APPLICATION FOR ADMISSION
Gulf Coast School of Blood Bank Technology
1400 La Concha Lane, Houston, TX 77054-1802
Program Director: Clare Wong; Medical Director: Beth Hartwell, MD
Date: ______________
Applicant name
Certification type
Certification number
Address
Citizen of United States?
Date of birth
Telephone (work)
Place of birth
Telephone (home)
Social security #
(last 4 numbers)
Telephone (cell)
__Yes, __No
If No, specify __________
E-mail address
Have you applied to other SBB programs currently
or previously?
__No
__If Yes, which program(s)? ______________________
Have you taken the SBB registry exam previously?
__No
__If Yes, when? _______________________________
Mentor’s name & credentials
Mentor’s telephone
Mentor’s e-mail
Undergraduate
CLS/MT Program
Others / Graduate School
College
City/state
Date
(from-to)
Year
completed
Degree
conferred
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
Page 1 of 6
TD1518.03 v5
Revised 7/7/14
Blood Bank/Transfusion Medicine Work Experience:
How many years of full-time transfusion service experience do you have? _________ years.
(*If part-time, add up all times and prorate into years.)
Start with your most current position.
Current facility:
Address:
Started (month/year):
Full or part time?
Shift (day/evening/night):
Title and duties:
Supervisor’s name:
Facility:
Address:
Date (month/year):
Full or part time?
Shift (day/evening/night):
Title and duties:
Supervisor’s name:
Reason for leaving?
Facility:
Address:
Date (month/year):
Full or part time?
Shift (day/evening/night):
Title and duties:
Supervisor’s name:
Reason for leaving?
Professional References:
List three persons from whom you will request a professional reference.
Include the full name, facility, telephone, and job title.
1.
2.
3.
Signature of Applicant: _________________________________ Date: _________________________
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
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TD1518.03 v5
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Gulf Coast School of Blood Bank Technology
SBB Applicant Practical Experience
Applicant__________________
To be completed by the applicant and supervisor
Please list the approximate number of procedures performed by the Applicant within the past year.
*If you are not currently routinely performing these procedures, indicate the last year in which you have
performed them. If you have never performed the procedure, enter a “0” in the column.
# Procedures
recently
performed by
applicant
PROCEDURE
1
2
3
Type and Screen
Crossmatch
Resolution of ABO discrepancies
4
5
7
8
9
10
Rh phenotyping and other antigen typing
Basic antibody identification (serum with 1-2 antibodies)
Complex antibody identification (used procedures
involving adsorption, ficin, DTT, EGA, neutralization, etc)
Enzyme (e.g. ficin) panel
Antibody titration
Elution procedures
Adsorption procedures (cold or warm)
11
12
13
14
15
16
Blood bank chemicals (e.g. DTT, EGA)
Fetal bleed screen
Investigation of adverse effects of transfusion
Donor blood collections
Donor blood testing (infectious disease testing)
Component preparation (Whole Blood to components)
17
18
19
20
21
HLA and molecular testing
Other molecular testing
IRL (Immunohematology Reference Laboratory)
Quality Assurance activities (worked in a QA department?)
Hematopoietic progenitor cell processing
Other experience (example: research, teaching (bench? formal?)
6
*Last performed
22
Membership in professional organizations
23
Workload of current facility
Estimated number of transfusions per month
Estimate number of donor blood units collected/month (if applicable)
Applicant Signature & Date _________________________________________
Supervisor Signature & Date ________________________________________
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
Page 3 of 6
TD1518.03 v5
Revised 7/7/14
Gulf Coast School of Blood Bank Technology
Memorandum of Understanding - SBB Clinical Rotation
The applicant’s current facility must complete a Memorandum of Understanding (MOU). If the
applicant’s facility will not be providing all clinical rotations, then additional MOUs must be
obtained from the facilities that have agreed to provide the clinical experience.
(Name) _____________________________,
student/applicant of Gulf Coast School of
Blood Bank Technology’s distance SBB
program requires a facility affiliation for the
purpose of clinical rotation.
