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
mailto:[email protected]
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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
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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: _______________________________________________