Dear Interested Applicant, - United Regional Health Care ...
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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 |
| | | | | | |
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| | | | | | |
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 |
| | | |
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| | | |
| | | |
| | | |
| | | |
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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