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AUTRY TECHNOLOGY CENTERANNUAL NOTICE OF REQUIRED DISCLOSURESOF STUDENT CONSUMER INFORMATION2017-2018What to Disclose, When & to WhomBrief Description of Information to be DisclosedWhere to Find Full DisclosureInformationWhat: Institutional InformationWhen: Upon RequestTo:Enrolled StudentsProspective StudentsWhat: Financial AssistanceInformationWhen: Upon RequestTo:Enrolled StudentsProspective Students What: Family Education Rights andPrivacy Act (FERPA) When: Upon Request,Annually Local Newspaper To: Enrolled StudentsParents of enrolled students underthe age of 18 Perspective StudentsWhat: Completion/Graduation Rate,Retention Rate, & Transfer Out RateWhen: OngoingUpon RequestTo:Enrolled StudentsProspective Students What : Drug & AlcoholAbuse PreventionWhen: Annually & UponEnrollment or HireTo:Enrolled StudentsCurrent Employees What: Campus Security ReportWhen: Annually by October 1To:Enrolled StudentsCurrent EmployeesWhen: Upon RequestTo:Prospective StudentsProspective EmployeesWhen: Annually by date specifiedTo:U.S. Dept. of EducationWhat: Gainful EmploymentTo:Prospective/Enrolled Students Cost of attending Autry Technology Center i.e.: Tuition and FeesInstitutional Refund Policy/Requirements for officially withdrawing from schoolInformation regarding the school’s programs & academic supportEntities that accredit, approve, or license the school & its programs & procedures for reviewingaccreditation, approval, or licensing documentationDescription of any special services & facilities for students with disabilitiesTitles & availability of employees responsible for dissemination of institutional & financial assistanceinformation & how to contact themPenalties & institutional policies on copyright Infringement, including unauthorized peer-to-peer filesharingNet Price CalculatorConstitution Day/Voter Registration/Vaccination PolicesGrievance ProceduresDescription of all available federal, state, local, private & institutional financial assistance, & adescription of: (1) application form & procedures; (2) student eligibility requirements; (3) selectioncriteria; & (4) criteria for determining the amount of a student’s awardRights & responsibilities of students receiving Title IV & other financial aid, including: (1) criteria forcontinued eligibility; (2) satisfactory academic progress (SAP) standards; (3) criteria to re-establisheligibility if student fails to maintain SAP; (4) method & frequency of financial aid disbursements; (5)books & supplies policyProcedures for the Return of Title IV Aid and Repayments by withdrawn studentsRight to & procedures for inspecting & reviewing student’s education recordsRight to & procedures for requesting amendment of student’s education records believed to beinaccurate or misleadingRight to file a complaint with the Department of Education for alleged school’s or educationalagency’s failure to comply with FERPA requirementsRight of school to disclose personally identifiable information contained in student’s educationrecords without prior consent (34 CFR §99.31)Students right & procedures for directory information to not be disclosedThe institution’s completion rate for full-time, first-time, certificate seeking students enrolled at thepost-secondary level who completed their career major within 150% of the normal time (scheduledlength of career major) for completionTransfer-out rate is not applicable to Technology Centers since it applies to schools whose missionincludes providing substantial preparation for students to enroll in another eligible institutionInformation on student body diversity in the categories of gender & ethnicity of enrolled studentswho receive Federal Pell GrantsRetention rates of certificate seeking first-time full-time students as reported to the IntegratedPostsecondary Education Data System (IPEDS)Information on preventing drug & alcohol abuseStandards of conduct that clearly prohibit, at a minimum, the unlawful possession, use, ordistribution of drugs & alcohol by students & employees on the school’s property, or as part of theschool’s activitiesA description of the sanctions under local, state & federal law for unlawful possession, use ordistribution of illicit drugs & alcoholA description of drug & alcohol abuse education programs, counseling, treatment, or rehabilitationprograms available to students & employeesA description of the health risks associated with the use of illicit drugs & alcoholA clear statement that the school will impose sanctions on students & employees for violations ofthe standards of conduct (consistent with local, state & federal law) & a description of thesesanctions, up to & including expulsion, termination of employment, & referral for prosecutionCrime statistics for 3 most recent years concerning the occurrence on campus, in or on non-campusbuildings or property & public property reported to campus security authority or local police.Policies concerning the security of & access to campus facilities & procedures to report campuscrimes or other emergenciesDisciplinary actions regarding the possession, use & sale of alcoholic beverages & illegal drugs &enforcement of state underage drinking laws & federal & state drug lawsPrograms to inform students & employees about campus security policies, procedures & practices &encourage responsibility for the prevention of crime.Policies regarding sex offenses & where to obtain information concerning registered sex offenders.Emergency response & evacuation policy, procedures & programsCampus Sexual Violence Elimination Act and Violence Against Women Reauthorization Actinformation, policies, and proceduresInformation on graduation rates, the median debt of students completing the program, programcosts, job placement, types of employment, etc. Autry Websitewww.autrytech.edu Student Handbook Consumer Information Guide Autry Course Catalog Program Description Handouts Autry Websitewww.autrytech.edu Student Handbook Consumer Information Guide FAFSA website: www.fafsa.gov Financial Aid Policy &Procedures Student Handbook Consumer Information Guide Board of Education Policy andProcedure Manual x.html U.S. Dept. of Ed’s CollegeOpportunities On-Line website:nces.ed.gov/collegenavigator Autry ODCTE Profile Autry Websitewww.autrytech.edu Student Handbook Consumer Information Guide Board of Education Policy andProcedure Manual Autry Websitewww.autrytech.edu Student Handbook Consumer Information Guide Emergency Handout for Staff Autry employmentdisclosuresPaper copies of Disclosure Information available from Student Services.This notice is distributed annually to all current and prospective students. It is also located on Autry’s website, in the Student Handbook, and Consumer Information Guide.Autry Technology Center does not discriminate on the basis of race, color, sex, pregnancy, gender, national origin, religion, disability,veteran status, sexual orientation, age, or genetic information. Autry Technology Center no discrimina en base a raza, color, género, estadode embarazo, nacionalidad de origen, religión, discapacidad, estado de veterano, orientación sexual, edad o información genética.Oct 31 2017 subject to change without notification Page 6 of 22

TRTERAUL TECHNOAICGYLOSURGSURGICAL TECHNOLOGY INFORMATIONAL PACKETYTECHN O LO G YNCE

Dear Prospective Student:Thank you for your interest in Autry Technology Center’s Educational Program in Surgical Technology. Anapplication along with program information is included.To qualify for the Surgical Technology program, you must have a high school diploma or equivalent. In order to beconsidered for the Surgical Technology program, you must complete the following requirements by June 1:1. Submit a completed application form.2. Submit official transcripts (mailed from the educational institution directly to the Student Services Center) fromall secondary and post-secondary educational institutions attended.3. Submit three (3) professional recommendations, using the attached forms (each recommender must mail his/her completed form directly to Student Services).4. Submit recent ACT scores. (Check with Autry counselor to see if college transcripts may be accepted in lieu oftest scores.)5. Attend one of the following Surgical Technology orientation sessions. All sessions will be held in Room 26 at1:00pm. Wednesday, December 6, 2017Wednesday, January 10, 2018Wednesday, February 7, 2018Wednesday, March 7, 2018Wednesday, April 4, 2018Wednesday, May 16, 2018Wednesday, June 20, 2018Two observation days and a personal interview are scheduled for qualified applicants.Meeting the requirements does not guarantee admission to the program. Qualified in-district applicants will beconsidered first. The decision regarding the selection of students is final. The surgical technology staff and schooladministration are not under any obligation to justify the selection. All interviewed applicants will be notified bymail of the admissions committee’s decision.Completed applications received after June 1 may be considered if openings are available.Please call me at (580) 242-2750 ext. 182 or send email to lbelknap@autrytech.edu if you have any questionsconcerning the application process.Sincerely,Linda BelknapCareer Counselor

Educational Program in Surgical TechnologyAccredited by The Commission on the Accreditation of Allied Health Education Programs (CAAHEP) in conjunctionwith the Accreditation Review Council on Education in Surgical Technology and Surgical Assisting (ARC/STSA)PROGRAM INFORMATION SHEET1.This 11-month program will take up the majority of a student’s time. The faculty discourages students fromattempting to work while attending this program; however, we realize that some students must continue towork. Students should realize that this may affect their performance in the program.2.Students who are successful in the program have financial arrangements in order, a supportive family,reliable transportation, and reliable childcare.3.It is necessary that the student have a flexible schedule. Instructional class hours are from 8:15 a.m. - 3:30p.m. Lab hours will be from 8:15 a.m. - 4:00 p.m. Clinical hours are eight hour shifts scheduled between6:00am and 6:00pm, with some evening assignments required. Students are not allowed to leave the clinicalsite for lunch.4.Acceptance into the program for any candidate is conditional pending results of the health examination(including required immunizations), background check (includes sex offender and violent offender status),drug screening, and completion of enrollment requirements.a. Clinical sites also have a right/obligation to require a background check prior to allowing students toparticipate in clinical rotations. If a student (1) has been arrested, (2) has been charged, (3) has a pendingconviction, (4) has been convicted of a felony, gross misdemeanor, misdemeanor, or has any alcohol and/or drug related violation, (5) has been judicially declared incompetent, or (6) has falsified records, the clinicalsite has a right to deny facility access. Without participation in the clinical component of the course, it willbe impossible for the student to fulfill the requirements for graduation from the program and he/she willnot be allowed to sit for the certification examination.b. Applicants with a positive drug screen will be denied continued admittance.5.The students’ acceptance notification will also serve as the letter of intent. The letter of intent must becompleted and returned by the designated date to complete enrollment. If the letter of intent is notreceived by the designated date, the student will lose his/her position in the program. The position will befilled by the next qualified alternate.6.When students return the letter of intent, 19.00 (amount subject to change based on current costs) will bedue for the background check (includes sex offender and violent offender status). This is non-refundable.7.Each student must complete a mandatory 10-panel urine drug screen test at Integris Bass OccupationalMedicine, 401 S. 3rd Street, Enid. The cost for this screening is 50.00.8.Once accepted, students will receive future mailings that give tuition and supply costs, a program calendar,and a form for a physical. All expenses are subject to change.

9.To meet the physical factors required by the medical industry, each student must be able to perform .t.Stand, bend stoop and/or sit for long periods of time in one location with minimum/no breaks.Lift a minimum of 20 pounds.Refrain from nourishment or restroom breaks for periods up to 6 hours.Demonstrate sufficient visual ability to load a fine (10-0) suture onto needles and needleholderswith/without corrective lenses and while wearing safety glasses.Must be able to distinguish and identify colors.Demonstrate sufficient peripheral vision to anticipate and function while in the sterile surgicalenvironment.Hear and understand muffled communication without visualization of the communicator’s mouth/lips within 20 feet.Hear activation/warning signals on equipment.Detect odors sufficient to maintain environmental safety and patient needs.Manipulate instruments, supplies and equipment with speed, dexterity, and good eye-handcoordination.Ambulate and move around.Assist with and/or lift, move, position, and manipulate the patient who is unconscious.Communicate and understand fluent English both verbally and in writing.Be free of reportable communicable diseases and chemical abuse.Demonstrate immunity (natural or artificial) to Rubella, Rubeola, Tuberculosis, Varicella, andHepatitis B, or be vaccinated against these diseases, or willing to sign a waiver of release of liabilityregarding these diseases.Possess short- and long-term memory sufficient to perform tasks such as, but not limited to,mentally tracking surgical supplies and performing anticipation skills intra-operatively.Make appropriate judgment decisions.Demonstrate the use of positive coping skills under stress.Demonstrate calm and effective responses, especially in emergency situations.Exhibit positive interpersonal skills during patient, staff, and faculty interactions.

