Magnetic Resonance Imaging Internship

Application of Admission

5/13 Personal Data Date______

Name ______Soc. Sec #______

Present Address______

______

Permanent Address______

______

Phone #______Email______

Education Cumulative GPA______

1. School Name______

City, State ______

Dates Attended______

City, State ______

Dates Attended______Must have an official copy of all transcripts sent to Iowa Central Community College Registrar’s office for credit from other facilities.

Employment (begin with most recent)

1. Employer’s Name______

Address ______

Dates Employed ______

Address ______

Are you a U.S. citizen ______yes ______no

ARRT # ______ARRT Score______IA Permit to Practice#______

If unavailable: Graduation date______ARRT exam date______

Minimum Requirements:  ARRT certification in Radiologic Technology, Nuclear Medicine, or Radiation Therapy. ~ If candidate has not graduation from an accredited Radiologic Technology program list graduation date ~ ARRT exam date if known  2 Letters of recommendation, individually sealed envelopes

 An essay

~ Include a brief summary of how the modality works and your interest in the area ~Include work or clinical experiences in the modality ~ Professional goals

 Completed background check

 Official transcripts if other than Iowa Central Community College

 Preferably GPA of 2.75 or higher

 MRI Internship’s Technical Standard Form read, signed and dated

Application Process Checklist

1. MRI/Radiology Technical Standards Form, read and signed.

2. Criminal background, adult and child abuse checks submitted.

3. Official transcripts from all colleges, Radiologic Technology, Nuclear Medicine or Radiation Therapy Programs submitted to Iowa Central Community College’s registrar.

4. Copy of ARRT examination scores from primary certification in Radiologic Technology, Nuclear Medicine or Radiation Therapy. If you have not completed boards but are board eligible submit testing date then upon receipt of your score you must submit it immediately. A passing score must be obtained prior to starting the internship.

5. Two personal references completed by individuals who are familiar with your personal, academic and/or employment background, reference form is included. To insure confidentiality each recommendation must be individually sealed in an envelope with the signature of the person writing the recommendation across the seal.

6. Essay completed.

MRI/Radiology Technical Standards Requirements

Individuals admitted to the Iowa Central MRI Internship must possess the capability to complete the internship. This will require proficiency in a variety of cognitive, problem solving, communicative and interpersonal skills. Students admitted into the MRI Internship must possess the following abilities and ability to meet the following expectations. Please contact the Program Director, Chantel Burns, at 515-574-1302.

1. Candidates must be able to learn to analyze, synthesize, solve problems and reach evaluative judgment. 2. Candidates must have sufficient use of the sense of vision, hearing, smelling and touch necessary to directly perform a radiologic examination, review and evaluate the recorded images, accurate procedural sequencing, proper radiographic quality and other appropriate and pertinent technical qualities.

3. Candidates must be able to relate reasonably to patients and establish a sensitive, professional and effective relationship with the patients. In addition, candidates must be able to communicate verbally in an effective manner to direct patients during radiologic procedures.

4. Candidates must be able to provide physical and emotional support to the patient during the MRI procedure, being able to respond to situations requiring first aid and providing emergency care to the patient in the absence of, or until the physician arrives.

5. Candidates must be able to display judgments in the assessment of patients. In addition the candidates must be able to learn and demonstrate the ability to recognize limitations in their knowledge, skills, and abilities and to seek appropriate assistance with their identified limitations.

6. Candidates are expected to work collaboratively with all members of the health care team.

7. Candidates are expected to be able to learn and perform routine MRI procedures along with selecting the proper protocol and changes in instrumentation according to the needs of the individual patient.

8. Candidates must have sufficient strength, motor coordination, and manual dexterity to transport, move, lift, and transfer patients from a wheelchair or cart to an x-ray and MRI table or to a patient bed.

9. Candidates must be able to learn to respond with precise, quick and appropriate action in stressful and emergency situations.

10. Candidates are expected to be able to accept criticism and adopt appropriate modifications in their behavior.

11. Candidates are expected to possess the perseverance, diligence, and consistency to complete the MRI Internship and enter into the practice of radiology as a certified MRI technologist.

Do you have any physical or mental handicaps that would interfere with the satisfactory performance of the TECHNICAL STANDARDS identified above? ______Yes ______No

Signature______Date ______

Personal Reference Form Pursuant to Public Law 93-380, all letters of recommendation written after January 1, 1975 are not considered confidential unless the applicant waives right of access

The signature below constitutes a waiver of the applicant’s right of access to this recommendation should he/she be accepted into the MRI Internship

Signature Date

If not signed, this recommendation can be available to the applicant.

Iowa Central Community College prohibits discrimination and it its educational programs and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associated preference. Iowa Central Community College also affirms its commitment to providing equal opportunities and equal access to Iowa Central facilities. For additional information on nondiscrimination policies, contact the Coordinator of Title IX, Section 504, and the ADA in the Office of Affirmative Action, (319) 335-0705 (voice) or (319) 335-0697 (text), Iowa Central Community College, One Triton Circle, Fort Dodge, Iowa 50501.

______

The applicant named below has requested admission to the MRI Internship at Iowa Central Community College. Your response to this inquiry will assist the Admissions Committee in assessing the applicant. The internship’s faculty and administration believes these are important items to be considered along with other data in predicting the potential professional success of persons in health care clinical settings. Your candid appraisal of the applicant’s characteristics is vital to our evaluation and subsequent decisions. Your assistant is appreciated.

