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Surgical Technology

(Program is located in the)

Charlie Wells Law Enforcement and Allied Health Building

5540 Lakewood Ranch Boulevard

Bradenton, FL 34211 Deb Kinley, Program Sec’y PH (941) 752-8100 x 2008 FX (941) 209-6212

(Counselor is located in the)

Richard Conard Medical Dental Building

5520 Lakewood Ranch Blvd. Bradenton, FL 34211 Kathy Matthews, Program Counselor

PH: (941) 752-8100 x 2127 FX: (941) 209-6215

Email: matthewsk@manateeschools.net

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No employee, student, applicant for admission or applicant for employment, volunteer, vendor, or member of the public, shall,

on the basis of race, color, national origin, sex, gender orientation, disability, marital status, age, religion, or any other basis

prohibited by law, be excluded from participation in, be denied the benefits of or be subjected to discrimination or

harassment under any educational programs, activities, services, or in any employment conditions, policies or practices

conducted by the School District of Manatee County. Please note: Classes that do not meet minimum enrollment requirements may be cancelled or postponed. All fees associated with this application process are non-refundable.

*If you do not register for the program that you are applying for, admission documents will be shredded 30 days after course start date. If you plan to reapply, you should make arrangements to pick up these documents within this time frame.

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Manatee Technical College – East Campus Surgical Technology Program

1330 hours

COURSE CONTENT The Surgical Technology program is designed to prepare students for employment as Surgical Technologists. The content includes communication and interpersonal skills, legal and ethical responsibilities, medical terminology, anatomy, physiology, pathophysiology, microbiology and pharmacology. In a simulated surgical environment, students practice preparing, setting up and maintaining a sterile field, sterilization and disinfection procedures, preparation of supplies and equipment for surgery, and patient preparation. Clinical experiences in an operating room and related areas are an integral part of this program.

PROGRAM SCHEDULE: Please see current handout.

APPROXIMATE FEES: Please see current handout.

DRUG SCREENING Due to clinical requirements, all students are given a drug screening during the program prior to their clinical rotation. A random drug and/or alcohol test may be given to a student if the safety of anyone is compromised. The student will incur the cost of testing if found to be positive. Positive tests results will be reviewed by administration and disciplinary measures, including possible withdrawal, will be addressed.

ACCEPTANCE The Surgical Technology program class size is limited; if you would like to secure a place in the next available class, please start the application process as soon as possible. Applicants are considered when all the required components are completed and submitted.

All applicants will be informed, by letter, prior to the start of classes of their acceptance. If an applicant is not selected for the upcoming class, he/she must reapply in order to be considered for a later class. Materials in your application packet will be released to you personally for 30 days after the course start date; otherwise, this information will be shredded after 30 days. Background checks will not be released.

INSURANCE Students are strongly encouraged to carry accident insurance. A limited accident insurance plan is provided by the school district to cover students while attending lab/clinicals. Manatee Technical College is not liable for medical expenses if a student is injured.

FINANCIAL AID Available for Those Who Qualify You may qualify for scholarships or grants. To see if you qualify, you will want to contact the Financial Aid office. This office is located on the first floor, north wing of the Law Enforcement/Allied Health Building; information regarding scholarships and grants is available. Processing can take up to six weeks, so applicants should plan ahead. The Financial Aid Specialists may be reached at 752-8100 ext. 2019. All students are encouraged to apply for financial aid early in the process. YOU MUST COMPLETE ALL FINANCIAL AID RESPONSIBILITIES AND OBTAIN ANY DEFERRALS FROM THE FINANCIAL AID OFFICE PRIOR TO THE REGISTRATION DATE.

The website to apply for the PELL grant using the FAFSA form is www.fafsa.ed.gov; the MTC school code is 015496.

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Surgical Technology Program

TRANSFER STUDENTS

Students transferring from other programs within this institution must satisfy the same admissions criteria as for new students. Advanced placement will be awarded to those individuals who have previously completed the Basic Health- care Worker OCP A (90 hours) within two years. You must have an official transcript documenting the completion of the 90-hour Health Science Basic Healthcare Worker OCP A and a grade of 80% or higher. Students transferring from another Florida Technical Institute/College Surgical Technology program should submit a copy of their transcript for review. If qualifications are met, advanced placement may be granted upon furnishing an official transcript from the previous institution and satisfaction of all policies for admission. The Florida Common Course Numbering System will be considered in determining the level of advanced placement for transfer students.

ACCREDITATION Manatee Technical College functions under the Manatee County District School System. The school is an accredited member of the Council on Occupational Education Institutions of the Southern Association of Colleges and Secondary Schools, 41 Perimeter Center East, NE, Suite 640, Atlanta GA 30346, 800-917-2081. The Surgical Technology Certificate Program is accredited through the Commission on Accreditation of Allied Health Education Programs, (1361 Park St., Clearwater, FL 33756, Phone: 727-210-2350, Fax: 727-210-2354, www.caahep.org) allowing students to sit for the Certified Surgical Technologist (CST) examination through NBSTSA.

Please save a copy of all documents for your file.

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Entrance Requirements

1. Attend information session

2. Register online to our school at www.manateetech.edu/apply.html

Then register and pay for the Test of Adult Basic Education (TABE), Survey Test, however, the test

is waived for those with at least an AAS or AA official college transcript or higher from a U.S.

institution.

Minimum scores required:

Reading 10.0 grade level

Math 11.0 grade level

Language 11.0 grade level

The survey test is offered at the East Campus only four days a week, both mornings and evenings. You must pre-

register for the exam at the front desk at the campus where taking the test and pay the TABE. Registration fee by

cash or credit card only. If the test was taken previously, it is valid for two years from the completion date of the

program you are entering. If the test was taken at another institution you must get copies of the test results and

include it in your application packet. The Surgical Technology Program accepts Level A9 or higher levels of the

Survey TABE ONLY. If scores on the TABE are below the required levels, students must be meet with their career

counselor to discuss options, and must be interviewed by the Program Director. Remediation courses are available

and students can re-test when after completing remediation. Students must wait 6 weeks before retaking the same

level/form TABE. It is advised to prepare for the TABE. Please ask for an information/preparation packet when

you sign up to take the test or purchase a TABE preparation textbook at our bookstore. The higher the score on

the TABE the more points awarded toward entry in the program.

3. Complete Program Application Form and pay $40 application fee

4. Copy of High School or GED Transcript

5. 2 -Copies of proof of Florida Residency & completed form

6. Physical Examination The physical must be dated within one year of the course start date. The only physical form accepted is

enclosed within this packet and must be given to the physician for completion.

7. Immunizations

Measles-Mumps-Rubella (MMR) - 2 doses required or titer

Tdap Tetanus/Diphtheria/Pertussis - within the last 10 years

Tuberculosis - 2 negative PPD test results, one must be current

or a current chest x-ray

or a Quantiferon Gold blood test

Varicella (chicken pox) - 2 does required, or blood titer

Hepatitis B Vaccine - 3 doses (Highly Recommended) (Vaccine status disclosure required by several interning facilities)

Acceptable proof includes physician records, school records, or a titer (lab test). If documented proof is not available, immunizations must be retaken, no matter what the age of the applicant.

8. Acceptance into the Surgical Technology Program is contingent upon a clear background check.

This test is completed after you receive your acceptance letter.

9. Self-addressed, stamped envelope.

The application form, high school or GED transcript, residency documentation and TABE score sheet and Clear

background check report must be received within 30 days of the program start date. The physical examination

and immunizations documentation may be turned in as late as the day of the registration. Students will need to

see the program director if they are requesting an extension.

