For Admissions use only.
Received By:_________
Return this form to:
Date:__________________
Advising Services, Wynn Center (Building 10), room 10-200
Durham Technical Community College
Medical Product Safety & Pharmacovigilance AAS Degree
Admissions Application
First Name: __________________________________ Last Name: ____________________________________
Durham Tech Student ID Number: _____________________________ Date: ___________________________________________
ConnectMail Email Address: _______________________________________________________________
NOTE: All official communication from the college is delivered via ConnectMail, including Health Technology admissions
decisions.
APPLICATION DEADLINE: July 10
Submit application to: Wynn Center (Building 10), room 10-200 (Advising Services office)
or banksa@durhamtech.edu
CHECKLIST:
All steps below are required. Please initial that each item is completed.
Enroll at Durham Technical Community College
View College enrollment steps on the website.
______ I am currently admitted to Durham Tech.
Note: If you have not been enrolled with Durham Tech within the last 12 months, you must reapply to
Durham Tech using the CFNC application
.
______ I have submitted an official transcript(s) from high school and/or college.
Submit to Admissions, Registration, and Records, located in Wynn Center (Building 10), room 10-201
______ I have applied for Financial Aid (recommended but not required).
______ I have attended a ConnectSession (Student orientation)
Note: Prospective students with 12 or more college credit hours transferred to Durham Tech are not
required to attend a ConnectSession, but it is recommended.
Meet Course Placement Requirements
Students must demonstrate they are college ready in one of the following ways (Initial each item that fulfills this
requirement):
______ Provide proof of unweighted US high school GPA of 2.8 or higher within the last ten years
______ Transfer credit for English and math (college-level algebra)
______ Provide proof of completion of an associate’s or bachelor’s degree
______ Provide proof of satisfactory scores on ACT, SAT, GED, HiSET, NCDAP, COMPASS, ASSET, or ACCUPLACER
scores within the last ten years
Revised 1/30/20 Page 1 of 2
______ Demonstrate mastery on RISE English placement test 2 and RISE Math placement test 2; OR successfully
complete ENG-002 through Tier 2 (grade of P2) & MAT-003 through Tier 2 (grade of P2)
Additional Required Documents:
Students must provide all of the documents listed below with the completed application:
______ I have attached a signed Clinical Training Form (download from Health Technologies admission steps)
______ I have attached a signed English Language Requirement Form (download from Health Technologies
admission steps
STATEMENT OF STUDENT RESPONSIBILITY
I verify that I have read all the information regarding admissions to the Medical Product Safety & Pharmacovigilance
(MSP) Program, and understand the steps I must take to qualify for admissions. I understand that it is my responsibility
to notify the Admissions, Registration and Records office regarding changes in name, address, or phone number through
eForms.
I understand that all official communication from the college is delivered via ConnectMail, including Health and Wellness
admissions decisions.
I understand that my MSP Admissions Application will not be accepted if incomplete.
I understand that the criminal background check and drug screening are not required to be completed prior to applying
to the Medical Product Safety & Pharmacovigilance (MSP) Program (this will be started after attending mandatory
orientation).
I understand upon my acceptance to the Medical Product Safety & Pharmacovigilance (MSP) program, clinical sites
require a criminal background check and drug screening prior to my placement for training at that site. I understand I
will pay a fee directly to a designated vendor for this background check. I understand that if I am admitted to the MSP
program but am denied clinical placement by any of the hospitals/healthcare facilities, I will be unable to successfully
complete the MSP program as the programs clinical objectives cannot be met. Program admission on two occasions
with two clinical denials will be considered a second entry into the MSP program. Students are only allowed two entries
(admissions) into the CTR program.
I understand that upon acceptance to the MSP program, I will be given a Student Medical form and required to
complete a physical examination and assessment (including proof of immunizations or titers). I must maintain up to-date
health care insurance throughout the program.
I understand failure to upload the completed clinical requirements and documentation by August 10 (no exception or
extensions) may result in the inability to progress in the program or dismissal from the program.
I understand that accepting a seat within the MSP program counts as the first admission. A maximum of two admissions
are allowed.
Name
________________________________________ Student ID#______________________
Signature ________________________________________ Date____________________________
Revised 1/30/20 Page 2 of 2
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome