north arkansas college...north arkansas college radiologic technology program 1515 pioneer drive...

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.

http://www.arrt.org/

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


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



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


1515 PIONEER DRIVE

HARRISON, ARKANSAS 72601-5599

Revised 6/14



CLINICAL OBSERVATION CRITERIA

Unsatisfactory: Unacceptable performance

Needs Improvement: Below expectations

Average: Meets expectations

Above Average: Exceeds expectations

Excellent: Outstanding performance


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



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



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


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



APPLICANT REFERENCE FORM CRITERIA








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


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



APPLICANT REFERENCE FORM CRITERIA






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

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