APPLICATION PACKET

0 | P a g e

RADIOLOGIC TECHNOLOGY PROGRAM

APPLICATION PACKET

2024

Pre-Application Meetings Are Mandatory

Students must attend one meeting

THERE ARE 2 SESSIONS SCHEDULED

TUESDAY, MARCH 19 - 11: 00 AM

AND

TUESDAY, APRIL 23 - 11:00 AM

Allen Building Room 112

Revised 02/2018; 02/2019; 02/2020; 2021; 2022, 2023, 2024

2 | P a g e

Southern University at Shreveport

Division of Allied Health Sciences and Nursing

Dear Applicant:

We certainly appreciate your interest in Southern University at Shreveport and the Radiologic Technology Program.

Upon completing the curriculum, the student will receive an Associate of Applied Science Degree in Radiologic

Technology. The Joint Committee on Education in Radiologic Technology (JRCERT) accredits the program.

Applicants to the Radiologic Technology Program must meet general admission requirements to the University as

outlined in the University Catalog. Southern University at Shreveport is an open admission institution; however, acceptance

into the Radiologic Technology Program is done by a selection process. Applicants are selected for clinical admission on a

competitive basis. Acceptance into the clinical portion of the program requires full-time commitment to combine both

clinical and classroom instruction.

The American Registry of Radiologic Technologists reserves the right to deny individuals to take the National

Registry if convicted of a felony or misdemeanor. Individuals who have been arrested, charged with, pled guilty, or no

contest to, or been sentenced for any criminal offense or misdemeanor in any state must contact the American Registry of

Radiologic Technologists regarding this offense ARRT (651) 687-0048. The final directive of the American Registry of

Radiologic Technologists will determine the individual's eligibility for consideration for admission to the Radiology clinical

setting. The ARRT clearance letter is to be submitted to the Radiologic Technology program director before clinical

orientation.

American Registry of Radiologic Technologists

1255 Northland Drive, St. Paul, Minnesota 55120-1155

Applications are available March–June for the fall admission. The number of students selected each year for

entry depends on the number of available openings at the program's local clinical, educational centers.

All completed application packets must be submitted on June 3, 2024 to 610 Texas, Suite 212, by 5:00 pm.

Applications submitted by mail must be postmarked by June 3, 2024. Only those who have met the academic

requirements and provided all the requested information will be considered for an interview. Meeting the MINIMUM

REQUIREMENTS DOES NOT GUARANTEE ADMISSION INTO THE PROGRAM. Applicants will be notified

by mail as to acceptance or non-acceptance into the program.

Southern University at Shreveport assures equal opportunity for all qualified persons without regard to race,

religion, sex, national origin, age, handicap, marital status, or veteran's status in admissions, participation, or employment

in the programs and activities of the college. Students needing reasonable accommodations are encouraged to contact the

Section 504 Coordinator.

If you have any questions, please contact the Radiologic Technology telephone this department at (318) 670-9646.

Sincerely yours,

Shelia S. Swift, Director

Radiologic Technology Program

Southern University at Shreveport

Metro Center-610 Texas Street, Suite 212

Shreveport, LA 71101

Phone: (318) 670-9646

Toll- Free: 1-800-458-1472, Ext. 641-Website: www.susla.edu

Non-Discrimination Statement

In compliance with Title IX of the Education Amendments of 1972, Title VI and VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and other federal,

state, and local laws, Southern University at Shreveport (SUSLA) forbids discriminating or harassing conduct that is based on an individual's race, color, religion, sex, ethnicity, national

origin or ancestry, age, physical or mental disability, sexual orientation, gender identity, gender expression, genetic information, veteran or military status, membership in Uniformed

Services, and all other categories protected by applicable state and federal laws.

3 | P a g e

The Mission of the Radiologic Technology Program

The Radiologic Technology Program of Southern University at Shreveport offers an Associate of Applied Science

Degree, which prepares students for careers in Radiography. Dedicated to excellence in Radiography education,

the program promotes an environment, which fosters the development of critical thinking, creativity, problem-

solving, and cooperative learning through a wide range of instructional methods. The program's offerings include

learning experiences from a variety of disciplines to provide a diverse foundation for science and radiography.

Using the classroom and clinical setting as the main thrust for enhancing the learning process, students are

prepared to function as qualified radiographers in hospitals, clinics, and physicians’ offices.

Program Goals

Goal 1- Students will demonstrate clinical competence.

Goal 2- Students will develop critical thinking and problem-solving skills.

Goal 3- Students will demonstrate effective written and oral communication skills

QUALIFICATIONS

Personal

Applicants must be 18 years of age or older. Individuals must be in good physical and mental health. Good

physical and mental health is necessary for students to meet physical performance standards and possess the

clarity of mind needed for healthcare duties. Applicants must be able and willing to work with sick or disabled

persons. They should also be able to think critically using sympathetic, pleasant, cordial, versatile, and

ambitious reasoning. Applicants must also be dependable, responsible, and reliable. Students will be

responsible for the rules and regulations in the University Student Handbook, the Program Student Handbook,

and the ARRT Code of Ethics. Upon receipt of your application to the program, you will be required to submit

your background checks to the State of Louisiana and the National Sexual Predator. Convictions hindering

your participation in clinical activities will prohibit your acceptance into this program. If you have specific

questions about this requirement, please make an appointment with the program director and prepare to

present any questionable criminal history to ARRT for ethics review. Applicants must be willing to work

with low levels of radiation exposure.

▪ Possess a high school diploma or equivalent

▪ Have completed twelve (12) semester hours at Southern University at

Shreveport by the application deadline.

▪ Score on the ACT or Southern University Placement Test sufficient to

place the student in college- level courses; and possess a solid educational

background in Biology/Science.

▪ Have acquired a cumulative GPA of at least 2.5 in all college courses

4 | P a g e

Students are conditionally accepted into the program. After conditional acceptance to the radiography program,

proof of the following additional requirements must be submitted to the radiography program by the required

dates: (Please note any associated fees will be the student's responsibility.)

a. A completed physical examination form includes verifying current vaccinations

and titers (Hepatitis B, Rubella, Rubeola, Mumps, PPD, Diphtheria-Tetanus, Varicella and COVID status).

b. A copy of the American Heart Association's current certification in "CPR for the Health Care Worker."

before entering the clinic.

c. Students are advised that influenza vaccinations are also a requirement each Fall semester as mandated by

various clinical settings.

d. Acceptable Drug Screening and Criminal Background Checks. All allied health students are required to

submit a pre-clinical urine drug screen according to the policy of the Allied Health Sciences and Nursing

Programs at SUSLA. The drug screen is completed at the student's expense. At their discretion, clinical

sites may also require an additional drug screening and a criminal background check before allowing

students into the clinical setting. The clinical facilities (hospitals, etc.) require criminal background checks

before students attend the clinical sites. In addition, SUSLA and the clinical sites may require random

drug testing or drug testing for reasonable cause. Generally, the urine drug test screens for alcoholic

beverages, illegal drugs, or drug-impaired judgment while in the clinical setting. Testing positive for the

screening or evidence of tampering with a specimen will disqualify students from participation in the

clinical assignment.

e. In addition to drug screening for patients' and healthcare workers' safety, allied health students must also

undergo a background check performed by Southern Research at the student's expense. Your acceptance

into the program at SUSLA will not be final until SUSLA has received your background check information

from the reporting agencies and the background check is clear of disqualifying offenses. As evidenced by

a criminal background check, certain criminal activities may disqualify students from clinical

participation. Students are advised that the inability to gain clinical education experiences can result in

failure to meet program objectives and outcomes. These circumstances may prevent final acceptance into

or progression through the program and ultimately result in dismissal from the program.

• In keeping with the program's due process policies, if a student disagrees with the accuracy of the

information obtained, s/he may request a confirmatory test and or a review of the background

information's accuracy. All requests must be made in writing to the Dean of Allied Health Sciences

and Nursing and must include relevant information or extenuating circumstances supporting the

request. A designated committee will review the results and the request and make the final decision

regarding the student's request. The student will be notified in writing of the committee's decision

within ten (10) working days

Note:

Certificate Eligibility Because the American Registry of Radiologic Technologists (ARRT) can deny certification,

applicants with any of the listed violations below should complete an Ethics Pre-Application Review (available

at www.arrt.org) before entering clinical setting, or more than six months before program completion. These

violations include:

5 | P a g e

• Criminal proceedings including misdemeanor charges and convictions, felony charges and convictions,

a military court-martial

• Disciplinary actions were taken by a state or federal regulatory authority or certification board; or

• Honor code violations.

The Louisiana State Board of Radiologic Technologists Examiners can also deny licensure if the board feels that

such denial is in the public's interest.

Applicants who have prior arrest or convictions for a felony or misdemeanor other than a traffic citation are

advised to seek clarification of eligibility to sit for the ARRT Registry examination before entering the clinical

program. The ARRT does maintain the standards of conduct, and a felony may exclude an applicant. Applicants should

inform the Program Director and complete the ARRT Pre-Application Review of Eligibility for Certification when

accepted into the program. Your clinical acceptance is conditional. Applicants that are not cleared by the ARRT

conditional acceptance will be withdrawn. Please visit www.arrt.org, request for ethics review. The fee associated

with this Application is $100.00 and should be mailed directly to the ARRT.

Revised: 01/2017; 02/2018; 02/2019; 02/2020/2021/2022

Technical Requirements & Standards

Each student accepted into the Radiologic Technology Program's clinical phase must have the ability to

adhere to the following technical, physical, and mental standards.

• Assist with radiography of a corpse

• Communicate effectively with patients and various members of the healthcare team,

including the ability to perceive nonverbal communication and use appropriate medical terminology both

orally and in writing

• Ability to work various shifts including early am and evening rotation

• Ability to travel and attend professional meetings and competitions

• Ability to travel and arrive on time to area clinical, educational facilities

• Ability to act as a team player

• Ability to work well with others, including those with difficult personalities

• Ability to practice cultural diversity

• Ability to understand and apply instructions given by SUSLA faculty and affiliate site personnel

• Ability to think critically

• Ability to work in stressful situations

• Ability to set up and manipulate x-ray equipment in a safe, reliable, and efficient manner

• Ability to practice and apply appropriate radiation protection and safety measures

• Ability to perceive the relationships of internal organs, the x-ray tube, and the image receptor in

order to obtain radiographic images of diagnostic value;

• Ability to adjust machine controls and arrange and adjust various radiographic support devices;

• Ability to handle radiographic cassettes and imaging plates, develop radiographic film, and process

digital radiographic images;

• Ability to perform reaching, lifting, and bending in order to assist or move patients and equipment

in a safe, reliable, and efficient manner, with or without assistance;

• Ability to recognize and respond to adverse changes in patient condition, including those

requiring emergency medical intervention;

• Ability to evaluate radiographs to determine their acceptability for diagnostic purposes;

• Ability to respect patients' confidentiality and demonstrate integrity, a motivation to serve,

and have concern for others.

6 | P a g e

Physical & Mental Requirements

Physical stamina is essential in this occupation because technologists are on their feet for long periods and may

lift or turn disabled patients. Technologists work at diagnostic machines but also may perform some procedures

at patients' bedsides. Technologists and students must be able to perform the following tasks that include

numerous physical and mental skills. Students are continuously in contact with patients who need physical

assistance. Therefore, students must be able to:

1. Hear faint sounds from a distance of 15 ft.

2. Far vision correctable in one eye to 20/20 and 20/40 in the other eye

3. Lift 20 pounds from the floor; carry 10 ft. and place on a surface 36 inches high

4. Frequent lifting and carry up to 50 lbs. may be required

5. Push/pull 1 to 20 lbs. force continuously, 20 to 50 lbs. occasionally force, 50 to 75 lbs. force rarely

6. Work with arms overhead for 15 to 20 minutes at a time

7. Safely and successfully manipulate and transport mobile radiographic equipment

8. Endure observing and working, hands-on, with severely injured trauma patients or critically ill patients

9. Ability to bend forward when lifting using proper body mechanic

10. Ability to use manual dexterity quickly and accurately

For those applicants selected for admission, a physical is required. The applicant must submit a program-approved

health form completed and signed by a physician of the applicant's choice confirming that the applicant is in good

physical and mental health and possess the required physical and mental abilities to function satisfactorily within

the program and the occupation.

Admissions and Progression Policies

Dismissal

A student found guilty by the Southern University Disciplinary Committee of any of the following violations will be

dismissed from the Radiologic Technology Program and may be subject to University sanctions:

• Academic cheating

• Plagiarism

• Unauthorized possession of an examination

• Falsification of Southern University documents

• Illegal possession, sale, use, or distribution of drugs

• Illegal possession of weapons

• Theft

• Any other activity that is incompatible with professional behavior as delineated in the American Registry of

Radiologic Technology Code of Ethics, Southern University Student Handbook, or Southern University Radiology

Program Student Handbook.

• Earning grades of "W," "D," or "F" in required professional coursework

Grading Scale

100-93 A

92-85 B

84-77 C

7 | P a g e

76-69 D

68- 0 F

Health Insurance

All students should have an insurance plan. The premium coverage is the students' responsibility. Students are responsible

for all related medical billing.

Liability Insurance

Students in the Radiologic Technology Program, being a division of Southern University at Shreveport, and thereby an

agency of the State of Louisiana. Is afforded professional liability protection under Act 660, Senate Bill # 467, which

amend and reenacts Section 66 of the 1976 Session of the Louisiana Legislature relative to medical malpractice, which

provides for the payment of malpractice claims against State healthcare providers.

Drug Policy

As part of the physical exam, students are required to undergo a pre-clinical Drug Screen. The drug policy of the Radiologic

Technology Program is consistent with that of Southern University. (See Program Student Handbook) Students who

demonstrate a reasonable suspicion based on objective and documented facts sufficient to lead to a prudent University

authorized person to suspect that a student is using alcohol or drugs shall submit to an "on-the-spot" search and inspection

of personal effects and drug testing as outlined in the Student Handbook.

