Fill - Free fillable DARTON COLLEGE OF (Darton State College) PDF form

1

Dear prospective studen

DARTON COLLEGE OF

HEALTH PROFESSIONS

Health Sciences Division

Histologic Technician

Application Packet

University System of Georgia • An Affirmative Action/Equal Opportunity Institution

Revised: February 18, 2019

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Thank you for your interest in the Albany State University Histologic Technician Program.

Included in this packet is an application for entrance into the Histologic Technician Program as

well as additional information about the program.

Histotechnicians are medical laboratory personnel who are trained to prepare microscopic slides

from human and veterinary tissue samples. Histotechnicians work closely with pathologists and

other doctorate level professionals in a variety of settings including hospitals, clinical

laboratories, pharmaceutical research, coroner’s offices and other independent laboratories.

While patient care is a major force in the services we provide there is very little or no patient

contact.

The job outlook looks quite bright as many established histotechnicans are closing in on

retirement, the standards for certification are raised and the number of laboratory tests increases.

Current entry level salaries are in the mid $30,000 per year range.

The certificate and associate of applied science options present students with alternatives to

acceptance into the Albany State University Histologic Technician Program. Both programs are

open to qualified applicants regardless of prior experience.

Selection is based on a number of factors which are outlined in this packet. Students will be

evaluated and ranked according to these metrics. The Program Director have the right to

increase or decrease the number of students accepted in any given year based upon the

fundamentals of the applicants.

Students interested in applying for admission into the Histologic Technician Program must first

be admitted to Albany State University ~ West Campus. Admissions to Albany State University

can be done online at https://www.asurams.edu/admissions/how-to-apply/or through the mail,

requires a $25.00 non-refundable fee if completed online and $20.00 if submitted through the

mail (application fee is currently being waived), and the submission of transcripts of all prior

academic coursework. A separate application to the Albany State University Histologic

Technician Program must be mailed, faxed, or hand-delivered to the Program Director by May

15th for early acceptance or the extended deadline of June 30th for the fall matriculation and by

September 30

th

for early acceptance or the extended deadline of November 30

th

for the spring

matriculating class. Please note that financial aid (FAFSA) must be completed by June 1

st

for fall and November 1

st

for spring.

If you have any questions feel free to contact the Histologic Technician Program Director in the

Health Sciences Division via the following methods:

e-mail: taiquanda.winbush@asurams.edu phone: (229) 500-2249

Sincerely,

Taiquanda Winbush

Taiquanda Winbush, Program Director

Histologic Technician Program

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Albany State University

Histologic Technician Program

Mission Statement

The mission of the Histologic Technician Program is to prepare competent entry-level graduates

committed to professional development through life-long learning in a positive and supportive

learning environment. The faculty is dedicated to providing students the knowledge and training

necessary to succeed as practicing professionals to meet the healthcare needs of the state, region,

and nation.

Program Goals

“Histology” by definition means the study of tissue. “Histotechnology” refers to all

practical and theoretical skills required to prepare both animal and human tissues for microscopic

examination. The Histologic Technician (HT) is an allied health professional who is qualified by

academic and practical training to provide these necessary skills.

The Albany State University Darton College of Health Professions Histologic Technician

Program prepares students to perform as Histotechnicians as evidenced by passing the National

Board exam administered by the American Society of Clinical Pathologists (ASCP). Students of

the Histologic Technician Program receive training in the following content areas that make up

the ASCP HT examination curriculum.

 Students will demonstrate professional conduct and interpersonal communication skills

with patients, laboratory personnel, and other health care personnel.

 Students will demonstrate patient confidentiality in the preparation of all histopathology

tests.

 Students will perform histological procedures involving tissue specimen including:

fixation, embedding, microtomy, frozen sectioning, and staining paraffin embedded

tissue.

 Students will demonstrate proper laboratory safety techniques including the handling of

chemicals and biohazardous waste.

 Students will demonstrate competence in the theoretical knowledge and technical skills

necessary to perform as entry level histotechnicians.

