Iowa Central Community College



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Ultrasound Internship - Application of Admission

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Personal Data Date____________________

Name _________________________________________ Soc. Sec #______________________

Present Address_______________________________________________________________

_______________________________________________________________

Permanent Address____________________________________________________________

____________________________________________________________

Phone #_________________________________ Email________________________________

Education Cumulative College GPA________

1. School Name____________________________________________________________

City, State _____________________________________________________________

Dates Attended__________________________________________________________

2. School Name____________________________________________________________

City, State _____________________________________________________________

Dates Attended__________________________________________________________

3. School Name____________________________________________________________

City, State _____________________________________________________________

Dates Attended__________________________________________________________

4. School Name____________________________________________________________

City, State _____________________________________________________________

Dates Attended__________________________________________________________

Must have an official copy of all transcripts sent to University of Iowa and Iowa Central Community College Registrar’s office for credit from other facilities.

Employment (begin with most recent)

1. Employer’s Name_____________________________________________________

Address _____________________________________________________

Dates Employed _____________________________________________________

2. Employer’s Name_____________________________________________________

Address _____________________________________________________

Dates Employed _____________________________________________________

3. Employer’s Name_____________________________________________________

Address _____________________________________________________

Dates Employed _____________________________________________________

4. Employer’s Name_____________________________________________________

Address _____________________________________________________

Dates Employed _____________________________________________________

Are you a U.S. citizen __________ yes ________ no

ARRT # ________________ARRT Score________IA Permit to Practice#_________________

If unavailable: Graduation date_______________________

ARRT exam date_______________________

Minimum Requirements:

• ARRT certification in Radiologic Technology, Nuclear Medicine, or Radiation Therapy.

~ If candidate has not graduation from an accredited Radiologic Technology program list graduation date

~ ARRT exam date if known

• 2 Letters of recommendation, individually sealed envelopes

• An essay

~ Include a brief summary of how the modality works and your interest in the area

~Include work or clinical experiences in the modality

~ Professional goals

• Completed background check

• Official transcripts if other than Iowa Central Community College

• Preferably GPA of 2.75 or higher

• Ultrasound Internship’s Technical Standard Form read, signed and dated

Please check one of the three options listed below.

_________I am applying for the General Ultrasound Internship only.

_________ I am applying for the Vascular Ultrasound Internship only.

_________ I am applying for both general and vascular Ultrasound Internships

Application Process Checklist

1. A completed application form submitted.

2. Radiology Technical Standards Form, read and signed.

3. Criminal background, adult and child abuse checks submitted.

4. Official transcripts from all colleges, Radiologic Technology, Nuclear Medicine or Radiation Therapy Programs submitted to Iowa Central Community College’s registrar and University of Iowa.

5. Copy of ARRT examination scores from primary certification in Radiologic Technology, Nuclear Medicine or Radiation Therapy. If you have not completed boards but are board eligible submit testing date then upon receipt of your score you must submit it immediately. A passing score must be obtained prior to starting the internship.

6. Two personal references completed by individuals who are familiar with your personal, academic and/or employment background, reference form is included. To insure confidentiality each recommendation must be individually sealed in an envelope with the signature of the person writing the recommendation across the seal.

7. Signed and dated Radiologic Technical Standard Form.

8. An interview may be needed, not all applicants will be interviewed. Applicant will be notified.

Radiology Technical Standards Requirements

Individuals admitted to the Iowa Central Ultrasound Internship must possess the capability to complete the internship. This will require proficiency in a variety of cognitive, problem solving, communicative and interpersonal skills. Students admitted into the Ultrasound Internship must possess the following abilities and ability to meet the following expectations. Please contact the Program Director, Chantel Burns, at 515-574-1302.

1. Candidates must be able to learn to analyze, synthesize, solve problems and reach evaluative judgment.

2. Candidates must have sufficient use of the sense of vision, hearing, smelling and touch necessary to directly perform a radiologic examination, review and evaluate the recorded images, accurate procedural sequencing, proper radiographic quality and other appropriate and pertinent technical qualities.

3. Candidates must be able to relate reasonably to patients and establish a sensitive, professional and effective relationship with the patients. In addition, candidates must be able to communicate verbally in an effective manner to direct patients during radiologic procedures.

4. Candidates must be able to provide physical and emotional support to the patient during the US procedure, being able to respond to situations requiring first aid and providing emergency care to the patient in the absence of, or until the physician arrives.

