Surgical Technology Application

APPLICATION FOR ADMISSION TO THE SURGICAL TECHONOLOGY PROGRAM

DEADLINE DATE: June 1, 2025

Before being considered for Surgical Tech admission, you must complete all College admission requirements. Please carefully complete the application by filling in all blanks and responding to all statements. Print or type your information. Submit completed application to Donna Michelle Richardson,CST at email [email protected]

Admission Requirements

  • Students must meet all the general admission requirements of JSCC.
  • Students must submit a JSCC application to the Enrollment Services Office.
  • Students must submit a Surgical Technology Program application to the Program Director by the specified deadline.
  • Students must possess a minimum cumulative Grade Point Average (GPA) of 2.0 on a 4.0 scale.
  • Students must attain a minimum of 16 composite score on the ACT and submit that score to the Enrollment Services Office. It is the responsibility of each applicant to ensure that his or her application is complete.
  • Eligibility for ENG 101 and MTH 116 and an ACT of 16 or proof of a bachelor degree.
  • Meet the essential functions or technical standards required for Surgical Technology.
  • Students who have not previously attended college must possess a minimum High School GPA of 3.0 on a 4.0 scale.
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Name(Required)
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NOTE: Notify Enrollment Services (205) 983-5911 immediately if/when there are ANY changes in your contact information.

Address(Required)
Spouse's/Partner’s Name:
Person to be notified in case of emergency:
Have you previously applied for admission to this program?
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Under what name did you apply?

OTHER COLLEGES ATTENDED

List all formal education beyond high school. If all colleges, universities, or schools previously attended are not listed, the student may be subject to dismissal action for falsification of records. Request that all other colleges attended send official transcripts to the Enrollment Services, Jefferson State Community College (see address on front). Official transcripts of all accredited colleges and universities attended must be on file in Enrollment Services by the application due date. Complete a “Request for Transcript Evaluation” and submit to Enrollment Services.
FIRST INSTITUTION CITY AND STATE
SECOND INSTITUTION CITY AND STATE
THIRD INSTITUTION CITY AND STATE
FORTH INSTITUTION CITY AND STATE
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"All Students must provide proof of hospitalization and malpractice insurance before entering clinical rotations. You must also have a clean background check as well as a negative drug screen. All documentation required above will be gathered after admission to the program Background and drug screening will be performed by a vendor on campus once you are admitted. Once submitted, this application packet becomes the property of Jefferson State and cannot be returned. If you are applying for a scholarship and a copy of your application is required, it is your responsibility to make copies of your application prior to submitting to Jefferson State.

It is the official policy of Jefferson State Community College, a post-secondary institution under the control of the Alabama Community College System Board of Trustees, that no person shall, on the grounds of race, color, sex, religion, national origin, disability, age, or sexual orientation be excluded
from participation in, be denied benefit of, or be subjected to discrimination under any program, activity or employment."

ESSENTIAL FUNCTIONS VERIFICATION FORM

Jefferson State Community College Health-Related Programs Division Surgical Technology Program
Demonstrate sufficient motor skills to manipulate and operate all equipment and instruments found in the clinical laboratory. Such motor skills should include but may not be limited to the following: Able to stand, bend, stoop, and/or sit for long periods of time in one location with minimum/no breaks.(Required)
Able to lift a minimum of 30 pounds(Required)
Demonstrate sufficient visual ability enough to load a fine (10-0) suture onto needles and needle holders with/without corrective lenses and while wearing safety glasses.(Required)
Demonstrate sufficient peripheral vision to anticipate and function while in the sterile surgical environment.(Required)
Hear and understand muffled communication without visualization of the communicator’s mouth/lips and within 20 feet.(Required)
Hear or visualize activation/warning signals on equipment.(Required)
Able to detect odors sufficient to maintain environmental safety and patient needs.(Required)
Manipulate instruments, supplies and equipment with speed, dexterity, and good eye-hand coordination.(Required)
Independently mobile, with or without assistive devices.(Required)
Able to assist with and/or lift, move, position, and manipulate the patient who is unconscious with or without assistive devices.(Required)
Communicate and understand fluent English both verbally and in writing.(Required)
To be free of reportable communicable diseases and chemical abuse.(Required)
Able to demonstrate immunity (natural or acquired) to rubella, rubeola, tuberculosis, and to hepatitis B, or be vaccinated against these diseases, or willing to sign a waiver of release of liability regarding these diseases.(Required)
Possess short- and long-term memory sufficient to perform tasks such as, but not limited to, mentally tracking surgical supplies and performing anticipation skills intraoperatively.(Required)
Able to make appropriate judgment decisions.(Required)
Demonstrate the use of positive coping skills under stress.(Required)
Exhibit positive interpersonal skills during patient, staff, and faculty interactions.(Required)

Disclaimer

The above statement of criteria is not intended as a complete listing of surgical technology behaviors but is a sampling of the types of abilities needed by the surgical technology (Surg Tech) student to meet program objectives and requirements. The Surgical Technology Program or its affiliated agencies may identify additional critical behaviors or abilities needed by students to meet program or agency requirements. The Program reserves the right to amend this listing based on the identification of additional standards or criteria for Surg Tech students.

Directions: Read the two OPTION declarations below and SIGN ONLY ONE.

If you are unable to fully meet any criterion, you must make an appointment with the Program Coordinator. - Donna Michelle Richardson, CST Shelby-Hoover Campus Math and Science Building Office 116B (205) 983-5222 [email protected] Shelby-Hoover Campus

Student Verification: OPTION 1 = ABLE TO MEET STANDARDS / OPTION 2 = UNABLE TO MEET STANDARDS

OPTION 1 - I have read the technical standards and to the best of my knowledge I currently have the ability to fully meet these standards. Type your name as your SIGNATURE
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OPTION 2 - Type your name as your SIGNATURE
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