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(Program is located)

MTC – East Campus

Allied Health Building

5540 Lakewood Ranch Blvd.

Bradenton, Florida 34211

Program Sec’y: (941) 752-8100 x 2008

Fax number: (941) 209-6212 (Counselor is located)

MTC – East Campus

Medical/Dental Building

5520 Lakewood Ranch Blvd.

Bradenton, Florida 34211

Kathy Matthew, Career Counselor

Counselor: (941) 752-8100 x 2127

Fax number: (941) 209-6215

Surgical Technology Application

Please Print Clearly Name__________________________________________ Date Submitted__________________ Other name(s) under which records may be listed: _____________________________________ Address________________________________________________________________________ __________________________________________________________Zip____________ Home Phone ____________________________ Work Phone _____________________________ Cell Phone ______________________________ Email address____________________________ Date of Birth______________________ Social Security Number___________________________ Person to contact in case of an emergency: Name ______________________________________ Relationship to you ___________________ Home Phone # _______________Work Phone #_________________Cell phone #_____________ T.A.B.E. Scores: Reading__________ Math _________Language ________Form Taken________ Date T.A.B.E. Taken__________________ Location Taken At_____________________________ Do you have a high school diploma? ____Yes ____No Do you have a GED? ____Yes ____No Do you have a college degree? ___Yes ___No Attach an official copy of the transcript

PLEASE PROVIDE COPIES

___ Apply at the College at

http://www.manateetech.edu/apply.html

Click new application

(You may have already done this to take TABE)

___ TABE Scores (R-10.0; M-11.0; L-11.0)

___ Program Application Form ____ fee receipt $40

___ Residency form & 2 proofs (copies)

___ High School or GED Transcript

___ AS degree or higher for TABE exemption

___ Physical Exam

___ Immunizations:

__MMR___Tdap__PPD___Pox___Hep B

___ Background check receipt $58

___ VECHS Waiver Form

___ Stamped self-addressed envelope

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Additional Information What work experience do you have that relates to this profession? If you have no health experience, list other employment. Employer Duties Employment Dates ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Will you be working while you attend classes? If so, how many hours/week? _________ Will you be able to arrange your work schedule/other responsibilities in order to attend the mandatory eight hour/day Clinical schedule starting as early as 6-6:30 a.m.?_________ Please share your reason(s) for choosing a career in Surgical Technology (attach an additional page, if more space is needed). ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ How did you hear about the Surgical Technology program? _____________________________________ ___________________________________________________________________________________ Have you ever been arrested and/or convicted of any misdemeanors or felonies? If yes, provide a brief statement (please note that additional documentation may be required for review). Being completely truthful is to your advantage. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Signed Statement: I understand that admission to the Surgical Technology program is based on a complete application, satisfaction of basic qualifications and space availability. I also acknowledge that I have read and understand The Criminal Conviction Policy included in this packet. I affirm that the information provided on this application is the truth to the best of my knowledge and that any misrepresentation will be cause for immediate dismissal. ____________________________________________________ Signature of Applicant

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MANATEE TECHNICAL COLLEGE

SURGICAL TECHNOLOGY PROGRAM

PRE-ENTRANCE PHYSICAL EXAMINATION

This section to be completed and signed by applicant.

Name _________________________________________________________ Phone ___________________________________

Address_________________________________________________________________________________________________

Street No. or P.O. Box City State Zip Code

Medical History: Do you now have or have you ever had any of the following:

Condition ………… Yes No Condition ………… Yes No Condition ………… Yes No

Asthma

Epilepsy Tuberculosis

Alcoholism

Fainting Spells Varicose veins

Arthritis

Heart condition High Blood Pressure

Back Trouble

Hepatitis Severe Headaches

Drug dependency/

Addiction

Hypertension Emotional/Psychiatric

Disturbance

Diabetes

Kidney disease Cancer

If you answered “Yes” to any of the above, please give details.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

List any allergies: ________________________________________________________________________________

Have you had any serious injuries or operations? ________________________________________________________

List with approximate dates: ________________________________________________________________________

List any medications taken regularly: _________________________________________________________________

In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery

program or impaired practitioner program _____Yes _____ No

If yes, please explain: _____________________________________________________________________________

In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment?

