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University of West Florida
Clinical Laboratory Sciences Program
Selection into the Clinical Year Application
1. Submit application materials by February 7, (or June 6 for summer starters) to:
Victoria Dubose, Office Administrator vdubose@uwf.edu
Clinical Laboratory Sciences Program Building 58
University of West Florida
11000 University Parkway
Pensacola, Fl 32514
2. Complete the Application for Selection into Clinical Year found at https:sites.google.com/a/uwf.edu/cls-clinical-yearstudents/. If you are not currently a student at The University of West Florida, complete the Application for Admission to
The University of West Florida and submit required documentation. Download and save the file to your H drive. Type
directly into the form. Email the completed form to vdubose@uwf.edu. You must include a scanned copy of your
immunization record.
3. Using the Reference Forms in the application packet, request three (3) letters of recommendation. Two letters must be
from academicians and one from an employer or someone (not a relative or friend) who knows you personally.
References may be mailed to the address above, or emailed to vdubose@uwf.edu
4. If you are not currently enrolled at UWF, forward official transcripts for all colleges and universities you have attended
directly to the Program Director (in addition to the UWF Office of Admissions).
5. If you are already at UWF, by now you should have completed all the prerequisites and are taking Hematology and
Diagnostic Micro I (and Immunology) in Spring semester. If you are applying in the summer, you should be taking the
summer MLS courses.
6. Students with foreign degrees must submit a transcript evaluation from an agency approved by the ASCP Board of
Registry. Check with the Program Director.
7. Eligible applicants will be invited for a personal interview by the Selection Committee
SELECTION CRITERIA
1. The Clinical Laboratory Sciences Program at The University of West Florida is a limited access program: that is, the
enrollment is capped. Applicants must be in good academic standing with a minimum overall GPA of 2.8 on a 4.0 scale,
and they must complete all prerequisite courses and other graduation requirements prior to beginning the clinical
program. Candidates must be capable of performing the “essential functions” with reasonable accommodations
2. Candidates with GPA between 2.5 and 2.8 will be considered, if clinical slots are available and if the student shows
merits other than GPA.
3. Candidates will be ranked in order on the basis of academic record, letters of recommendation, and the personal
interview.
SELECTION COMMITTEE AND PROCESS
1. The Selection Committee is made up of representative members from UWF faculty and education coordinators from
participating hospitals.
2. The Selection Committee will review the application materials and conduct the personal interviews. The selected
candidates and alternates will be announced by the first week of April.
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Application for Selection into Clinical Year
Clinical Laboratory Sciences Program
The University of West Florida
Application Deadline:
2/7 or 6/6
Date: _____________________
I. Personal Data:
Name:
(Last)
(First)
(Middle)
Student ID Number
Date of Birth
Nationality*
Current Address:
Sex* Race*
Native Language*
Street
City
Phone:
State
Zip
Last 4 digits SSN ______ email:
List any other names under which your education records are filed.
Type of Student:
(Check which applies to you)
UWF native student (entered UWF as a freshman)
A.A. transfer from a Florida Public Community College or University
Transfer from other university/college
4+1 student (already have a B.S. degree)
*Students are selected without regard to gender, race, nationality or ethnicity. These questions are
asked to generate the diversity profile of the program.
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II. Education: List in chronological order every college or university you have attended.
Name and Location
Dates of
Attendance
Major
Degree/Year
Current Academic Classification: Junior (<90 SH) ______Senior (>90 SH) _____
Second undergraduate degree ______
Current UWF Grade point average _______ (Use SASS audit for this information)
III. Course Work: Indicate courses completed at the time of application or their equivalent courses by
listing the semester hours of credit and checking the correct column. Indicate the planned date for
completion of other courses. Use your SASS audit for this information
Yes
1.
2.
3.
No
General education requirements complete
Have an A.A. degree from a Florida Public Community College
Foreign language requirement met
5. Science and Math Prerequisites (or equivalents):
Course Number
MAC 1105
STA 2023
BSC 1010 or
ZOO 2010
PCB 2131
PCB 4703
XXX XXXX
XXX XXXX
CHM 2045
CHM 2046
CHM 2210
CHM 2211
CHM 3120
PCB 3063
HSC 3550
BSC 3033
PCB 4233
MCB 3020
Course Name
College Algebra
Statistics
Gen Biology/lab or Zoology/lab
SH
Grade
In progress
Cell Biology/Lab and
Human Physiology
or
Anatomy & Physiology I and Lab and
Anatomy & Physiology II and Lab
General Chemistry I/Lab
General Chemistry II/Lab
Organic Chemistry I/Lab
Organic Chemistry II or
Analytical Chemistry /Lab
Genetics/Lab
Pathophysiology
Biochemistry I/Lab
Immunology/Lab
Microbiology/Lab
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IV. Work Experience: (Include volunteer work and military experience). If you are currently working,
indicate how many hours a week.
Employer
Type of Work
Dates of Employment
From - To
V. License: Are you currently licensed as a health professional in the State of Florida?
Yes ___ No ___
If yes, name the profession__________________________________________________
Current license number ____________________________________________________
VI. Activities: (Clubs, hobbies, volunteer work, etc.)
VII. List any awards, scholarships or special recognitions you have received (in college, as well as
others):
VIII. References: (The people you will be asking to mail the references form to Program Director)
If you are selected into the clinical year of the Program you will be required to apply and to be
eligible for receiving approval as a Clinical Laboratory Sciences Program Trainee by BCLP
(Board of Clinical Laboratory Personnel) of State of Florida. The following questionnaire is
part of the application for trainee license. If you answered yes to any of the following
questions please provide documentation of adjudication and evidence of restoration of civil
rights, when applicable.
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Yes
No
Have you ever been convicted of a misdemeanor (other than traffic violations) or a
felony?
Regardless of adjudication, have you ever been convicted of a violation of or pled
nolo contendere to any federal, state, local statute, regulation or ordination, or
entered into any plea, bargain or settlement, relating to a misdemeanor or felony?
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?
Have you ever been convicted of, or entered plea of guilty, nolo contendere, or no
contest, to a crime in any jurisdiction other than a minor traffic offense? You must
include misdemeanors and felonies, even if adjudication was withheld by the court so
that you would not have a record to of conviction. Driving under influence or driving
while impaired is not a minor traffic offense for purposes of this question.
In the last 5 years, have you been treated for or had a recurrence of a diagnosed
mental disorder or impairment?
In the last 5 years, have you been treated for or had a recurrence of a diagnosed
physical impairment?
In the last 5 years, have you been treated for or had a recurrence of a diagnosed
addictive disorder?
Have you ever had a license disciplined for sexual misconduct or committed any act
in any other state that would constitute sexual misconduct?
Have you had any application for professional license, or any application to practice,
denied by any state board or other governmental agency of any state?
Have you ever had any professional license or license to practice revoked,
suspended, or any other disciplinary action taken in any state?
Have you been refused a license to practice, or the renewal thereof in any state?
(The intent of this question does not pertain to the failure of previous examination)
Explanation of Yes for any questions above:
IX. Briefly explain why you want to become a Clinical Laboratory Scientist stating your future
educational/career goals (you may attach a separate page).
Attach a copy of your immunization records for the following:
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MMR (measles, mumps and rubella). Two dates are required, or a titer showing immunity.
Hepatitis B series. Three dates for series or titer showing immunity.
Varicella (chicken pox). Immunization or titer showing immunity.
If you did not have all of these immunizations, explain in the dialog box.
I have attached the records
I am missing the following:
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X. The clinical (hospital) affiliates of the UWF program include hospitals that not within driving
distance of the university. You may be placed at any affiliate. If you have a compelling reason that
you must stay in the Pensacola area, (e.g. children, own your home, etc), please state it here.
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Statement of Understanding and Acceptance
I. I understand that it is necessary for The University of West Florida CLS Program to share my
application materials with selection committee members. I hereby give permission for sharing my
application file with authorized personnel associated with the Clinical Laboratory Sciences Program at
The University of West Florida.
II. I have read the attached document entitled "Statement of Essential Functions" and have accurately
provided the required information. I confirm that my answers and statements are true and accurate,
and I agree to inform the Director of the Clinical Laboratory Sciences program should any of the
information change prior to entry into the clinical program
III. I realize that with satisfactory completion of the clinical experience, including training at The
University of West Florida and the hospital, I will be eligible to take the certification examinations in
Clinical Laboratory Sciences. I realize that the opportunity to be trained at a UWF affiliate does not
entitle me to a job at that Hospital.