5. Candidates must be able to display judgments in the assessment of patients. In addition the candidates must be able to learn and demonstrate the ability to recognize limitations in their knowledge, skills, and abilities and to seek appropriate assistance with their identified limitations.

6. Candidates are expected to work collaboratively with all members of the health care team.

7. Candidates are expected to be able to learn and perform routine US procedures along with selecting the proper protocol and changes in instrumentation according to the needs of the individual patient.

8. Candidates must have sufficient strength, motor coordination, and manual dexterity to transport, move, lift, and transfer patients from a wheelchair or cart to an x-ray and US table or to a patient bed.

9. Candidates must be able to learn to respond with precise, quick and appropriate action in stressful and emergency situations.

10. Candidates are expected to be able to accept criticism and adopt appropriate modifications in their behavior.

11. Candidates are expected to possess the perseverance, diligence, and consistency to complete the US Internship and enter into the practice of radiology as a registered US technologist.

Do you have any physical or mental handicaps that would interfere with the satisfactory performance of the TECHNICAL STANDARDS identified above? ______ Yes ______ No

Signature________________________________________ Date ____________________

Personal Reference Form

Pursuant to Public Law 93-380, all letters of recommendation written after January 1, 1975 are not considered confidential unless the applicant waives right of access

The signature below constitutes a waiver of the applicant’s right of access to this recommendation should he/she be accepted into the Radiology Technology program

Signature Date

If not signed, this recommendation can be available to the applicant.

Iowa Central Community College prohibits discrimination and it its educational programs and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associated preference. Iowa Central Community College also affirms its commitment to providing equal opportunities and equal access to Iowa Central facilities. For additional information on nondiscrimination policies, contact the Coordinator of Title IX, Section 504, and the ADA in the Office of Affirmative Action, (319) 335-0705 (voice) or (319) 335-0697 (text), Iowa Central Community College, One Triton Circle, Fort Dodge, Iowa 50501.

_____________________________________________________________________________________

The applicant named below has requested admission to the Ultrasound Internship Program at Iowa Central Community College. Your response to this inquiry will assist the Admissions Committee in assessing the applicant. The program’s faculty and administration believes these are important items to be considered along with other data in predicting the potential professional success of persons in health care clinical settings. Your candid appraisal of the applicant’s characteristics is vital to our evaluation and subsequent decisions. Your assistant is appreciated.

Applicant’s Name (please print): __________________________________________________________

How long have you known the applicant? ___________________________________________________

In what capacity do you know the applicant (student, friend, co-worker, etc.)? _____________________

Please complete the following table by marking in the appropriate box.

| |Exceptional top|Above |Average 50% |Below Average |Poor Below 1/3 |Unable to |

| |2% |Average top | | | |Judge |

| | |1/3 | | | | |

|Responsibility: Ability and willingness to accept| | | | | | |

|responsibility; complete tasks; honor commitments.| | | | | | |

|Attitude: Displays positive actions and | | | | | | |

|behaviors. | | | | | | |

|Problem-Solving: Takes initiative and has the | | | | | | |

|ability to identify, confront, and solve problem | | | | | | |

|situations. | | | | | | |

|Honesty: Extent to which the candidate displays | | | | | | |

|an ethical code of integrity. | | | | | | |

|Motivation: Degree to which candidate applies | | | | | | |

|self without prompting | | | | | | |

|Appearance: Extent to which professional | | | | | | |

|standards of neatness or cleanliness are met. | | | | | | |

|Stress/Anxiety Response: Ability to handle or | | | | | | |

|cope with stressful/anxious situations. | | | | | | |

|Interpersonal Relationships: Ability to interact | | | | | | |

|& communicate in a positive manner with | | | | | | |

|co-workers, peers, etc. | | | | | | |

|Constructive Criticism: Ability to accept and | | | | | | |

|handle positive and constructive criticism. | | | | | | |

|Verbal/Writing Skills: Ability to clearly express| | | | | | |

|oneself. | | | | | | |

|Attendance Reliability: | | | | | | |

|Organizational Skills: Uses time wisely and | | | | | | |

|prepares for upcoming events | | | | | | |

Please feel free to make comments explaining selections made in the previous table, as well as present additional information you believe would be relevant to this applicant’s pursuit of admission.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check one of the following categories that best describes your overall rating of the candidate:

_____ Recommend with enthusiasm

_____ Recommend with confidence

_____ Recommend with reservations

_____ Do not recommend

________________________________________ _______________________________________

Name of Evaluator (Please Print) Signature of Evaluator (date)

________________________________________

Title/Position

________________________________________ _______________________________________

Address Phone number can be reached at.

