Master of Medical Science in Anesthesiology

Master of Medical Science in Anesthesiology

Program Application

University of Colorado

Anesthesiologist Assistant Program Application Form

This application must be completed on the computer or printed legibly in dark ink. Illegible applications may not be processed.

APPLICANT INFORMATION:

Name: (Last) (First)(Middle)(Maiden)______

Date of Birth: ____/_____/______

MailingAddress: ______
______

______

Telephone: (Primary) ______(Cell)______

Primary E-mail address: ______

Are you currently a student? [ ] Full-Time [ ] Part-Time [ ] No

If yes, where are you enrolled? ______

Are you currently enrolled or have you ever attended University of Colorado? [ ] Yes [ ] No

If yes, specify the program and provide dates of attendance:______

Are you currently employed? [ ] Full-Time[ ] Part-Time[ ] No

Occupation: ______

Employer: ______

City:______State: ______Zip:______

Business Telephone: ______

Please indicate how you found out about the program:

[ ] College Advisor[ ] Anesthesiologist

[ ] Premed Advisor[ ] Other Physician/Healthcare Worker

[ ] Internet[ ] Other______

[ ] Anesthetist (AA or CRNA)

Substance Abuse

Both anesthesiologists and anesthetists are at a greater risk for substance abuse than practitioners in other medical specialties or individuals in the general population. Handling and administering controlled substances occurs daily in the practice of anesthesia, and current literature suggests that individuals with a history of abuse of any kind are more likely to develop a drug abuse problem if they enter the field of anesthesiology.

Have you ever been diagnosed with or treated for any substance abuse disorder? [ ] Yes[ ] No

**If yes, please explain and submit a separate attachment. The program will contact you to discuss any information disclosed regarding substance abuse to discuss the role of addiction and dependency in the field of anesthesia.

______

MASTER OF MEDICAL SCIENCE PROGRAM

DEPARTMENT OF ANESTHESIOLOGY

UNIVERSITY OF COLORADO

Drug and Alcohol Policy

Students in the Master of Medical Science Program, Department of Anesthesiology, University of Colorado School of Medicine, must be knowledgeable about and adhere to federal, state, and local laws regardingalcohol and illegal drug use, as well as the alcohol and drug policies of University of Colorado.

Due to the nature of the practice of anesthesia, the safety and well-being of patients is every practitioner'sfirst and foremost concern. To this end, physical and/or mental impairment due to drug or alcohol abusecannot be tolerated. Therefore, any student in whom illegal drug use or alcohol abuse is confirmed willbe dismissed from the Master of Medical Science Program and from University of Colorado. This one-strikepolicy is in force continuously during enrollment in the Master of Medical Science Program.

The Master of Medical Science Program will arrange for an initial drug screen to be performed during theweek of matriculation. Certain clinical rotation sites may require an additional drug screen prior tobeginning their rotation. Random drug testing may also be initiated at any time by the Master of MedicalScience Program or by clinical rotation sites.

REFERENCES:

Please provide the names of at least three (3) individuals you have asked to serve as a reference:

1. Name: ______

Institution: ______City: ______State: ______

Telephone: ______

Relationship:______

Email: ______

1. Name: ______

Institution: ______City: ______State: ______

Telephone: ______

Relationship:______

Email: ______

1. Name: ______

Institution: ______City: ______State: ______

Telephone: ______

Relationship:______

Email: ______

UNDERGRADUATE EDUCATION

Beginning with the most recent, list all undergraduate institutions which you have attended and degrees which you have or will have received within the next six (6) months. Be sure to calculate both Overall GPA and Science GPA.

INSTITUTION / ATTENDANCE / MAJOR / DEGREE / GPA: OVERALL/SCIENCE

GRADUATE EDUCATION

List all graduate and professional programs which you have attended and degrees which you have or will have received within the next six (6) months.

INSTITUTION / ATTENDANCE / MAJOR / DEGREE / OVERALL GPA

Have you ever been dismissed from an Academic Institution? [ ] Yes [ ] No

**If yes, please explain and submit a separate attachment.

PREREQUISITE COURSEWORK

Complete the following table even though the courses appear on the transcripts that you submitted. Note that survey courses or courses for non-science majors (except English) will not be accepted.

