Dear Interested Applicant,



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School of Medical Laboratory Science

Application Packet

Please mail completed application packet and required documents to

Untied Regional HealthCare System

Att; Asma Javed, Program Director

School of Medical Laboratory Science

1600 11th St, Bethania Building

Wichita Falls, TX 76301

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School of Medical Laboratory Science

URHCS School of Medical Laboratory Science is an equal opportunity provider of education. This entity does not discriminate on the basis of race, religion, sex, national origin, age and disability, sexual orientation and gender identity.

Dear Interested Applicant,

Enclosed is an application form for the Medical Technology Program at URHCS. Academic Prerequisites for Medical Technology, Criterion for Student Selection, Description of lectures and rotation curriculum, and the Immunization policy are provided on the website at



The Applicant must provide with the following along with the application

o At least a 2.5 Overall and Science GPA

o Official Transcripts from all schools attended (if degree not complete, unofficial copy is acceptable. Official copy will be required before the start of the rotation)

o Three letters of reference; one personal, two academic

o A Student letter of Intent explaining your interest in the field and why you should be accorded an interview

o Immunization records

In addition to your Application and Health Questionnaire, please sign and return the enclosed Essential Functional Tasks document. Please have your references send the letters directly to the MT school office or seal to give you to add to the application packet. There is no form for the reference letter.

To attend our school, you should be eligible for a Bachelors in Science in Biology or related field at the end of the rotation from any of the accredited Universities in the United States or already have a Bachelor of Science in Biology or related field with the necessary prerequisites and criteria for selection (lists are enclosed) from any accredited US institution of higher education.

Eligible United States resident or citizens with a foreign degree will need to get their degrees equalized by an accredited institution.

The MLS School at United Regional is currently affiliated with the following Universities.

Midwestern State University University of North Texas

Wichita Falls, TX Denton, TX

Texas Woman’s University Northeastern State University

Denton, TX Tahlequah, OK

Southwestern Oklahoma State University

Weatherford, OK

Additional affiliation maybe setup if a student from a nonaffiliated university is accepted.

If you have any questions, please do not hesitate to contact me.

Sincerely,

Asma Javed

Asma Javed, MS, MT (ASCP) Program Director

Ph; 940-764-3187

Email; ajaved@

Please mail completed application packet and required documents to

Untied Regional HealthCare System

Att; Asma Javed, Program Director

School of Medical Technology

1600 11th St, Bethania Building

Wichita Falls, TX 76301

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School of Medical Laboratory Science

Essential Functional Tasks --- School of Medical Technology Applicants

The ability to perform certain essential tasks is necessary for all students entering the United Regional Health Care System School of Medical Technology. The function of these tasks is essential for successfully completing the clinical education component of the Medical Technology Program. These essential functions are based upon the specialized nature of the work in the profession of medical technology, and are aligned with the job performance standards for an employed medical technologist. Reasonable effort will be made to accommodate any disabilities to allow for performance of these essential functional tasks.

To meet the essential function requirements, the student shall:

1. Complete a pre-entry health history given by the Program Director and reviewed by the Medical Director.

2. Obtain or update all required immunizations as required by the school.

3. Complete visual testing and laboratory screening studies. These tests will be performed free of charge.

In addition to completing the above, the student shall possess:

4. The ability to read and write.

5. Visual acuity in order to discriminate color in urine chemistry reactions, chemical reactions, and microscopic identification of cell morphology, special stains, etc.

6. Adequate motor skills in order to perform phlebotomy procedures; instrument calibration and maintenance; delicate sampling procedures; a variety of manual, semi-automated, and automated analytical procedures; and computer keyboarding.

7. Physical ability to tolerate long periods of standing.

8. Physical strength for light lifting of weights of 25 pounds or less from the floor to waist level.

9. Communication skills, to include appropriate telephone skills, necessary to interact effectively with instructors, patients, and other members of the health care team.

