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 received
From / 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 / Procedure
Laboratory 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 ADDRESS

Describehow 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, State
Transfusion 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