Academic Admissions

To meet the academic qualifications for the Radiologic Technology Program, the applicant must:

1. Meet the general admissions criteria of the University

2. Have completed (12) semester credit hours at Southern University at Shreveport

3. Submit a completed application packet for admission to the Radiologic Technology Program

4. Score on the ACT or University Placement Test sufficient to place in college-level courses

5. Possess a GPA of 2.5 or better in all college coursework

6. Take the HESI Health Sciences pre-admission exam.

7. Complete the interview process upon receipt of a letter from the program

8. Complete 24 hours of Observation

Rev. 2014/2016

General Education Courses:

College Success 120S

Physical Science 102S

Freshman English 101S

Intro to Computer Concepts 101S

Pre-Calculus 121S

Social or Behavioral Science Elective

Anatomy and Physiology + Lab 221S

Anatomy and Physiology + Lab 222S

Humanities Elective

Intro to Radiologic Technology 103S

Radiologic Technology Clinical Courses:

Clinical Radiography 107S

Radiographic Procedures/Positioning I 112S

Radiographic Procedure/Positioning I Lab 113S

Radiographic Exposure 118S

8 | P a g e

Radiographic Exposure

119S

Clinical Radiography II

117S

Radiographic Procedures/Positioning II

122S

Radiographic Procedures/Positioning II Lab

123S

Clinical Radiography III

135S

Level I Review

265S

Radiographic Procedures/Positioning III

232S

Radiographic Procedures/Positioning III Lab

233S

Radiology Physics

200S

Clinical Radiography IV

207S

Exposure II

215S

Radiation Biology and Protection

220S

Clinical Radiography V

237S

Equipment Operation and Maintenance

235S

Radiographic Pathology/ Film Critique

244S

Clinical Radiography VI

257S

Radiography Seminar

255S

Radiography Seminar

260S

72 Total Credit hours are listed

Rev; 01/2018;01/2019;02/2020

Selection Criteria:

An applicant for admission to the Clinical Program is expected to demonstrate capacities for academic

achievement, problem-solving, and competence in oral and written expression. Qualities such as responsibility,

dependability, compassion for patients and their relatives, courtesy, consideration, honesty, and motivation must

also be evident.

An applicant for admission to the Clinical Program in Radiologic Technology must have at least twelve (12) hours

of college from Southern University at Shreveport. If applicable, the student must have earned at least a 2.5

GPA in all previous coursework from other higher education institutions

A rating scale point system is used to determine the selection of students. An initial screening process will utilize

academic achievement as the primary assessment. Also, all Radiologic Technology majors are required to take a

pre-admission exam. The tentative cost of the exam is $65.00. Please contact the Testing Administrator, Ms.

Precious Phillips, [email protected].

Coursework completed in mathematics and the sciences will be given special consideration. Applicants will

also be evaluated using non-academic criteria, including personal interviews, reference forms, observational

evaluations, and an evaluation of writing and critical thinking skills. The final screening will be based on the total

points awarded for both academic and non-academic criteria. Applicants receiving the highest total points will

be admitted based on the availability of spaces in the clinical, educational centers.

9 | P a g e

APPLICATION CHECKLIST

TO APPLY TO THE RADIOLOGY TECHNOLOGY PROGRAM, THE STUDENT MUST:

_____ Application packet should be turned into Suite 212 at the Metro Campus on Monday, June 3, 2024, from 8:00

a.m. to 5:00 0 p.m. ONLY or postmarked by the June 3, 2024.

_____ Complete an application and be accepted by the University.

_____ Complete an application for the Clinical Radiologic Technology Program and submit a non-refundable fee of

$100.00 in the form of a money order, made payable to Southern University at Shreveport (SUSLA) Rad

Tech Club and paid at the cahier’s window. Receipt of payment must be included with the application

packet.

_____ Complete a Disclosure Form. This form is for background checks.

_____ Complete HESI pre-admission exam through the Allied Health Sciences & Nursing Academic Advisor.

Contact Testing Administrator, Ms. Precious Phillips at precious.phil[email protected].

_____ Submit an official high school transcript or General Education Development (GED) test scores.

______ Submit an official transcript (s) from ALL colleges attended with the application packet.

_____ Submit a degree plan with all course information and attach an unofficial copy of your transcript (s) to include

spring semester grades and summer registration if applicable.

https://www.susla.edu/assets/susla/Academic_Affairs/AcademicDegreePlans2023-

2024/RadiologicTechnologyDegreePlan20232024.pdf

_____ Submit an official copy of ACT scores with the application packet.

_____ Submit the three (3) personal recommendation forms which are provided in your Application packet.

Applicants are responsible for ensuring that the forms are completed and returned, (Individuals

completing the recommendation letters/forms must provide a signature across the sealed envelope)

_____ Review and study information related to a career in Radiologic Technology on the American Society of

Radiologic Technology website at (www.asrt.org).

_____ Construct an essay that discusses your career choice. Please include research regarding the field of Radiologic

Imaging. https://www.asrt.org/main/career-center/careers-in-radiologic-technology.

• The research essay must be completed in APA format. Include an abstract, a minimum of (2) typed

pages to include 1” margins, 12 font size, and 1 ½ line spacing. (THE ESSAYS WILL BE

REVIEWED AND SCORED)

_____ Include two (2) stamped, self-addressed envelopes (include complete mailing address (i.e. P. O. Box, Apt #,

etc.)

Please sign and submit the Application Checklist & this page with your Application Packet.

Applicant’s Signature _______________________________________ Date _______________

I have reviewed the Application Checklist. I understand it is the applicant's responsibility to ensure that all materials have been

included in this packet.

10 | P a g e

Upon completing the admissions procedure, qualified applicants are scheduled for an interview. The interview

committee chair sends a notification of the interview schedule.

**********In an effort to ensure successful completion of the program, the HESI Exam has been

incorporated as an assessment tool.

Applications and all related documents must be submitted to the Radiologic Technology Program at the

following address: 610 Texas Street, Suite 212, Shreveport, LA. 71101. Applications must have all information

submitted by June 3, 2024. Packets or information presented after the date as mentioned above WILL NOT BE

ACCEPTED.

Applicants not accepted into the program in the fall of 2024 and are planning to reapply must follow the

current curriculum. Please make an appointment with your advisor or program director for an updated

degree plan.

***NOTE***

Please group and arrange all documentation in the following order:

Application, a copy of cashier receipt, and complete disclosure form

Essay

All academic information (Transcripts, ACT scores, Degree Plan)

Reference forms

All signed forms (Confidentiality forms, Rotational Agreement) (Morality/Standards) along with a

written statement regarding the future need for an ARRT Pre-Eligibility Clearance letter or

documentation

(2) self-addressed/stamped envelopes

Pre-examination exam scores

Revised: 02/ 2015;02/ 2016;02/2017;02/2019;02/20;2021;2022, 2023

11 | P a g e

Financial Application and Admissions Requirement

(Upon acceptance into the program, some out-of-pocket expenses are assessed on a semester-by-semester basis as a course

fee and are a part of the student's tuition.

1. A $100.00 non-refundable application fee is made payable to SUSLA Rad Tech Club and paid at the cashier's

window on the MLK campus. This fee includes background checks/interviews. The receipt must be included

in the admission packet.

2. HESI - Health Sciences Pre-admission Exam fee is $65.00. This fee is paid at the cashier's window on the

MLK campus and a copy of the paid receipt must be presented to the Allied Health Sciences and Nursing

Testing Administrator.

3. Students accepted into the program MUST purchase required uniforms and shoes.

4. Due to the potential for exposure to a communicable disease, students accepted into the clinical program are

required to submit a current immunization record, TB skin test(or results), physical exam, and drug screen. The

student will incur the cost of medical expenses. Only students selected to enter the clinical phase of the

program are required to complete the above tests.

5. Students accepted into the program must have transportation to the various clinical, educational centers,

including travel to clinical sites outside of the Shreveport-Bossier area.

6. Students are required to become members of the Louisiana Society of Radiologic Technology at the cost of

$20.00 per year. This will require travel to state meetings, which may require an overnight stay. Students are

responsible for the cost incurred for membership and travel.

7. Accepted applicants with a felony and/or misdemeanors MUST seek clearance by completing the ARRT Pre-

Application Review of Eligibility for Certification. Visit the website at http://www.arrt.org for additional

information. The ARRT requires a fee of $100.00. Applicants should send the $100.00 application fee and other

required documentation to the ARRT, 1255 Northland Drive-St. Paul, MN. 55120-115. Applicants who do not

receive a clearance letter WILL NOT progress into the clinical program.

a. Students are advised that the inability to gain clinical education experiences can prohibit the ability to

meet program objectives and outcomes. These circumstances may prevent final acceptance into or

progression through the program and ultimately result in dismissal from the program.

