NORTHERN MICHIGAN UNIVERSITY
Respiratory Therapy Program
Application for Admission
I.
Admission Requirements
a. Must be admitted as a student to Northern Michigan University with an overall
minimum GPA of 2.50, and no less than a “C” in the following prerequisite
courses: BI 201 Human Anatomy, BI 202 Human Physiology, and RSP 106
Introduction to Oxygen Therapy. Transfer student’s courses will be evaluated by
NMU as part of the evaluation process. Transfer students must earn at least 16
credits of their prerequisites at NMU. (Prerequisite courses are listed on the
following web site:
http://www.nmu.edu/bulletin1213/node/72?ProgramCode=1254168905).
b. Students shall complete the Respiratory Therapy Program application by May 1
to be considered for the class beginning in the Fall semester.
c. Students must have completed at least three hours of job shadowing with a
Respiratory Care Practitioner. Documentation should be attached to the
application.
d. Students must write a short (two page, typed, double spaced) essay describing or
explaining their reasons for wanting to pursue a career in Respiratory Care and
submit it with their application.
e. Students need to submit the names and addresses of three references. The
applicant will give the Recommendation Form (included with the application) to
their reference of choice. Be certain to include your name, major, and graduation
date on the Recommendation Form. The confidential recommendation should be
mailed by your reference directly to the Clinical Sciences Department.
f. Students must meet the Functional Abilities required of the Program. Please
review the Functional Abilities for the Respiratory Therapy Program in the
Department of Clinical Sciences Policy Manual.
II.
Application Process
a. Students who have submitted a complete application and have met the entrance
criteria will be invited for an interview with three representatives from the
Respiratory Therapy Program. The openings for the Program will be filled only
with qualified applicants. Applicants will be notified of their status via email and
regular mail.
b. Students are required to submit proof of immunizations for Varicella, Rubella and
Rubeola, a one-step tuberculosis (TB)/purified protein derivative (PPD) test, and
a Hepatitis-B or signed refusal/declination statement before the Program begins
in the Fall. The applicant will pick up the Verification of Immunization and
Health Status for Clinical Placement Form from the Clinical Sciences
Department, have it completed, and returned to the Program Director upon
request. Proof does not need to be submitted at the time of application.
c. Students admitted to the Respiratory Therapy Program must submit to a criminal
background check (CBC). This policy is based on a standard of The Joint
Commission (TJC), which requires health care organizations/institutions to verify
criminal background information on students who provide care, treatment, and
services to patients/clients during clinical activities. The cost of the CBC is a
student responsibility and is non-waivered and non-refundable. The CBC will be
performed only by an external vendor designated by Northern Michigan
University and/or the clinical affiliate. Student eligibility for clinical activities is
determined by the clinical affiliated based on the CBC. Inability to participate in
clinical activities prohibits successful completion of clinical courses and therefore
prohibits program progression, since the classroom and clinical courses must be
successfully completed in the same semesters.
d. Equal Opportunity Policy
The Respiratory Therapy Program fully supports Northern Michigan University
civil rights policy and does not unlawfully discriminate on the basis of race,
color, religion, sex, national origin, age, height, weight, marital status, family
status, disability, sexual orientation, or veteran status. Application practices will
not be influenced or affected by an applicant’s race, color, religion, sex, sexual
orientation, national origin, age, disability or any characteristics protected by law.
NORTHERN MICHIGAN UNIVERSITY
Respiratory Therapy Program
Application for Admission
Name: _______________________________________________________ ________
Last
First
Middle
List any previous last name used on educational records
University Student IN: _______________________ Date of Birth: ____________________
(used for identification purposes)
Current address: ________________________________________________________
Street
_______________________________________________________________ _____
City
State
Zip Code
Telephone:_____________ Work Phone: _________
E-mail Address: _____________________________________
Person to be notified in case of emergency
Name: __________________ Relationship:_____________
Telephone: ______________
JOB SHADOW EXPERIENCE: Please attach documentation to the application.
ESSAY: Please attach essay to the application.
REFERENCES
Please list three educational/professional references such as instructors, school personnel,
employers, or supervisors.
Name/Title
Complete Address
Phone
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
I hereby declare that all the information provided in this application is true and correct to the best of
my knowledge. Knowingly giving false or misleading information or statements during the
application process would prevent my acceptance into the Program or be grounds for dismissal from
the Program. I hereby authorize the Respiratory Therapy P r o g r a m access to my academic records.
I authorize the school to contact references and conduct a criminal background check ( C B C) as
required by Law for students practicing direct patient care. I understand that the State of Michigan
also reviews individual criminal records on a case-by-case basis when seeking licensure and may deny
applications for some offenses. I grant the Program Admission Committee the right to review my
application for the purpose of evaluating my capability to succeed in the Program. If accepted to the
Respiratory Therapy P r o g r a m , I agree to promptly return my notice of acceptance, and abide by the
policies and regulations of the Respiratory Therapy Program.