Please return to the student applicant
Or email to cwong@giveblood.org
Or FAX (713-791-6610)
Facility: ______________________________________________________________________
Address: ____________________________________________________________________________
City, State, Zip: _______________________________________________________________________
Facility accredited/licensed by? (Circle all that apply)
AABB
CAP
TJC
FDA
CLIA
Check the rotation
that will be provided
1
Rotation
Transfusion service – routine T/S, T/C
2
3
4
5
6
7
8
Transfusion service management & Transfusion Committee
Serologic evaluation of HDFN (FMH, KB stain, etc)
Antibody identification - routine
Antibody identification – advanced (e.g. Reference Lab)
Rare donors, freezing and deglycerolization
Donor recruitment
Donor blood collection
9
10
11
12
13
14
Donor mobile blood drive
Hospital services/distribution
Blood component preparation, labeling and storage
Transmissible diseases testing
Donor apheresis
Therapeutic apheresis
15
16
17
18
19
HLA/molecular testing
Hematopoietic progenitor cell (HPC) processing
Quality management (e.g. audit, cGMP, SOP, error management)
Quality control (e.g. daily QC, equipment, reagent)
Supervisory rotation (e.g. Laboratory operation, education)
Would you and/or your staff be willing to listen and evaluate the student for oral presentations?
Would you and/or your staff be willing to discuss policies and procedures with the student?
Would you be able to allow the student the use of equipment and/or reagents?
Would your facility require the student to pay for the instruction/reagents provided?
*If yes, list the items and the amount that you would expect the student to pay.
Completed by:_______________________________________
yes
yes
yes
yes*
no
no
no
no
Date _______________________
Title:_______________________________________________
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
Page 4 of 6
TD1518.03 v5
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Gulf Coast School of Blood Bank Technology
Professional Reference
Applicant: ______________________
To be completed by the Evaluator
The above named individual has applied for a position in the Specialist in Blood Bank Technology
Program and has listed you as a reference. Please evaluate the applicant on the characteristics listed
below according to your personal knowledge of the individual:
Scale:
5 = Outstanding; 4 = Very good; 3 = Satisfactory; 2 = Needs improvement; 1 = Unsatisfactory
0 = Unknown or no opinion
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Responsibility:
Dependability:
Organization:
Flexibility:
Response to stress:
Initiative:
Attitude:
Maturity:
Self-confidence:
Decision-making:
Leadership:
Application of knowledge:
Interaction with peers:
Interaction with supervisors:
Verbal communication:
Written communication:
Continuing education:
Accountable for one's own actions
Prompt; completes assignments in a timely fashion
Arranges by systematic planning to complete tasks efficiently
Capable of adapting to changing situations
Maintains composure and ability to function in stressful situations
Motivated to pursue actions independently
Positive approach to work and co-workers
Demonstrates common sense, tact, and empathy for patient care
Assured of one's own abilities and skills
Ability to analyze a problem and formulate a solution
Has the capability to direct the activities of others
Ability to apply academic theory to practice
Ability to get along with peers and co-workers
Ability to get along with supervisors and instructors
Contributes knowledge and opinion in an articulate manner
Expresses self clearly in writing
Eager to continue learning to improve skills/knowledge
Additional information pertinent to evaluation of the applicant (attach additional page if desired):
How long have you known the
applicant?
________years
Relationship to the applicant:
____ Advisor
____ Instructor
____ Supervisor
____ Other:_________________
Evaluator (print) ____________________________________
(Signature)____________________________________
Present Title _______________________________________
Institution __________________________________________
Address ___________________________________________
City/State/Zip _______________________________________
Telephone / e-mail___________________________________
Place this completed form in an envelope, seal it, sign your name across the back flap, and
return it to the applicant or
email the completed form to Clare Wong, cwong@giveblood.org, or
Fax to 713-791-6610
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
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TD1518.03 v5
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Gulf Coast School of Blood Bank Technology
Application Checklist
Applicant: __________________
To be completed by the applicant and returned with the application packet.
Check if
Present
Check if
In Progress
______
______
1.
This Application Checklist
______
______
______
______
2.
3.
Application for Admission form - completed and signed
Copy of ASCP or NCA certification (or ID card)
______
______
______
______
4.
5.
SBB Applicant Practical Experience form
Blood bank continuing education for the past two years (listed on one page)
______
______
6.
Memo of Understanding for clinical rotations
______
______
7.
Written essay of goals and expectations from SBB education (limited to one
single-spaced typed page)
______
______
______
______
8.
9.
Official transcripts (or copy) of undergraduate studies
Three Professional References, one of which from your current supervisor
______
______
______
______
10. Copy of permanent residency visa (if applicable)
11.* Official evaluation of academic transcripts by an accredited agency in the US
listing course names, hours earned, and US equivalent grades.
Item
* Required for applicants who received high school and/or college education outside of the United States.
Please send application to:
Clare Wong
Gulf Coast Regional Blood Center
1400 La Concha Lane
Houston, TX 77054-1802
Gulf Coast Regional Blood Center
1400 La Concha Lane, Houston, TX 77054
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TD1518.03 v5
Revised 7/7/14