Medical Laboratory Science Program Application Procedure Application form Complete the enclosed “Application for Admission and Essential Functions Acknowledgement Statement” and submit it to: Morristown Medical Center Department of Pathology and Laboratory Medicine 100 Madison Avenue - Laboratory, Box 17 Morristown, New Jersey 07960 Attention: Program Director

Transcripts Official transcripts of all college-level course work must be submitted to the office of the program director. For degrees in progress, transcripts should minimally include courses completed through the sophomore year of study (for 3+1 students only). For students that have completed an undergraduate degree(s), all transcripts must be submitted as part of the application process.

References Three references are required from college professors, teachers, instructors, and guidance counselors who are familiar with your academic performance. The enclosed recommendation forms are to be used by individuals submitting references.

Interview Once the application and supporting credentials are reviewed and admission requirements are evaluated, the applicant will be contacted to schedule a personal interview, only if the applicant meets the initial requirements for admission. Interviews are scheduled during the months of October and November.

Application Deadline Applications and supporting credentials must be submitted to the program by October 1 for admission the following May. Applications received after October 1 will be acted upon at the discretion of the program director, only if time permits an adequate review of credentials and if space is still available.

Non-Refundable Application Processing Fee Applicants are required to pay a non-refundable application fee of $100.00, which MUST be a money order or certified bank check, payable to Morristown Medical Center - Medical Lab Science Program. The application fee must be submitted with your packet for your application to be processed and evaluated for admission to the program.

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Department of Pathology and Laboratory Medicine 100 Madison Avenue - Laboratory, Box 17 Morristown, New Jersey 07960 Attention: Program Director

APPLICATION FOR ADMISSION Please Print Clearly:

Name: ________________________________________________________________________ Last

First

Middle

Permanent address: ______________________________________________ Street Address

___________________________________________________ City

State

Zip Code

Current/ School Address: (if different from home address) ____________________________________________________ Street Address

____________________________________________________ City

Telephone: Home (

State

) ______________ Cell (

Zip Code

) ______________

Social security #: ___________________

Email address _________________________________________________

United States Citizen: _________Yes _________No If No, you must provide proof of Permanent Residency Status (J-1 Visa) to be considered for admission. Language: Is English your first language? _______yes ______no If you answered “No” above: Have you taken the TOEFL (Test of English as a Foreign Language) ______yes ______ no Month/Year Taken ____________

Score _________________

Have you been convicted of any criminal violation of law, or are you now under pending investigation or charges of violation of criminal law. If yes, explain _______yes _______ no

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EDUCATION: List the colleges/universities you have attended beginning with the current or most recent. Institution

Attended from to

Credits

Major

Graduation date

Please obtain official transcripts from each college/ university you have attended and submit them with the application in a sealed envelope. If you are taking classes to meet entrance requirements, list the classes you are currently enrolled in and /or those you plan to enroll in for the next semester. Current Classes

Planned Classes

EMPLOYMENT HISTORY: List the positions you have held in chronological order beginning with the current or most recent. Employer

Position

Dates from to

REFERENCES: List the names and positions of two science instructors who have agreed to submit recommendations on your behalf. Both of these people should be familiar with your academic performance. Name

Are you currently certified as a MLT?

Title/Position

Yes

no

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Briefly describe your reasons for pursuing a degree or certification in clinical laboratory science. Include specific reasons for selecting this field of study and a statement of your current career goals. Please neatly print your essay.

I certify that the information contained in this application is true. I further understand that falsification of information or incomplete statement herein will result in cancelation of this application. I agree that examination and verification of employment or previous education, except as it pertains to age, race, gender, sex, color, creed, national origin, marital status or disability, may be made and used relative to my application status. I therefore authorize investigation of all statements on this application is complete and accurate.

Applicant Signature: _____________________________________

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Date:

____________________

Essential Functions Acknowledgement Statement Applicants who accept a position in Atlantic Health System’s Medical Laboratory Science Program should do so with a clear understanding of the functional expectations of the program. The student must be able to fulfill these expectations in order to successfully complete this program. You are asked to read the following essential functions and determine whether you can perform these functions to complete the program. Students of the Medical Laboratory Science Program are expected to: - possess vision which allows the student to:  Read typewritten text from hard copy and computer monitors  Discriminate color in order to identify reagents/media, physical properties of specimens, and cells or organisms by microscopic examination. - read, write, and communicate verbally with staff and patients in the English language     

- possess manual dexterity as required in tasks such as: performing venipuncture operating delicate analytic instruments handling small containers of bio hazardous substances (1” X1”) using measuring devices focusing and manipulation of a microscope

- traverse hospital and laboratory corridors, spaces, and doorways (minimum 3’ width) - adjust to changes in environment to accommodate distractions such as moderate noise and activity in the work environment. - travel to supplemental rotation sites.

I have read and understand the essential functions required and listed above for the completion of the Medical Laboratory Science Program.

________________________________ ______________ Applicant signature

Date

____________________________________ Applicant Name (PRINTED)

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Medical Laboratory Science Program Letter of Recommendation Section above the double line to be completed by the applicant ______________________________________ Name of applicant

has requested that this recommendation be completed as part of his/her application for the program in clinical laboratory science at the facilities of Atlantic Health System.

I am aware of my right to inspect letters of recommendation under Title IV of Public Law 90-247. I

waive

do not waive my right to inspect this recommendation.

Please complete both sides of this form. How long have you known the applicant and in what capacity? _______________________________________________________________ _______________________________________________________________ Please evaluate the applicant in each of the areas listed below using the following scale: 3 = superior, consistently exceeds minimum requirements 2 = above average, meets and occasionally exceeds minimum requirements 1 = average, meets minimum requirements 0 = below average, unable to meet minimum requirements N/A = did not observe, unable to evaluate 3 1. Classroom performance 2. Laboratory performance 3. Verbal expression of ideas 4. Written expression of ideas 5. Emotional maturity 6. Ability to work with others 7. Ability to work independently 6

2

1

0

N/A

Please comment on the applicant’s potential for success in a clinical curriculum. Include, as appropriate, the applicant’s demonstrated interest in health care, technical and problem-solving skills, and academic achievement.

__________________________________________________ Signature and Title

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_______________ Date