Application Form


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Application Form

  1. 1. UW-LA CROSSE NUCLEAR MEDICINE TECHNOLOGY Program Admission Application PLEASE TYPE -OR- PRINT IN INK Date:       Name:                   Last First Middle/Maiden Current Address:             Number and Street City/State/Zip Permanent Address:             Number and Street City/State/Zip Current Phone: (     )       UW-L Student ID:       Date of Birth:       Social Security Number:       email:       In Case of Emergency, Please Notify:             (     )       Name Relationship Phone Work Experience Give employment history starting with the most recently held job: Company Position Held Dates Employed (Month/Year)             from:       to:                   from:       to:                   from:       to:                   from:       to:       Please describe any volunteer experiences. Where appropriate give the name of the organization, the estimated amount of time you devoted, and the approximate dates of the experience.                         NMT Program Admission Application, Page 1 of 4
  2. 2. Formal Education College/University Location Dates (Month/Year) Degree             from:       to:                         from:       to:                         from:       to:             Pre-Internship Curriculum Identify courses as completed (C), in progress (I), or not planned (NP). For the remaining courses, indicate when you plan on taking the course (e.g. F11, Sp12) Specify course number and credits for “Others”. Biology Credits Physics Credits       General Biology 4       Fund. Physics or Phys. for Life Sci. 4       Human Anatomy and Physiology I 4       Introduction to Nuclear Science 2       Human Anatomy and Physiology II 4       Others:                   Radiation Biology 3       Others:             Mathematics Credits       College Algebra 4 Chemistry Credits       Elementary Statistics 4       General Chemistry I 5       Others:                   General Chemistry II 5       Intro. to Biochem & Org. Chem. 3 NMT Credits       Analytical Chemistry 5       Introduction to NMT 1       Nuclear Chemistry 4       Cross-Sectional Anatomy 2       Others:                   Immunology for NMT 1 Sociology Credits Health Education and Health Promotion Credits       The Social World or Social Problems 3       Medical Terminology for Health Education 1       Health Care/Illnes or Death-Greif-Brevmt 3       Others:             Health Professions Credits       Pathophysiology 3 What other courses (in particular, general education or courses for a minor) do you need to take before beginning your internship? Please indicate when you plan to take each course.       Considering the remaining courses listed above, and the 12-month internship, when do you plan on graduating? (e.g. Summer 2013)       NMT Program Admission Application, Page 2 of 4
  3. 3. Original Composition Please give an explanation of how you became interested in pursuing a career in Nuclear Medicine Technology. In your explanation try to include: (i) the reasons why you chose NMT (ii) why you think NMT will be a good career for you (iii) a description of your professional goals, and (iv) what reservations (if any) you have concerning pursuing a career within the profession. Please feel free to include any pertinent biographical information. Your responses should be typed, single-spaced, well written, and limited to the space available on this page.       NMT Program Admission Application, Page 3 of 4
  4. 4. References List three people from whom you intend to solicit recommendations. One should be someone who has instructed you in a laboratory section, another should be an employer or co-worker (past or present) and the third is your choice. Reference Number 1             Name/Title Institution/Address Reference Number 2             Name/Title Institution/Address Reference Number 3             Name/Title Institution/Address A candidate for the Nuclear Medicine Technology Program should be able to speak, to hear and to observe patients in order to elicit information, and to perceive nonverbal communications. A candidate must be able to communicate effectively and sensitively with patients. Communication includes not only speech, but also in reading and writing. The candidate must be able to communicate effectively and efficiently in oral and written form with all members of the health care team. A candidate should be able to execute motor movements reasonably required to provide general care and emergency treatment of patients. This includes the ability to turn and maneuver the patient and to administer radiopharmaceuticals or other intravenous medications. The candidate must be able to operate imaging equipment including computers. Such actions require coordination of both gross and fine muscular movements, equilibrium and functional use of the senses of touch and vision. A candidate must possess the intellectual skills, (a minimum GPA of 2.50, and a grade of ‘C’ or higher in all NMT courses are required), emotional health and stability required for the full utilization of his or her intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities attendant to the care of patients. Compassion, integrity, concern for others, interpersonal skills, interest and motivation are all personal qualities that are assessed during the admissions and educational processes. I understand that upon successful completion of the Nuclear Medicine Technology program, I will be eligible to take a national certification examination in the profession. Two certification examinations are available in Nuclear Medicine Technology; one offered by American Registry of Radiologic Technologists (ARRT) and the other by Nuclear Medicine Technology Certification Board (NMTCB). I agree to take at least one of these examinations and to provide my scores to the UW-L NMT Director. Eligibility for the ARRT examination requires that the candidate be of "good moral character". Conviction of a misdemeanor or felony may indicate a lack of good moral character for ARRT purposes. ARRT pre-application review procedures allow individuals who are not yet enrolled in an educational program to determine if a conviction would interfere with their later certification exam eligibility. The NMTCB is dedicated to the promotion of safe, competent medical care for any and all individuals. To that end, the NMTCB processes and evaluates applications for NMTCB certification, administers certification exams and monitors adherence to legal and ethical standards, including but not limited to the Code of Ethics of the Society of Nuclear Medicine Technologist Section. Also, in 1998 a Caregiver Law went into effect in the state of Wisconsin. This law requires that hospitals and clinics in Wisconsin have background disclosure forms and criminal background checks on all employees and students (interns) that work with patients. If this is a concern for you please contact the NMT Program Director at UW-L, for further information. Internships are determined by the hospitals or clinics, not by the university. I agree to apply to each of the internship sites that I would like to attend (The Mayo Clinic has a GPA requirement of 2.75 while the others are 2.50). Furthermore, I agree to accept an internship at any of the sites if offered. I understand, however, that I will be able to rank the internship sites that the University of Wisconsin-La Crosse is affiliated with, and that every effort will be made to place me into one of my higher ranked sites. I acknowledge that the information I have supplied in this application form is truthful and, to the best of my knowledge, correct and I understand that any falsification of the information on this form may be considered as just cause for my rejection as an applicant to the NMT program. I authorize the UW-L NMT Selection Committee to review a current copy of my academic records as part of this application. I further authorize the UW-L NMT Selection Committee and the Program Directors of any of the Nuclear Medicine Technology Hospital affiliates to verify my employment and academic history. I also authorize the institutions of higher education that I have attended to supply any information regarding my association with them that the Selection Committee or the Program Directors of the affiliate hospitals desire. I further release members of the Selection Committee and the Program Directors of the affiliate hospitals from any liability associated with their review and associated investigations of my application materials. Finally, I will accept the Selection Committee’s decisions. Applicant’s Signature Date NMT Program Admission Application, Page 4 of 4