Division of Health
Surgical Technology Program
2016 Application
The CCC Surgical Technology Program is accredited by Commission on Accreditation of Allied Health
Education Programs (CAAHEP), 1361 Park Street, Clearwater, Florida 33756, phone (727) 210-2350,
www.caahep.org upon the recommendation of Accreditation Review Council on Education in
Surgical Technology and Surgical Assisting (ARC/STSA), 6 West Dry Creek Circle, Suite 110, Littleton,
Colorado 80120, phone (303)694-9262, www.arcstsa.org
Graduates of CAAHEP accredited programs are eligible to sit for the National Certified Surgical
Technologist exam. The CST exam is managed by the National Board of Surgical Technology and
Surgical Assisting (NBSTSA).
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Surgical Technology
2016 Application Process
You are strongly advised to carefully read all application instructions and other information
available on the Surgical Technology website at www.calhoun.edu
If you have a question about the application process or ST program, please verify that it has not been
answered in the FAQ section of the website prior to contacting the Allied Health Department &/or
Program Director.
If not already completed, at least one month before you apply to the ST Program, submit a Calhoun
Community College Application for Admission and request that transcripts of coursework from
previously attended institutions are forwarded to CCC Admissions and Records.
Applicants to the Surgical Technology program must minimally:
•
Meet all admission requirements of Calhoun Community College
•
Possess a high school diploma or equivalent
•
Have completed English Composition I (ENG 101) with a grade of C or >
•
Have completed Medical Terminology (EMS 106) with a grade of C or >
•
Have completed one of the following mathematics courses with a grade of C or >
•
Intermediate College Algebra (MTH 100)
Finite Mathematics (MTH 110)
Precalculus Algebra (MTH 112)
Submit a 2016 Surgical Technology application packet which includes:
o
A completed Personal Information Sheet – pg. 6
o
An unofficial CCC transcript documenting all completed general education
coursework taken at Calhoun or accepted in transfer
o
A completed General Education Points Worksheet – p. 7
o
A ST Program Information Video Q & A Sheet – p. 8 - completed after viewing
the online video posted on the CCC ST Program webpage.
o
A 1-2 page typed essay which discusses why you are interested in a career as
a Surgical Technologist.
o
Signed and dated Statements of Understanding – pp. 9-13
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Surgical Technology
2016 Application Process
Meeting minimal admission requirements does not guarantee acceptance. The number of students
enrolled in the Surgical Technology program must be limited and therefore the application process is
competitive. All applications are evaluated by the Surgical Technology Admissions Committee and
assigned a score based solely on the defined point system. Points are awarded on the basis of the
information included in the application packet.
Applications to begin the ST program August 2016 must be received no later than Tuesday, May 24th,
2016 at 3:00 PM to be considered. Incomplete applications are not considered. An application packet
can be mailed or delivered in person to the Allied Health Secretary on the third floor of the Health
Sciences Building, Decatur campus but must be received by the deadline date and time. Information
cannot be accepted via fax or by email. Applications will not be accepted past the deadline.
Persons who meet the minimal admission requirements will be invited to take a manual dexterity test
in early June as a component of the application scoring system. The Surgical Technology Admissions
Committee will meet in late June. An invitation to enroll in the ST program will be sent to the 28
students with the highest application score. In the event of a tie, the date an application was submitted
will determine the selection for admission.
All applicants will be notified by mail of admission status into the ST Program. Letters will be mailed to the
address provided by the applicant.
Estimated Program Costs (in addition to tuition):
Malpractice insurance (per year) . . . . . . . . . . . . . . . . . . . . . . . . . $10.00
Drug Screen / Background Check / Credentialing Service . . . . . $100.00
Textbooks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600.00
Health exam, immunizations, PPD test . . . . . . . . . . . . . . . . . . . . . varies
CPR course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . varies
Uniforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200.00
NBSTSA Practice Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00
Certification Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $265.00
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CCC SURGICAL TECHNOLOGY PROGRAM
APPLICATION POINT SYSTEM
NOTES / HELPS
→ No points will be awarded unless an unofficial transcript from
the CCC Admissions Office is included in the application packet
→ A copy from MYCALHOUN is “OK”; your name should appear
on the transcript
→ It is the applicant’s responsibility to make certain all relevant
courses and the grade earned is noted on the transcript
→ Highlight completed courses & grades on the CCC transcript
that you are claiming for application points
→ If you have taken more than one of the prerequisite math
courses (MTH 100, 110, 112) highlight the one with highest
grade
→If you have taken more than one speech course &/or ENG II,
highlight the one with the highest grade
→ A list of courses that qualify as a HUM requirement can be found
in the CCC Catalog, p. 41
→ Do not submit transcripts from other colleges with the
ST application
1. General education
coursework
70 points
possible
2. Essay
10 points
possible
→ Applicants should conduct online research about the field of
surgical technology and read the career information found at
http://www.ast.org/AboutUs/About_AST/
→ The essay should be 1-2 pages in length
→ The essay should be typed with standard margins, spacing, and a
standard font.
→ The essay should discuss, in your own words, surgical technology
as a healthcare field and why you are interested in a career as a
ST
3. Online
information
session
10 points
possible
→Applicants should view an informaƟonal video found on the
ST program website
→After viewing the video, answer the 10 questions in the ST
Program Information Video Q & A Sheet and include the
sheet in the application packet
4.Manual dexterity
exam results
10 points
possible
→ Eligible applicants will be invited to sit for a manual dexterity
test in June 2016
Total = 100 application points possible
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Surgical Technology Program
Application Envelope Checklist
To be considered complete, an application packet must include all of the following documentation in
ONE ENVELOPE:
□
ST Application Personal Information Sheet, page 6
□
ST Application General Education Points Worksheet page 7
□
An unofficial copy of a Calhoun Community College transcript. Do not submit
transcripts from other colleges with the ST Application. The CCC transcript
should include all coursework taken at CCC and at other colleges and accepted in
transfer. The Admissions Office should be contacted with questions regarding
the transfer of credit. Coursework taken at other educational institutions must
be evaluated and accepted by CCC Admissions and Records to be considered. It
is the applicant’s responsibility to make certain all relevant coursework and the
grade earned is listed on the CCC transcript.
□
ST Application Program Information Video Q & A Sheet page 8
□
1-2 page type written essay discussing the field of surgical technology and your
career interest.
□
ST Application Statements of Understanding pages 9-13, dated and signed.
Documentation should be complete, legible, and all aforementioned forms must be included in the
application packet. Applications missing the required documentation will not be considered. PLEASE
DO NOT STAPLE FORMS OR OTHER DOCUMENTATION.
Each time an individual applies to the ST program an application packet must be completed in its’
entirety; copies of items submitted should be retained as information will not be released from
previous application packets.
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Surgical Technology Program
Personal Information Sheet
An application to begin ST Fall 2016 must be received by 3:00 PM on Tuesday, May 24th, 2016. An
application packet may be mailed or delivered in person to the Allied Health Secretary on the third
floor of the Health Sciences Center, Decatur campus.
PLEASE PRINT
Name ________________________________________
Last
Mailing
Address________________________________________
________________________________________________
First
MI
City_____________________________________________
State_______________________ Zip__________________
Home Phone____________________________________
Cell Phone______________________________________
Email____________________________________________
Work Phone_____________________________________
C#______________________________________________
List all colleges and/or universities you have attended and any degrees received:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Mailing address:
Calhoun Community College
Health Sciences Center – Surgical Technology Program
ATTN: Allied Health Secretary
P.O. Box 2216
Decatur, AL 35609
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Name of Applicant: ___________________________________________
Surgical Technology Program
General Education Points Worksheet
Record the grades for general education courses you have completed and assign points for the grade earned.
If a course has not been completed or a grade of D or lower was received, zero points should be entered.
Points will not be awarded if the course & grade is not HIGHLIGHTED on an enclosed CCC transcript.
Course Name and Number
BIO 201 Human Anatomy & Physiology I
BIO 202 Human Anatomy & Physiology II
ENG 101 English Composition I
Mathematics Elective: (MTH 100, 110, 112)
PSY 200 General Psychology
PSY 210 Human Growth & Development
SPH 106/107/116 Speech Elective or English
Composition (ENG 102)
Humanities Elective: Art, Music, Foreign Language,
Literature, Philosophy, Religion, Theatre
EMS 106 Medical Terminology for Health Professions
Possible Points
Letter
Grade
Points
Earned
Office only:
course / grade
highlighted?
A=15 points
B=10 points
C=5 point
A=15 points
B=10 points
C=5 point
A or B = 5 points
C=3 points
A or B = 5 points
C=3 points
A or B = 5 points
C=3 points
A or B = 5 points
C=3 points
A or B = 5 points
C=3 points
A or B = 5 points
C=3 points
A or B = 10 points
C=5 points
TOTAL=
(MAXIMUM GENERAL EDUCATION POINTS = 70)
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Surgical Technology Program
Program Information Video - Q & A
Applicant Name: _______________________________________________________________
1. List the three roles in which a surgical technologist functions.
2. Under which role does a surgical technologist hold retractors or instruments as directed by
the surgeon?
3. Through which organization is the Calhoun Community College Surgical Technology Program
accredited?
4. How long must a surgical technology student be able to refrain from nourishment or
restroom breaks?
5. A surgical technologist typically is required to return to work in ______ minutes or less when
on call.
6. What two completion options are offered by the Calhoun Community College Surgical
Technology program?
7. When will manual dexterity exams be completed?
8. When will invitations be sent to the top 28 applicants to enroll in the program?
9. Can a student progress in the program if they fail to meet minimum competency for skills?
10. Students must be able to be at a clinical site by ______ AM and must be able to remain at a
clinical site until _______ PM.
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Surgical Technology Program
Statements of Understanding
1.
Liability Release
I, _________________________, hereby acknowledge that I am eighteen years of age or older, or that if I am
under the age of eighteen I am signing this release with the written consent of my parent(s) or legal
guardian(s). I further acknowledge that I fully understand the contents of this release and that I am signing it
voluntarily.
As a student or a prospective student of the Surgical Technology Program at Calhoun Community College, I am
aware of the risk of personal illness and/or injury which are inherent in my participating in ST educational
activities.
Upon full awareness and consideration of the risks which I assume in participating in hospital or other clinical
rotation activities, I hereby agree to release Calhoun Community College and its instructors, officials, agents,
representatives, preceptors, and employees from any liability for any type of illness or injury which is incurred
during a period in which I am participating in clinical or laboratory activities.
_________________________________________
Student signature
Date
_________________________________________
Parent or guardian signature
If < 19 years of age
2.
Date
Statement of Understanding of Policy
I, _________________________, agree to abide by rules and policy set forth by the ST program and all clinical
affiliates that I visit during the course of my studies. I realize that I have access to and a personal obligation to
become aware of these rules. I have also been advised and hereby indicate my understanding that ST program
policy requires a 75% or better average in all coursework in any primary SUR course.
________________________________________
Student signature
Date
9
3.
Surgical Technologist Program Admission, Progression, and Graduation Contract
1.
I understand that all information in the ST Program Application is subject to verification prior to admission to
the program. Falsification and/or omission of information on the College and/or ST application shall be
grounds for dismissal from the program in accordance with College procedures.
2.
I understand that enrolled students in healthcare programs are required to submit to a background check and
drug screening by a vendor designated by the College to comply with clinical affiliate contracts. I understand
that the background check &/or a confirmed positive drug screen may render me ineligible to participate in
required learning experiences at clinical affiliates because I will be denied access. In this event, I understand
that I will be dismissed from the program and a grade of “F” will be recorded for course(s) if I do not officially
withdraw.
3.
I understand that enrolled students in healthcare programs are required to submit to a preclinical health
examination by a licensed physician or CRNP and to provide documentation of immunization to certain
communicable diseases and to undergo tuberculosis screening.
4.
I understand that I will be required to submit evidence of current CPR certification, a liability release, and must
purchase malpractice insurance by a deadline provided by faculty prior to clinical education experiences.
5.
In the clinical portion of the ST Program, I understand that I must attend scheduled clinical rotations according
to the program’s clinical rules and regulations. Failure to comply fully with these will result in my receiving a
lower grade or being ineligible to complete my clinical training due to my non-compliance. I agree to read and
know the Program’s Clinical Practice Policies and Procedures outlined in the ST Student and course syllabi
before entering any clinical area.
6.
I understand that I am required to abide by the rules and regulations of the clinical agency in which the clinical
component of each course is performed. Failure to do so will result in dismissal from the program and a grade
of “F” for the course assigned in accordance with College procedures.
7.
I understand that the clinical agency with which the program is affiliated has the right to request that a student
be removed from their facility, as well as the right to refuse a student admission to their facility for clinical
education.
8.
I understand that evaluation materials, i.e., clinical evaluations with instructor notations and counseling forms,
will be maintained in my student folder. I understand that upon my request, I have the right to see any
information that is retained in my student folder.
9.
Due to the nature of the training received in the ST Program, I understand that there are risks in demonstrating
or receiving return demonstration in practical application of skills in the classroom segment. I also understand
that there are certain risks involved in completing clinical rotations with clinical affiliates of the ST Program at
Calhoun Community College. I fully understand that I am not required to involve myself in any activity that, in
my opinion, would be potentially dangerous to me. I will not hold Calhoun Community College, any of its’
employees, or other ST students, any clinical instructor, or any ST Program Clinical Affiliate responsible for any
injury occurred as a result of 1) any classroom practical application or 2) performing clinical rotations.
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10. I understand that during my ST education that I will come in contact with infectious diseases. I further
understand that my health and accident insurance and/or expenses are my responsibility.
11. I understand that I am responsible for transportation, meals, health care expenses and any liability incurred
during and while traveling to and/or from educational experiences.
12. I certify that I am of good moral character and that I have no known physical or mental difficulties that would
prevent me from completing this training program.
13. I understand that failure to comply with all legal requirements of the profession and the Codes of Ethics of the
Association of Surgical Technologist constitute grounds for dismissal from the program, regardless of course
standing. A grade of “F” will be assigned for any ST course from which the student is dismissed for
unacceptable behavior.
14. I understand that the rules above apply to me in any ST course I should take in the Surgical Technology
Assistant Program through Calhoun Community College, at the present or in the future.
15. I understand that a student may be readmitted to a surgical technology course one time following a failure of
or a withdrawal from a SUR course. Students who return following a failure are considered to be using their
second and final opportunity to complete the ST program. Requests for readmission will be considered
competitively with new applications and is not guaranteed.
16. I understand that it is my responsibility to read the College Catalog, each course syllabus, clinical evaluation
forms and other materials that are provided to the class which outline my responsibilities as a ST student. I
understand that failure to abide by these published materials will be grounds for dismissal from the program.
I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND THAT THE CRITERIA STATED HEREIN AND IN THE
COLLEGE CATALOG APPLY TO ME AND THAT FAILURE TO ABIDE BY ANY STATED CRITERIA IS GROUNDS FOR
DISMISSAL.
_____________________________________________
Printed student name
_____________________________________________
__________________________
Student signature
Date
11
4.
Statement of Understanding of Clinical Studies Component
As a student enrolling in a clinical studies component of the Surgical Technology Program at Calhoun
Community College, I am aware that:
1. I will be enrolled in a clinical course that requires my presence at one or more health care facilities;
2. I am not an employee of the College or of the health care facility and if I am an employee of the College or
of the health care facility I must notify the ST Program Director at the beginning of my ST education
coursework at Calhoun Community College;
3. I do not expect and will not receive compensation from the College or health care facility for participation
in the clinical course; and
4. I have not been promised and do not expect to be offered a job at the health care facility as a result of
participation in the clinical course.
5. I may be required by the hospital/clinical site to undergo drug and/or alcohol testing at any time as a
precondition to beginning a clinical rotation or to continue a clinical rotation at the hospital/clinical site.
6. I will be required to purchase medical malpractice Insurance at an approximate cost of $20.00. This fee will
be added to my class tuition the semester of my first clinical experience. If I am attending classes on loans
or grants, which do not pay this fee, I will contact the Allied Health secretary immediately to arrange
payment prior to beginning clinical rotations.
____________________________________________
Student signature
5.
Date
Information for ST Applicants:
I understand that completion of this application is a component of the student profile and does not in itself
grant admission to the Surgical Technology Program. I understand I must submit a new application if I am not
selected and choose to apply in the future. I certify that the information given in this application is true and
correct. I understand that providing false information may be deemed sufficient reason to dismiss a student
and/or refuse admission.
Minimum admission standards include:
1. Unconditional admission to the college
2. Completion of ENG 101 and EMS 106 and MTH 100, 110, or 112 – all with a grade of C or >
3. Receipt of a completed ST Program Application Packet
4. An unofficial CCC transcript documenting all courses and grades taken at Calhoun &/or accepted in transfer
5. An ACT or COMPASS reading score from the past three years
Admission to the Surgical Technology Program is competitive, and the number of students is limited by the
number of faculty and clinical facilities available. Meeting minimal requirements does not guarantee
acceptance.
______________________________________________
Student signature
Date
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6.
ST Program Essential Functions
The purpose of the Essential Functions is to delineate the cognitive, affective and psychomotor skills deemed minimally
necessary for admission, progression, and graduation and for the provision of safe and effective patient care as a
Surgical Technologist. If a student cannot demonstrate the following skills and abilities, it is the responsibility of the
student to request appropriate accommodations through the Office of Disabled Students.
a.
b.
c.
d.
Able to stand, bend, stoop, and/or sit for long periods of time in lone location with minimum/no breaks.
Able to lift a minimum of 30 pounds.
Able to refrain from nourishment or restroom breaks for periods up to six (6) hours.