10. Demonstrated ability to function effectively under stress.

A student who fails to meet the above essential functions may be denied admission to the program or be removed anytime during the rotation

(Please retain pages 1-4 for your records)

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School of Medical Laboratory Science Application for Admission

Application Deadline; January 5th

APPLICATION TO THE SCHOOL OF MEDICAL TECHNOLOGY

DATE OF APPLICATION ________________________ SS# ________________________

Expected entrance date ______________________________________________________

Name ______________________________________________________________________

Last First MI

Gender: M______ F_______ Email: ________________________________

Are you a U.S. citizen or permanent resident? Yes_______ No_______

If no, please indicate type of visa and country of origin._____________________________

Address ____________________________________________________________________

Street Apt. #

City State Zip-code Phone #

Name of parent, nearest relative or guardian:______________________________________

Address ____________________________________________________________________

Street Apt. #

City State Zip-code Phone #

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School of Medical Laboratory Science Application for Admission

Education: Please start with High School

|Institution |Dates attended |Degree awarded |Major |Total GPA |Science GPA |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

If need to add more institutions, please attach a typed sheet.

Activities and Honors;

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

List of three references;

1.___________________________________________________________________________

Name address email

2.___________________________________________________________________________

Name address email

3. __________________________________________________________________________

Name address email

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School of Medical Laboratory Science Application for Admission

Have you ever worked for United Regional? _________

Still employed? _________

If not employed any longer, please explain? ______________________________________

____________________________________________________________________________

Work and Volunteer Experience;

|Name of Company/Organization |Type of Work |Dates |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

If more experience, please attach a typed sheet.

Background check:

Have you ever been convicted of a felony or misdemeanor, or received deferred adjudication? A conviction will not necessarily automatically disqualify you for admission. Rather, such factors such as date of conviction and seriousness and nature of the crime will be considered. However, false, misleading or incomplete information may likely result in rejection of your application or dismissal from MT school.

NO_________ YES, Explain ________________________________________

Signature of the Applicant Date

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School of Medical Laboratory Science Application for Admission

HEALTH REPORT FOR MT SCHOOL APPLICANTS

Personal History: To be completed by applicant

Family Health Record

Father: Living ____ Deceased _____ Cause of Death _____________________

Mother: Living ____ Deceased _____ Cause of Death _____________________

Student/Employee Health Record

Checks once (x) those conditions you have had. Double check (xx) those you now have.

Acne Headaches, frequent Rheumatism/Arthritis

AIDS Heart ailment Rheumatic fever

Appendicitis Hay fever Scarlet fever

Asthma Hepatitis Sinusitis, chronic

Back complaints Hernia Smallpox

Chickenpox High blood pressure Sore throat, frequent

Cold, Frequent Kidney disorder Tonsillitis

Diabetes Malaria Typhoid fever

Digestive disturbances Measles Venereal disease

Ear infections, frequent Meningitis Varicose veins

Easily fatigued Pleurisy Whooping cough

*Food Allergies Pneumonia

*Other Allergies Polio

*Allergies (food and other)

_________________________________________________________________________

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School of Medical Laboratory Science Application for Admission

Illnesses, Injuries, Surgeries (Please be specific)

Incident Date Degree of Recovery

Handicaps________________________________________________________________

Impediments (speech, color blindness etc.) ____________________________________

Attach your immunization record (see the immunization policy in the packet)

Date of last Diphtheria / Tetanus ____________________________________

The above data is true and correct to the best of my knowledge. I understand it is to be included as part of my application and student record.

Student Signature Date

Data obtained after enrollment

Tuberculin Skin Test ____________________________

Color Blindness Test ____________________________

Survey 8 (Optional) ____________________________

CBC (Optional) ____________________________

Urinalysis (Optional) ___________________________

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School of Medical Laboratory Science Application for Admission

Essential Functions Tasks: School of Medical Technology Applicants

Please sign and return this page with the Application Packet and Health Report.

The other signatures will be obtained after you are accepted into the program.

I have read and do understand this document and agree to abide by its contents.

________________________________________

Student Name

________________________________________ DATE: __________________

Student Signature

________________________________________ DATE: __________________

Medical Advisor, School of Medical Technology

________________________________________ DATE: __________________

Laboratory Director, URHCS Laboratory

________________________________________ DATE: __________________

Program Director, School of Medical Technology

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