# Mammography/Breast Sonography Application Including Modality Shadowing Form #### Arkansas State University College of Nursing and Health Professions --- ## Mammography/Breast Sonography Program Application for Admission ##### Deadline for Applications: The application packet must be received before April 1st for admittance into the program. Applications are reviewed after the application deadline and are not reviewed on a first served basis. Upon completion of the application, students should add their transcripts, statement of purpose, completed modality/shadowing form, and English or Spanish proficiency scores (if applicable) to the PDF. Only complete applications submitted as 1 PDF document will be reviewed for admission. Email PDF document to Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Last First Middle E-mail: Phone Numbers: ( ) ASU ID Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Present Address: City State Zip Permanent Address (If different): City State Zip List any work experiences in health care institutions: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ If your name, address or phone number changes during the application process, please notify the Radiologic Sciences Department of these changes. (870) 972-3073. Transfer students applying to the Mammography/ Breast Sonography program must also apply for admissionton Arkansas State University. Please see the A-State website for admission information at [http://admissions.astate.edu/](http://admissions.astate.edu/) or contact the Office of Admissions and Records, P. O. Box 1630, State University (Jonesboro), AR 72467. Phone: (870) 972-3024. --- ### APPLICATION PACKET ##### Only completed packets will be accepted and must include the following: 1. College/Hospital Transcript(s) of all work attempted (required by the University but also required as part of the application packet, so please attach a copy of official transcripts with this application) 2. Completed Modality / Shadowing form - Current A-State Students' optional program application form or completed Trajecsys modality summary form - Transfer students submit the program application shadowing form with a signature from a technologist 3. Mammography/ Breast Sonography application form 4. Statement of purpose describing yourself and why you want to enter the Mammography/ Breast Sonography program 5. Signed Criminal Background document Students accepted into the Mammography/Breast Sonography program will be expected to travel to assigned clinical affiliates and will be responsible for transportation and all expenses related to travel. I hereby affirm that all information supplied on this application is complete and accurate. It is my understanding that I will not be considered for admission to this program until I have submitted all credentials specified by the set date. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date Signature For applicants who are proficient in the Spanish language: Actualmente en la región que sirve ASU, se necesitan profesionales de la salud que hablen español. Por favor, indique aquí si usted tiene esta habilidad. Se da crédito adicional a los candidatos que puedan demostrar esta competencia. La facultad de idiomas extranjeros de ASU administra la prueba de habilidad en español. Por favor, póngase en contacto con el programa de Ciencia Radiologica para arreglar una cita para tomar el examen. #### Please submit the completed application packet to: Mary Grace Caubble, Program Director --- ### Arkansas State University College of Nursing & Health Professions Criminal Background Student name: I understand that criminal background checks may occur as part of my professional education at ASU. Evidence of a previous charge or conviction of a felony/misdemeanor on my record may affect my progress in this program. While the faculty cannot realistically determine whether this will have any future impact on my ability to work in my profession, I do understand that the following issues could arise during my time as a student or as a graduate of the program. 1. Certain rotation sites could deny me access for rotation. 2. Hospitals or other health care institutions could refuse to allow me access for a clinical experience. 3. The above two issues could make it impossible for me to complete the clinical portion of my education and, therefore, not graduate. 4. Upon graduation, a state licensing agency could refuse to grant me a license. 5. As a licensed professional, certain health care institutions could refuse to grant me privileges. 6. There could be other, unforeseen impacts of this incident on my ability to practice as a professional. Student signature: Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ --- ### Arkansas State University Mammography/ Breast Sonography Shadowing Form Student Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ This student completed a shadowing experience in the Medical Imaging Department at \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ facility on \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ date. ##### Circle one 1. The student was punctual and professional. Yes No 2. The student was prepared with questions and showed eagerness to learn. Yes No 3. The student demonstrated good patient interactions and good communication skills. Yes No 4. The student had appropriate questions related to Mammography or Breast Sonography. Yes No Mammography Technologist or Ultrasound Technologist comments: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Technologist Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Student Section: Discuss your shadowing experience. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Student Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_