____Yes ____No If yes, please explain ________________________________________________________

In the last 5 years have you been treated for or had a recurrence of a diagnosed physical impairment? ___Yes ___No

If yes, please explain: _____________________________________________________________________________

In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder? ___Yes ___No

If yes, please explain: _____________________________________________________________________________

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Student/Applicant Signature: ______________________________________________________________________ Applicant Name: Hgt ____________Wgt ____________Blood Pressure______________Temp.__________Pulse___________Resp.___________ Visual Acuity: Right with / without corrective lenses _______________/_________________ Left with / without corrective lenses _______________/_________________ Are there any abnormalities of the following systems? Describe fully on separate sheet and attach

System: No Yes Comments:

1. Respiratory

2. Cardiovascular

3. Gastrointestinal

4. Hernia

5. Eyes/Ears

6. Genitourinary

7. Musculoskeletal

8. Metabolic/Endocrine

9. Neuropsychiatric

10. Skin

Name of examiner: _______________________________________ Phone Number: ___________________________ Address: _______________________________________ City: __________________ State: ___ Zip: ______________ Signature of examiner: ____________________________________ Date of exam__________________________ Physician or Nurse Practitioner

Immunizations Date Given or Results

Signature of Doctor or Nurse

Measles/Mumps/Rubella

1st MMR

2nd MMR

Or Positive Titer (for all 3) with lab report

Tdap-Tetanus/Diphtheria/Pertussis (within last 10 yrs)

Tuberculosis (for health care providers )

PPD Skin Tests #1

PPD Skin Tests #2

OR Quantiferon Gold in tube test

OR statement of negative chest x-ray within 2 years and

statement of “no current symptoms”

Varicella (Chicken pox)

1st varicella

2nd varicella

OR positive titer with Lab report

Hepatitis B (strongly recommended)

NOTE: The Hepatitis B vaccine is highly recommended for the profession for which you are training. Clinical/field internships may expose you to

carriers of the Hepatitis B strain. PROOF OF IMMUNITY:

1) Documentation of immunization will consist of a written dated statement by a physician on this form or on his/her stationary that specifies the date seen and states that the person has had the specific vaccines listed above. All immunizations are required regardless of age.

2) Laboratory (serology) evidence of measles, mumps, rubella and chicken pox immunity would be acceptable Lab report required

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Florida Residency Classification

To receive in-state tuition rates, students must prove that they have maintained Florida residency for at least 12 complete months prior to their first day of school. (See approved documents listed on back).

Dependent or Independent Student? Please check the appropriate classification

_____ I am an independent person and have maintained legal residence in Florida for at least 12 months. A student who meets any of the of following criteria shall be classified as an independent student for the determination of residency for tuition purposes:

1. The student is 24 years of age or older by the first day of classes of the term for which residency status is sought at a Florida institution;

2. The student is married; 3. The student has children who receive more than half of their support from the student; 4. The student has other dependents who live with and receive more than half of their support from the student; 5. The student is a veteran of the United States Armed Forces or is currently serving on active duty in the United States Armed Forces for

purposes other than training; 6. Both of the student’s parents are deceased or the student is or was (until age 18) a ward/dependent of the court; 7. The student is working on a master’s or doctoral degree during the term for which residency status is sought; or 8. The student is classified as an independent by the financial aid office at the institution.

Applicants under age 24 can claim independence with proof of acceptable income and based on strict guidelines from Florida Statues. See: http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=1000-1099/1009/Sections/1009.21.html

_____ I am a dependent person and my parent or legal guardian has maintained legal residence in Florida

for at least 12 months.

_____ I am a dependent person who has resided for five years with an adult relative other than my parent or legal

guardian, and my relative has maintained legal residence in Florida for at least 12 months. (Required: A copy of most recent tax return on which you were claimed as a dependent or other proof of dependency).

_____ I am married to a person who has maintained legal residence in Florida for at least 12 months. I have now

established legal residence and intend to make Florida my permanent home. (Required: A copy of marriage certificate, claimant’s voter registration, driver’s license and vehicle registration). Residence in Florida must be as a bonafide domicile rather than for the purpose of maintaining a residence incident to enrollment at an institution of higher education. To qualify as a Florida resident, you must be a U.S. Citizen or an eligible non-citizen. Living in or attending school in Florida will not, in itself, establish legal residence. Students who depend on out-of-state parents for support are presumed to be legal residents of the same state as their parents.

