Fillable Surgical Technology Associate Degree Program (Durham Technical Community College)

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Surgical Technology Associate Degree Program (Durham Technical Community College)

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Return this form to:
Admissions Registration, and Records.
View submission instructions below.
For Admissions use only.
Received By: ___________
Date: _
Surgical Technology Associate Degree Program
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: March 31
Submit completed paper application packets between November 1 and March 31.
Email donesa@durhamtech.edu if you have admission questions.
Submit completed application packets electronically to the Admissions, Registration, and Records office. Follow
the instructions to submit electronic documents using our secure system. Acceptable digital formats include PDF, JPEG,
TIFF, GIF, and PNG. No faxed or emailed applications will be accepted.
CHECKLIST:
All steps below are required. Plea
se check 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 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 (check one):
☐ 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
☐ 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)
Revised 10/2020
Page 1 of 2
Meet Natural Sciences Requirement:
Students must demonstrate readiness for BIO 168 – Anatomy and Physiology I in one of the following
ways (initial one):
☐ Provide proof of completing high school biology and chemistry within the last 10 years with a grade of
C (70%) or above
☐ Complete CHM 094 Basic Biological Chemistry
☐ Complete college biology and chemistry (both including a lab). Must show a grade of C (70%) or above in
the lecture and lab (no time limit).
Students who transfer in BIO 168 are not required to meet one of the above requirements
Additional Required Documents:
Students must provide all of the documents listed below with the completed application:
☐ I have attached a signed Clinical Training Form (attached below)
☐ I have attached a signed English Language Requirement Form (attached below)
☐ I have attached a signed Essential Skills Form (attached below)
Statement of Student Responsibility
I verify that I have read all the information regarding admissions to the Surgical Technology Program, and understand
the steps I must take to qualify for admissions. I understand that it is my responsibility to notify the Student Information
and Records office regarding changes in name, address, or phone number.
I understand that all official communication from the college is delivered via ConnectMail, including Health Technology
admissions decisions.
I understand that my Surgical Technology application will not be accepted unless everything is completed.
Note: Once an applicant has accepted a seat within the Surgical Technology program, this is considered their first
admittance. Students are only allowed to be accepted into the Surgical Technology program twice (this also applies to
returning students – only allowed to return once).
Signature Date
Revised 10/2020
Page 2 of 2
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Statement of Policy Regarding Acceptance for Clinical Training in the Following
Programs at Durham Technical Community College
Associate Degree Nursing Medical Assisting Practical Nursing
Anesthesia Technology Occupational Therapy Assistant Respiratory Therapy
Clinical Trials Research Associate Pharmacy Technology
Surgical Technology
Health Information Technology Medical Product Safety and Pharmacovigilence
Students accepted into the above programs must meet the standards of both the College and the
affiliated clinical sites in order to participate in the appropriate clinical training for the program. Each
clinical site where a student receives training reserves the right to refuse clinical training to any student
found to be unacceptable according to that site’s policies and regulations. Clinical sites require a
Criminal Background Check (CBC) prior to the student’s placement for training at that site.
Reasons for refusal could include, among other considerations, a documented criminal background check
indicating convictions for drug or alcohol related charges, child abuse or molestation, burglary, larceny, or
other convictions deemed inappropriate to the particular clinical setting. In addition, students may be
required to submit to a 12-panel drug screening per the clinical site’s requirement.
The student must conform to and be subject to all policies and regulations of the assigned clinical site. The
site reserves the right to end clinical training of any student whose performance violates rules, policies,
procedures or professional standards expected by the agency. Written justification from the clinical site will
be provided to the college for such suspension. The clinical site and college personnel reserve the right to
take appropriate immediate action, when necessary, to maintain the proper and safe operation of its
facilities and the safety of clients in the clinical setting.
Criminal Background Check and Drug Screening: When students are admitted into the program of study, the
student receives the CBC and drug screening information and directions: The criminal background check will
include reports from all states where the student has lived, worked, or gone to school from the date that they
turned eighteen (18) years of age. The CBC will include both felonies and misdemeanors. The National Sex
Offender Registry is included in the CBC. Flagged reports are sent directly from the designated CBC vendor to
the clinical sites. Durham Tech does not retain copies of the results. Note: Please do not get this report from
your local police department. The drug screening is a 12-panel test.
Students will pay a fee directly to a designated vendor for the CBC and drug screening.
Additional information on the Criminal Background Check requirement may be obtained from the Durham
Tech website.
I verify that I have read and fully understand the Statement of Policy Regarding Acceptance for Clinical
Training at Durham Technical Community College. I also understand that a criminal background check
and/or drug testing will be required for placement in clinical training sites for Durham Technical Community
College.
NAME (Print) __________________________________________ STUDENT ID# ______________________
Program of Study _________________________________________________________________________
SIGNATURE ___________________________________________ DATE ____________________________
Health Technologies Clinical Training Form 6/2018
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Durham Technical Community College
English Language Requirement Form
All health care workers (native and non-native U.S. English speakers alike) are expected to use clear
communication skills in the workplace. Students whose native language is not U.S. English are expected
to demonstrate "near native" U.S. English language abilities. To confirm this ability, all students entering
a Health Technologies program are required to meet the English language requirement.
Students meeting the following criteria must comply with this revised requirement:
1. Students who applied to a Health and Wellness program on or after January 1, 2016, OR
2. Students who applied to a Health and Wellness program before January 1, 2016, but have not
yet met the previous English language requirement.
Please check the ONE that applies:
☐ I have only attended a U.S. high school, and my first language is U.S. English.
☐ I have attended school outside the United States.
☐ My first language is not U.S. English.
If you checked the first checkbox, please sign here. There is nothing further that you need to do.
I understand that this is an official Durham Technical Community College document and that any
falsification on this document may result in disciplinary action according to the Student Code of
Conduct.
My signature below indicates that I am responding truthfully.
Student Name (print): ____________________________________ Student ID: __________________
Student Signature: _______________________________________ Date: ______________________
If you checked the second or third checkboxes, you must meet the English Language Requirement by
successfully completing one of the following options listed on the following page.
1. Take the Duolingo English Test and score 100 points or higher or
2. Take the Test of English as a Foreign Language (TOEFL), iBT version (obtain a score of 22 in
listening and above 26 in speaking or
3. Complete EFL 055 OR EFL 064 and other EFL courses as recommended or required by placement
testing (obtain a score of 80% or above).
Note: Scores for the above tests and classes are valid for up to 5 years.
I understand that this is an official Durham Technical Community College document and that any
falsification on this document may result in disciplinary action according to the Student Code of
Conduct.
English Language Requirement Form, revised Nov. 2020 1
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I checked the second or third checkboxes; however, I have met the English Language Proficiency
Requirement as follows:
☐ I have taken the Duolingo English Test and scored 100 points or higher.
☐ I took the Test of English as a Foreign Language (TOEFL), iBT version and scored above 22 in
listening and above 26 in speaking.
☐ I have completed one or more EFL curriculum courses in the areas listening/speaking and have
scored an 80% or higher.
My signature below indicates that I am responding truthfully.
How to complete this section: Fill in your name but no other information in the admissions application
and email it to wilderp@durhamtech.edu. She will sign it and return it to you. You can then complete
the application and submit it electronically (see instructions at the top of the application).
Student Name (Print): ___________________________________ Student ID: __________________
Student Signature: ______________________________________ Date: ______________________
EAP Representative Name/Title ________________________________________________________
EAP Representative Signature: ___________________________________ Date__________________
English Language Requirement Form, revised Nov. 2020 2
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SURGICAL TECHNOLOGY PROGRAM
ESSENTIAL SKILLS FOR ADMISSION AND PROGRESSION
PHYSICAL AND PSYCHOLOGICAL REQUIREMENTS
Students applying to the Surgical Technology (ST) program must demonstrate sufficient physical and emotional health to be considered fit to participate in academic education and
laboratory experiences, and to practice clinically with the public in a safe and effective manner.
ISSUE
STANDARD
EXAMPLES OF NECESSARY ACTIVITIES (not inclusive)
Critical Thinking
• Possess critical thinking ability sufficient for
problem solving & clinical judgment
• Ability to be oriented to time, place, and person,
organize responsibilities, and make quick
appropriate decisions.
• Organize and prioritize; arranging instrumentation or actions in a certain order/pattern
according to specific rules; must be able to bring together and relate the similarities of surgical
procedures & situations in order to function on unfamiliar procedures.
• Concentrate for prolonged periods of time in a sterile environment.
•
Need to quickly assess needs for surgical procedures, anticipate surgeon’s needs.
Interpersonal
Interpersonal abilities sufficient to interact with
• Display patience, empathy and concern for others.
Skills individuals, families, and groups from a variety of social,
emotional, cultural, and intellectual backgrounds.