Educational Program in Surgical TechnologySTATEMENT OF UNDERSTANDINGI have reviewed the Surgical Technology program information sheet.I understand that if I am not selected, neither the Surgical Technology program nor the school is under anyobligation to justify the selection.I realize that acceptance into the program is conditional pending results of the health examination (includingrequired immunizations), background check (includes sex offender and violent offender status), drugscreening, and completion of enrollment requirements.I am aware that arrests, charges, pending charges; convictions of a felony, gross misdemeanor, misdemeanor;being judicially declared incompetent; or falsification of records are grounds for being denied the opportunityto participate in the clinical site rotation component of Surgical Technology. Without participation in clinicals,it will be impossible for me to fulfill the requirements for graduation.SignatureDateAutry Technology Center does not discriminate on the basis of race, color, sex, pregnancy, gender, national origin, religion, disability, veteran status,sexual orientation, age, or genetic information. Autry Technology Center no discrimina en base a raza, color, género, estado de embarazo, nacionalidad de origen, religión, discapacidad, estado de veterano, orientación sexual, edad o información genética.

Educational Program in Surgical TechnologyAGREEMENT TO MAINTAIN CONFIDENTIALITY OF PATIENTPROTECTED HEALTH INFORMATION WHILE PERFORMING HOSPITAL OBSERVATION FOR APPLICATIONMaintaining patient information in a confidential manner is important to the Surgical Technology Programat Autry Technology Center. As an applicant applying to the Program, it is imperative you maintain theconfidentiality of all patient information you encounter while doing your hospital observation.AGREEMENTI understand the information I will be reviewing at an off-campus facility (or facilities) will containinformation of a confidential nature. By signing this document I hereby agree to maintain the strictestconfidence of the information observed/obtained and will not divulge such information to another ina manner which could or does breach the patient’s right of confidentiality. I understand that I maybe withdrawn involuntarily from the selection process for program acceptance should it bedetermined that I have indeed breached a patient’s right to have their protected health informationmaintained in a confidential nature.Signature DatePrinted NameAutry Technology Center does not discriminate on the basis of race, color, sex, pregnancy, gender, national origin, religion, disability, veteran status, sexual orientation, age, or genetic information. Autry Technology Center no discrimina en base a raza, color, género, estadode embarazo, nacionalidad de origen, religión, discapacidad, estado de veterano, orientación sexual, edad o información genética.

Educational Program in Surgical TechnologyAPPLICATION FOR ADMISSIONPlease Print or TypeLast Name First Name Previous Last NameAddress City StateZip CodeSocial Security Number: Email Address:Home PhoneBusiness PhoneCell PhoneEDUCATIONAL HISTORYSchools/Colleges AttendedDegree/Certificate GrantedYear1.2.3.4.5.EMPLOYMENT HISTORYList all jobs held within the last five years, beginning with the most current.EmployerPhone NumberPositionImmediate Supervisor1.2.3.4.5.I hereby give permission to Autry Technology Center to obtain references from the employers listed herein. I certify that all information is true andcorrect. I understand that any misrepresentation or omission of facts could result in not being accepted into the Surgical Technology Program.Signature of Applicant(Turn over and complete other side.)

Describe any health occupations experience (such as nurse’s aide, ward clerk, etc.)The completed application, official transcripts, and recommendations must be forwarded directly to:Linda Belknap, Care

anesthesia, cardiac catheterization lab, outpatient department, endoscopy and the post anesthesia care unit. Upon completion of the program students may test to become Certified Surgical Technologists (CST) through the National Board of Surgical Technology and Surgical Assisting. CAREERS AVAILABLE IN THE INDUSTRY: LICENSURE / CERTIFICATIONS: