Please complete the following to request a clinical rotation. If this form is incomplete or submitted later than the deadline, you will not be registered for the practica. I. Student Information * First Name * Last Name * GWID * Email Address * Program Please select BSHS Fully online BSHS Blended Certificate in MLS Certificate in Blood Banking Certificate in Chemistry Certificate in Hematology Certificate in Microbiology MSHS in Clinical Microbiology MSHS in Molecular Diagnostic Science * Anticipated Rotation Semester Please select Fall Spring Summer * Anticipated Rotation Year Please select 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Clinical Rotation Semester Timeline to Submit CRR Fall Semester February 15th - March 15th preceding the rotation (Fall) semester Spring Semester July 1st - August 1st preceding the rotation (Spring) semester Summer Semester ** November 1st - December 1st preceding the rotation (Summer) semester ** Be advised that summer rotations in Local GW Primary Affiliates will only be considered under special circumstances due to a decreased number of available clinical training staff during the summer. II. Clinical Site Option * Please initial and indicate your clinical site option. If you choose to go to a local affiliate, please indicate your preferred clinical site. Placement for the preferred site will be considered, but cannot be guaranteed. If you have secured your own clinical site, please indicate the name of the site(s). 1. Local GW Primary Affiliate Once a schedule has been determined for a local affiliate, the student is committed to enter and finish the clinical rotations according to the schedule. Students who are scheduled for a local affiliate and subsequently decide not to enter the rotation at that time will lose the privilege of attending the local affiliate sites and will need to find their own clinical site. In the event of limited availability of clinical rotations, the GW MLS Program may have to schedule the student's clinical rotation in the semester following the requested semester. Please initial: OR 2. Approved Clinical Site(s): Applicants residing outside the Washington, DC area and/or who wish to complete the clinical practicums in their area of residence must have identified an acceptable accredited (TJC and/or CAP) clinical laboratory willing to provide the clinical instruction. In addition, these applicants must initiate a facility review process between the proposed clinical facility and the GWU MLS program. The purpose of this facility review is to ensure that the student will have an acceptable clinical site for the clinical portion of the program and to complete a legal agreement between the GWU MLS Program and the clinical site. The affiliation agreement may take as long as six months to complete, so it is imperative that this process be started at the time of admissions into the program. Please initial: III. Clinical Rotation Requirements 1. Each student must have successfully completed all didactic coursework (Phase I) prior to entry into the clinical rotations (Phase II). Students in MSHS MolDx Science program must complete the following courses before they can enter rotations: Molecular Biology, Genetics, Molecular Pathology and Medical Biotechnology. 2. Effective for students entering the program in the Spring 2013 semester or later, a minimum cumulative GPA and major GPA of 2.5 are required in order to begin clinical practicum courses (Phase II). Students in MSHS programs must maintain a minimum of 3.0 GPA. 3. Each student must have completed a Criminal Background Check (CBC) and Drug Screen (DS). 4. Each student must have completed the required health documents prior to rotations. Additional documentation may be needed depending on your clinical site requirements. Once you submit this form, you will receive an invitation email to create an account in the myRecordTracker database to complete the following requirements: 1. Physical Exam 2. Immunization including; MMR, Hep B, TD or Tdap, Varicella, Meningococcal Vaccine (or Waiver), Influenza 3. Proof of Health Insurance Coverage 4. Cardiopulmonary Resuscitation Certification (CPR) - waiver can be provided if not required by the student's clinical site 5. Essential Functions Statement of Acknowledgement IV. Previous Clinical Lab Experience * Please check and initial the space next to the statement that describes the level of previous clinical laboratory experience: Clinical Laboratory Experience I have never worked in a clinical laboratory. I have worked in MLS labs in phlebotomy and/or specimen processing only. I have worked in MLS labs as an MLT, certified (i.e. ASCP, AMT, etc) for years. Other (please list): If you have clinical lab experience; please summarize your role in the lab; including the areas of expertise and dates Rotation Area Standard Rotation(non-MLT certified) MLS Certificate Program Shortened Rotation(MLT certified) BSHS Program Clinical Area Length In Weeks * Length In Hours ** Certificate Practicum Courses Number of Credits Length In Weeks * Length In Hours ** BSHS Practicum Courses Number of Credits Chemistry 4 160 Clinical Biochemistry PracticumMLS 4161 4 2 80 Clinical Experience IMLS 4136 2 Microbiology 4 160 Clinical Microbiology PracticumMLS 4164 4 2 80 Clinical Experience IMLS 4136 2 Hematology 2 80 Hematology PracticumMLS 4162 2 2 80 Clinical Experience IIIMLS 4138 2 Urinalysis 1 40 Urinalysis PracticumMLS 4165 1 2 80 Clinical Experience IIIMLS 4138 2 Coagulation 1 40 Coagulation PracticumMLS 4166 1 2 80 Clinical Experience IIIMLS 4138 2 Blood Bank 4 160 Blood Bank PracticumMLS 4160 4 2 80 Clinical Experience IVMLS 4139 2 Non-MLT certified MLS certificate students must complete the standard amount and take certificate practicum courses. MLT certified MLS certificate students may elect to do shortened rotations and will take certificate practicum courses. MLT certified BSHS students may elect to do shortened rotations and will take BSHS practicum courses (Clinical Experiences) Categorical certificate students (i.e. Microbiology certificate, Chemistry certificate, etc.) will only take the practicum course(s) in their specific area of study. Shortened rotations for MLT certified students are based on competency in each area. If the student is unable to demonstrate competency within the given timeframe, they may be asked to complete the standard amount or more to meet competency standards. Rotation lengths listed are minimum rotation amounts. * Standard GW Schedule; Clinical Rotations are Monday through Friday, 8 hours/day. ** The individual clinical site may choose to allocate the clinical experience hours in other than the standard schedule. CLINICAL ROTATIONS: 16 WEEKS LENGTH OF ROTATIONS: 16 WEEKS Chemistry Clinical Education Block (4 weeks) Microbiology Clinical Education Block (4 weeks) Hem/Coag/UA Clinical Education Block (4 weeks) Blood Bank Clinical Education Block (4 weeks) Standard Rotation Shortened Rotation Studying for EOR exam Studying for EOR exam Studying for EOR exam Studying for EOR exam Note: each educational block is 4 weeks long and cannot be shortened. Only the time spent in training at the clinical site can be decreased to a minimum of 50% of the standard rotation if all competencies are met at that time (shaded areas represent the minimum time spent in rotations at the clinical site). The end-of-rotation exam will be scheduled to be taken at the conclusion of the clinical education block. Students must complete their rotations within two semesters. Please answer the following questions. The following questions will be used to schedule your rotations accordingly and to process any necessary paperwork that may be required prior to your rotations. The answers will not affect your eligibility to enter clinical rotations. * I am a veteran and will be using Veterans Affairs (VA) benefits during clinical rotations. Please select Yes No * I will be using Financial Aid during clinical rotations, therefore, need to be scheduled for at least 6 credits per semester. Please select Yes No * I am MLT certified and would like to do shorter rotations. Please select Yes No MLT certified students must send a copy of their MLT certification to the clinical coordinator * I would like to do Please select Full-time Part-time rotations Option available for Clinical Site Option 2 students only. * I need to do longer rotations due to state licensure purposes. Please select Yes No * I am attending clinical rotations in Florida and will need a Trainee License. Please select Yes No All students attending rotations in a facility located in Florida must obtain a Trainee License before they can enter clinical rotations. Please contact your coordinator for more information. If you have any questions, please contact the GW MLS Coordinator (firstname.lastname@example.org). Thank you!