Person claiming Florida Residency must complete this section and sign.

If student is a dependent, documents and signature must be from a parent/guardian.

Include photocopies of two documents from approved list on back.

Name of student _________________________________________________ Name of person claiming Florida residency __________________________ Relationship to student_________________ I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification as a Florida resident for tuition purposes. I understand that a false statement in this affidavit will subject me to penalties for making a false statement pursuant to 837.06, Florida Statues, and to Rule 6C-7.005 F.A.C.

Signature of person claiming Florida Residency ________________________________________ Date ____________________

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In-State Tuition for MTC Students

State statutes require that all adult students who attend MTC pay for tuition rates based on whether or not the student, or parent/guardian for a dependent student, has resided in Florida for the past 12 months.

What is Proof of Residency?

Two documents are required. At least one (1) must be from First Tier; the second document may also be from First Tier or may be from Second Tier. First Tier

Florida Driver license or State of Florida identification card

Florida voter registration card

Florida vehicle registration

Proof of purchase of a permanent home in Florida that is occupied as a primary residence of the claimant

Transcripts from a Florida high school for multiple years if Florida high school diploma or GED was earned within last 12 months

Proof of permanent full-time employment in Florida (one or more jobs for at least 30 hours per week for a 12-month period)

Second Tier

A Florida professional or occupational license

Florida incorporation

Documents evidencing family ties in Florida

Proof of membership in Florida-based charitable or professional organizations

Utility bills and proof of 12 consecutive months of payments

Lease agreement and proof of 12 consecutive months of payments

State or court documents evidencing legal ties to Florida

Benefit histories from Florida agencies or public assistance programs

Declaration of domicile in Florida (12 months from the date the document was sworn and subscribed as noted by the Clerk of Circuit Court)

Unacceptable Documents that May NOT be Used

Hunting or fishing licenses

Library cards

Shopping club/rental cards

Birth certificate

Passport

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Directions for the

Criminal Background Check

Allied Health Programs

MTC East Campus

Allied Health programs include: Massage Therapy, Medical Assisting, Optometric Assisting, Orthopedic

Technology, Pharmacy Technician, and Surgical Technology Programs.

Due to the externship/clinical requirement of each of the Allied Health programs, Manatee Technical College

requires all Allied Health students to be cleared with a level two, FBI live-scan fingerprinting background check

prior to enrollment. “At Your Service” is the company we use to complete this process.

The cost of $58 is payable directly to At Your Service (there is a $3.00 charge for credit card payments).

You may pay with cash, check, money order, deferral, credit or debit cards (Discover Card is NOT accepted).

At Your Service is at the MTC-East Campus on the second Tuesday of each month from 3:00-6:00 p.m. and on

the third Wednesday of each month from 9:00 am-12:00 noon. They will be located in Room 135 in the Conard

Medical Building. You do not need to make an appointment; please check in at the front desk upon your arrival.

Your application packet will not be submitted to the admissions committee for review until your background

check results are received by MTC.

Complete the paperwork during your appointment time and your results will be electronically sent to MTC. You

will be contacted if your results prohibit you from participation in clinicals, licensure and/or future employment

in the field or if additional information is needed.

Appointment Date: ________________________ Time: _______________

BRING YOUR PHOTO ID TO YOUR APPOINTMENT

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Manatee Technical College Surgical Technology

Background Information/Policy

Criminal Background On your Surgical Technology Application form you will be asked if you have ever been arrested and or convicted of a crime, except for minor traffic violations not related to the use of drugs or alcohol; if you have, you must answer yes. You must submit a self-explanation as to why you are answering yes to this question on a separate sheet of paper. You will need to include any final disposition records for all offenses.