8. Applicants are advised that clinical rotation times and sites vary throughout the semester. The shifts are as early

as 5 a.m. – 1 p.m. or as late as 3 p.m.-11 p.m. Clinical site location may include locations outside of the

Shreveport-Bossier area. It is strongly recommended that students have the available support for such shifts in

that each student will be scheduled for the rotations as mentioned earlier during his/her clinical experience.

9. Applicants must have completed twenty-four (24) observation hours as a part of the eligibility to submit an

application process. All students that use a Willis Knighton site for observation are required to; attend the WK

orientation meeting, complete Observational Paperwork, and complete a TB skin test.

10. The estimated cost of this program is $17,500. The clinical fees and course fees may not be inclusive of all

out-of-pocket expenses.

Please sign and submit this page with your Application Packet.

Applicant’s Signature Date

12 | P a g e

Radiologic Technology Program Application

610 Texas Street, Suite 212

Shreveport, Louisiana 71101

Today’s Date Application for Fall

Year

Name (Last)

(First)

(Middle)

Student ID Number

Street Address

City

State

ZIP

Contract Number

Are you 18 yrs. of age or

older?

Email Address

EDUCATION

HIGH SCHOOL

# of Years

Attended

Did you

Graduate

Year Graduated

College Degree

Major/ Minor

Subject

List all Colleges

Attended

ACT Yes No

Score

Did you take the HESI Entrance Exam?

Yes No Score

Did you complete the Observation hour requirement? Yes

List dates and location below;

No Observation hours are a requirement.

Dates

Location of Observation:

13 | P a g e

EMPLOYMENT HISTORY-

LIST LAST THREE EMPLOYERS OR PAST (10) YEARS OF EMPLOYMENT (INCLUDING MILITARY SERVICE)

EMPLOYER'S NAME AND

ADDRESS

DATES

SUPERVISOR'S NAME

JOB TITLE

REASON FOR

LEAVING

From:

To:

No. of Yrs.

From:

To:

No. of Yrs.

From:

To:

No. of Yrs.

LIST REFERENCES FROM RECOMMENDATION FORMS (Excluding Relatives)

NAME

ADDRESS

PHONE

OCCUPATION

After conditional acceptance to the program, our clinical, educational partners may require an additional

background check. If you have ever been convicted of a felony, you must complete ARRT Pre eligible Board

of Ethics Clearance. Students are advised that the inability to gain clinical education experiences can result in the failure

to meet program objectives and outcomes. These circumstances may prevent final acceptance into or progression through

the program and ultimately result in dismissal from the program.

PLEASE READ CAREFULLY BEFORE SIGNING

I UNDERSTAND that all of the information provided in this Application is pertinent to determining my eligibility for

admission into the Radiologic Technology Program of Southern University at Shreveport and EXPRESSLY AUTHORIZE the

program personnel to conduct a reasonable investigation to verify said information.

I FURTHER UNDERSTAND that acceptance in the program is conditional. Applicants must complete a physical

examination, drug screen, background check, and a C or better in coursework. The applicant must have the ability to perform

specific essential technical standards adequately. Applicants unable to perform any designated tasks may request SUSLA to

make reasonable accommodations if these accommodations do not constitute an undue hardship and if those accommodations

do not interfere with the performance of a radiographer's essential functions' duties and educational requirements.

I MOREOVER UNDERSTAND that any false or misleading information contained in this Application may subject me to

sanctions including, but not limited to, rejection of my Application or immediate disqualification from the Radiologic

Technology Program.

IF ACCEPTED into the Radiologic Technology Program, I agree to abide by all program and affiliate hospital rules and

regulations.

THIS APPLICATION IS FOR ADMISSION INTO THE PROGRAM IN RADIOLOGIC TECHNOLOGY ONLY. IF I AM

TO ENTER SOUTHERN UNIVERSITY AT SHREVEPORT, I MUST FILL OUT AND SUBMIT AN APPLICATION FOR

ADMISSION TO SOUTHERN UNIVERSITY.

**COMPLETION OF THIS FORM DOES NOT INDICATE THAT YOU ARE ACCEPTED INTO THE PROGRAM**

SIGNATURE OF APPLICANT DATE

14 | P a g e

Southern University at Shreveport does not discriminate on the basis of race, color, national origin, gender, age, disability or any other protected

class. Title IX Coordinator: Dr. Tuesday W. Mahoney, Fine Arts Building, Room C14, (318) 670-9201. Section 504 Coordinator: Dr. Anjelica Hart,

NCR Building, Room 125, (318) 670-9367

Revised 02/017; 20/2018; 02/2019; 02/20;2021;2022

Disclosure Forms

Please submit

complete these forms

when submitting your

Application Packet.

Please print the disclosure form as a single page.

No front and back copies.

15 | P a g e

20990-(SUSLA) Radiologic Technology Program

RELEASE FOR BACKGROUND INVESTIGATION FOR SOUTHERN RESEARCH COMPANY, INC.

By my signature below, I hereby authorize SOUTHERN RESEARCH COMPANY, INC., to procure a consumer report and/or an

investigative consumer report, including but not limited to: my consumer criminal history, driving record, education, employment,

professional licenses verification, credit history, personal interviews with neighbors, friends, or associates of my character, general

reputation, personal characteristics, mode of living and other public records, which may confirm or deny my eligibility for

employment, with the Facility named above. I authorize without reservation, any party, including, but not limited to, employers, law

enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by SOUTHERN

RESEARCH COMPANY, INC. to furnish any or all of the above-listed information in order to successfully complete a background

investigation. I waive such legal rights and release all persons from any liabilities and damages in connection with furnishing such

information to the Facility named above.

1. APPLICANT OR SUBJECT OF INVESTIGATION – PLEASE PRINT OR TYPE

Last Name

First Name

Middle Name

Social Security Number

- -

List AKA, Maiden, and/or previous married name(s) to be searched (there is an additional charge for each name)

aka/maiden name

Address

City

State

Zip Code

Date of Birth

/ /

Gender

❑ Male ❑ Female

Race

Drivers License Number

State

 Applicant’s signature: ________________________________________

Date: ____/____/____

2. SCOPE OF INVESTIGATION – PLEASE CHECK RECORDS

TO BE SEARCHED

_____ Social Security Number Trace _____ E-Verify

Criminal Court Records–Computer Name Index Search

_____ 5-Local Search (Caddo & Bossier Parish, Western District of LA, Shreveport & Bossier City Courts)

_____ County/Parish Search: (List County/Parish): _____________________________________________________

_____ Statewide Search: (List State Name): ___________________________________________________________

_____ International Search: (List Country Name): ______________________________________________________

Civil Court Records–Computer Name Index Search

_____ Caddo Parish, Bossier Parish, and Western District of LA

_____ County/Parish Search (List County/Parish): _____________________________________________________

U. S. District Court Records - _____________________________________________________________ Search

Type: _____ Bankruptcy; _____ Criminal; _____ Civil

_____ Official Driving Record: Louisiana (three-year covering period)

_____ Official Driving Record: Out-of-State Record (List State): _____________________________________

_____ National Sex Offender Registry _____ OIG Exclusion _____ RapidCrim _____ GAPSA

_____ Employment Verification _____ Education/Professional Credential Verification

For Official Use ONLY (Please do not write below this line)

Client Information: Phone Number: (318) 670-9646 Fax Number: (318) 670-6698

Date of Request: __________________ Total Cost of Request: $______________________

Receipt #: ________________ Paid by (Circle one): Check Cash Credit Card Money Order

SRC Specialist Signature:_____________________________________ PAYG (Employment/Student) – rev: 12/2013

15 | P a g e

20990 _ SUSLA Radiologic Technology Program

In connection with my application for

the School Program,

I understand that a consumer report

and/or an investigative consumer report may be requested and obtained for

school

purposes on

behalf of

the institution named above.

