WIXLIB

SURGICALTECHNOLOGYProgram Application2021-2022Franciscan Health Education Center 421 N Emerson Ave, Greenwood, IN e Surgical Technology Program at Franciscan Health accredited by the Commission on Accreditation of Allied Health EducationPrograms (www.caahep.org). CAAHEP 25400 US Highway 19 North Suite 158 Clearwater, FL 33763 P:727-210-2350,mail@caahep.orgFranciscan Health is HFAP accredited.

Directions regarding the Application Packet1. Please read the program booklet in its entirety to ensure that you qualify for the program.2. Make sure to copy all forms!3. Complete the application completely.4. Only write your name on the top of the form and then give it to your references. The references will sendthem back to the Program Director. Make sure you give plenty of time for your references to fill out the formand mail it back in. (Franciscan Health reserves the right to contact all references for validity).5. You must submit your official, sealed, transcript from high school or GED by mail, in person orelectronically. You should also include any secondary education transcripts as well. Contact your school(s)to obtain copies and pay fees if necessary.Please note: Official transcripts are sent directly from the school to the Program Director either in a sealedenvelope to the same address as your application or emailed to claire.hervey@franciscanalliance.org.Franciscan Health Education CenterAttn: Claire Hervey421 N. Emerson AveGreenwood, IN 461437. If you have any questions regarding application processing or the program, please call 317-528-8473 oremail EducationIndy@franciscanalliance.org. Email is preferred.

Surgical Technology ProgramApplication for Admission2022-2023All information on the application must be completed. Please print legibly.Application may be submitted in person or mailed to:Franciscan Education CenterAttn: Claire Hervey421 N. Emerson Ave.Greenwood, IN 46143General InformationApplication Date:ID # ( last 5 digits of SS#) :First Name:MI---Last Name:Maiden Name:Address:CityState:Email:ZipPhone:ResidencyAre you a US Citizen or possess a Permanent Residence Card (Green Card)?Documentation may be requiredyesnoyesnoResourcesDo you have a home computer, laptop, or tablet and access to the internet?If not, are you willing to acquire the resources required for admission?Educational BackgroundEducation LevelName of SchoolDates AttendedHigh oOtherFromToyesnoArea of StudyCertificate or Degree

Franciscan Health Employment InformationHire Date:Department:Job Title:Full Time:Part time:Brief Description of Duties:Non- Franciscan Health Employment HistoryHire Date:Employer:Job Title:Full Time:Part time:Brief Description of Duties:If you have had more than one job, please attach a resume including all your employment history.Prior EmploymentHave you ever been involuntarily terminated from any Franciscan Health facility?If yes, please complete the following:When:Explanation:Where:yesno

Criminal HistoryHave you ever been convicted of a crime?yesnoIf yes, please list all convictions and dates below, including all traffic ty/State:Please Note: Conviction means you were found guilty by a judge, jury, “no contest”, or guilty plea in court. A convictionmay have taken place even if you did not pay a fine or spend any time in jail/prison. Franciscan Health policy willdetermine which convictions disqualify you form entering this program. A conviction will not automatically disqualifyyou form entering this program. Any misrepresentation will disqualify you from admission into this program.If selected to participate in this program, your acceptance will be based upon your ability to successfully pass a criminal backgroundcheck (at your own expense). Information will be provided in the acceptance packet.Please Read Carefully and SignFranciscan Health is an Equal Employment Opportunity Employer. We select the most qualified applicants withoutregard to race, color, religion, sex, national origin, age or disability, as long as they are able to perform the essentialfunctions of the position for which they are applying, with or without any necessary reasonable accommodation. Title IIof the Genetic Information Nondiscrimination Act of 2008 also protects applicants and employees from discriminationbased on genetic information and restricts employers’ acquisition of and strictly limits disclosure of genetic information.These policies apply to all terms and conditions of employment, including (but not limited to) hiring, placement,promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.The receipt of this application does not imply that the applicant will be admitted into the education program. Eachquestion should be answered in a complete and accurate manner since not action will be taken unless all questions arecompleted.I certify the information on this application and any documents accompanying it is true and complete. If acceptance intothe education program, I understand any omission; false or misleading information on this application discovered at anytime during the admission process or after acceptance is initiated, may lead to my termination from the program.I understand that consideration for admission into the program is contingent upon completing the application process,submitting all related forms by the required deadline, and successfully meeting all admissions requirements.If accepted for enrollment in the education program, I agree to comply with established rule, policies and procedures ofFranciscan Health and as established in the handbook.Applicant’s Printed NameApplicant’s SignatureDate

How did you hear about the Franciscan Health Surgical Technology Program?How did you hear about us?Please check all that apply. This will help us better reach future students. Thanks for your input.I hear about this program through:1.Department Educator2.Program Director3.Franciscan Health Program website4.Franciscan Health employee5.friend6.My case manager/case coordinatorrelative7. Other (Please explain):former student nameWhich organization?

Short EssayIn the space provided below, explain why you want to enter the Surgical Technology profession andwhat you have done to investigate the profession.