Criminal Background Ineligibility Generally speaking, any felony convictions and/or drug convictions will provide barriers to both clinical placement and employment opportunities in the healthcare field. The hospitals where you complete your clinicals often request a copy of the background check. If we are unable to place you in a clinical rotation, you will not be able to complete the program.

Manatee Technical College Allied Health Program Admission and Retention Policy Admission to the health programs at Manatee Technical College-East requires basic skills and aptitudes necessary for potential success in the chosen field. In addition to the application requirements, applicants must also meet the following conditions for admission.

I. Health Risks To ensure that the applicants career choice will not pose a detriment to his/her physical or mental well-being or be a safety risk factor for the student and/or the patient, each applicant’s Medical History questionnaire will be thoroughly evaluated by the Admissions Committee. A. A medical release will be necessary for certain medications and physical conditions. These conditions that

require a release include, but are not limited to, the following: 1. Back problems 2. Pregnancy 3. Seizure activity 4. Cardiac problems 5. Hypertension 6. Uncontrolled endocrine problems 7. Neuromuscular disorders

B. Students taking any medication that may affect their ability to function optimally while in the clinical/lab/practicum/externship setting placing themselves or their patient(s) at risk will be required to take a medical leave of absence until they are no longer under the influence of the prescribed medication. Student will be readmitted during the next available course/clinical rotation.

C. Students with medical problems must assume all personal liability for their health. D. Please note: students must be able to lift a minimum amount of weight in order to participate in

labs/clinicals (weight limit varies with program-generally 25-50 lbs). E. Most programs/professions require students to stand for long periods of time without a break; manual dexterity (handling small pills or surgical instruments, phlebotomy skills, etc.); and the ability to hear (blood pressure, etc.). If you have any concerns about your ability to perform a particular skill required for program completion, please discuss this with the program director and/or counselor prior to admission.

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II. Chemical Impairment Applicants who have undergone therapy for chemical abuse (including alcohol and drug abuse) will be denied admission or continuation in the program until one full year of stability is documented. A. Any applicant who has been treated or received counseling for drug addiction or abuse, or

excessive alcohol use must: 1. Submit documentation of treatment from the treating agency or physician. 2. Submit a letter of recommendation from the agency or physician granting approval for

admission to the program based on the program requirements. 3. Agree to pre-admission and subsequent drug/alcohol screening (at the students expense),

which must be negative in order to enter or continue in the program. Refusal of screening will result in denial of admission or withdrawal from the program, as applicable.

B. Students who show evidence of chemical impairment, or who are admitted to a facility for alcohol or drug treatment while a student in the program, will be withdrawn. Re-admission into the program will follow guidelines set forth under chemical impairment.

III. Mental or Emotional Illness/Instability Applicants who have been institutionalized or received treatment for emotional or mental illness/instability will be denied admission or continuation in the program until at least one year of stability is documented by a physician or therapist. A. Any applicant who has ever been treated for mental or emotional illness/instability must:

1. Submit documentation of treatment from the treating agency, physician, or therapist. 2. Submit a letter of recommendation from the treating agency, physician, or therapist granting

approval for program admission. Documentation must include the applicant’s ability to handle stress, level of neuromuscular function, and appropriateness of affect. If the student is on any narcotic medication, they may have to take a leave of absence during their clinical rotation if there is any indication that the student and/or patient(s) under the student’s care may be compromised or placed at risk.

3. Agree to follow-up visits with documentation during the course of training, as required. B. Students who are admitted to a facility for treatment of emotional or mental illness/instability or

who show evidence of unstable behavior that may place themselves or others at risk while in the program will be withdrawn. Re-admission will be considered based on documentation of stability from physician or therapist.

IV. Criminal Background Please refer to Senate Bill 1986, Section 456.0635 of the Florida Statutes for additional information regarding guidelines given to the various health care boards regarding licensure, certification or registration.

V. Falsification of Information Failure of an applicant to reveal information or the falsification of information related to chemical impairment, mental instability, arrests, or health risks will be cause for denial of admission to or immediate withdrawal from the program.

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