APPLICATION FOR ADMISSION



APPLICATION FOR ADMISSION

Gulf Coast School of Blood Bank Technology

1400 La Concha Lane, Houston, TX 77054-1802

Program Director: Clare Wong; Medical Director: Beth Hartwell, MD

Date: ______________

|Applicant name | |Certification type | |

| | |Certification number | |

|Address | | |__Yes, __No |

| | |Citizen of United States? |If No, specify __________ |

|Date of birth | |Telephone (work) | |

|Place of birth | |Telephone (home) | |

|Social security # | |Telephone (cell) | |

|(last 4 numbers) | | | |

| | |E-mail address | |

|Have you applied to other SBB programs currently or previously? |__No |

| |__If Yes, which program(s)? ______________________ |

|Have you taken the SBB registry exam previously? |__No |

| |__If Yes, when? _______________________________ |

|Mentor’s name & credentials | |

|Mentor’s telephone | |

|Mentor’s e-mail | |

| |Undergraduate |CLS/MT Program |Others / Graduate School |

|College | | | |

|City/state | | | |

|Date | | | |

|(from-to) | | | |

|Year | | | |

|completed | | | |

|Degree | | | |

|conferred | | | |

Blood Bank/Transfusion Medicine Work Experience:

How many years of full-time transfusion service experience do you have? _________ years.

(*If part-time, add up all times and prorate into years.)

Start with your most current position.

|Current facility: | |

|Address: | |

|Started (month/year): | |

|Full or part time? | |

|Shift (day/evening/night): | |

|Title and duties: | |

|Supervisor’s name: | |

|Facility: | |

|Address: | |

|Date (month/year): | |

|Full or part time? | |

|Shift (day/evening/night): | |

|Title and duties: | |

|Supervisor’s name: | |

|Reason for leaving? | |

|Facility: | |

|Address: | |

|Date (month/year): | |

|Full or part time? | |

|Shift (day/evening/night): | |

|Title and duties: | |

|Supervisor’s name: | |

|Reason for leaving? | |

Professional References:

List three persons from whom you will request a professional reference.

Include the full name, facility, telephone, and job title.

|1. | |

| | |

|2. | |

| | |

|3. | |

| | |

Signature of Applicant: _________________________________ Date: _________________________

Gulf Coast School of Blood Bank Technology Applicant__________________

SBB Applicant Practical Experience

To be completed by the applicant and supervisor

Please list the approximate number of procedures performed by the Applicant within the past year.

*If you are not currently routinely performing these procedures, indicate the last year in which you have performed them. If you have never performed the procedure, enter a “0” in the column.

| | |# Procedures |*Last performed |

| |PROCEDURE |recently performed by | |

| | |applicant | |

|1 |Type and Screen | | |

|2 |Crossmatch | | |

|3 |Resolution of ABO discrepancies | | |

|4 |Rh phenotyping and other antigen typing | | |

|5 |Basic antibody identification (serum with 1-2 antibodies) | | |

|6 |Complex antibody identification (used procedures involving adsorption, ficin, | | |

| |DTT, EGA, neutralization, etc) | | |

|7 |Enzyme (e.g. ficin) panel | | |

|8 |Antibody titration | | |

|9 |Elution procedures | | |

|10 |Adsorption procedures (cold or warm) | | |

|11 |Blood bank chemicals (e.g. DTT, EGA) | | |

|12 |Fetal bleed screen | | |

|13 |Investigation of adverse effects of transfusion | | |

|14 |Donor blood collections | | |

|15 |Donor blood testing (infectious disease testing) | | |

|16 |Component preparation (Whole Blood to components) | | |

|17 |HLA and molecular testing | | |

|18 |Other molecular testing | | |

|19 |IRL (Immunohematology Reference Laboratory) | | |

|20 |Quality Assurance activities (worked in a QA department?) | | |

|21 |Hematopoietic progenitor cell processing | | |

|22 |Other experience (example: research, teaching (bench? formal?) |

| | |

| | |

| | |

|23 |Membership in professional organizations |

| | |

| | |

| | |

Workload of current facility

|Estimated number of transfusions per month | |

|Estimate number of donor blood units collected/month (if applicable) | |

Applicant Signature & Date _________________________________________

Supervisor Signature & Date ________________________________________

Gulf Coast School of Blood Bank Technology

Memorandum of Understanding - SBB Clinical Rotation

The applicant’s current facility must complete a Memorandum of Understanding (MOU). If the applicant’s facility will not be providing all clinical rotations, then additional MOUs must be obtained from the facilities that have agreed to provide the clinical experience.

|(Name) _____________________________, student/applicant of Gulf |Please return to the student applicant |

|Coast School of Blood Bank Technology’s distance SBB program |Or email to cwong@ |

|requires a facility affiliation for the purpose of clinical |Or FAX (713-791-6610) |

|rotation. | |

Facility: ______________________________________________________________________

Address: ____________________________________________________________________________

City, State, Zip: _______________________________________________________________________

Facility accredited/licensed by? (Circle all that apply) AABB CAP TJC FDA CLIA

| | |Check the rotation that will be|

| |Rotation |provided |

|1 |Transfusion service – routine T/S, T/C | |

|2 |Transfusion service management & Transfusion Committee | |

|3 |Serologic evaluation of HDFN (FMH, KB stain, etc) | |

|4 |Antibody identification - routine | |

|5 |Antibody identification – advanced (e.g. Reference Lab) | |

|6 |Rare donors, freezing and deglycerolization | |

|7 |Donor recruitment | |

|8 |Donor blood collection | |

|9 |Donor mobile blood drive | |

|10 |Hospital services/distribution | |

|11 |Blood component preparation, labeling and storage | |

|12 |Transmissible diseases testing | |

|13 |Donor apheresis | |

|14 |Therapeutic apheresis | |

|15 |HLA/molecular testing | |

|16 |Hematopoietic progenitor cell (HPC) processing | |

|17 |Quality management (e.g. audit, cGMP, SOP, error management) | |

|18 |Quality control (e.g. daily QC, equipment, reagent) | |

|19 |Supervisory rotation (e.g. Laboratory operation, education) | |

Would you and/or your staff be willing to listen and evaluate the student for oral presentations? yes no

Would you and/or your staff be willing to discuss policies and procedures with the student? yes no

Would you be able to allow the student the use of equipment and/or reagents? yes no

Would your facility require the student to pay for the instruction/reagents provided? yes* no

*If yes, list the items and the amount that you would expect the student to pay.

Completed by:_______________________________________ Date _______________________

Title:_______________________________________________

Gulf Coast School of Blood Bank Technology Applicant: ______________________

Professional Reference

To be completed by the Evaluator

The above named individual has applied for a position in the Specialist in Blood Bank Technology Program and has listed you as a reference. Please evaluate the applicant on the characteristics listed below according to your personal knowledge of the individual:

Scale:

5 = Outstanding; 4 = Very good; 3 = Satisfactory; 2 = Needs improvement; 1 = Unsatisfactory

0 = Unknown or no opinion

____ Responsibility: Accountable for one's own actions

____ Dependability: Prompt; completes assignments in a timely fashion

____ Organization: Arranges by systematic planning to complete tasks efficiently

____ Flexibility: Capable of adapting to changing situations

____ Response to stress: Maintains composure and ability to function in stressful situations

____ Initiative: Motivated to pursue actions independently

____ Attitude: Positive approach to work and co-workers

____ Maturity: Demonstrates common sense, tact, and empathy for patient care

____ Self-confidence: Assured of one's own abilities and skills

____ Decision-making: Ability to analyze a problem and formulate a solution

____ Leadership: Has the capability to direct the activities of others

____ Application of knowledge: Ability to apply academic theory to practice

____ Interaction with peers: Ability to get along with peers and co-workers

____ Interaction with supervisors: Ability to get along with supervisors and instructors

____ Verbal communication: Contributes knowledge and opinion in an articulate manner

____ Written communication: Expresses self clearly in writing

____ Continuing education: Eager to continue learning to improve skills/knowledge

Additional information pertinent to evaluation of the applicant (attach additional page if desired):

How long have you known the applicant? ________years

Relationship to the applicant:

____ Advisor

____ Instructor

____ Supervisor

____ Other:_________________

Evaluator (print) ____________________________________

(Signature)____________________________________

Present Title _______________________________________

Institution __________________________________________

Address ___________________________________________

City/State/Zip _______________________________________

Telephone / e-mail___________________________________

Place this completed form in an envelope, seal it, sign your name across the back flap, and

return it to the applicant or

email the completed form to Clare Wong, cwong@, or

Fax to 713-791-6610

Gulf Coast School of Blood Bank Technology Applicant: __________________

Application Checklist

To be completed by the applicant and returned with the application packet.

Check if Check if

Present In Progress Item

______ ______ 1. This Application Checklist

______ ______ 2. Application for Admission form - completed and signed

______ ______ 3. Copy of ASCP or NCA certification (or ID card)

______ ______ 4. SBB Applicant Practical Experience form

______ ______ 5. Blood bank continuing education for the past two years (listed on one page)

______ ______ 6. Memo of Understanding for clinical rotations

______ ______ 7. Written essay of goals and expectations from SBB education (limited to one single-spaced typed page)

______ ______ 8. Official transcripts (or copy) of undergraduate studies

______ ______ 9. Three Professional References, one of which from your current supervisor

______ ______ 10. Copy of permanent residency visa (if applicable)

______ ______ 11.* Official evaluation of academic transcripts by an accredited agency in the US listing course names, hours earned, and US equivalent grades.

* Required for applicants who received high school and/or college education outside of the United States.

Please send application to:

Clare Wong

Gulf Coast Regional Blood Center

1400 La Concha Lane

Houston, TX 77054-1802

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