Radigraphy Prgram Admissin Prcess and Checklist Welcme t Minnesta State Cllege Sutheast. We are pleased that yu have indicated an interest in the Radigraphy (AAS) prgram. The deadline t be cnsidered fr admissin is June 15. All items must be cmpleted in rder t be cnsidered an applicant fr admissin t the Radigraphy prgram. Admissin t Minnesta State Cllege Sutheast Students nt enrlled at MSC Sutheast must apply nline and submit the $20.00 applicatin fee. In rder t be cnsidered fr the Radigraphy Prgram, yu must be accepted t MSC Sutheast. Request cllege transcripts frm all institutins the applicant has attended (except any Minnesta State clleges and universities institutins attended after 1990). Official transcript(s) frm any ther clleges must be sent directly frm the previus institutin(s) t the Registrar s Office. ACT scres are accepted; therwise students will be required t take the Accuplacer placement exam (taken in LRC) Cmputer Skills Prficiency Test; set up an appintment at the frnt desk fr the.03 Health prfile t incrprate the Cmputer Skills Prficiency test when taking the Accuplacer r just ask fr the Cmputer Skills Prficiency test See specifics in checklist belw) Apply t the Radigraphy Prgram by cmpleting the frms belw Once students have been accepted, they will be required t submit t at least ne randm urine drug testing prir t attending any clinical practicum. This is at the student s expense and is dne at the discretin f prgram faculty. The Radigraphy prgram des nt maintain a waiting list; therefre applicatins must be resubmitted every year fr cnsideratin. Please nte: The Radigraphy prgram is available n the Winna Campus nly. CHECKLIST Student Name: Applicatin frm $20.00 applicatin fee, a ne-time fee fr new enrllees (Fee waived fr students wh attended credit curses at MSC Sutheast, Red Wing r Winna campus) Cmpleted Prgram Prerequisite Checklist: PAGES 2-3 t include the fllwing: Health Recrd Frm: PAGES 4-6 Radigraphy Essential Abilities Frm: PAGES 7-8 Criminal Backgrund Check Frm: PAGE 9. The study will be run prir t yur first fall radigraphy curses and annually thereafter. (Return frm t Allied Health ffice.) Cpy f current CPR card (American Heart Assciatin-CPR fr the Healthcare Prvider r American Red Crss- CPR/AED fr the Prfessinal Rescuer) Cpy f current TB test (Mantux) Anatmy and Physilgy I prerequisite (Cmpletin f BIOL2515 r equivalent curse with a grade f C r higher) (Cmpletin f required curse BIOL2516 Anatmy and Physilgy II r equivalent with a grade f C r higher is als strngly advised befre starting the prgram) Cllege Algebra prerequisite (Cmpletin f MATH1220 r equivalent curse with a grade f C r higher) Cllege English prerequisite (Cmpletin f ENGL1215 r equivalent curse with a grade f C r higher) Official cllege transcript(s) t be sent directly frm previus institutins (If yu are a frmer student f MSC-ST, yu d nt need t request a transcript) Patient Care Experience (see criteria belw) (Revised 8/22/17) 1 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Radigraphy Prgram Prerequisite Checklist (Pages 2-3) Student Date/Time Cmpleted Date Received in Admissins Applicatin Deadlines: June 15th t be cnsidered fr fall semester. The checklist must be cmplete and all dcumentatin received t be cnsidered fr admissin. This checklist will be retained fr ne year. Initials Date mm/dd/yy Required Item Passing grade: Transfer Passing grade: Transfer Passing grade: Transfer Passing grade: Transfer CSP Scre: Test Date: COMP1508 COMP2515 Date Submitted: Physical Date: Mantux Date: CPR Date: Exp. Date: Math Prerequisite (a Math curse is required fr the prgram) Cmpletin f MATH1220 Cllege Algebra r equivalent curse with a grade f C r higher Cmmunicatin/English Prerequisite (an English curse is required fr the prgram) Cmpletin f ENGL1215 Cllege Writing 1 r equivalent curse with a grade f C r higher Anatmy and Physilgy (4 credits) Prerequisite Cmpletin f BIOL2515 r equivalent curse with a grade f C r higher (Cmpletin f BIOL2516 Anatmy and Physilgy II is nt a prerequisite, but as a prgram requirement, cmpletin is strngly advised befre starting the prgram due t rigrus 1 st semester) Cmputer Prficiency 1. Cmputer Skills Prficiency test minimum scre f 50% and may be taken nly nce. This test is in additin t the Accuplacer and administered at the LRC test center OR 2. Cmpletin f COMP1508 r COMP2515 with a grade f C r higher OR 3. Requirement waived with an fficial transcript dcumenting a transfer curse f equal r higher level Criminal Backgrund Study Frm Minnesta law requires that any persn wh prvides services that invlve direct cntact with patients at a health