8910 Linwood Avenue
Shreveport, LA, 71106
SpecialistinBloodBankTechnologyProgramApplicationforAdmission
Completeentireapplication,evenifsubmittingadditionaldata
Name:______
(Last)(First)(Middle/Maiden)
Address:
(Street)(City)(State/Zip)
Home Phone:()SSN (last 4 digits):
Work Phone: ()Work Hours:
CellPhone: ()
Emailaddress:
US or Canadian Citizen? (Circle one) Yes No If No, are you a legal US Resident? Yes No
Certifiedas by
YearNumber
OtherCertification(indicate credential, agency,year, andnumber):
Education (Post HighSchoolOnly):
Dates / Name ofSchool / Location / Major / Degree receivedFrom / To / Title/Date
SBB Program ApplicationforAdmission
LifeShare Blood Centers, Shreveport, LA 71106
Have youpreviouslyapplied foradmissionhere? No [ ] Yes [ ][If yes,statewhen]
Applyingforadmission to class beginning:
Whatcareer goals haveyouset foryourself?
How will your career goals change after obtaining SBBtraining and certification?
What qualities do youhave that will helpyousucceed in a distance learning program?
Howmanyhours a daydo youanticipate studyingforthis program?
Describe the personal strengths which makeyoueffective workingin a team? Do you prefer to work in a group or independently?
ListHonors, Awards,andActivities(includeorganizational memberships,publications,presentations, and attendance atseminars/workshops/meetings):
SBB Program Application for Admission
LifeShare Blood Centers, Shreveport, LA 71106
Please indicate how oftenyouperform the followingprocedures (daily,weeklyormonthly)bycheckingthe applicable box. If it hasbeen morethan ayearsince a procedurewasperformed, list thelast year it wasperformed(LYP).Leaveblank anyproceduresyouhave not performed.Do not includeschool or workshop experience.
Daily / Weekly / Monthly / LYP / ProcedureLaboratory Generalist
ABOand Rh Typing:
bytube
bymicroplate
bygel
bysolid phase
Redcellphenotyping
Directantiglobulintesting
Type andscreens
Compatibilitytests
Resolution of ABOdiscrepancies
Singleantibodyidentification
Multiple antibodyidentification
Enzymepanels
DTT/ZZAPtreatmentof cells
Neutralizationtechniques
Autoadsorptions
Differential (allo) adsorptions
Elutions, temperature (LuiFreeze or Heat)
Elutions, pH (ELU kit)
Fetomaternalhemorrhage screen
Kleihauer-Betkestain
Donorblood collection
EIA/RIAtesting
Component preparationforstorage (prepareFFP,platelets,cryo)
Component preparationforadministration(poolplts,thaw,aliquot)
Blood or components issuing
Investigation of transfusionreaction
HLAtyping (indicate technique:______)
Molecular testing
Otherrelevant experiencewhich is not listed above:
NAME[PLEASEPRINT]:
RELEASEOFINFORMATION
NAME[PLEASEPRINT]:
SSN (last 4 digits):DATE:
Iherebygrantpermissionfor LifeShare Blood Centers, Shreveport, Louisiana, to receiveallinformationregardingmyemploymentand/orscholastic standingwith yourorganization/institution.
Signed:
(Applicant’s Signature)
SBB Program ApplicationforAdmission
LifeShare Blood Centers, Shreveport, LA 71106
List all work experience, most recent positionfirst. Print additionalpages if needed.Explain any gaps in employment> 2 months.
DATE / EMPLOYER andMAILINGADDRESS / TITLE AND JOBDESCRIPTION / %TIME inBLOOD BANK / IfHOSPITAL,# BEDS / REASON FORLEAVING
From(Mo/Yr)
To (Mo/Yr)
To (Mo/Yr)
From(Mo/Yr)
To (Mo/Yr)
From(Mo/Yr)
To (Mo/Yr)
To (Mo/Yr)
From(Mo/Yr)
To (Mo/Yr)
To (Mo/Yr)
SBB Program ApplicationforAdmission
LifeShare Blood Centers, Shreveport, LA 71106
Please provide alistof professional references that wemaycontact.Besure to include email addresses.
* Firstentrymust be currentsupervisor or medicaldirector.
NAME, TITLE / EMAIL ADDRESS and PHONE / INSTITUTION and ADDRESSDescribehow yousee this on-line programimpactingyourlife. Explain how you will find time forstudying,completingrotationsandwritinga researchpaper.
Complete the table below to indicate whereyou willcompleteyourclinical rotations.
Name of Organization / City, StateTransfusion Service
Donor Center
(must perform NAT and EIA)
Reference Laboratory
Who will act as you mentor?(Provide Name, Title, Organization)
______
Completed application and 3 reference forms may be scanned and submitted by email or sent as hardcopy. College transcriptsshould be forwardeddirectlyto:
LifeShare Blood Centers
Attn: Katrina Billingsley,MT(ASCP)SBB
Education Coordinator, SBB Program
8910 Linwood Avenue
Shreveport, LA 71106
Phone 318.673.1546