_____________________________________________________________________
Signature
Date
Return application to:
Eric I. Burdick, MBA, RRT
Program Director – Instructor
Respiratory Therapy Program
2814 West Science
1401 Presque Isle Avenue
Marquette, Ml 49855
Functional Abilities
The following statements are given to provide the student with a description of the type of physical/technical
abilities necessary to complete the Respiratory Therapy Program and/or work in a hospital or clinical setting.
These abilities are not measured as a requirement for Program admission. However, the student is encouraged
to consider the physical and mental requirements of the Program and to make an appointment with the Program
Director and/or Clinical Education Coordinator to discuss concerns or requests for accommodation for his/her
disability. Students with documented needs for accommodations are to meet with Northern Michigan
University’s Disability Services Department.
In order to perform the tasks required of a Respiratory Care Practitioner, certain physical capabilities are
required. Students must demonstrate the ability to perform required functions as a routine part of classroom,
laboratory, or clinical education. Students should be aware that successful graduation of the Respiratory
Therapy Program will depend upon the ability to meet the following technical standards:
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Gross Motor Skills: Move within confined spaces, maintain balance in multiple positions, reach above
shoulders (e.g. monitors), reach below waist (e.g. plug electrical equipment in wall outlet), reach out front
Fine Motor Skills: Pick up objects with hands, grasp small objects with hands (e.g. pen/pencil, needles), write
with pen or pencil, key/type (e.g. use a computer), pinch/pick or otherwise work with fingers (e.g. manipulate a
syringe), twist (e.g. turn objects/knobs using hands, assemble objects), squeeze with finger (e.g. medication
ampules)
Physical Endurance: Stand (e.g. at patient bedside during surgical or therapeutic procedure), sustain repetitive
movements (e.g. CPR), maintain physical tolerance (e.g. work on your feet for 8 hours)
Physical Strength: Push and pull 50 pounds (e.g. position patient, move equipment), support 50 pounds of
weight, lift 50 pounds (e.g. pick up a child, transfer patient, and bend to lift an infant or child), carry
equipment/supplies, use upper body strength (e.g. performs CPR, physically restrain a patient), squeeze with
hands (operate fire extinguisher)
Mobility: Twist, bend, stand/squat, kneel, and move quickly (e.g. respond to an emergency), climb stairs, walk
Hearing: Hear normal speaking-level sounds (e.g. person-to-person report), hear faint voices, hear faint body
sounds (e.g. blood pressure sounds, lung auscultation), hear in situations when not able to see lips (e.g. when
masks used), hear auditory alarms (e.g. monitors, fire alarms, call alerts)
Visual: See objects up to 20 inches away (e.g. information on a computer screen, read medication labels), see
objects up to 20 feet away (e.g. patient in a room), use depth perception, use peripheral vision, distinguish color
and color intensity (e.g. color code on supplies, skin color)
Tactile: Feel vibrations (e.g. palpate pulses), detect temperature (e.g. skin, solutions), feel differences in surface
characteristics (e.g. skin turgor, rashes), feel differences in sizes, shapes (e.g. palpate vein, artery, identify body
landmarks), detect environmental temperature
Smell: Detect odors (e.g. foul smelling drainage, alcohol break, smoke, gases or noxious smells)
Environment: Tolerate exposure to allergens (e.g. latex gloves, chemical substances), tolerate strong soaps,
tolerate strong odors
Reading: Read and understand written documents (e.g. flow sheets, charts, graphs), read digital displays
Math/Arithmetic: Comprehend and interpret graphic trends, calibrate equipment, convert numbers from metric
and American systems (e.g. dosages), tell time, measure time (e.g. count duration of contractions, CPR, etc.),
count rates (e.g. breaths per min., pulse), read and interpret measurement marks (e.g. measurement tapes and
scales), add, subtract, multiply, and/or divide whole numbers, compute fractions and decimals (e.g. medication
dosages), document numbers in records (e.g. charts, computerized data bases)
Emotional Stability: Establish professional relationships, provide client with emotional support, adapt to
changing environment/stress, deal with the unexpected (e.g. patient condition, crisis), focus attention on task,
cope with own emotions, perform multiple responsibilities concurrently, cope with strong emotions in others
(e.g. grief)
Analytical Thinking: Transfer knowledge from one situation to another, process and interpret information from
multiple sources, analyze and interpret abstract and concrete data, evaluate outcomes, problem solve, prioritize
tasks, use long-term memory, use short-term memory
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Critical Thinking: Identify cause-effect relationships, plan/control activities for others, synthesize knowledge
and skills, sequence information, make decisions independently, adapt decisions based on new information
Interpersonal Skills: Establish rapport with individuals, families, and groups, respect/value cultural difference in
others, negotiate interpersonal conflict
Communication Skills: Teach (e.g.: client/family about health care), influence people, direct/manage/delegate
activities of others, speak English, write English, listen/comprehend spoken/written word, collaborate with others
(e.g.: health care workers, peers)
I have read the Functional Abilities for the Respiratory Therapy Program and I have the ability to
satisfactorily perform the described functions.
Name ______________________________________________________________________
Signed ____________________________________
_
Date_______________________
Witness Name ________________________________________________________________
Witness Signature _______________________________
This form must be submitted with clinical placement application.
Date_______________________
CONFIDENTIAL RECOMMENDATION CONCERNING
Clinical Sciences Department
College of Professional Studies
Northern Michigan University
West Science 3513
Marquette, MI 49855
(RETURN TO THE ABOVE ADDRESS)
Name:_____________________________________________
Major______________ Graduation Date____________
Basis for Rating Candidate
_____ Employer
_____ Professor
_____ Know candidate well
_____ Limited knowledge of candidate
_____ Do not remember candidate
The traits listed below are of importance to employers in selecting college graduates. Please rate this individual with
respect to other students of comparable age and experience by PLACING A CIRCLE AROUND the number following
each characteristic. Leave blank those characteristics which you have no basis for rating.
OUTSTANDING
AVERAGE
BELOW AVERAGE
1.
PERSONALITY
1
2
3
4
5
6
7
2.
ATTITUDE
1
2
3
4
5
6
7
3.
MATURITY
1
2
3
4
5
6
7
4.
ORIGINALITY AND INITIATIVE
1
2
3
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5
6
7
5.
MASTERY OF SUBJECT MATTER
1
2
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5
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7
6.
DEPENDABILITY
1
2
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7.
WRITTEN EXPRESSION
1
2
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5
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8.
ORAL EXPRESSION
1
2
3
4
5
6
7
GENERAL COMMENTS:
(Please discuss any outstanding qualities, possible weaknesses or overall impression)
Rater’s Signature________________________________
Rater’s Name_________________________________
Position________________________________________
Organization_________________________________
Department_____________________________________
Date________________________________________
Address_________________________________________________________________________________________
CONFIDENTIAL RECOMMENDATION CONCERNING
Clinical Sciences Department
College of Professional Studies
Northern Michigan University
West Science 3513
Marquette, MI 49855
(RETURN TO THE ABOVE ADDRESS)
Name:_____________________________________________
Major______________ Graduation Date____________
Basis for Rating Candidate
_____ Employer
_____ Professor
_____ Know candidate well
_____ Limited knowledge of candidate
_____ Do not remember candidate
The traits listed below are of importance to employers in selecting college graduates. Please rate this individual with
respect to other students of comparable age and experience by PLACING A CIRCLE AROUND the number following
each characteristic. Leave blank those characteristics which you have no basis for rating.
OUTSTANDING
AVERAGE
BELOW AVERAGE
1.
PERSONALITY
1
2
3
4
5
6
7
2.
ATTITUDE
1
2
3
4
5
6
7
3.
MATURITY
1
2
3
4
5
6
7
4.
ORIGINALITY AND INITIATIVE
1
2
3
4
5
6
7
5.
MASTERY OF SUBJECT MATTER
1
2
3
4
5
6
7
6.
DEPENDABILITY
1
2
3
4
5
6
7
7.
WRITTEN EXPRESSION
1
2
3
4
5
6
7
8.
ORAL EXPRESSION
1
2
3
4
5
6
7
GENERAL COMMENTS:
(Please discuss any outstanding qualities, possible weaknesses or overall impression)
Rater’s Signature________________________________
Rater’s Name_________________________________
Position________________________________________
Organization_________________________________
Department_____________________________________
Date________________________________________
Address_________________________________________________________________________________________
CONFIDENTIAL RECOMMENDATION CONCERNING
Clinical Sciences Department
College of Professional Studies
Northern Michigan University
West Science 3513
Marquette, MI 49855
(RETURN TO THE ABOVE ADDRESS)
Name:_____________________________________________
Major______________ Graduation Date____________
Basis for Rating Candidate
_____ Employer
_____ Professor
_____ Know candidate well
_____ Limited knowledge of candidate
_____ Do not remember candidate
The traits listed below are of importance to employers in selecting college graduates. Please rate this individual with
respect to other students of comparable age and experience by PLACING A CIRCLE AROUND the number following
each characteristic. Leave blank those characteristics which you have no basis for rating.
OUTSTANDING
AVERAGE
BELOW AVERAGE
1.
PERSONALITY
1
2
3
4
5
6
7
2.
ATTITUDE
1
2
3
4
5
6
7
3.
MATURITY
1
2
3
4
5
6
7
4.
ORIGINALITY AND INITIATIVE
1
2
3
4
5
6
7
5.
MASTERY OF SUBJECT MATTER
1
2
3
4
5
6
7
6.
DEPENDABILITY
1
2
3
4
5
6
7
7.
WRITTEN EXPRESSION
1
2
3
4
5
6
7
8.
ORAL EXPRESSION
1
2
3
4
5
6
7
GENERAL COMMENTS:
(Please discuss any outstanding qualities, possible weaknesses or overall impression)
Rater’s Signature________________________________
Rater’s Name_________________________________
Position________________________________________
Organization_________________________________
Department_____________________________________
Date________________________________________
Address_________________________________________________________________________________________