Medical Laboratory Assistant

Spring 2021 Program Application

Application Deadline: October 15, 2020

ADMISSION REQUIREMENTS

To become a candidate for selection to the Medical Laboratory Assistant (MLA) Program, please complete and return the attached application by email to vbardhi@aacc.edu. Alternatively students may mail their application to:

Anne Arundel Community College ATTN: School of Health Sciences, FLRS 112

101 College Parkway Arnold, MD 21012

If the application deadline falls on a weekend, then applications will be accepted until the close of business on the next business day.

First consideration will be given to candidates whose resident address is in Anne Arundel County for at least three months prior to the date the application is submitted. The Address Verification form must be submitted with the application. Out-of-county applicants will be reviewed if space is available. Priority will be given to candidates who are currently in or have recently completed the AACC Phlebotomy Technician Letter of Recognition Program in the past three years prior to the date the application is submitted or who have worked at least one year as a phlebotomist.

Applicants who have phlebotomy experience but not through AACC’s Phlebotomy Technician Program must make an appointment with the MLA Program Academic Chair prior to submitting an MLA Program application.

To be considered for conditional acceptance, the applicant must meet the following criteria:

Attend a face-to-face information session prior to submitting application. Session schedules can be found on https://www.aacc.edu/apply-and-register/credit-application/health-science-applicants/ or you can call 410-777-7310. Admission and selection information will be reviewed.

During the summer and fall 2020 semesters, real-time virtual information sessions will be considered face-to-face.

High school graduate or equivalency: Official high school transcripts or official GED equivalency certificate to verify high school graduation or equivalency.

o Official transcripts are to be received by AACC Records and Registration office in the sending institution’s original sealed envelope or through acceptable electronic method. Visit https://www.aacc.edu/apply-and-register/credit-application/apply/transfer-credit-to-aacc/ for details. The application will not be considered complete if required official transcripts are not submitted with the application or previously submitted to the AACC Records Office.

Demonstrate eligibility for ENG 101/ENG 101A. Demonstrate eligibility for general education mathematics or have a score of 27 or better on the Arithmetic

Placement Test or a grade of B or better in Arithmetic (MAT 005). Submission of official transcripts, if applicable. Official transcripts are to be received by AACC Records and

Registration office in the sending institution’s original sealed envelope or through an acceptable electronic method; visit https://www.aacc.edu/apply-and-register/credit-application/apply/transfer-credit-to-aacc/ for details.

Must be 18 years of age or older by the first day of class. Have a minimum adjusted GPA of 2.0 at AACC.

Eligible applicants will receive a selection packet assigning them to one of the following categories:

Conditional Acceptance: Applicants who have met the academic and admission requirements and have been selected into the Medical Laboratory Assistant Program. With the selection packet, conditionally accepted students will receive the health examination record, criminal background check and CPR instructions to be completed by a designated deadline. Conditional acceptance candidates who do not meet this deadline will not be considered for admission and the next person on the list will be contacted.

Wait List: In the event there are more qualified applicants than seats available, qualified applicants not initially conditionally accepted will be placed on the wait list in rank order and notified of selection if and when seats become available.

Final acceptance into the program will be contingent upon satisfactory completion of a criminal background check, health examination record and submission of a copy of the required CPR card.

IMPORTANT INFORMATION 1. Direct all inquiries regarding the application process to Valerie Bardhi via email at vbardhi@aacc.edu.

Following review of all applications, students will receive a letter regarding the status of their application.

2. All Health Sciences students who are offered admission and/or clinical placement will be required to submit to a complete criminal background check and urine drug screen. All student applicants’ final acceptance in the program shall be contingent upon satisfactory completion of a criminal background check and of a urine drug screen.*

All letters of acceptance shall state that the acceptance is conditional and contingent on submission to a criminal background check and urine drug screen—as may be required by the program—that results in satisfactory reports. If an accepted student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program. Separate, additional criminal background checks and urine drug screens may be required by clinical sites prior to placements. Students with an unsuccessful background check or urine screening who are denied by a clinical site that is required to meet program competencies shall be dismissed from the program and their registrations shall be withdrawn from courses related to the program of study. If the student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program even if a denied placement was not required to meet program competencies. Successful reports of criminal background checks and urine drug screens do not assure eligibility for specific clinical site placement, program completion, and/or eligibility to sit for professional licensure/board examinations. Students are reminded that licensing boards for certain health care occupations and professions may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work if it is determined that an applicant has a criminal history or has been convicted of, or pleads guilty, or pleads nolo contendere or the like to a felony or other serious crime. Successful completion of a Health Sciences program of study at Anne Arundel Community College does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant health care occupation. Students may be automatically denied admission or, if enrolled, dismissed from the program if they have not been truthful or have provided inaccurate information on the application or on any other form or submission. Students who have questions or concerns are encouraged to contact the Health Sciences Admissions Office at healthsciencesadmissions@aacc.edu. * Notwithstanding the statements herein regarding urine drug screens, as of September 2010, only certain programs will be requiring drug screening. AACC shall inform students which programs presently require them. However, AACC, at any time, has the right, upon notice, to require any and all students in any and all programs to comply with drug screening.

AACC will only accept criminal background checks performed by college approved vendor. Criminal background checks are completed online and must be paid for by the student. Information and instructions are given to applicants once accepted into the program.

D:\Applications\MLA Application Spring 2021.VB.tdn.edit 5.28.2020.docx

MEDICAL LABORATORY ASSISTANT

Spring 2021

Application Deadline – October 15, 2020

Program Application

DEMOGRAPHIC INFORMATION (Please print) Last Name First Name Middle

Address City State Zip Code County of Residence

Last 4 digits of social security # College ID #

The mailing address you provide will be your address of record. It is your responsibility to notify the Health Sciences Office as well as the Records Office of name, address and phone number changes during the application process. Home Phone Cell Phone Work Phone

AACC Email Address – Required No other email is acceptable @mymail.aacc.edu

Admission/Academic Requirement Checklist By signing below, I agree/understand the following:

1. I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college. 2. All admission requirements, including testing and eligibility, must be completed by the application deadline. 3. I have submitted an official copy of my high school transcripts or GED equivalency certificate to the AACC

Records Office or have confirmed that it is on file with AACC Records office. 4. I must submit final official transcripts from previously attended colleges from which I am transferring courses

toward the Medical Laboratory Assistant Program by the stipulated deadline. International students must submit official transcript evaluation report from ECE, WES or SpanTran to verify/authenticate high school/college transcripts by the stipulated deadline.

5. I am or will be at least 18 years of age or older by the first day of class. 6. I have attended a mandatory Medical Laboratory Assistant Program Information Session. 7. I have submitted a phlebotomy experience form, signed by my employer, if applicable. 8. If information is incomplete/missing from my application or file, it will NOT be processed and will be returned to

me. 9. I understand that by filling in my name below, it will be considered my signature.

SIGNATURE: DATE:

ADMISSION/ACADEMIC REQUIREMENTS

Please answer the following questions:

High School Graduate or Equivalency Yes No I have submitted an official high school transcript or official GED equivalency certificate and have

confirmed that it is on file with the AACC Records office.

Math and English Eligibility Yes No I have demonstrated English eligibility and am eligible for ENG 101/ENG 101A.

Yes No I have demonstrated eligibility for general education mathematics or a score of 27 or better on the Arithmetic Placement Test or a B or better in Arithmetic (MAT 005).

Information Session Yes No I have attended an MLA Information Session. Date:

INTERNATIONAL STUDENTS

Have you submitted an official transcript evaluation report from ECE, WES or SpanTran to verify/authenticate your high school and/or college transcripts to the records office?

Yes No Agency Used:

PHLEBOTOMY EXPERIENCE (IF APPLICABLE)

Yes No I have successfully completed the Phlebotomy Technician Letter of Recognition at Anne Arundel Community College with a GPA of 2.0 or higher. Students must complete all required courses with a grade of C or better.

Completion Date:

Yes No I am currently enrolled in the Phlebotomy Technician Letter of Recognition Program at Anne Arundel Community College.

Yes No I have phlebotomy experience but not through Anne Arundel Community College.*

Yes No I am decelerating from the MLT Program at Anne Arundel Community College into the MLA Program.

*Applicants who have phlebotomy experience must complete page 8 of this application and have their employer verifytheir experience. Contact vbardhi@aacc.edu for assistance.

Note: Applicants who have phlebotomy experience but not through Anne Arundel Community College’s Phlebotomy Technician Program must make an appointment with the Medical Laboratory Assistant Program Academic Chair prior to submitting a Medical Laboratory Assistant Program application.

BACKGROUND INFORMATION

Submit explanation of questions for which you answer "yes" and provide documents relating to your answer emailed to tdneall@aacc.edu or mailed separately to address on first page of this application, ATTN: Tammie Neall.

Do not write explanation(s) on the application

Yes No

Were you ever disciplined for any academic or behavior/conduct issue by any college, university, or any other educational institution after High School including, but not limited to, probation, dismissal, suspension, disqualification, or imposition of a failing grade as a disciplinary sanction? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes No

Have you ever been convicted of a crime, driving while intoxicated or impaired (either by alcohol or drugs), had your driving privileges suspended or revoked, and/or are there any pending charges regarding any of the above? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes No Have you ever surrendered your driver's license or had such license suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes No Have you ever surrendered a professional license, certification or registration, or had one restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes No Have you ever been placed on professional probation, had conditions or limitations placed on your ability to work even if your license had not been restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes No Have you ever had your clinical privileges at any office or facility restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

NOTE: Licensing boards for certain health care occupations, including Medical Laboratory Assistant, may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other serious crime. If applicable, it is recommended to contact national certifying boards for your program of interest.

I certify that the information on this application is true and accurate to the best of my knowledge. I am aware that falsification or

misrepresentation may result in being denied admission, or if enrolled, dismissed from this program. I understand that final acceptance

into the Medical Laboratory Assistant Program shall be contingent upon satisfactory completion of a criminal background check and

satisfactory completion of a health examination record.

I understand that by filling in my name below, it will be considered my signature.

Signature: Date:

PRINT NAME:

Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative formatbooks or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct,discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or MarylandRelay 711.

Please review prior to submitting this application. This application must be completed in its entirety.

WRITTEN STATEMENT Submit a written statement consisting of a minimum of two paragraphs explaining why you

plan to pursue the Medical Laboratory Assistant profession.

Note: This is for informational purposes only and does not affect the admission process.

Name: Date:

ANNE ARUNDEL COMMUNITY COLLEGE MEDICAL LABORATORY ASSISTANT PROGRAM 101 College Parkway, Arnold, MD 21012 Application Spring 2021 Program

PHLEBOTOMY EXPERIENCE VERIFICATION FORM

It is not required to have phlebotomy experience; however, preference is given to candidates who are currently in or have completed the Anne Arundel Community College Phlebotomy Technician Letter of Recognition Program in the past three years prior to the date the application is submitted or who have worked at least one year as a phlebotomist. To verify phlebotomy experience, the employer must complete this verification form.

APPLICANT INFORMATION Name: Address: Telephone Number: Employer: Address: Telephone Number:

Name of Business: Position Held: Description of Duties:

Supervisor: Telephone Number: Dates of Employment/Experience: From To Number of Months Worked: Full-time Part-time Total Hours of Phlebotomy Experience From This Employer:

STATEMENT OF CERTIFICATION

I certify that all the information I have provided on this form is true, complete and correct to the best of my knowledge and belief, and is made in good faith. I know and understand that any or all items contained herein are subject to verification and I consent to the full release of information from the employer listed for the purpose of verifying the information I have provided. I understand that by filling in my name below, it will be considered my signature.

Applicant Signature Date

EMPLOYER VERIFICATION Please complete this form and return it in a sealed and signed envelope to the applicant.

I verify that the employment information provided by the applicant is true and correct to the best of my knowledge.

Signature of Supervisor Title Date

Printed Name Name of Company & Department Telephone Number

COMMENTS:

This page is left intentionally blank.

ADDRESS VERIFICATION

The Address Verification Form is part of the application packet and must be completed in its entirety with two supporting documents. Applications received without this form and documentation will be considered incomplete and will be returned to the applicant. Be certain to include two (2) forms of supporting documentation as stipulated on the form. Consideration will be given only to candidates whose verified resident address is in Anne Arundel County for at least three months prior to the date the application is submitted. Questions pertaining to this form can be addressed to Melissa Mumma in the Records Office at 410-777-2721 or mgmumma@aacc.edu.

Out-of-county/state applicants will be reviewed only when space is available.

June 2020

Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711.

101 College Parkway, Arnold, Maryland 21012-1895 410-777-2243

ADDRESS VERIFICATION FOR HEALTH SCIENCE PROGRAM APPLICANTS Directions: This form must be completed entirely and supporting documents submitted as part of the health sciences program application process. Applications submitted without this document will be returned as incomplete.

If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date.

OR If for the most recent 12 months, you, the student, have resided in Anne Arundel County, but are supported by someone in another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date.

OR If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a minimum of two documents listed below in your supporter’s name, showing current resident addresses that are dated three months prior to the application deadline date. In addition, you will need to provide one document from the list below in your name showing current resident address and dated three months prior to the application deadline date in addition to the two documents from your supporter. The supporter must also complete the information requested in Section B. Military Personnel Only: Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy of housing assignment, lease, deed or utility bill showing your resident address. Example: All documents must be dated three months prior to application submission date.

Acceptable Documents • Maryland Driver’s License• Voter Registration Card• Copy of Deed of Trust or Signed Lease• Maryland Withholding Form – MW 507 (Not U.S. W-2)• Maryland Income Tax Return (not U.S.)• Utility Bill including gas, electric, water, phone, cable, etc.• Vehicle Registration Card

The college reserves the right to request additional information and documentation as necessary.SECTION A – TO BE COMPLETED BY STUDENT

Student Name Student ID or SSN (last 4 digits)

Resident Address

City State Zip

County Day Phone Evening

Dates of Occupancy at above address Own Rent

Previous Address

City State Zip

How long did you live at this previous address?

Are you registered to vote? Yes No County State

Do you possess a valid driver’s license? Yes No

If yes, what state issued? County Date of Issuance

OFFICE USE ONLY

Program: MLA Verify Term: FA20

Do you own a motor vehicle? Yes No

If yes, in what state issued? County Date of Issuance

Do you have the use of another person’s motor vehicle? Yes No

If yes, provide name Relationship to student

Are you paying Maryland income tax for this year on all earned income? Yes No

If yes, what county? List where you have filed tax returns for the past two (2) years: Year State County

Year State County

If employed, is Maryland income tax currently being withheld? Yes No

If yes, what county? For the most recent 12 months, has another person(s) provided one-half or more of your financial support? *Yes No*If the answer to the above question is “Yes”, SECTION B of this form must be completed by your supporter.

Additional Information

The college reserves the right to request additional information and documentation as necessary.

I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature of Student (required) Date

OFFICE USE ONLY ACCEPTABLE DOCUMENTS: MILITARY/BRAC WAIVER:____ MD driver’s license ____ Military ID (& Dependent ID if spouse or dependent)____ MD income tax return (not U.S.) ____ Copy of Orders____ Voter Registration Card ____ Copy of housing assignment, lease, deed or utility bill____ Vehicle registration showing resident address ____ Utility bill showing home address ____ Copy of deed of trust or signed lease ____ MD withholding form – MW 507 (not U.S. W-2)

STATUS OF RESIDENT ADDRESS Anne Arundel County Other MD county Out-of-State Term & Year

Authorized signature: Date:

SECTION B TO BE COMPLETED BY SUPPORTER IF YOU ANSWERED “YES” to the following question:

For the most recent 12 months, has another person(s) provided one-half or more of your financial support?

Name of supporter Relationship to student

Supporters Address

City State Zip

County Day Phone Evening

Date of Occupancy at above address Own Rent

Previous Address

City State Zip

How long did you live at this previous address?

Are you registered to vote? Yes No County

Do you possess a valid driver’s license? Yes No

If yes, in what state issued? County Date of Issuance

Do you own a motor vehicle? Yes No

If yes, in what state issued? County Date of Issuance

Do you have the use of another person’s motor vehicle? Yes No

If yes, provide name Relationship to student

Are you paying Maryland Income tax for this year on all earned income? Yes No

If yes, which county?

List where you have filed tax returns for the past two (2) years: Year State County

Year State County

If employed, is Maryland income tax currently being withheld? Yes No

If yes, in which county?

Additional information:

The college reserves the right to request additional information and documentation as necessary.

Signature of supporter: Date:

Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711.

G:\ALHEALTH\HDrive\AHCOMMON\TDN\Admissions Forms\Residence Petitions by Program\ MLA-FA20 Residence Petition FILLABLE FORM 5.2020