or more EFL curriculum courses in the areas listening/speaking and have scored an 80percent or higher. My signature below indicates that I am responding truthfully. Student Name (Print): Student ID: Student Signature: Date: EFL Director (Print): EFL Director Signature: Date: This form must be submitted to Admissions, Advising, and Enrollment Support with other required documentation. Refer to the Health Technologies program admissions checklist to determine additional requirements. Read more information about this requirement and view test dates. Page 6 of 6

SURGICAL TECHNOLOGY PROGRAM ESSENTIAL SKILLS FOR ADMISSION and PROGRESSION PHYSICAL & PSYCHOLOGICAL REQUIREMENTS Students applying to the Surgical Technology (ST) program must demonstrate sufficient physical and emotional health to be considered fit to participate in academic education and laboratory experiences, and to practice clinically with the public in a safe and effective manner. ISSUE STANDARD EXAMPLES OF NECESSARY ACTIVITIES (not inclusive) Critical Thinking Possess critical thinking ability sufficient for problem solving & clinical judgment Organize and prioritize; arranging instrumentation or actions in a certain order/pattern according to specific rules; must be able to bring together and relate the similarities of surgical Ability to be oriented to time, place, and person, organize responsibilities, and make quick appropriate decisions. procedures & situations in order to function on unfamiliar procedures. Concentrate for prolonged periods of time in a sterile environment. Need to quickly assess needs for surgical procedures, anticipate surgeon s needs. Interpersonal Interpersonal abilities sufficient to interact with Display patience, empathy and concern for others. Skills individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds. Deal with fear and hostility in a calm manner. Work with others in stressful situations. Communication Mobility Motor Skills Sufficient written and oral skills to communicate needs promptly and effectively, express and exchange ideas, and interact with patients, surgeons, peers, and other medical personnel. Physical abilities sufficient to move from room to room and maneuver in small spaces. Gross & fine motor abilities sufficient to provide safe and effective patient care, as well as providing a safe and effective environment for the surgical team. Receive constructive feedback positively. Must be able to communicate in a concise manner (able to get to the point). Must be able to speak clearly and respectfully. Must be able to restate, rephrase, and reframe ideas (paraphrase) to ensure clear understanding of orders/direction given by surgeons, anesthesiologists, nurses, peers and other medical personnel. The surgical technology student must be able to complete surgical counts prior to the beginning of the procedure, during the procedure and upon completion of the procedure without interruptions; must also be able to communicate/relay information about the patient, the surgical procedure, and the surgeon(s) to relief personnel in order to facilitate a smooth transition from one surgical technologist to another. Must be able to communicate needs during an emergency situation intraoperatively. o The surgical technology student must be able to verbally request additional sponges in the event of a hemorrhage. Move around in operating rooms without contaminating sterile workspaces. Must also be able to work in a small area without contaminating him/herself and the surgical team. Pass surgical knives, hypodermic needles, and sharp instrumentation without causing injury to the patient, him/herself or to the remainder of the surgical team; handle fine sutures and delicate instrumentation; position and transport patients. Respond promptly to the surgeon's/patient's needs, Manipulate equipment, Lift a minimum of 50 pounds, exert a sustained force of 20 pounds, push/pull mobile equipment weighing up to 300 pounds. Stand in sterile scrub attire for prolonged periods (sometimes wearing a 12-20 pound lead apron underneath the gown). Walk an equivalent of 5 miles per day. Revised February 2014

Tactile Skills Visual Shall possess tactile ability to sufficiently handle all the microscopic supplies, instruments, and equipment. Visual ability and acuity sufficient for observation & assessment necessary during a surgical procedure. Hearing Auditory ability sufficient to monitor and access health needs of the patient, & maintain facility safety. Weight Bearing Should possess the ability to maneuver/move/lift 40-50 pounds, daily. Occupational Exposures The ST student is at high risk for exposure to blood and body fluids, toxic substances, anesthetic preparations, and chemical sterilization practices at all times. Emotional Ability to tolerate environmental stressors. Loading fine sutures onto needle drivers and for passing to the surgeon delicate instrumentation; good hand eye coordination; keep hands and arms steady while moving your arm or while holding your arm and hand in one position. Implantable items for patients may be very delicate, in combination with sterile surgical gloves, some supplies and instruments require very delicate manipulation. Handling fine sutures and needles safely and efficiently in response to the needs of the surgeon and surgical procedure, being able to visualize and follow the surgical procedure, and working with small supplies and instruments that require calibration. Hear monitor alarms, emergency signals, & commands given by the surgeon and the circulating nurse. Lift a tray of surgical instruments; position patients and move equipment. Lifting extremity. Standing for a surgical procedure that may last several hours. Pathogens (HIV, AIDS, HBV, MRSA, TB) Bone cement, ethylene oxide, radiation, electricity, gases. Sharp instrumentation. Patient death. Different personalities. Physical stressors as room temperatures, noises, odors, patient conditions, and standing for a long period of time either in an ergonomically or non-ergonomical position). The student must be able to cope effectively with stress in the workplace; cope with patient & colleague emotions calmly; while demonstrating a high degree of patience. A prospective student with a disability, which may impact upon their ability to provide patient care, should contact the Students with Disabilities Program coordinator in the Counseling Services (536-7207, ext 1400). o Student Signature Date Revised February 2014