If I am accepted into the clinical year of the Clinical Laboratory Sciences Program at The University of
West Florida, I understand the responsibilities and confidentiality expected of me. I realize that
physicians will rely on the accuracy of my work in diagnosing diseases and treating patients. Because
of the quality of my work affects the health and even the life of patients, I agree to perform my clinical
laboratory assignments with extreme care, thoroughness and accuracy. I also understand that I will
have access to confidential information concerning patients, and agree not to discuss this information
with anyone who is not authorized to receive it.
I understand that The University of West Florida reserves the right to dismiss a student for personal
misconduct, academic cheating, incompetence, violation of UWF or Hospital regulations, and
unsatisfactory grades. I may refer to the University Student Handbook, The Clinical Laboratory
Sciences Handbook and the appropriate hospital handbooks for regulations and requirements
Signature*
Date emailed
*Your electronic signature is acceptable. Receipt of this application by a valid UWF email constitutes
electronic signature.
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The University of West Florida
Clinical Laboratory Sciences Program
Statement of Essential Functions
Purpose:
The purpose of this document is two-fold:
1.
To assure that the students applying for selection into the clinical year of the Program are
cognizant of the essential functions and abilities necessary to perform adequately and to
succeed in the Clinical Laboratory Sciences Program; and to be proficient in duties and
responsibilities of a clinical laboratory scientist upon graduation.
2.
To assure that the Clinical Laboratory Sciences Program, whenever applicable or feasible,
provides the necessary accommodation/s to students with disabilities to enable them to
perform the essential functions and achieve student learning outcomes in each area of
instruction.
First, read the accompanying document, "Essential Functions", found on the following page. This
defines each standard and gives some examples of the necessity for each function. Select the
statement that best applies to you.
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The University of West Florida Clinical Laboratory Sciences Program
Standards for Essential Functions
FUNCTION
STANDARD
Communication
Ability to interact with
others in English, both
verbally and in legible
written form. Ability to
read English.
Hearing
Ability to gather
information aurally or to
adapt
Interaction
Ability to interact with
individuals or groups
from a range of social,
cultural, emotional and
intellectual backgrounds
Mobility
Ability to move from
room to room, and to
maneuver in small
places, e.g. around
instruments, between
beds, benches, etc.
Demonstrate/possess
gross and fine motor
skills to operate dials,
switches, pipetting
devices, smoothly
inoculate agar, and to
assist patients.
Ability to present a
professional appearance
as a lab representative.
Maintain own health,
hygiene and safety on
the job.
Demonstrate sufficient
olfactory sense to
maintain environmental
safety.
Motor Skills
Self Care
Olfaction
EXAMPLE
ACTIVITY
I am capable
of meeting
these
requirements
I am not
capable of
meeting
these
requirements
I am capable
with the
following
accommodations
(write below)
Keep accurate
records. Read and
write procedures.
Read and follow
instruction in
manufacturer's
inserts. Explain
procedures and
results to patients,
health care providers, coworkers.
Recognize
instrument signals,
alarms. Use
telephone.
Establish and
maintain rapport
and trust with
patients,
coworkers, other
health care
professionals and
general public.
Move around
hallways,
laboratory, patient
room, storage
areas as
necessary.
Reach and
manipulate
equipment,
reagents and
supplies. Assist
patients as
necessary.
Observe
safety/OSHA
policies. Practice
Universal
precautions.
Use odors to
assess specimens,
tests, instrument
malfunction and
smoke in case of
fire. Maintain a safe
work environment.
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FUNCTION
STANDARD
Temperament
Ability to work in high
stress work place
environment.
Vision
Ability to accurately
perform and assess
laboratory procedures
requiring microscopic
examination as well as
gross visual examination.
EXAMPLE
ACTIVITY
I am capable
of meeting
these
requirements
I am not
capable of
meeting
these
requirements
I am capable
with the
following
accommodations
(write below)
Perform duties in
emergency
situations; in
situations with time
and manpower
constraints and
high stress
conditions.
Distinguish colors
and opacity.
Discern fine
agglutination,
precipitation.
Resolve 1 micron
objects using a
bright field
microscope.
Identify cells,
parasites and other
elements in
microscopic
procedure for
diagnosis.
I have received, reviewed and understand the standards necessary to perform the essential functions
of the Clinical Laboratory Scientist. I have indicated areas where I may need accommodation.
Signature*
Date
*electronic signature received in official UWF email is acceptable.
Special accommodations that I require:
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