I also understand that, if I am

elected for the program,

a consumer report and/or an investigative consumer report may be requested and obtained during

the course of

the Program.

The report may include information regarding my character, general reputation, personal

characteristics mode of living, and credit standing which may confirm or deny my eligibility for

the program with

the Institution named above.

The information contained in the report will be

obtained from private and public record sources, including, as may be appropriate, personal

interviews with sources such as neighbors, friends and associates.

providing the informatio11 reques ted below and signing this Disclosure Authorization,

authorize the Institution named above to reques

and obtain a consumer report and/or

investigate a consumer report regarding me.

I also acknowledge that a facsimile or photographic

copy of this signed Disclosure Authorization will be as valid as the original.

Applicant's Full Name (Please Print): ______________________________________________________________

Street Address:

City:

State:

Zip:

Date of Birth (MM/DD/YY): ss # ______________________

Driver's License: State ________________ Number:

Applicant’s Signature: ___________________________ Date: ___/___/___

18 | P a g e

19 | P a g e

21 | P a g e

22 | P a g e

CLINICAL PERFORMANCE STANDARDS FOR ADMISSIONS

Radiologic Technology is a health care profession that may require very strenuous physical activity.

Applicants must be physically capable of successfully performing procedures both safely and

expeditiously. The twelve (12) activities listed below are examples of the profession's kind of work.

Using these standards, please assess your ability to perform these tasks.

1. Lift, move and transport a patient from bed to wheelchair/stretcher or from wheelchair/stretcher to

radiographic table without causing undue pain or discomfort to the patient or oneself.

2. Position the patient for various radiographic examinations without injury to the patient.

3. Check patient identification, positioning, imaging field placement, and alignment and work with and

assist the patient with being positioned on a standard radiologic exam table that has a height of 36"

above the floor level.

4. Reach and manipulate the x-ray equipment into proper positions, including imaging and treatment of

tables, x-ray tubes, nuclear detectors, radiotherapy equipment, related collimators, control consoles,

computer console, x-ray processor, surgical c-arm, ultrasound equipment, and mobile x-ray equipment.

5. Respond instantly to emergencies that may otherwise jeopardize a patient's physical state if speedy

care is not administered.

6. Handle and utilize materials needed in various radiologic procedures, including pharmaceuticals, vials,

syringes, sterile linens and instruments, catheters, intravenous systems, dressings, and other patient

care items.

7. Handle and use imaging detectors, imaging plates, image mechanisms, imaging detectors, pass boxes,

and immobilization devices.

8. Evaluate written requisitions for radiographic procedures.

9. Effectively communicate the explanation of the procedure to the patient and give proper instructions.

10. Obtain the medical history of patients and communicate this information to the Radiologists when

applicable.

11. Evaluate the quality of radiographic images regarding the exposure factors, image quality, and proper

positioning of anatomical parts.

12. Transport mobile equipment to assigned areas of the hospital in a timely and cautious manner.

13. Perform venipuncture procedures without assistance.

***PLEASE NOTE***

SUSLA reserves the right to verify the students' performance level related to the aforementioned technical

standards.

23 | P a g e

Division of Allied Health Sciences and Nursing

Rotational Site and Time Agreement

The Southern University at Shreveport Radiologic Technology Program require clinical students various

clinical shift assignments such as 5:00 AM-1:00 PM; 6:00 AM-2:00 PM; 7:00 AM-3:00 PM; 8:00 AM-4:00

PM; 8:00 AM-5:00 PM; 11:00 AM to 7:00 PM, and 3:00 PM-11:00 PM. Rotational assignments are to be

determined by the Clinical Coordinator.

I, , understand that if accepted into the clinical

aspect of the Radiologic Technology Program of Southern University at Shreveport I must adhere to all

rotational assignments. I understand that I will work at various clinical, educational centers that may not be

limited to the Shreveport-Bossier City area. I will make all necessary arrangements to report to my assigned

clinical site at the time specified by the Clinical Coordinator.

I understand that if I fail to comply with my assigned clinical rotational assignment, I may earn a failing grade

in the clinical course. I further understand that if I choose to withdraw from the program's clinical phase for

any reason and reapply to the Southern University at Shreveport Radiologic Technology Program, that my

Application will be considered with all other applicants. Students must sign below indicating acknowledgment

and agreement to all clinical rotational shift assignments.

Signature Date

Metro Center - 610 Texas Street, Suite 212

Shreveport, LA 71101

Phone: (318) 670-9646

Toll- Free: 1-800-458-1472 - Website: www.susla.edu

Revised 02/2018; 02/2019; 02/2020; 2021

24 | P a g e

Division of Allied Health Sciences and Nursing

STUDENT STATEMENT OF CONFIDENTIALITY

I, , will not reveal any information concerning

patients or clients to anyone not authorized to discuss the individual’s physical and/ or psychological

condition. I agree not to discuss or seek information concerning patients, fellow students, instructors or

personal acquaintances (i.e. grades, attendance records or medical history), to which I have no authorization

nor legitimate interest. If I commit either of the aforementioned violations, I understand that I am subject to

non-acceptance/dismissal from the Radiologic Technology Program of Southern University at Shreveport.

Student signature Date

Print Name

Metro Center-610 Texas Street, Suite 212

Shreveport, LA 71101

Phone: (318) 670-9646

Toll- Free: 1-800-458-1472 - Website: www.susla.edu

Revised; 02/2019; 02/2020

25 | P a g e

Division of Allied Health Sciences and Nursing

MORALITY STANDARDS

ELIGIBILITY TO SIT FOR ARRT EXAMINATION

I, , understand that eligibility to sit for the ARRT

Examination in Radiography requires that I submit for review any conviction for misdemeanors (other than

minor traffic citations that do not involve the use of alcohol), and felonies, even if I plead nolo contendere. I

further understand that it is my responsibility to seek eligibility from the ARRT clearance early to ensure I

am eligible to practice in the Radiologic Technology profession.

Student’s Signature Date

Print Name

Revised: 02/2017; 02/2018; 02/2019; 02/2020

Division of Academic Affairs and Workforce

Development

2023-2024 Degree Plan

RADIOLOGIC TECHNOLOGY

Associate of Applied Science Degree

Student’s Name: Banner ID Number:

PRE-REQUISITES

Course

Prefix

Course

Number

Course Title

Credit

Hour

Grade

Term

Substitute (S)

Transfer (T)

Transfer

Institution

SENL

101S

Freshman English I

CMPS

101S

Introduction to Computer

Concepts

SBIO

221S

Human Anatomy and

Physiology Lecture I

SBIO

221LS

Human Anatomy and

Physiology Lab I

SMAT

121S

Pre-Calculus Algebra

*Social or Behavioral

Science Elective

FROR

120S

College Success

*Humanities Elective

PHYS

102S

Physical Science I

RADT

103S

Intro to Radiologic Tech I

SBIO

222S

Human Anatomy and

Physiology Lecture II

SBIO

222LS

Human Anatomy and

Physiology Lab II

FRESHMAN YEAR

RADT

107S

Clinical Radiography I

RADT

112S

Radiographic Procedures

and Positioning I

RADT

113S

Radiographic Procedures

and Positioning I Lab

RADT

117S

Clinical Radiography II

RADT

118S

Radiographic Exposure

Lecture I

RADT

119S

Radiographic Exposure

Lab I

RADT

122S

Radiographic Procedures

and Positioning Lecture II

RADT

123S

Radiographic Procedures

and Positioning II

RADT

135S

Clinical Radiography III

MLTC

100S

Phlebotomy Workshop

RADT

265S

Level I Review

DAHSN:2020-2021; JAB

Division of Academic Affairs and Workforce

Development

2023-2024 Degree Plan

RADIOLOGIC TECHNOLOGY

Associate of Applied Science Degree

Student’s Name:

Banner ID Number:

SOPHOMORE YEAR

Course

Prefix

Course

Number

Course Title

Credit

Hour

Grade

Term

Substitute (S)

Transfer (T)

Transfer

Institution

RADT

200S

Radiologic Physics

RADT

215S

Exposure II

RADT

232S

Radiographic Procedures

and Positioning III

RADT

233S

Radiographic Procedures

and Positioning Lab III

RADT

207S

Clinical Radiography IV

RADT

220S

Radiation Biology and

Protection

RADT

235S

Equipment Operations and

Maintenance

RADT

237S

Clinical Radiography V

RADT

244S

Radiographic Pathology

Image Critique

RADT

255S

Radiologic Seminar

RADT

260S

Radiologic Seminar II

RADT

257S

Clinical Radiography VI

TOTAL CREDIT HOURS:

*Approved Humanities electives: (MUSC 200S (0nly); SHIS courses; SENL (Literature only

200 or above); SFIA 101S (only); SCOM 101S (only)

NOTE: Students must secure the list of approved Humanities electives from his/her advisor.

Approved by:

Student’s Signature Date

Advisor’s Signature Date

Division Head’s Signature Date

DAHSN:2020-2021; JAB

RADIOLOGIC TECHNOLOGY PROGRAM

Application for Admission

Request for Reference

Name of Applicant Semester

I now waive my right to access the material recorded below. (Optional)

Signature of Applicant Date

To the Respondent:

May we have your judgment of this applicant's qualifications and promise, of this applicant's intellectual ability, motivation,

and capacity for acquiring technical skills in Radiologic Technology. Please include information regarding his/her character

and personality by marking an "X" in the appropriate box.

Superior

Above Average

Average

Below Average

No Information

Intellectual Ability

Critical Thinking Ability

Problem Solving Ability

Ethical Behavior

Interpersonal Skills

Motivation

Perseverance

Receptivity to New Ideas

I have known the applicant for approximately years.

Identify one character strength

Identify an area of improvement

Please check one of the following:

Highly recommend Recommend Recommend with Reservation

Respondent’s Signature: Title:

Name Printed or Typed

Address and Contact Number

Revised:02/2019;02/2020;2022

Under the provisions of the Family Education Rights and Privacy Act of 1974, this applicant (if

admitted/enrolled) will have access to the information provided below unless he/she waives such access.

RADIOLOGIC TECHNOLOGY PROGRAM

Application for Admission

Request for Reference

Name of Applicant

I now waive my right to access the material recorded below. (Optional)

Semester

Signature of Applicant Date

To the Respondent:

May we have your judgment of this applicant's qualifications and promise, of this applicant's intellectual ability, motivation,

and capacity for acquiring technical skills in Radiologic Technology. Please include information regarding his/her character

and personality by marking an "X" in the appropriate box.

Superior

Above Average

Average

Below Average

No Information

Intellectual Ability

Critical Thinking Ability

Problem Solving Ability

Ethical Behavior

Interpersonal Skills

Motivation

Perseverance

Receptivity to New Ideas

I have known the applicant for approximately years.

Identify one-character strength

Identify an area of improvement

Please check one of the following:

Highly recommend Recommend Recommend with Reservation

Respondent’s Signature: Title:

Name Printed or Typed

Address and Contact Number

Revised:02/2019;02/2020;2022

Under the provisions of the Family Education Rights and Privacy Act of 1974, this applicant (if

admitted/enrolled) will have access to the information provided below unless he/she waives such access.

RADIOLOGIC TECHNOLOGY PROGRAM

Application for Admission

Request for Reference

Name of Applicant Semester

I, with this, waive my right to access the material recorded below. (Optional)

Signature of Applicant Date

To the Respondent:

May we have your judgment of this applicant's qualifications and promise, of this applicant's intellectual ability, motivation,

and capacity for acquiring technical skills in Radiologic Technology. Please include information regarding his/her character

and personality by marking an "X" in the appropriate box.

Superior

Above Average

Average

Below Average

No Information

Intellectual Ability

Critical Thinking Ability

Problem Solving Ability

Ethical Behavior

Interpersonal Skills

Motivation

Perseverance

Receptivity to New Ideas

I have known the applicant for approximately years.

Identify one character strength

Identify one character weakness

Please check one of the following:

Highly recommend Recommend Recommend with Reservation

Respondent’s Signature: Title:

Name Printed or Typed

Address and Contact Number

Revised:02/2019;02/2020;2022

Under the provisions of the Family Education Rights and Privacy Act of 1974, this applicant (if

admitted/enrolled) will have access to the information provided below unless he/she waives such access.

Please include the following information/ forms in your application packet:

1. ⁮Application for admission

2. ⁮Student Confidentiality forms

3. ⁮Morality Standard Form

4. ⁮Rotational Site and Time Agreement

5. ⁮Request for Reference Forms(Signature across the seal of the envelope)

6. ⁮Observation Form Time Sheet(s)

7. ⁮Financial Application and Admissions Requirement

8. ⁮Application Checklist

9. ⁮Career Choice Essay

10. ⁮ACT Scores

11. ⁮HESI Exam scores

12. ⁮Transcripts

• ⁮ High School (Official)

• ⁮Degree Plan w/ Banner Transcript

• ⁮Official transcripts from all universities and colleges attended

(In sealed envelopes)

13. ⁮ Disclosure Authorization Form

14. ⁮Application Fee Receipt

15. ⁮(2) Self-addressed, stamped envelopes

***Note***

Please group and arrange all documentation in the following order:

–Checklist, Application, a copy of cashier receipt, and Background Check Disclosure Form

-Essay

-All academic information (Transcripts, ACT scores, Degree Plan, and HESI Results)

-Reference forms and (2) self-addressed/stamped envelopes

-All signed forms (Confidentiality forms, Morality/Standards, Rotational Agreement, Financial

Application, and Admissions Requirement)

Observation Information

Students must complete 24 observational hours is currently available at one of the

following locations:

▪ Willis-Knighton (Bossier, North, Pierremont, South)

▪ Ochsner Louisiana State University Health Science Center—Approval Pending

▪ Christus Shumpert Highland - Approval Pending

OBSERVATION

1. Students must follow observation guidelines and policies as delineated by the medical facility that you

elect to utilize.

2. Each applicant must complete a total of 24 observational hours in the Radiology department of a

hospital or clinic.

3. Students reapplying must without clinical experience must complete 24 hours.

4. Students must submit their observation forms to the Chief Technologist or Designee.

5. Observational hours must be completed at one (1) of the hospitals, as mentioned earlier.

6. Students must schedule observation hours between March 19 through May 31

7. Students must wear scrubs during observation hours. (Please Do not wear Royal Blue, Navy, Black,

or Gray as these colors reflect current clinical students. Printed tops and solid bottoms are appropriate)

8. Students must observe as many procedures as available during observation hours.

9. Students must not congregate or sit in work areas.

10. Students must complete all observation hours as scheduled.

11. Students must adhere to all hospital rules and regulations.

12. Student's cell phones and electronic devices are prohibited during the observation.

13. Students are encouraged to review the asrt.org website to gain knowledge regarding careers in

Radiology https://www.asrt.org/main/career-center/careers-in-radiologic-technology.