Demonstrate sufficient visual ability enough to load a fine (10-0) suture onto needles and needle holders
with/without corrective lenses and while wearing safety glasses.
e. Demonstrate sufficient peripheral vision to anticipate and function while in the sterile surgical environment.
f. Hear and understand muffled communication without visualization of the communicator’s mouth/lips and
within 20 feet.
g. Hear activation/warning signals on equipment.
h. Able to detect odors sufficient to maintain environmental safety and patient needs.
i. Manipulate instruments, supplies and equipment with speed, dexterity, and good eye-hand coordination.
j. Ambulate/move about without assistive devices.
k. Able to assist with and/or lift, move, position, and manipulate the patient who is unconscious with or without
assistive devices.
l. Communicate and understand fluent English both verbally and in writing.
m. To be free of reportable communicable diseases and chemical abuse.
n. Able to demonstrate immunity (natural or acquired) to rubella, varicella, and Hepatitis B or willing to sign a
waiver of release of liability. Able to demonstrate being free of active or latent tuberculosis and provide
documentation of current vaccination to influenza.
o. Possess short- and long-term memory sufficient to perform tasks such as, but not limited to, mentally tracking
surgical supplies and performing anticipation skills intraoperatively.
p. Able to make appropriate judgment decisions.
q. Demonstrate the use of positive coping skills under stress.
r. Demonstrate calm and effective responses, especially in emergency situations.
s. Exhibit positive interpersonal skills during patient, staff, and faculty interactions.
I have reviewed the Essential Functions for the Surgical Technology Program.
________________________________________
Student signature
Date
Title III of the 1990 American with Disabilities Act provides comprehensive civil rights protection for “qualified
individuals with disabilities. The Alabama College System endorses the Americans’ with Disabilities Act. If you have a
disability that might require special materials, services, or assistance, please contact Calhoun’s Disability Services Office
in the Chasteen Student Center, Room 218 (Decatur Campus) or call (256) 306-2630 or (256) 306-2635.
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SURGICAL TECHNOLOGY
Certificate Plan = 44 credits
Semester 1
ENG 101
EMS 106
Math Elective
(1)
Semester 2
SUR 100
SUR 102
SUR 107
SUR 108
Semester 3
SUR 103
SUR 104
Speech Elective
or English
Composition
Semester 4
SUR 105
SUR 106
SUR 204
English Composition I
Medical Terminology
MTH 100 – Intermediate College Algebra
MTH 110 – Finite Mathematics
MTH 112 – Precalculus Algebra
Total =
3 credits
2 credits
3 credits
8 credits
Total =
5 credits
4 credits
3 credits
2 credits
14 credits
Total =
5 credits
4 credits
3 credits
12 credits
Total =
5 credits
1 credits
4 credits
10 credits
Total =
1 credit
3 credits
2 credits
4 credits
3 credits
13 credits
Total =
4 credits
3 credits
3 credits
3 credits
13 credits
Total =
5 credits
4 credits
3 credits
2 credits
14 credits
Total =
5 credits
4 credits
3 credits
12 credits
Total =
5 credits
1 credits
4 credits
10 credits
Principles of Surgical Technology
Applied Surgical Techniques
Surgical Anatomy and Pathophysiology
Pharmacology for the Surgical Technologist
Surgical Procedures
Surgical Practicum I
SPH 106 – Fundamentals of Oral Communication
SPH 107 – Fundamentals of Public Speaking
ENG 102 – English Composition II
Surgical Practicum II
Role Transition in Surgical Technology
Surgical Practicum III
Associate of Applied Science Degree = 62 credits
Semester 1
ORI 100
ENG 101
EMS 106
BIO 201
Math Elective
Semester 2
BIO 202
PSY 200
Speech Elective
Humanities
Elective
Semester 3
SUR 100
SUR 102
SUR 107
SUR 108
Semester 4
SUR 103
SUR 104
PSY 210
Semester 5
SUR 105
SUR 106
SUR 204
Freshman Seminar
English Composition I
Medical Terminology
Human Anatomy & Physiology I
MTH 100, 110, or 112
Human Anatomy & Physiology II
Introduction to Psychology
SPH 106, 107 or ENG 102
Art, Music, Foreign Language, Literature, Philosophy,
Religion, Theatre
Principles of Surgical Technology
Applied Surgical Techniques
Surgical Anatomy and Pathophysiology
Pharmacology for the Surgical Technologist
Surgical Procedures
Surgical Practicum I
Human Growth and Development
Surgical Practicum II
Role Transition in Surgical Technology
Surgical Practicum III
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