Thank you for your cooperation in evaluating this applicant.

When completed with the evaluation, enclose this form in an envelope and sign over the sealed portion to ensure confidentiality. Return it to the applicant or send to us at the address below.

Iowa Central Community College

Attn: Chantel Burns-Radiology applicant reference

One Triton Circle

Fort Dodge, IA 50501

Personal Reference Form

Pursuant to Public Law 93-380, all letters of recommendation written after January 1, 1975 are not considered confidential unless the applicant waives right of access

The signature below constitutes a waiver of the applicant’s right of access to this recommendation should he/she be accepted into the Radiology Technology program

Signature Date

If not signed, this recommendation can be available to the applicant.

Iowa Central Community College prohibits discrimination and it its educational programs and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associated preference. Iowa Central Community College also affirms its commitment to providing equal opportunities and equal access to Iowa Central facilities. For additional information on nondiscrimination policies, contact the Coordinator of Title IX, Section 504, and the ADA in the Office of Affirmative Action, (319) 335-0705 (voice) or (319) 335-0697 (text), Iowa Central Community College, One Triton Circle, Fort Dodge, Iowa 50501.

_____________________________________________________________________________________

The applicant named below has requested admission to the Ultrasound Internship program at Iowa Central Community College. Your response to this inquiry will assist the Admissions Committee in assessing the applicant. The program’s faculty and administration believes these are important items to be considered along with other data in predicting the potential professional success of persons in health care clinical settings. Your candid appraisal of the applicant’s characteristics is vital to our evaluation and subsequent decisions. Your assistant is appreciated.

Applicant’s Name (please print): __________________________________________________________

How long have you known the applicant? ___________________________________________________

In what capacity do you know the applicant (student, friend, co-worker, etc.)? _____________________

Please complete the following table by marking in the appropriate box.

| |Exceptional top|Above |Average 50% |Below Average |Poor Below 1/3 |Unable to |

| |2% |Average top | | | |Judge |

| | |1/3 | | | | |

|Responsibility: Ability and willingness to accept| | | | | | |

|responsibility; complete tasks; honor commitments.| | | | | | |

|Attitude: Displays positive actions and | | | | | | |

|behaviors. | | | | | | |

|Problem-Solving: Takes initiative and has the | | | | | | |

|ability to identify, confront, and solve problem | | | | | | |

|situations. | | | | | | |

|Honesty: Extent to which the candidate displays | | | | | | |

|an ethical code of integrity. | | | | | | |

|Motivation: Degree to which candidate applies | | | | | | |

|self without prompting | | | | | | |

|Appearance: Extent to which professional | | | | | | |

|standards of neatness or cleanliness are met. | | | | | | |

|Stress/Anxiety Response: Ability to handle or | | | | | | |

|cope with stressful/anxious situations. | | | | | | |

|Interpersonal Relationships: Ability to interact | | | | | | |

|& communicate in a positive manner with | | | | | | |

|co-workers, peers, etc. | | | | | | |

|Constructive Criticism: Ability to accept and | | | | | | |

|handle positive and constructive criticism. | | | | | | |

|Verbal/Writing Skills: Ability to clearly express| | | | | | |

|oneself. | | | | | | |

|Attendance Reliability: | | | | | | |

|Organizational Skills: Uses time wisely and | | | | | | |

|prepares for upcoming events | | | | | | |

Please feel free to make comments explaining selections made in the previous table, as well as present additional information you believe would be relevant to this applicant’s pursuit of admission.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check one of the following categories that best describes your overall rating of the candidate:

_____ Recommend with enthusiasm

_____ Recommend with confidence

_____ Recommend with reservations

_____ Do not recommend

________________________________________ _______________________________________

Name of Evaluator (Please Print) Signature of Evaluator (date)

________________________________________

Title/Position

________________________________________ _______________________________________

Address Phone number can be reached at.

Thank you for your cooperation in evaluating this applicant.

When completed with the evaluation, enclose this form in an envelope and sign over the sealed portion to ensure confidentiality. Return it to the applicant or send to us at the address below.

Iowa Central Community College

Attn: Chantel Burns-Radiology applicant reference

One Triton Circle

Fort Dodge, IA 50501

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