Revised 02/017; 02/2018; 02/2019; 02/2020; 2021; 2022, 2023, 2024

Willis-Knighton

Observation Requirements

All students interested in completing observation at any Willis-Knighton facility must follow the

outlined procedures.

The students must attend one of two scheduled Orientation meetings on Tuesday, March 19 at 11:00

am or Tuesday, April 23 at 11:00 am. (Allen Building, Room 112).

• Students must complete Level I Student/ Observer Registration Forms (please return to Suite 212 on

completion.

• Return within 1-Week of receiving with/TB Skin Test Results

Upon completion of all Observation Paperwork:

▪ Observation must be scheduled after paperwork returned and background check is completed

▪ Students may schedule observation five days a week between the hours of 8 am-4

▪ Students must wear scrubs that are clean and neatly pressed.

▪ Students must keep the observation badge visible at all times during the observation.

▪ Students must complete the Level I Student Observer informational packet.

Rev. 02/2019;02/2020;2021;2022, 2023

Ochsner LSU Health Science Center

Observation Requirements

Student Observers (Pre-Radiology Technology)

Purpose:

Job shadowing is an educational experience option in which participants learn about a job by walking through the

work day as a shadow to an employee. The job shadowing education experience is temporary, unpaid exposure to

the workplace in an occupational area of interest to the participant. Participants witness firsthand the work

environment, employability and occupational skills in practice, the value of professional training, and potential

career options. Job shadowing is designed to increase career awareness, help model Participant behavior through

examples, and reinforce in the Participant the link between classroom learning and work requirements.

Policy:

1. Observation hours are to be scheduled by the prospective student by completing the Job Shadowing.

Application form and returning it to Zelda.timmonsmosley@ochsnerlsuhs.org

2. After the application is approved, Contact the Education Coordinator in the Department of Radiology at

Ochsner LSU Health. Office hours are 7:30 am until 4:00 pm, Monday through Friday. The number

Is (318) 626-0646 or email Lauren.kerns@ochsnerlsuhs.org for St. Mary’s Medical Center location.

3. You are not required to inform the Education Coordinator when observing during hours with a

Clinical Instructor on-site at this facility.

4. Observation hours are limited to the standard day shift hours.

5. Student observers must comply with the following dress code

a. Scrubs are recommended and the preferred attire.

i. Please Do Not Wear the following colors; Royal Blue, Black, Navy, or Gray, as these

colors reflect current clinical students.

ii. Printed tops and solid bottoms are appropriate)

b. If scrubs are not worn, dress pants and shirts may be allowed. A white lab coat MUST be worn

over this attire.

c. Clothing must be clean and neat.

d. No holes or cut-outs are allowed.

e. For safety reasons, sandals and open-toed shoes are not allowed.

f. Comfortable shoes such as athletic shoes are recommended for safety and comfort.

g. See-through, low-cut or revealing clothing is not allowed.

h. No shorts or miniskirts.

i. No headwear such as scarves, caps, hats, etc., is allowed.

j. No denim is allowed.

k. Sagging pants are not allowed.

l. Excessive perfumes, colognes, or lotions may cause reactions in compromised patients and are

not allowed.

m. Overall appearance is to be neat, clean, and professional.

2. Student observers are not allowed to participate in Radiology procedures in any way. They are here to

observe only.

3. Confidential patient information is not to be shared with student observers.

4. Student observers are required to comply with all of the medical center's confidentiality policies.

5. Students MUST have a confidentiality agreement and a HIPPA form signed and in their folder from the

program in which they are enrolled.

Written:

4/2/2003

Revised: 2/4/2004:2018,

2019, and 2024

Ochsner LSU Health – Shreveport

Adult Job Shadow

Job Shadow Description:

At Ochsner LSU Health Shreveport, we have a structured job shadowing program that allows individuals an opportunity to

shadow a physician, advanced practice provider, or other healthcare professional for no more than 3 days in a year.

(Shadowing days are usually a half day and cannot exceed 8 hours.) If you would like to have a more extended experience,

we encourage you to apply for the volunteer program.

Any adult who currently desires to seek further insight into a particular department in order to gain personal understanding and

general knowledge related to job function and environment is invited to apply for a job shadow experience. Participants must

be at least 18 years of age and fully vaccinated for COVID-19 to participate

Purpose:

Job shadowing is an educational experience option in which participants learn about a job by walking through the work day as

a shadow to an employee. The job shadowing education experience is temporary, unpaid exposure to the workplace in an

occupational area of interest to the participant. Participants witness firsthand the work environment, employability and

occupational skills in practice, the value of professional training, and potential career options. Job shadowing is designed to

increase career awareness, help model Participant behavior through examples, and reinforce in the Participant the link

between classroom learning and work requirements.

Behavioral Standards:

• Participants will be respectful and courteous to patients, family members, and staff at all times.

• Participants will not touch patients. If participants are allowed to observe a patient during a procedure, the director

or manager must obtain the patient’s consent first, or if the patient does not have capacity, the director or manager

must obtain the consent of the patient’s legal representative

• Participants will not make any decisions regarding or render any advice or recommendations as to the treatment or

care of patients.

• Participants will not touch medical equipment.

• Participants will not have medical record, chart, or computer access.

• Participants will not assist in feeding a patient but may assist in food delivery.

• Participants will not approach physicians about personal illness or medications.

• Participants will dress professionally. NO jeans or shorts; scrubs or lab coats; sandals or flip-flops; dangling jewelry.

• Participants will not be permitted to wear scrubs or lab coats, as they are reserved for the care provider team.

• Participants will not perform personal care in the clinical setting (i.e. eating or drinking, brushing hair, etc.)

• Participants will not be permitted in areas of contamination, such as isolation rooms, soiled linen areas, labs, and

autopsy rooms.

• Participants cannot participate in the program on days they are ill, including but not limited to, Cold/Cough, Fever

(must be fever-free for 24 hours), Chicken Pox, Pertussis (Whooping Cough), Influenza (Respiratory Flu),

Stomach/Gastrointestinal Flu, Tuberculosis, MRSA.

• Participants will not need a purse, cell phone, or backpack; no storage will be available on-site for personal items.

• Cell phone use is not permitted.

• Ochsner is not liable for any theft of or damage to personal property while you are on campus for your job shadow.

It is best to leave important personal items at home.

If interested in a Job Shadow experience at Ochsner LSU Health Shreveport, please review the educational

PowerPoint available online, then complete and submit the following forms to:

zelda.timmonsmosley@ochsnerlsuhs.org

1. Job Shadow Application

2. Participant Agreement/Release

3. Copy of COVID Vaccination Card

You will be contacted as soon as a mentor is identified to discuss your schedule availability.

For any questions, please call 318-626-1202 or email zelda.timmonsmosley@ochsnerlsuhs.org.

Adult Job Shadow Application

Participant Contact Information

Name _______________________________________________________________________________________

Last First Middle

Home Address ________________________________________________________________________________

Street Number Street Name Apt City State Zip

E-Mail Address__________________________________________@_______________________._____________

Birth Date _________/_________/_________ Phone Number (_______) _______–_________

Month Day Year

Emergency Contact Information

Name _____________________________________________ Relationship _____________________________

Primary Phone (_______) ________–___________ Secondary Phone (________) _________–____________

Placement Information

Classification: □ College Student □ Post-Graduate/Professional

In what field of study/department/career are you looking to complete your job shadow?