• Deal with fear and hostility in a calm manner.
• Work with others in stressful situations.
• Receive constructive feedback positively.
Communication
Sufficient written and oral skills to communicate needs
promptly and effectively, express and exchange ideas,
and interact with patients, surgeons, peers, and other
medical personnel.
• Must be able to communicate in a concise manner (able to get to the point).
• Must be able to speak clearly and respectfully.
• Must be able to restate, rephrase, and reframe ideas (paraphrase) to ensure clear
understanding of orders/direction given by surgeons, anesthesiologists, nurses, peers and other
medical personnel.
• The surgical technology student must be able to complete surgical counts prior to the beginning
of the procedure, during the procedure and upon completion of the procedure without
interruptions; must also be able to communicate/relay information about the patient, the
surgical procedure, and the surgeon(s) to relief personnel in order to facilitate a smooth
transition from one surgical technologist to another.
• Must be able to communicate needs during an emergency situation intraoperatively.
o The surgical technology student must be able to verbally request additional spongesin
the event of a hemorrhage.
Mobility
Physical abilities sufficient to move from room to room
and maneuver in small spaces.
• Move around in operating rooms without contaminating sterile workspaces.
• Must also be able to workin a small area without contaminating him/herself and the surgical
team.
Motor Skills
Gross and fine motor abilities sufficient to provide
safe and effective patient care, as well as providing a
safe and effective environment for the surgical team.
• Pass surgical knives, hypodermic needles, and sharp instrumentation without causing injury to
the patient, him/herself or to the remainder of the surgical team; handle fine sutures and
delicate instrumentation; position and transport patients.
• Respond promptly to the surgeon's/patient's needs,
• Manipulate equipment,
• Lift a minimum of 50 pounds, exert a sustained force of 20 pounds, push/pull mobile
equipment weighing up to 300 pounds.
• Stand in sterile scrub attire for prolonged periods (sometimes wearing a 12-20 pound lead
apron underneath the gown).
• Walk an equivalent of 5 miles per day.
Revised 11/10/2020
ISSUE
STANDARD
EXAMPLES OF NECESSARY ACTIVITIES (not inclusive)
Tactile Skills
Shall possess tactile ability to sufficiently handle all the
microscopic supplies, instruments, and equipment.
• Loading fine sutures onto needle drivers and for passing to the surgeon delicate
instrumentation; good hand eye coordination; keep hands and arms steady while moving your
arm or while holding your arm and hand in one position. Implantable items for patients may be
very delicate, in combination with sterile surgical gloves, some supplies and instruments
require very delicate manipulation.
Visual
Visual ability and acuity sufficient for observation
and assessment necessary during a surgical
procedure.
• Handling fine sutures and needles safely and efficiently in response to the needs of the surgeon
and surgical procedure, being able to visualize and follow the surgical procedure, andworking
with small supplies and instruments that require calibration.
Hearing
Auditory ability sufficient to monitor and access health
needs of the patient, & maintain facility safety.
• Hear monitor alarms, emergency signals, & commandsgiven by the surgeon and the circulating
nurse.
Weight Bearing
Should possess the ability to maneuver/move/lift 40-50
pounds, daily.
• Lift a tray of surgical instruments; position patients and move equipment.
• Lifting extremity.
•
Standing for a surgical procedure that may last several hours.
Occupational
Exposures
The ST student is at high risk for exposure to blood and
body fluids, toxic substances, anesthetic preparations,
and chemical sterilization practices at all times.
• Pathogens (HIV, AIDS, HBV, MRSA, TB)
• Bone cement, ethylene oxide, radiation, electricity, gases.
•
Sharp instrumentation.
Emotional
Ability to tolerate environmental stressors.
• Patient death.
• Different personalities.
• Physical stressors as room temperatures, noises, odors, patient conditions, and standing for a
long period of time either in an ergonomically or non-ergonomical position).
• The student must be able to cope effectively with stress in the workplace; cope with patient &
colleague emotions calmly; while demonstrating a high degree of patience.
A prospective student with a disability which may impact upon their ability to provide patient care, should contact Accessibility Services.
I certify that I have read the Essential skills for Admission and Progression form. I certify that I understand the physical and psychological requirements needed for providing
safe surgical technology care. I have assessed my ability to perform these skills and am able to demonstrate these essential skills.
Student Signature __________________________________ Date _______________________
Revised 11/10/2020
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Completed 3 February 2021

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