COURSE # INSTITUTION DATE COMPLETED GRADE CREDIT HOURS

English
Gen Biology I
Gen Biology I Lab
Gen Biology II
Gen Biology II Lab
Gen Chemistry I
Gen Chemistry I Lab
Gen Chemistry II
Gen Chemistry II Lab
Org Chemistry I
Org Chemistry I Lab
Org Chemistry II
Org Chemistry II Lab
Biochemistry
Gen Physics I
Gen Physics I Lab
Gen Physics II
Gen Physics II Lab
Calculus
Statistics
Anatomy
Physiology

ADDITIONAL COURSEWORK IN SUPPORT OF YOUR APPLICATION(optional)

If you have taken additional coursework that you feel is relevant to your graduate studies in the anesthesiologist assistant program that you want to bring to the attention of the admission committee, enter them here (ex: Microbiology, Pharmacology, Immunology, Histology, etc).

COURSE / COURSE # / INSTITUTION / DATE COMPLETED / GRADE / CREDIT HOURS

RESEARCH EXPERIENCE

List research projects in which you have made significant contributions.

PROJECT TITLE / PRINCIPLE INVESTIGATION / INSTITUTION/SUPERVISOR / DATE

PUBLICATIONS

List publications for which you have been an author and enclose reprints with the application.

TITLE / JOURNAL CITATION / DATE

GRADUATE RECORD EXAM(University of Colorado Code is 4875)

Provide the scores you have received on the GRE general test in reverse chronological order. If you plan to retake the exam after submission of the application, please indicate below. Scores must be sent directly to University of Colorado. Note that scores that are more than 5 years old will not be accepted.

DATE TAKEN OR PLANNED / DATE THAT SCORES WERE REQUESTED TO BE SENT / VERBAL SCORE / QUANTITATIVE SCORE / ANALYTICAL SCORE

MEDICAL COLLEGE ADMISSION TEST

Provide the scores you received on the MCAT in reverse chronological order. If you plan to retake the exam after submission of the application, please indicate below. Note that scores that are more than 5 years old will not be accepted.

DATE TAKEN OR PLANNED / DATE THAT SCORES WERE REQUESTED TO BE SENT / VERBAL SCORE / PHYSICAL SCIENCES SCORE / BIOLOGICAL SCIENCES SCORE

STAFF USE ONLY

OVERALL GPA / PREREQUISITE GPA / SCIENCE GPA / GRE SCORES / MCAT SCORES

CERTIFICATION AND LICENSURE

List any current or previous certification or licensure (ex: EMT, RN, RRT, etc)

CERTIFICATION / CERTIFYING ORGANIZATION / DATE OF EXAM / EXPIRATION
LICENSURE / LICENSING AGENCY / STATE / EXPIRATION

Have you ever been turned down when requesting licensure or certification? [ ] Yes[ ] No

Have you ever had a license or certificate revoked? [ ] Yes[ ] No

**If yes to either question, please explain below.

EMPLOYMENT HISTORY

EMPLOYER
(include contact information) / DATES
(FROM-TO) / DUTIES AND RESPONSIBILITIES / FULL/PART TIME

HONORS AND AWARDS

Please list any collegiate honors and other awards with contact information for verification.

INSTITUTION/ORGANIZATION / DATE / AWARD / PURPOSE

VOLUNTARY MEDICAL EXPERIENCE

Provide a history of medical experience gained through voluntary programs.

INSTITUTION
(provide contact information) / DATES
(FROM-TO) / DUTIES AND RESPONSIBILITIES

REFERENCES

Three references are required as part of the application to the Master of Medical Science in Anesthesiology Program. You must use the two-page forms provided.

Applicant

• Complete each of the three reference forms by following the directions on each.
• When you print out this application document, submit one two-page reference form and a return envelope to each of your three references.

REFERENCE FORM

APPLICANT

• Complete this page above the bold line.
• Enter your full name: ______
• Enter your reference’s name: ______
• Under the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their educational records, including letters of recommendation. You may waive that right if you so desire. Please select one of the following two options, then sign and date your choice.

[ ] I expressly waive any rights that I might have of access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law, regulation, or policy.

[ ] I do NOT waive my right to access this letter of recommendation.

Signature ______Date ___/___/____

• When you print out this application document, provide a copy of this page to your reference.

EVALUATOR

This individual is applying to the Master of Medical Science Program in Anesthesiology at the University of Colorado – a 27 month program of didactic and clinical education culminating in an individual’s entry into healthcare as an anesthetist member of the anesthesia care team, providing direct patient care daily. The academic and clinical demands of this program are great. The student, and later the practitioner, must have unquestionable integrity. Your candid evaluation of this applicant will be greatly appreciated.