Applicant’s Name (please print): ______

How long have you known the applicant? ______

In what capacity do you know the applicant (student, friend, co-worker, etc.)? ______

Please complete the following table by marking in the appropriate box. Exceptional Above Average Below Poor Below Unable to top 2% Average 50% Average 1/3 Judge top 1/3 Responsibility: Ability and willingness to accept responsibility; complete tasks; honor commitments. Attitude: Displays positive actions and behaviors. Problem-Solving: Takes initiative and has the ability to identify, confront, and solve problem situations. Honesty: Extent to which the candidate displays an ethical code of integrity. Motivation: Degree to which candidate applies self without prompting Appearance: Extent to which professional standards of neatness or cleanliness are met. Stress/Anxiety Response: Ability to handle or cope with stressful/anxious situations. Interpersonal Relationships: Ability to interact & communicate in a positive manner with co- workers, peers, etc. Constructive Criticism: Ability to accept and handle positive and constructive criticism. Verbal/Writing Skills: Ability to clearly express oneself. Attendance Reliability: Organizational Skills: Uses time wisely and prepares for upcoming events

Please feel free to make comments explaining selections made in the previous table, as well as present additional information you believe would be relevant to this applicant’s pursuit of admission.

______

Please check one of the following categories that best describes your overall rating of the candidate: _____ Recommend with enthusiasm _____ Recommend with confidence _____ Recommend with reservations _____ Do not recommend

______

Name of Evaluator (Please Print) Signature of Evaluator (date)

______

Title/Position

______

Address Phone number can be reached at.

Thank you for your cooperation in evaluating this applicant.

When completed with the evaluation, enclose this form in an envelope and sign over the sealed portion to ensure confidentiality. Return it to the applicant or send to us at the address below.

Iowa Central Community College-Chantel Burns Attn: MRI applicant reference One Triton Circle Fort Dodge, IA 50501

Personal Reference Form Pursuant to Public Law 93-380, all letters of recommendation written after January 1, 1975 are not considered confidential unless the applicant waives right of access

The signature below constitutes a waiver of the applicant’s right of access to this recommendation should he/she be accepted into the MRI Internship

Signature Date

If not signed, this recommendation can be available to the applicant.

Iowa Central Community College prohibits discrimination and it its educational programs and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity, or associated preference. Iowa Central Community College also affirms its commitment to providing equal opportunities and equal access to Iowa Central facilities. For additional information on nondiscrimination policies, contact the Coordinator of Title IX, Section 504, and the ADA in the Office of Affirmative Action, (319) 335-0705 (voice) or (319) 335-0697 (text), Iowa Central Community College, One Triton Circle, Fort Dodge, Iowa 50501.

______

The applicant named below has requested admission to the MRI Internship at Iowa Central Community College. Your response to this inquiry will assist the Admissions Committee in assessing the applicant. The internship’s faculty and administration believes these are important items to be considered along with other data in predicting the potential professional success of persons in health care clinical settings. Your candid appraisal of the applicant’s characteristics is vital to our evaluation and subsequent decisions. Your assistant is appreciated.

Applicant’s Name (please print): ______

How long have you known the applicant? ______

In what capacity do you know the applicant (student, friend, co-worker, etc.)? ______

Please complete the following table by marking in the appropriate box.

Exceptional Above Average Below Poor Below Unable to top 2% Average 50% Average 1/3 Judge top 1/3 Responsibility: Ability and willingness to accept responsibility; complete tasks; honor commitments. Attitude: Displays positive actions and behaviors. Problem-Solving: Takes initiative and has the ability to identify, confront, and solve problem situations. Honesty: Extent to which the candidate displays an ethical code of integrity. Motivation: Degree to which candidate applies self without prompting Appearance: Extent to which professional standards of neatness or cleanliness are met. Stress/Anxiety Response: Ability to handle or cope with stressful/anxious situations. Interpersonal Relationships: Ability to interact & communicate in a positive manner with co- workers, peers, etc. Constructive Criticism: Ability to accept and handle positive and constructive criticism. Verbal/Writing Skills: Ability to clearly express oneself. Attendance Reliability: Organizational Skills: Uses time wisely and prepares for upcoming events

Please feel free to make comments explaining selections made in the previous table, as well as present additional information you believe would be relevant to this applicant’s pursuit of admission.

______

Please check one of the following categories that best describes your overall rating of the candidate:

_____ Recommend with enthusiasm _____ Recommend with confidence

_____ Recommend with reservations

_____ Do not recommend

______

Name of Evaluator (Please Print) Signature of Evaluator (date)

______

Title/Position

______

Address Phone number can be reached at.

Thank you for your cooperation in evaluating this applicant.

When completed with the evaluation, enclose this form in an envelope and sign over the sealed portion to ensure confidentiality. Return it to the applicant or send to us at the address below.

Iowa Central Community College Attn: Chantel Burns-MRI applicant reference One Triton Circle Fort Dodge, IA 50501

Tentative MRI Course Schedule Credits Location

Summer 676:100EXW Sectional Anatomy for Imaging Sciences 3 s.h. U of I Fall HSC 965 MRI Internship 1 8 s.h. ICCC 674:820EXW MRI Procedures I 4 s.h. U of I 676:840EXW MRI Acquisition & Principles I 4 s.h. U of I 674:810EXW Fundamentals for the MRI Technologist 3 s.h. U of I

Spring HSC 966 MRI Internship 2 8 s.h. ICCC 674:830EXW MRI Procedures II 3 s.h. U of I 674:850EXW MRI Acquisition & Principles II 4 s.h. U of I 676:110EXW Pathology for Imaging Sciences 3 s.h. U of I

*Offered in summer and fall semesters. Accepted student can elect to have a summer session upon approval from instructor.