 Students will troubleshoot staining problems and take appropriate corrective actions.

 Students will develop critical thinking skills through student/teach interaction.

 Students will perform and monitor quality control within predetermined limits.

 Students will perform preventive maintenance of equipment and instruments or refer to

appropriate sources for repairs

 Students will demonstrate an understanding of the importance of ongoing professional

development.

The Albany State University Histologic Technician Program strives to provide high quality

laboratory professionals to meet the needs of local, state, regional and national employers.

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CAREER ENTRY COMPETENCIES

The ultimate goal of the program is to prepare students for career entry positions as

Histotechnicians. The program strives through educational methods and specific professional

competencies to incorporate all facets of quality laboratory practices with a curriculum designed

to prepare graduates in various hands-on and analytical skills.

1. Collect and safely handle tissue specimens for analysis.

2. Perform accurate laboratory testing including special stains.

3. Identify problems and take corrective actions.

4. Operate equipment properly and perform preventive and corrective maintenance.

5. Use quality assurance to monitor procedures, equipment and technical

competencies.

6. Comply with established laboratory safety procedures.

7. Demonstrate ethical behavior and maintain confidentiality in terms of patients and

results.

8. Interact professionally with patients and other health care professionals.

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Courses Required

The following is the course sequence as outlined in the Albany State University Catalog for both

the Histologic Technician Certificate and Associate of Applied Science Degrees.

Freshman Year

First Semester Semester Hours

ENGL 1101

English Composition I

3

BIOL 2411K

Human Anatomy & Physiology I

4

ARTS 1100

Art Appreciation

1

3

MATH 1111

College Algebra or higher math

3

Semester Hours

13

Second Semester

BIOL 2412K

Human Anatomy & Physiology II

4

ENGL 1102

English Composition II

3

COMM 1110

Public Speaking

2

3

CHEM

1211K

Principles of Chemistry I

4

Semester Hours

14

Third Semester

CHEM

1212K

Principles of Chemistry II

4

BIOL 2111K

Essentials of Microbiology

4

Semester Hours

8

Sophomore Year

Fall Semester Hours

MLTS 1300

Introduction to Histology*

3

MLTS

1310W

Histology I*

3

MLTS 1310L

Histology I Lab*

1

MLTS

1320W

Histology II*

2

MLTS 1320L

Histology II Lab*

1

MLTS 1330

Histology III*

1

Semester Hours

11

Spring

MLTS 1340

Histology IV (Clinical Externship)*

5

MLTS 1350

Histology V*

2

MLTS 1360

Histology VI*

1

POLS 1101

American Government

3

BUSA 2101

Fundamentals of Computer Applications

3

Semester Hours

14

Total Semester Hours: 60

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Humanities requirement may be met by taking any ONE of the following: ARTS 1100, ENGL 2112,

ENGL 2131, ENGL 2111, ENGL 2122, ENGL 2132, MUSC 1100, THEA 1100, ENGL 2141, ENGL

2142

2

COMM 1100

*Certificate option only

Bold courses are to be completed at an approved clinical affiliate for online students

Depending on your enrollment status, you may be required to take ASU 1101, “First Year

Experience”.

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Distance Learning Option A

The following is the course sequence as outlined in the Albany State University Catalog for both

the Histologic Technician Certificate and Associate of Science Degrees.

Freshman Year

First Semester Semester Hours

ENGL 1101

English Composition I

3

BIOL 2411K

Human Anatomy & Physiology I

4

ARTS 1100

Art Appreciation

1

3

MATH 1111

College Algebra or higher math

3

Semester Hours

13

Second Semester

BIOL 2412K

Human Anatomy & Physiology II

4

ENGL 1102

English Composition II

3

COMM 1110

Public Speaking

2

3

CHEM 1211K

Principles of Chemistry I

4

Semester Hours

14

Third Semester

CHEM 1212K

Principles of Chemistry II

4

BIOL 2111K

Essentials of Microbiology

4

Semester Hours

8

Sophomore Year

Fall Semester Hours

MLTS 1300

Introduction to Histology*

3

MLTS 1310W

Histology I*

3

MLTS 1310L

Histology I Lab*

1

MLTS 1320W

Histology II*

2

MLTS 1320L

Histology II Lab*

1

MLTS 1330

Histology III*

1

Semester Hours

11

Spring

MLTS 1340

Histology IV (Clinical Externship)*

5

MLTS 1350

Histology V*

2

MLTS 1360

Histology VI*

1

POLS 1101

American Government

3

BUSA 2101

Fundamentals of Computer Applications

3

Semester Hours

14

Total Semester Hours: 60

1

Humanities requirement may be met by taking any ONE of the following: ARTS 1100, ENGL 2112,

ENGL 2131, ENGL 2111, ENGL 2122, ENGL 2132, MUSC 1100, THEA 1100, ENGL 2141, ENGL 2142

2

COMM 1100

*Certificate option only

Bold courses are to be completed at an approved clinical affiliate for online students

Depending on your enrollment status, you may be required to take ASU 1101, “First Year

Experience”.

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Distance Learning Option B

The following is the course sequence as outlined in the Albany State University Catalog for both

the Histologic Technician Certificate and Associate of Science Degrees.

Freshman Year

Spring Semester Hours

ENGL 1101

English Composition I

3

BIOL 2411K

Human Anatomy & Physiology I

4

ARTS 1100

Art Appreciation

1

3

MATH 1111

College Algebra or higher math

3

Semester Hours

13

Summer

BIOL 2412K

Human Anatomy & Physiology II

4

ENGL 1102

English Composition II

3

CHEM 1211K

Principles of Chemistry I

4

Semester Hours

11

Fall

COMM 1110

Public Speaking

2

3

BIOL 2111K

Essentials of Microbiology

4

POLS 1101

American Government

3

Semester Hours

10

Sophomore Year

Spring Semester Hours

MLTS 1300

Introduction to Histology*

3

MLTS 1310W

Histology I*

3

MLTS 1310L

Histology I Lab*

1

MLTS 1320W

Histology II*

2

MLTS 1320L

Histology II Lab*

1

MLTS 1330

Histology III*

1

Semester Hours

11

Summer

MLTS 1350

Histology V*

2

MLTS 1360

Histology VI*

1

BUSA 2101

Fundamentals of Computer Applications

3

Semester Hours

6

Fall

MLTS 1340

Histology IV (Clinical Externship)*

5

CHEM 1212K

Principles of Chemistry II

4

Semester Hours

9

Total Overall Semester Hours: 60

1

Humanities requirement may be met by taking any ONE of the following: ARTS 1100, ENGL 2112, ENGL

2131, ENGL 2111, ENGL 2122, ENGL 2132, MUSC 1100, THEA 1100, ENGL 2141, ENGL 2142

2

COMM 1100

*Certificate option only

Bold courses are to be completed at an approved clinical affiliate for online students.

**Students starting the program in the spring, can have 30 to 35 hours completed prior to acceptance if

they have taken at least both Biology courses and one Chemistry or both Chemistry courses and one

Biology.

Depending on your enrollment status, you may be required to take ASU 1101, “First Year Experience”.

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Application for Admission

Albany State University Histologic Technician Program

PROGRAM ADMISSION REQUIREMENTS TO THE HISTOLOGIC TECHNICIAN

PROGRAM

Prior to being considered for admission into the Albany State University Histologic Technician

Program, a student must be admitted to Albany State University. IMPORTANT MESSAGE

FOR OUT-OF-STATE APPLICANTS: Every state government regulates whether universities

located in other states can enroll students in online programs. This process is called “state

authorization.” Some states do not allow their students to enroll students in online programs at

outside universities at all; other states charge the outside universities high fees to enroll even one

student from that state. For this reason, Albany State University may not be able to enroll

students from outside Georgia in every online program we offer. We accept students from as

many states as possible. Please visit the following link, https://www.asurams.edu/distance/SA/,

to find out if your state is authorized for Albany State University. In addition, the following

requirements must be met:

1. Due to requirements mandated by NAACLS, applicants for the certificate program

will be required to have a prior college degree.

2. The student must have exited all required learning support courses.

3. Complete courses in Biology, Chemistry and Algebra with a grade of “C” or better.

Coursework in Biology would preferably be Anatomy or some related field. Acceptance

of coursework will be at the discretion of the Program Director.

4. Completed Histologic Technician Program application**

5. Completion and submission of all immunizations including Hepatitis B series.

6. Completion of a physical examination form by a physician (form enclosed)**

7. Completion of a Laboratory Visitation Form verifying a minimum of 2 observational

hours in a Histology laboratory setting (form enclosed).

8. Completion of the grade point average form. Cumulative grade point average (GPA) (all

coursework ever attempted), or you may choose to substitute the cumulative GPA with

another GPA by calculating only the last 35 credit hours attempted.

9. Applicants must submit two professional letters of recommendation(forms

enclosed)**

10. Students completing the Associate of Applied Science degree in Histologic Technician

must meet all the above requirements and complete a minimum of 35 hours of the general

and science education courses towards the degree before applying to the program.

11. Submit all applicable transcripts from college coursework (unofficial accepted)**

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** Must be submitted at time of application

Both the Certificate and Associate of Applied Science Degree options are eligible to sit for the

National Board Exam.

Selection Process

After the June 30

th

extended deadline or November 30

th

extended deadline, the HT Program

Director reviews and scores each application. After completion of scoring, the top 20 applicants

for fall or the top 10 applicants for spring will be selected. Correspondence of acceptance or

regret will be made through the mail or e-mail and should be received no later than July 15

th

for

fall and December 10

th

for spring. Scoring is based on the following criteria: GPA (cumulative or

last 35-hrs), the number of hours observed in Histology Laboratory setting, appropriate

professional recommendations received, clinical affiliation (online only), and completed HT

application. The Albany State University HT program does not utilize a waiting list and those

denied acceptance must re-apply if not being considered for the next matriculation.

Financial Aid

Financial aid is available for students who qualify.

Darton College of Health Professions

Financial Aid Department

Building C, RAM Central

Phone (888) 845-4690

https://www.asurams.edu/financial-aid-home/

Email Address: ifinaid@asurams.edu

If you do not qualify for financial aid, please make sure that you are able to meet the

financial obligations of this program.

Student Expenses

In addition to the standard tuition fees administered by Albany State University and the book

requirements, the student will also be responsible for some other Program expenses. They are

broken down as follows:

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COSTS (subject to change)

Hours

Resident

Tuition/Fees

Non-Resident

Tuition/Fees

Online

Tuition/Fees

Textbooks

1

$845.67

$ 1,103.87

$4200

0

$ variable

2

$938.34

$ 1,454.74

$550

$ variable

3

$1,031.01

$ 1,805.61

$680

$ variable

4

$ 1,123.68

$ 2,156.48

$810

$ variable

5

$ 1,216.35

$ 2,507.35

$940

$ variable

6

$ 1,441.02

$ 2,990.22

$1,070

$ variable

7

$ 1,533.69

$ 3,341.09

$1,200

$ variable

8

$ 1,626.36

$ 3,691.96

$1,330

$ variable

9

$ 1,719.03

$ 4,042.83

$1,460

$ variable

10

$ 1,811.70

$ 4,393.70

$1,590

$ variable

11

$ 1,904.37

$ 4,744.57

$1,720

$ variable

12

$ 1,997.04

$ 5,095.44

$1,850

$ variable

13

$ 2,089.71

$ 5,446.31

$1,980

$ variable

14

$ 2,182.38

$ 5,797.18

$2,110

$ variable

15

$ 2,275.00

$ 6,148.00

$2,240

$ variable

Histologic Technician Program Fall Matriculation (costs listed are approximate)

Semester

Resident*

Tuition/Fees

Non-Resident#

Tuition

Online

Tuition/Fees

Textbooks

Prices may vary

Fall Semester

$1,904.37

$4,744.57

$1,588.00

~$350.00

Spring Semester

$1,626.36

$3,691.96

$1,234.00

$0

Total

$3,530.73

$8,436.53

$2,822

~$350.00

Histologic Technician Program Spring Matriculation (costs listed are approximate)

Semester

Resident*

Tuition/Fees

Non-Resident #

Tuition/Fees

Online

Tuition/Fees

Textbooks

Prices may vary

Spring Semester

$1,904.37

$4,744.57

$1,588

~$350.00

Summer Semester

$1,031.01

$1,805.61

$644.00

$0

Fall Semester

$1,216.35

$2,507.35

$880.00

$0

Total

$4,151.73

$9,057.53

$3,112

~$350.00

*Resident tuition and fees are for students that live in GA, FL, AL, or SC and are

attending classes on campus.

# Non-Resident tuition and fees are for students that did not live in GA, FL, AL, or SC but

are attending classes on campus.

Additional fees

Background Check Fees

$49.50

ASCP Exam Fee

$215.00 - $240.00

AceMapp fees

$50.00

Graduation Fee

$75.00

Laboratory Supplies

$50.00

Liability Insurance

$17.50

Specified Immunizations

$200.00

Uniforms/Lab Coat

$100.00-150.00

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Students participating in the Online (Distance Learning) program must have a clinical

affiliate to fulfill the laboratory/clinical components required for graduation. Complete the

following and submit with your application. If your facility is not affiliated with us, you will

need to send your affiliate’s facility information as soon as possible to the e-mail provided

below.

a. Name of the facility

______________________________________

b. Is this facility a current affiliate of Albany State University ~ Darton College

of Health Professions?

_______ yes _______ no

If you answered “yes”, a letter of support from the facility must be provided

via e-mail to the following e-mail address taiquanda.winbush@asurams.edu.

Or included in your application packet on company letterhead.

If you answered “no”, send the following information: **

i. Facility’s mailing address

_____________________________________________

ii. Contact person’s name

________________________________________

iii. Contact person’s:

1. office number _________________________

2. fax number __________________________

3. e-mail address ________________________

**If a contract has to be initiated with a clinical facility, acceptance into the program may

be delayed.

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PROGRAM APPLICATION

Albany State University Histologic Technician Program

Term/year you plan to begin ( ) Fall _____ ( ) Spring ______

Name: _________________ ____________________ ____________

Last First Middle

Albany State University Student ID number: _____________________

Address:

Street _____________________________________

Apt _________

City ____________________ State ___________Zip ______________

Telephone:

Home ( ) ____________ Work ( ) ____________

Cell ( ) ____________

E-Mail Address: _________________________________

Are you currently working in the field of Histotechnology?

Yes _______ No _______

If yes, please complete the work experience form and not the laboratory visitation form

Do you plan to use this facility to complete your labs/clinical requirements?

Yes _______ No _______

Are you going to complete the first semester lab requirements at Albany State University

(fall entrance only?)

Yes _______ No _______

Do you plan to relocate after graduation?

Yes _______ No _______

Please give the names and numbers for your two professional references

1) ___________________________________ ( ) _______________

2) ___________________________________ ( ) _______________

Date received by HT Program:

__________________

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GRADE POINT AVERAGES (G.P.A. must be a minimum of a 2.5)

1.

The G.P.A. to include on this page is your choice and may be either your overall cumulative

G.P.A. or the G.P.A. for the last 35 hours of earned college credit.

Use the Cumulative G.P.A. Form to calculate the G.P.A. you choose to include and include the

completed form with the

application.

Indicate which G.P.A. has been included by writing in the designated

box for which you calculated. (i.e. either Cumulative or Last 35 hours)

Cumulative G.P.A. =

OR

Last 35 hrs G.P.A. =

*Date of Birth____________________ (optional)

*Sex ( ) Male ( ) Female

*Race ( ) Black (Not of Hispanic Origin) ( ) White

( ) American Indian or Alaskan ( ) Hispanic

( ) Asian or Pacific Islander ( ) Other

*The only use of this information is to submit data for institutional use and will not be

considered for acceptance into the program.

How did you learn about the Histologic Technician Program?

____________________________________________________________________

Have you previously applied to Albany State University HT program? Yes____ No___

Do you currently have an Associate’s degree or Higher? Yes_____ No_______

If you answered yes, please provide proof (transcript that shows degree awarded or copy of

diploma).

I hereby apply for admission to the HT Program for Fall ( ) Spring ( ) Semester 20 _____

and certify this application is both correct and complete. I have read the application

packet, including the essential abilities required and understand the application and

selection criteria and that the class size is limited to 20 students for the fall semester and 10

students for the spring semester.

I further understand that any failure on my part to comply with these processes will result

in my application not being reviewed. I understand that meeting all minimum

requirements does not guarantee admission into the program.

Yes ____ No _____

_______________________________ _______________________

Signature Date

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Mandatory Student Health Insurance

Beginning Fall Semester 2014, all new students accepted into ANY Health Sciences or Nursing

Program at Albany State University will be required to verify active Medical Insurance coverage.

This is a new Board of Regents of the University System of Georgia mandate and not a Albany

State University mandate. Proof of coverage must be submitted during a specified time period

after acceptance into any Health Sciences or Nursing Program at ASU. Submissions CANNOT

be done BEFORE or AFTER the given time period. Submission is done via the following

website:

Health Insurance link

Proof of coverage must be provided in one of the following ways:

1) Through a currently active parent plan.

2) Through a currently active individual or family plan.

3) Through a currently active Employer-Sponsored plan.

4) Through a currently active Albany State University Student Health Insurance Plan

(SHIP).

5) Through a currently active Government Sponsored Plan.

If a student fails to provide appropriate proof of coverage during the dates stated above, the

student will be automatically enrolled (via the Business Office) into plan #4 above. As of May

1, 2014, the Annual Premium rate for Plan #4 was as follows:

Student – Age 26 and Under $1,381.00

Student – Age 27 and Older $1,782.00

*These rates are subject to change without notice.

Additionally, Health Insurance coverage must be maintained by the student throughout the entire

time that he/she remains enrolled and is actively progressing through his/her respective Health

Sciences or Nursing Program. If a student fails to maintain Health Insurance coverage, then

he/she will be immediately dismissed from their respective Health Sciences or Nursing Program

for failure to maintain the mandatory coverage as required by the Board of Regents of the

University System of Georgia. If you have any questions regarding this requirement, please

contact your respective Program Director, the Health Sciences Division Office, or the Nursing

Division Office.

I have read the above statement and I understand the requirements as listed above and understand

that my acceptance into any Albany State University Health Sciences or Nursing Program

requires Mandatory Medical Insurance coverage.

___________________________________________ _________________

Student Signature Date

___________________________________________

Printed Name

15

Albany State University

Histologic Technician Program

Physical Evaluation Form

To be completed by physician/health care provider

I have examined ______________________________ and find that she/he meets the

following essential functions required for participation in the Albany State University Histologic

Technician Program. The essentials are as follows:

Visual Acuity (with or without corrective lenses) sufficient to differentiate colors used as

reaction indicators; to differentiate and identify specimens utilizing microscopic examination; to

read laboratory manuals, procedures, policies, specimen labels, test requisitions and other

materials pertinent to professional practice;

Physical Ability to manipulate clinical laboratory instruments and equipment in a manner

consistent with operational procedures;

Manual Dexterity to perform procedures and operate equipment consistent with operational

guidelines.

________________________________ ______________

Physician/Health Care Provider Date

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Albany State University

Histologic Technician Program

Applicant Recommendation Form

Applicant: (Print Name) _________________________________________________________________

Instructions:

To the applicant: Please give this form to the person chosen to provide this recommendation for you. This

person should be a professional who is able to evaluate your personal characteristics such as an employer,

supervisor, teacher, physician, healthcare worker or counselor, etc. Recommendations from friends or family are

prohibited.

To the person completing the recommendation form: The applicant is applying for admission to the

Histologic Technician Program. We consider the following characteristics to be important for the success of students

in this program.

Please evaluate each of these personal characteristics of the applicant by circling the most appropriate

choice using the following scale...

5 = Strongly Agree, 4 = Agree, 3 = Neutral, 2 = Disagree, 1 = Strongly Disagree, N/A = Unable to Evaluate

Please feel free to list any additional comments on the back of this form

__________________________________________________________________________________

Responsibility – Accountable for one’s actions 5 4 3 2 1 N/A

Initiative – Motivated to pursue actions independently 5 4 3 2 1 N/A

Flexibility – Adapts to new or changing situations 5 4 3 2 1 N/A

Organization – Able to arrange or order tasks efficiently 5 4 3 2 1 N/A

Self Confidence – Assured in one’s abilities and skills 5 4 3 2 1 N/A

Independent work - Completes tasks with minimal supervision 5 4 3 2 1 N/A

Verbal Communication – Expresses self effectively. 5 4 3 2 1 N/A

Written communication – Writes clearly and effectively. 5 4 3 2 1 N/A

Stress Response – Maintains composure & ability to function. 5 4 3 2 1 N/A

Attitude – Positive approach to assignments and coworkers. 5 4 3 2 1 N/A

Manual Dexterity – Ability to perform hands on skills 5 4 3 2 1 N/A

Team Player – Able to work as part of a group. 5 4 3 2 1 N/A

Accepts Supervision – Willing to learn. 5 4 3 2 1 N/A

Maturity – Demonstrates common sense, self-control, tact. 5 4 3 2 1 N/A

Dependability – Reliable follows through on tasks. 5 4 3 2 1 N/A

Decision Making – Analyzes facts and formulates solution. 5 4 3 2 1 N/A

Knowledge Application – Can apply what has been taught 5 4 3 2 1 N/A

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Additional Comments: (Please use to indicate applicant’s strengths particularly those not

indicated already, and any areas you feel need improvement.)

__________________________________________________________

Relationship to applicant: ___ Advisor ___ Teacher ___ Supervisor ___ Employer

___ Other (Please describe) ______________________________________________

How long have you known the applicant? ____________________________________

How well do you know the applicant? _______________________________________

Do you ___ Highly Recommend, ___ Recommend

___ Recommend with reservation ___ Not Recommend this applicant?

Signature: ____________________________________ Date: _________________

Name: ________________________________________________________________

Title: _________________________________________________________________

Institution: _____________________________________________________________

Address: _______________________________________________________________

Telephone: _____________________________

Would you mind if someone contacted you about this applicant? ___ Yes ___ No

Thank you. To assist the applicant in completing the application process we ask that you seal this

recommendation in an envelope and sign your name across the flap before returning it to the

applicant. If you prefer you may mail this recommendation directly to:

Albany State University

Health Sciences Division

Taiquanda Winbush, Program Director

Histologic Technician Program

2400 Gillionville Rd.

Albany, GA 31707

18

Albany State University

Histologic Technician Program

Applicant Recommendation Form

Applicant: (Print Name) _________________________________________________________________

Instructions:

To the applicant: Please give this form to the person chosen to provide this recommendation for you. This

person should be a professional who is able to evaluate your personal characteristics such as an employer,

supervisor, teacher, physician, healthcare worker or counselor, etc. Recommendations from friends or family are

prohibited.

To the person completing the recommendation form: The applicant is applying for admission to the

Histologic Technician Program. We consider the following characteristics to be important for the success of students

in this program.

Please evaluate each of these personal characteristics of the applicant by circling the most appropriate

choice using the following scale...

5 = Strongly Agree, 4 = Agree, 3 = Neutral, 2 = Disagree, 1 = Strongly Disagree, N/A = Unable to Evaluate

Please feel free to list any additional comments on the back of this form

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