• Please enter contact information for yourself:

Name: ______Degree: ______Title: ______

Institution:______Position:______

Relationship to applicant:______

Address: ______

Telephone: ( ) _____- ______

• How long have you known the applicant?______
• In what capacity have you known the applicant? ______
• Please evaluate the applicant in each category in terms of how he/she has met your expectations:

DID NOT MEET / MET / EXCEEDED / NOT OBSERVED
WRITING ABILITY
MOTIVATION
INITIATIVE
ACCEPTS RESPONSIBILITY
ABLE TO WORK WITH OTHERS
MATURITY
INTEGRITY
DEPENDABLE
COMMON SENSE
VERBAL COMMUNICATION
INTELLECTUAL ABILITY
WELL ORGANIZED

• Please mark your recommendation for admission based on the applicant’s overall suitability for the Program:
• Recommend without reservation
• Recommend
• Do not recommend

• Below, please provide any additional information that you may feel might be useful in evaluating this applicant for the Anesthesiology Program.

• Please check the following box if you are providing a letter of recommendation: [ ]
• Please date and sign this recommendation form:

SIGNATURE: ______DATE: ____/_____/______

Please return this form to:

Master of Medical Science in Anesthesiology Program

12401 E. 17th Ave. Campus Box B113

Aurora, CO 80045

REFERENCE FORM

APPLICANT

• Complete this page above the bold line.
• Enter your full name: ______
• Enter your reference’s name: ______
• Under the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their educational records, including letters of recommendation. You may waive that right if you so desire. Please select one of the following two options, then sign and date your choice.

[ ] I expressly waive any rights that I might have of access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law, regulation, or policy.

[ ] I do NOT waive my right to access this letter of recommendation.

Signature ______Date ___/___/____

• When you print out this application document, provide a copy of this page to your reference.

EVALUATOR

This individual is applying to the Master of Medical Science Program in Anesthesiology at the University of Colorado – a 27 month program of didactic and clinical education culminating in an individual’s entry into healthcare as an anesthetist member of the anesthesia care team, providing direct patient care daily. The academic and clinical demands of this program are great. The student, and later the practitioner, must have unquestionable integrity. Your candid evaluation of this applicant will be greatly appreciated.

• Please enter contact information for yourself:

Name: ______Degree: ______Title:______

Institution:______Position: ______

Relationship to Applicant:______

Address: ______

Telephone: ( ) _____- ______

• How long have you known the applicant? ______
• In what capacity have you known the applicant? ______
• Please evaluate the applicant in each category in terms of how he/she has met your expectations:

DID NOT MEET / MET / EXCEEDED / NOT OBSERVED
WRITING ABILITY
MOTIVATION
INITIATIVE
ACCEPTS RESPONSIBILITY
ABLE TO WORK WITH OTHERS
MATURITY
INTEGRITY
DEPENDABLE
COMMON SENSE
VERBAL COMMUNICATION
INTELLECTUAL ABILITY
WELL ORGANIZED

• Please mark your recommendation for admission based on the applicant’s overall suitability for the Program:
• Recommend without reservation
• Recommend
• Do not recommend
• Below, please provide any additional information that you may feel might be useful in evaluating this applicant for the Anesthesiology Program.

• Please check the following box if you are providing a letter of recommendation: [ ]
• Please date and sign this recommendation form:

SIGNATURE: ______DATE: ____/_____/______

Please return this form to:

Master of Medical Science in Anesthesiology Program

12401 E. 17th Ave. Campus Box B113

Aurora, CO 80045

REFERENCE FORM

APPLICANT

• Complete this page above the bold line.
• Enter your full name: ______
• Enter your reference’s name: ______
• Under the Family Educational Rights and Privacy Act of 1974, students are given the right to inspect their educational records, including letters of recommendation. You may waive that right if you so desire. Please select one of the following two options, then sign and date your choice.

[ ] I expressly waive any rights that I might have of access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law, regulation, or policy.

[ ] I do NOT waive my right to access this letter of recommendation.

Signature ______Date ___/___/____

• When you print out this application document, provide a copy of this page to your reference.

EVALUATOR

This individual is applying to the Master of Medical Science Program in Anesthesiology at the University of Colorado – a 27 month program of didactic and clinical education culminating in an individual’s entry into healthcare as an anesthetist member of the anesthesia care team, providing direct patient care daily. The academic and clinical demands of this program are great. The student, and later the practitioner, must have unquestionable integrity. Your candid evaluation of this applicant will be greatly appreciated.

• Please enter contact information for yourself:

Name: ______Degree: ______Title:______

Institution:______Position: ______

Relationship to Applicant:______

Address: ______

Telephone: ( ) _____- ______

• How long have you known the applicant? ______
• In what capacity have you known the applicant? ______
• Please evaluate the applicant in each category in terms of how he/she has met your expectations:

DID NOT MEET / MET / EXCEEDED / NOT OBSERVED
WRITING ABILITY
MOTIVATION
INITIATIVE
ACCEPTS RESPONSIBILITY
ABLE TO WORK WITH OTHERS
MATURITY
INTEGRITY
DEPENDABLE
COMMON SENSE
VERBAL COMMUNICATION
INTELLECTUAL ABILITY
WELL ORGANIZED

• Please mark your recommendation for admission based on the applicant’s overall suitability for the Program:
• Recommend without reservation
• Recommend
• Do not recommend
• Below, please provide any additional information that you may feel might be useful in evaluating this applicant for the Anesthesiology Program.

• Please check the following box if you are providing a letter of recommendation: [ ]
• Please date and sign this recommendation form:

SIGNATURE: ______DATE: ____/_____/______

Please return this form to:

Master of Medical Science in Anesthesiology Program

12401 E. 17th Ave. Campus Box B113

Aurora, CO 80045

DOCUMENTATION OF FAMILIARITY WITH ANESTHESIA PRACTICE

The Anesthesiology Program requires that every applicant be familiar with the practice of anesthesia and the operating room environment. Some applicants can meet this requirement with previous work experience or clinical experience. Others will have to arrange to spend at least one day with an anesthetist or anesthesiologist in an operating room observing the administration of anesthesia and other patient care activities.

APPLICANT

• Complete this page above the bold line.
• Enter your full name: ______
• Check the reason that you are familiar with the practice of anesthesia and the OR environment:
• I have worked in an anesthesiology department or service.
• I have had an anesthesiology rotation as part of previous clinical training.
• I have spent at least 8 hours with an anesthetist or anesthesiologist in the operating room observing the administration of anesthesia on (date) ____/____/______.
• Enter the name, hospital, address, and phone number of the person responsible for the activity which you checked:

Name: ______

Hospital: ______

Address: ______

______

______

Phone: (_____) _____- ______

• When you print out this application document, provide a copy of this page to your preceptor or supervisor.

PRECEPTOR OR SUPERVISOR

• Please sign below to acknowledge the anesthesia-based exposure which the applicant has checked above.
• Please return this form to that individual for inclusion in their application.
• Please check the following box if you are providing a letter of recommendation for this person [ ]
• Please date and sign this form:

Signature:______Date: ____/____/______

APPLICANT

• Enter your full name: ______
• Check the one box below that is applicable to you.
• When you print out this application document, date and sign this form.
• Return this dated and signed form with the printed application document.

DOCUMENTATION CONCERNING TECHNICAL STANDARDS

To undertake and successfully complete the Anesthesiology Program, as well as to function successfully as ananesthetist after graduation, you must meet certain fundamental physical, cognitive, and behavioral standards. To becertain that each applicant understands these technical standards and has the opportunity to discuss the standards andany related matters during the application process, please complete and submit this form as part of your application.

[ ] I declare that I have no physical, cognitive, or behavioral limitations that will prevent me from:

• Effectively communicating verbally with patients and their family members and with other healthcareprofessionals.
• Interacting with patients, including obtaining a history and performing a physical examination.
• Effectively communicating in writing, and by record keeping, those data and information essential to thepractice of anesthesia and the care of patients.
• Reading and comprehending written parts of the medical record and other patient care documents in order tosafely and effectively participate in the practice of anesthesia.
• Having sufficient knowledge, motor skill, and coordination to perform diagnostic and therapeutic tasks,including invasive procedures, on patients in a timely manner so as to insure the safety and well-being of thepatients. These tasks include but are not limited to peripheral and central venous catheterization, arterialpuncture and cannulation, breathing bag-and-mask ventilation, laryngeal mask airway insertion andmanagement, and endotracheal intubation.
• Having sufficient strength, motor skill, and coordination to lift, move, and position patients as required foradministration of anesthesia and performance of cardiopulmonary resuscitation.
• Having sufficient speed and coordination to quickly and safely react to emergent conditions throughout thehospital in order to assure patient safety.
• Recognizing and differentiating colors of signals displayed on monitors; being able to work in both light anddark conditions as exist in patient care areas (ex: operating room, radiology suite, endoscopy suite); being ableto recognize details of objects both near and far.
• Hearing, processing, and interpreting multiple conversations, monitor signals, alarms, and patient soundssimultaneously in fast-paced patient care settings (ex: operating room, intensive care unit, emergency room).
• Continuously performing all of the above activities or any and all of the other activities that are an integralpart of an Anesthesiologist Assistant’s participation in the anesthesia care team.

[ ]I have read the Technical Standards section of the Application to the Anesthesiology Program and would like todiscuss the Technical Standards and/or related matters with the Program Director before my applicationis finalized.