Surgical Technology ProgramCONFIDENTIAL Candidate Reference Form*(APPLICANT do not write below this line)Applicant's Name:Prepared by:Relationship to Applicant:Preparer's Title:Preparer's Employer:Preparer's Number:Date Completed:How to use the Rating Scale: Circle the rating that best applies to this applicant.PunctualityConsider frequency of latenessand number of absencesDependabilityConsider amount of supervisionrequired and application toworkCooperationConsider cooperation withemployees and patientsConsistencyConsider volume and accuracyof work regularly produced321Always PunctualSeldom Late or absentOccasionally late or absentVery reliable and attentive; does Generally reliable and attentive;Reliable and attentive; needs littlenot need supervision; veryfollows xceedingly cooperative; goodteam member; presents newideasCriticismJudgementOrganizationConsider arrangement of workarea, use of filing systems andreferencesInitiativeConsider originality andresourcefulnessProceduralConsider ability to understandand retainVery reliable; asks for facts tohelp generate best conclusions0Often late or absentoccasionally unreliable andinattentive; needs routinesupervisionReluctantly cooperative; hesitates Uncooperative; unwilling to try newto accept suggestionsideasGenerally inconsistent; limitedoutput; occasionally unacceptablequalityInconsistent; little output; often ofpoor qualityResponsive; uses criticism toimproveGenerally receptiveIndifferent/HostileReliable; considers facts andreaches sound conclusionsGenerally reliable; usually makespractical decisionsOccasionally questionable;influenced by opinions and feelingsConsistent; above average output Generally consistent; averageof acceptable qualityoutput of acceptable qualityConsider immediate and long‐ Very responsive; asks for criticismto improve performanceterm reactions to constructivecriticismConsider ability to evaluatesituations and make sounddecisionsGenerally cooperative; usuallywilling to try new ideasPreparer, please mail form to:Franciscan Health Education CenterAttn: Surgical Technology Program421 N Emerson AveGreenwood, IN 46143Organized; materials easilylocated by self and othersUsually organized; locates most Occasionally disorganized, cannotmaterials quicklylocate materials quicklyDisorganized often cannot locatematerialsSubstantial; above averageinterest and initiativeAverage; does obviously relatedpast without urgingMarginal; works routinely; doesonly enjoyable tasksMinimal; does what is needed to getby; lazy; must always be directedKnowledgeable; readilyunderstands and retainsAverage knowledge; retainswell, occasionally ask questionsAdequate knowledge: somerepeated instructions neededLimited knowledge; must beinstructed often*Franciscan Health reserves the right to contact the preparer to verify reference information. Total Number of Points:

Surgical Technology ProgramCONFIDENTIAL Candidate Reference Form*Applicant's Name:(APPLICANT do not write below this line)Prepared by:Relationship to Applicant:Preparer's Title:Preparer's Employer:Preparer's Number:Date Completed:How to use the Rating Scale: Circle the rating that best applies to this applicant.PunctualityConsider frequency of latenessand number of absencesDependabilityConsider amount of supervisionrequired and application toworkCooperationConsider cooperation withemployees and patientsConsistencyConsider volume and accuracyof work regularly produced321Always PunctualSeldom Late or absentOccasionally late or absentVery reliable and attentive; does Generally reliable and attentive;Reliable and attentive; needs littlenot need supervision; veryfollows xceedingly cooperative; goodteam member; presents newideasCriticismJudgementOrganizationConsider arrangement of workarea, use of filing systems andreferencesInitiativeConsider originality andresourcefulnessProceduralConsider ability to understandand retainVery reliable; asks for facts tohelp generate best conclusions0Often late or absentoccasionally unreliable andinattentive; needs routinesupervisionReluctantly cooperative; hesitates Uncooperative; unwilling to try newto accept suggestionsideasGenerally inconsistent; limitedoutput; occasionally unacceptablequalityInconsistent; little output; often ofpoor qualityResponsive; uses criticism toimproveGenerally receptiveIndifferent/HostileReliable; considers facts andreaches sound conclusionsGenerally reliable; usually makespractical decisionsOccasionally questionable;influenced by opinions and feelingsConsistent; above average output Generally consistent; averageof acceptable qualityoutput of acceptable qualityConsider immediate and long‐ Very responsive; asks for criticismto improve performanceterm reactions to constructivecriticismConsider ability to evaluatesituations and make sounddecisionsGenerally cooperative; usuallywilling to try new ideasPreparer, please mail form to:Franciscan Health Education CenterAttn: Surgical Technology Program421 N Emerson AveGreenwood, IN 46143Organized; materials easilylocated by self and othersUsually organized; locates most Occasionally disorganized, cannotmaterials quicklylocate materials quicklyDisorganized often cannot locatematerialsSubstantial; above averageinterest and initiativeAverage; does obviously relatedpast without urgingMarginal; works routinely; doesonly enjoyable tasksMinimal; does what is needed to getby; lazy; must always be directedKnowledgeable; readilyunderstands and retainsAverage knowledge; retainswell, occasionally ask questionsAdequate knowledge: somerepeated instructions neededLimited knowledge; must beinstructed often*Franciscan Health reserves the right to contact the preparer to verify reference information. Total Number of Points:

The Surgical Technology Program at Franciscan Health accredited by the Commission on Accreditation of Allied Health Education Programs (www.caahep.org). CAAHEP 25400 US Highway 19 North Suite 158 Clearwater, FL 33763 P:727-210-2350, mail@caahep.org . Franciscan Health is HFAP accredited.