___________________________________________________________________________________________

Do you already have a mentor confirmed? □ YES □ NO

(If yes) Mentor’s Name: _______________________________________ Department: ________________________

Job shadow opportunities are provided without regard to religion, creed, race, national origin, age or sex. This

application is submitted with understanding that approval from the authorized Ochsner designee must be in

place prior to commencing the shadow as a condition to begin. I certify that the answers given to the foregoing

statements are correct and without omission. I authorize the company to investigate the foregoing; and my

former employers from any liability for damage, which may result from any such investigation. If upon

investigation, anything contained in this application is found to be untrue, I understand I will be subject to

dismissal at any time during the period of shadowing. Ochsner is not obligated to provide a placement, nor am

I obligated to accept the placement offered. I understand that if accepted, I will schedule my placement in a

timely manner. I also understand that I will not be paid for this experience.

_______________________________ ___________________________________ ______________

Participant Signature Participant Printed Name Date

Ochsner LSU Health – Shreveport

Health Career Exploration/Job Shadow

Participant Agreement

I, _____________________________________, have been selected to participate in a job shadow to

(Print Participant Name)

seek further insight into a particular department in order to gain personal understanding and general

knowledge related to job function and environment.

Consent: I give permission to have myself photographed and/or videotaped while participating in any

Program by Ochsner Clinic Foundation and all its affiliates (together “Ochsner”) for use by Ochsner in

all public relations activities, including use by or for news media, and further authorize the use of my

name with said photos, film, print or tape in all advertising activities, including television commercials,

print ads, brochures, web sites, and outside billboards.

Release. In consideration of being allowed to participate in the Volunteer Program, I hereby release

Ochsner Clinic Foundation, as well as its subsidiaries, affiliates, representatives, agents, physicians,

employees, servants, officers, directors, insureds, insurers, successors, and assigns (collectively

“Ochsner”) from any and all liability for any injury or damage which may occur as a result of my

participation in the Program including all risk connected therewith, whether foreseen or unforeseen;

and further, agree to save and hold harmless Ochsner from any claim by myself individually or on

behalf myself, family, estate, heirs or assigns arising out of my participation in the Program.

In the event of an injury requiring medical attention, I hereby grant permission to Ochsner to provide

initial medical services to me. If the injury warrants further medical attention, and my specific

authorization is unable to be obtained before action is taken, I grant permission for necessary medical

treatment to be given. In addition, I hereby give my permission to the supervising instructor(s) or

Ochsner staff (including medical staff) to take me to the appropriate medical department for treatment

within the hospital or, if a physician, to administer treatment if an accident or serious illness occurs.

Under all circumstances, I agree to accept full responsibility for and to pay for the cost of any medical

care, transportation and other incidental expenses for any medical treatment or services I receive at

Ochsner.

HIPAA Acknowledgement: My signature below indicates I have read and understand information

related to HIPAA and my responsibilities while shadowing at Ochsner. I acknowledge that there are

civil and criminal penalties for the unauthorized access and/or use of confidential patient information. I

will adhere to the guidelines as outlines in the training provided.

_________________________________________ __________________________________

Participant Signature Date

_______________________________________ ______________________________

Division of Allied Health Sciences & Nursing

OBSERVATION CONFIDENTIALITY STATEMENT

I understand and agree that in the performance of my Radiologic Technology observation as a student at (fill in

name of medical center) , I must hold all medical information

in confidence. I understand that any violation of this policy will result in legal action or removal from the

facility. I will not reveal any information concerning patients or clients to anyone not authorized to discuss the

individual's physical or psychological condition.

DATE SIGNATURE OF STUDENT

NON-DISCRIMINATION STATEMENT

I understand and agree that in the performance of my Radiologic Technology observation as a student at (fill in

the name of medical center) , I will not harass the employees or visitors

nor discriminate against any patient while serving as an observer because of race, color, national origin, gender,

age, marital status, religion, veteran's status, financial status, or mental or physical handicap. I understand that

any violation of this policy will result in legal action or removal from the facility.

DATE SIGNATURE OF STUDENT

This form should be submitted to designated personnel.

Ochsner LSU Health Science Center

Division of Allied Health Sciences and Nursing

Radiology Department Observation Form

Student Applicant Name Date of Visit:

(One visit per page)

Radiology Facility Name

Date and time of scheduled observation:

(Please check one) Hospital Clinic

Observation Start time End time

Radiologic Technologist: Please check the appropriate blanks listed below.

Observed Not Available

Chest

Fluoroscopy

To be completed by the Technologist:

Yes No

Arrived on time

IVP

Stayed required time

Extremities

Portables

Dressed appropriately

Good hygiene

Other areas observed (please list):

Signature of Radiologic Technologist

Chief Technologist

Contact number

To the Technologist: In the space provided below, you may summarize this observation student.

I permit to be evaluated as an observation student at this facility. I understand that this information may or

may not be disclosed to me.

Student Signature Date

Sign form and then either fax to the Department of Radiologic Sciences at (318) 670-6698 or submit the original document to

program faculty. ***Please treat the information on this form confidentially *** Revised 02/2019; 02/2020

Showed interest

Asked appropriate questions

Followed directions

Demonstrated interpersonal

skills

Followed rules

Division of Allied Health Sciences and Nursing

Radiology Department Observation Form

Student Applicant Name Date of Visit:

(One visit per page)

Radiology Facility Name

Date and time of scheduled observation:

(Please check one) Hospital Clinic

Observation Start time End time

Radiologic Technologist: Please check the appropriate blanks listed below.

Observed Not Available

Chest

Fluoroscopy

To be completed by the Technologist:

Yes No

Arrived on time

IVP

Stayed required time

Extremities

Portables

Dressed appropriately

Good hygiene

Other areas observed (please list):

Signature of Radiologic Technologist

Chief Technologist

Contact number

To the Technologist: In the space provided below, you may summarize this observation student.

I give permission to be evaluated as an observation student at this facility. I understand that this information

may or may not be disclosed to me.

Student Signature Date

Sign form and then either fax to the Department of Radiologic Sciences at (318) 670-6698 or submit the original document to program faculty. ***Please treat the

information on this form confidentially ***

Showed interest

Asked appropriate questions

Followed directions

Demonstrated interpersonal

skills

Followed rules

Revised 02/2019; 02/2020

Division of Allied Health Sciences and Nursing

Radiology Department Observation Form

Student Applicant Name Date of Visit:

(One visit per page)

Radiology Facility Name

Date and time of scheduled observation:

(Please check one) Hospital Clinic

Observation Start time End time

Radiologic Technologist: Please check the appropriate blanks listed below.

Not Available

Observed

Chest

Fluoroscopy

IVP

Extremities

Portables

Other areas observed (please list):

Signature of Radiologic Technologist

Chief Technologist

Contact number

To the Technologist: In the space provided below, you may summarize this observation student.

I permit to be evaluated as an observation student at this facility. I understand that this information may or

may not be disclosed to me.

Student Signature Date

Sign form and then either fax to the Department of Radiologic Sciences at (318) 670-6698 or submit the original document to

program faculty. ***Please treat the information on this form is a confidential manner*** Revised 02/2019; 02/2020

To be completed by the Technologist:

Yes No

Arrived on time

Stayed required time

Dressed appropriately

Good hygiene

Showed interest

Asked appropriate questions

Followed directions

Demonstrated interpersonal

skills

Followed rules