care facility licensed by the Minnesta Department f Health have a backgrund study. An individual wh is disqualified frm having direct patient cntact as a result f the backgrund study and whse disqualificatin is nt set aside by the Cmmissiner f Health, will nt be permitted t participate in clinical placement and therefre will nt able t successfully cmplete the radigraphy prgram. As radigraphy uses facilities in Minnesta, Wiscnsin and Iwa, the same backgrund criterin is used. The study will be run at the time prir t fall start f classes Health Recrd Frm (The frm is specific t Radigraphy) This self-disclsure frm MUST include a mantux test r chest x-ray infrmatin. Mantux tests must be renewed annually. Chest x-ray is a ne-time dcumentatin with annual cmpletin f a questinnaire. An annual flu vaccinatin is required and shuld be btained during the fall semester CPR - Prf f ne: American Heart Assciatin-CPR fr the Healthcare Prvider OR American Red Crss-CPR/AED Fr the Prfessinal Rescuer (Checklist cntinued next page) 2 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Date Submitted: Date Received: Radigraphy Essential Abilities Frm Review the prgram essential abilities list. Sign, date and submit the statement f understanding Patient Care Experience This requirement is met by exhibiting DOCUMENTED experience in the fllwing areas: Certified Nursing Assistant (CNA certificatin) Ward Secretary/Health Unit Crdinatr Patient Care Technician/Medical Assistant Dental Hygienist/Assistant Emergency Medical Technician/First Respnder Athletic Trainer Ski Patrl Vlunteer Ambulance r Fire Fighter Minimum f 40 hurs f dcumented vlunteer wrk with direct patient cntact Minimum f 40 hurs f dcumented care giving fr a disabled family member Hspice experience Radigraphy Grade Requirements Curses taken at Minnesta State Cllege Sutheast must be a grade f C r higher Transfer grades in Liberal Arts must be a grade f C r higher Transfer grades in Technical Curses must be a grade f B r higher 3 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Radigraphy Prgram Health Recrd Frm (Pages 4-6) Minnesta State Cllege Sutheast is asking yu t prvide private infrmatin in rder t prcess yur Radigraphy Health Recrd Frm. This infrmatin will be used t update yur health recrds. Yu are nt legally required t prvide this infrmatin; hwever, the cllege may nt be able t effectively prcess yur request if yu d nt prvide sufficient infrmatin. Access t this infrmatin will be limited t schl fficials, including faculty wh have legitimate educatinal interests in the infrmatin. Under certain circumstances, federal and state laws authrize release f private infrmatin withut yur cnsent: t ther schls in which yu seek r intend t enrll, r are enrlled; t federal, state r lcal fficials fr purpses f prgram cmpliance, audit r evaluatin; as apprpriate in cnnectin with yur applicatin fr, r receipt f, financial aid; if the infrmatin is sught with a curt rder r subpena; r as therwise permitted by ther state r federal law. If yu have any cncerns r questins abut this frm, please cntact the Radigraphy Prgram Directr at 507-453-1488. Please return cmpleted frm t the Allied Health Office. Part A: Student cmpletes Name Last First Middle/Maiden Address Phne ( ) Birth date City, State, Zip In Emergency Ntify: Name Address Phne Health Insurance is strngly recmmended. Any hspital r medical csts incurred while a student are the respnsibility f the student. Please read carefully and sign: I understand that there are cnditins fr which accmmdatins may be apprpriate under the Americans with Disabilities Act and that the Radigraphy Prgram will make all reasnable accmmdatins required by law fr therwise qualified individuals. T receive accmmdatins, I must cntact the cunselr s ffice. I understand that any health care csts incurred during the perid f time I am a student in the Radigraphy Prgram will be my respnsibility. I hereby grant Minnesta State Cllege Sutheast permissin t share infrmatin cntained in the HEALTH RECORD FORM with thse clinical institutins with whm I affiliate in my student rle, shuld the clinical institutin request r require it. I understand that failure t sign this frm r t prvide the infrmatin requested culd mean that a clinical site may refuse me placement at their facility. The Radigraphy Prgram des nt guarantee an alternative facility placement. I als understand that if n alternative facility placement is available, I may be unable t prgress in the Radigraphy Prgram. I certify that the infrmatin I have prvided n this frm is cmplete, accurate, and true t the best f my knwledge. (Signature f Student) (Date) 4 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Radigraphy Prgram Health Recrd Frm Immunity Requirements Tuberculsis Immunity Mantux test: A licensed persn must read the Mantux. Date given: Date read: Result: Name f persn reading Mantux Credential Signature f persn reading Mantux Administrating Agency Chest X-ray: required nly if yur Mantux result is psitive. The Radigraphy prgram requires a yearly chest x-ray fr individuals with a psitive Mantux. Date f X-ray: Results: MMR Immunity All students must have ONE f the fllwing: Dcumentatin f tw MMR s OR Rubella titer indicating immunity Dates f Vaccinatin: Date Titer Read: Result Hepatitis All students must be vaccinated against hepatitis B. Date f 1st dse f vaccinatin Date f 2nd dse f vaccinatin Date f 3rd dse f vaccinatin Diphtheria Tetanus (Adult Type) All students must knw their diphtheria-tetanus status Date f last vaccinatin Inculatin fr tetanus with in the last 10 years is required. (Cntinued next page) 5 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Chicken Px All students must knw their chicken px status either by: having had chicken px have nt had chicken px OR, if yu d nt knw yur chicken px status yu must have a titer. Chicken px titer Date Titer Read: Chicken px titer indicates immunity. Chicken px titer des nt indicate immunity. Annual flu sht All students must have an annual flu sht t attend clinical practicum and we recmmend yu wait t get ne during the fall semester when new flu vaccinatins are made available. Immunity Requirements: please d nt submit this frm until all requirements are met* and data are prvided. *Exceptin Hepatitis B has been initiated. Revised 5/29/14 6 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Radigraphy Prgram Essential Abilities Frm (pages 7-8) The Radigraphy prgram essential abilities listing is t make yu aware f the physical, cgnitive, and mental capabilities yu may encunter nce emplyed in a radigraphy psitin. These abilities are typical f the demands f a radigrapher in the wrk setting. The curriculum requires demnstrated prficiency in a variety f cgnitive, prblem-slving, manipulative, cmmunicative and interpersnal skills. If yu have any questins regarding these, yu shuld cntact the Prgram Directr r the Admissins advisrs. Please sign and turn in this cmpleted frm with yur checklist. Physical Activity Requirements Occasinal Cruching - psitining patients fr exams and stcking supplies Repetitive mtins - entering cmputer data Grasping - psitining patients fr exams and prcedures Pulling - mving items that can weigh as much as 100 punds Frequent Pushing - transprting patients in wheelchairs r n carts using up t 50 punds f frce. Mving prtable and C- arm equipment with up t 50 punds f frce t areas f the hspital. Pulling - assisting and mving patients ff and nt carts using 8 t 40 punds f frce. Lifting - mving patients (wh can weigh mre than 50 punds) frm wheelchair/cart r stretcher ff and nt exam tables. Fingering - entering cmputer data and setting radigraphic expsure techniques fr exams. Carrying - carrying imaging cassettes that can weigh as much as 25 punds. Rutine Stping - psitining f exams and assisting patients in and ut f wheelchairs. Reaching - psitining patients and manipulating prtable equipment. Standing - all clinical assignments require standing. Walking- transprting and assisting patients int dressing/exam rms. Walking t ther areas f the department and hspital t d exams r have images interpreted. Talking - must be able t cmmunicate verbally in an effective manner with patients, c-wrkers, and physicians. Hearing - perceiving the nature f sunds during auscultatin (listening) and percussin (tapping n a surface t determine the underlying structure). Feeling - perceiving attributes f patients and bjects such as when psitining patients fr prcedures r palpating veins fr IV insertin. Visual & Hearing Acuity Requirements During clinical assignments, students are required t use a cmputer cnsle and select the prper expsure techniques n the x-ray equipment. Clinical assignments require critiquing (evaluatin) f radigraphs. Clinical assignments require wrking with printed and/r written dcumentatin. Students must be able t assess patient s cnditin, i.e., clr, respiratin, mtin, etc. Students must be able t hear in rder t cmmunicate with patients while taking a histry, giving psitining instructins, r interacting with ther team members. Students must be able t hear instructins frm dctrs under cnditins such as: in a darkened flurscpy rm & in surgical attire. (Frm cntinued next page) 7 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Intellectual and Emtinal Requirements Students must be able t critique (evaluate) radigraphs and determine diagnstic quality. Students must be able t make adaptatins and respnd with precise, quick and apprpriate actin during emergency situatins. Students must maintain patient cnfidentiality. Students must be able t maintain a high standard f curtesy and cperatin in dealing with c-wrkers, patients, and visitrs with satisfactry perfrmances despite the stress f a hspital/clinic wrk envirnment. Students must be able t learn t analyze, synthesize, slve prblems and reach evaluative judgment. Students are expected t be able t learn and perfrm rutine radigraphic prcedures. In additin, students must have the mental and intellectual capacity t calculate and select prper technical expsure factrs accrding t the individual needs f the patent and the requirements f the prcedure with speed and accuracy. Students must be able t accept criticism and adpt apprpriate mdificatins in their behavir. Students must demnstrate apprpriate emtinal health required fr utilizatin f intellectual abilities and exercise gd judgment. Clinical Situatins Students may be subjected t electrical, radiant energy, and chemical hazards. Students may be subjected t trauma situatins r surgical experiences. Persns in the radilgic sciences have been identified as having the likelihd f ccupatinal expsure t bld r ther ptentially infectius materials and, therefre, are included in the OSHA Expsure Cntrl Plan with its specificatins t prevent cntact with the abve materials. If yu have a dcumented disability, there may be accmmdatins that can be made t assist in yur successful cmpletin f the prgram, please see a cllege cunselr. Yes N I have read and understand the Prgram Essential Abilities relative t the Radigraphy Prgram. The inability t meet all f the Prgram Essential Abilities will in n way prhibit yur acceptance t the Radigraphy Prgram. The Americans with Disabilities Act bans discriminatin f persns with disabilities, and in keeping with this law, Minnesta State Cllege Sutheast makes every effrt t ensure quality educatin fr all students. It is ur bligatin t infrm students f the essential abilities demanded by the prgram and f the ccupatin. Students with dcumented disabilities which require accmmdatins r special services t meet the Essential Abilities f the prgram shuld cntact Disability Services (507-453-1443) fr assistance, advising and arrangement f apprpriate accmmdatins. Sign and turn in this cmpleted frm with yur checklist. Student Signature Name (print) Date 8 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17
Radigraphy Prgram Criminal Backgrund Check Frm (Page 9) DISCLOSURE PREPARATION OF A CONSUMER REPORT T prcess yur applicatin with Minnesta State Cllege Sutheast, a backgrund check will be cnducted by NetStudy 2.0. In accrdance with the U.S. Fair Credit Reprting Act SS 606, we ntify yu f the fllwing: A backgrund check reprt may cntain infrmatin bearing n yur character, general reputatin, persnal characteristics, mde f living and credit standing, infrmatin may include, but is nt limited t: emplyment histry, educatin, criminal recrds, credit histry, mtr vehicle recrds, persnal references, and any data prvided n this applicatin, r during the interview prcess. Please read the fllwing and, if acceptable, authrize us t rder an investigative reprt t be prepared by NetStudy 2.0. AUTHORIZATION TO PREPARE INVESTIGATIVE, CONSUMER REPORT I authrize the apprpriate individuals, cmpanies, institutins r agencies t release infrmatin required fr the preparatin f an investigative reprt n me and t respnd t all inquiries necessary fr the same. Legal Last Name Legal First Name Legal Middle Name Cmplete Street Address Email address City Cunty State Zip Cde Phne Number Driver License # and expiratin date dd/m/yyyy Please list ut f state address yu have lived in during the past 5 years: Street Address City State Zip Cde Years Start t End Street Address City State Zip Cde Years Start t End Please list ther names yu have used and dates changed, if applicable, in the past 5 years: Name Date Changed Name Date Changed Race Sex Eye Clr Hair Clr Height Weight Birth State Date f Birth I AUTHORIZE A PHOTOCOPY AND/OR AN ELECTRONIC COPY OF THIS AUTHORIZATION TO BE ACCEPTED WITH THE SAME AUTHORITY AS THE ORIGINAL AND IF EMPLOYED BY THE ABOVE NAMED COMPANY THIS AUTHORIZATION WILL REMAIN IN EFFECT THROUGHOUT MY EMPLOYMENT. Signature Scial Security Number Date Parent/Legal Guardian Signature is required fr applicants under 18 years f age Date 9 Minnesta State Cllege Sutheast Radigraphy Prgram www.sutheastmn.edu Updated 8.22.17