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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