Radiography Program Admission Process and Checklist

Radiography Program Information/Application Packet

1 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Welcome to Minnesota State College Southeast. We are pleased that you have indicated an interest in the Radiography (AAS)

program. The deadline to be considered for admission is June 15. All items must be completed in order to be considered an

applicant for admission to the Radiography program.

Admission to Minnesota State College Southeast

o In order to be considered for the Radiography Program, you must be accepted to MSC Southeast.

o Request college transcripts from all institutions the applicant has attended (except any Minnesota State colleges and

universities institutions attended after 1990). Official transcript(s) from any other colleges must be sent directly from the

previous institution(s) to the Registrar’s Office.

o ACT scores are accepted; otherwise students will be required to take the Accuplacer placement exam (taken in LRC)

Apply to the Radiography Program by completing the forms below

o Once students have been accepted, they will be required to submit to at least one random urine drug testing prior to

attending any clinical practicum. This is at the student’s expense.

o The Radiography program does not maintain a waiting list; therefore applications must be resubmitted every year for

consideration.

Please note: The Radiography program is available on the Winona Campus only.

CHECKLIST

Student Name: ______________________________________________________________________________

_____ Application form for Minnesota State College Southeast Online application if you are not currently attending the

college.

_____ C

ompleted Program Prerequisite Checklist: PAGES 2-3

_____ Health Record Form: PAGES 4-6

_____ Radiography Essential Abilities Form: PAGES 7-8

_____ Criminal Background Check Form: PAGE 9. The study will be run prior to your first fall radiography courses and

annually thereafter.

_____ Copy of current CPR card (Basic Life Support for adult/child/infant)

_____ Copy of current TB(Mantoux) test (within the last year

_____ Anatomy and Physiology I prerequisite (Completion of BIOL2515 or equivalent course with a grade of C or higher)

(Completion of required course BIOL2516 Anatomy and Physiology II or equivalent with a grade of C or higher is also

strongly advised before starting the program)

_____ College Algebra prerequisite (Completion of MATH1220 or equivalent course with a grade of C or higher)

_____ College English prerequisite (Completion of ENGL1215 or equivalent course with a grade of C or higher)

_____ Official college transcript(s) to be sent directly from previous institutions (If you are a former student of MSC-ST,

you do not need to request a transcript)

_____ Patient Care Experience (Revised 5/27/22)

Radiography Program Information/Application Packet

2 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Radiography Program Prerequisite Checklist (Pages 2-3)

Student ___________________________________________ Date/Time Completed _______________

Date Received in Admissions __________________________________

Application Deadlines: June 15th to be considered for fall semester. The checklist must be complete and all documentation

received to be considered for admission. This checklist will be retained for one year.

Initials

Date mm/dd/yy

Required Item

Passing grade:

Transfer ______

Math Prerequisite

(a Math course is required for the program)

Completion of MATH1220 College Algebra or equivalent course with a grade of C or higher

Passing grade:

Transfer ______

Communication/English Prerequisite

(an English course is required for the program)

Completion of ENGL1215 College Writing 1 or equivalent course with a grade of C or higher

Passing grade:

Transfer _____

Passing grade:

Transfer _____

Anatomy and Physiology (4 credits) Prerequisite

Completion of BIOL2515 or equivalent course with a grade of C or higher

(Completion of BIOL2516—Anatomy and Physiology II is not a prerequisite, but as a program

requirement, completion is strongly advised before starting the program due to rigorous 1

semester)

Date Submitted:

Criminal Background Study Form

Minnesota law requires that any person who provides services that involve direct contact

with patients at a health care facility licensed by the Minnesota Department of Health have

a background study. An individual who is disqualified from having direct patient contact as a

result of the background study and whose disqualification is not set aside by the

Commissioner of Health, will not be permitted to participate in clinical placement and

therefore will not able to successfully complete the radiography program. As radiography

uses facilities in Minnesota, Wisconsin and Iowa, the same background criterion is used.

1. The study will be run at the time prior to fall start of classes

Physical Date:

Mantoux Date:

Health Record Form

(The form is specific to Radiography)

This self-disclosure form MUST include a mantoux test or chest x-ray information. Mantoux

tests must be renewed annually. Chest x-ray is a one-time documentation with annual

completion of a questionnaire. An annual flu vaccination is required and should be obtained

during the fall semester

CPR Date:

Exp. Date:

CPR - Proof of one:

Basic Life Support for Adult/Child?Infant

Date Submitted:

Radiography Essential Abilities Form

Review the program essential abilities list. Sign, date and submit the statement of

understanding

(Checklist continued next page)

Radiography Program Information/Application Packet

3 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Date Received:

Patient Care Experience

This requirement is met by exhibiting DOCUMENTED experience in the following areas:

Certified Nursing Assistant (CNA certification or completion of the course)

Ward Secretary/Health Unit Coordinator

Patient Care Technician/Medical Assistant

Dental Hygienist/Assistant

Emergency Medical Technician/First Responder

Athletic Trainer

Phlebotomist

Volunteer Ambulance or Fire Fighter

Minimum of 40 hours of documented volunteer work with direct patient contact

Minimum of 40 hours of documented care giving for a disabled family member

Hospice experience

Radiography Grade Requirements

o Courses taken at Minnesota State College Southeast must be a grade of C or higher

o Transfer grades in Liberal Arts must be a grade of “C” or higher

o Transfer grades in Technical Courses must be a grade of “B” or higher

Radiography Program Information/Application Packet

4 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Radiography Program Health Record Form (Pages 4-6)

Minnesota State College Southeast is asking you to provide private information in order to process your Radiography Health Record Form. This information

will be used to update your health records. You are not legally required to provide this information; however, the college may not be able to effectively

process your request if you do not provide sufficient information. Access to this information will be limited to school officials, including faculty who have

legitimate educational interests in the information. Under certain circumstances, federal and state laws authorize release of private information without

your consent: to other schools in which you seek or intend to enroll, or are enrolled; to federal, state or local officials for purposes of program compliance,

audit or evaluation; as appropriate in connection with your application for, or receipt of, financial aid; if the information is sought with a court order or

subpoena; or as otherwise permitted by other state or federal law. If you have any concerns or questions about this form, please contact the Radiography

Program Director at 507-453-2799. Please return completed form to the Allied Health Office.

Part A: Student completes

Name _____________________________________________________________________________________________

Last First Middle/Maiden

Address ____________________________________________________________ Phone (_______) _________________

__________________________________________________________ Birth date ____________________________

City, State, Zip

In Emergency

Notify: _____________________________________________________________________________________________

Name Address Phone

Health Insurance is strongly recommended. Any hospital or medical costs incurred while a student are the responsibility of the

student.

Please read carefully and sign:

I understand that there are conditions for which accommodations may be appropriate under the Americans with Disabilities

Act and that the Radiography Program will make all reasonable accommodations required by law for otherwise qualified

individuals. To receive accommodations, I must contact the counselor’s office.

I understand that any health care costs incurred during the period of time I am a student in the Radiography Program will be

my responsibility.

I hereby grant Minnesota State College Southeast permission to share information contained in the HEALTH RECORD FORM

with those clinical institutions with whom I affiliate in my student role, should the clinical institution request or require it.

I understand that failure to sign this form or to provide the information requested could mean that a clinical site may refuse

me placement at their facility. The Radiography Program does not guarantee an alternative facility placement. I also

understand that if no alternative facility placement is available, I may be unable to progress in the Radiography Program.

I certify that the information I have provided on this form is complete, accurate, and true to the best of my knowledge.

___________________________________________________________________________________________________

(Signature of Student) (Date)

Radiography Program Information/Application Packet

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Radiography Program Health Record Form

Immunity Requirements

Tuberculosis Immunity

Mantoux test: A licensed person must read the Mantoux.

Date given: _______________ Date read: _________________ Result: _______________________

Name of person reading Mantoux ______________________ Credential _____________________

Signature of person reading Mantoux _________________________________________________

Administrating Agency ______________________________________________________________

Chest X-ray: required only if your Mantoux result is positive. The Radiography program requires a yearly chest

x-ray for individuals with a positive Mantoux.

Date of X-ray: ___________________________ Results: _______________________________

MMR Immunity All students must have ONE of the following:

Documentation of two MMR’s Dates of Vaccination: _______________________________

Rubella titer indicating immunity Date Titer Read: ________________Result______________

Hepatitis All students must be vaccinated against hepatitis B. *Exception–Hepatitis B has been initiated.

________________________ Date of 1st dose of vaccination

________________________ Date of 2nd dose of vaccination

________________________ Date of 3rd dose of vaccination

Diphtheria – Tetanus (Adult Type) All students must know their diphtheria-tetanus status

________________________ Date of last vaccination

Inoculation for tetanus with in the last 10 years is required.

(Continued next page)

adiography Program Information/Application Packet

6 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Chicken Pox All students must know their chicken pox status either by:

__ having had chicken pox

____ have not had chicken pox

R, if you do not know your chicken pox status you must have a titer.

hicken pox titer Date Titer Read: __________________

__ Chicken pox titer indicates immunity.

____ Chicken pox titer does not indicate immunity.

Annual flu shot All students must have an annual flu shot to attend clinical practicum and we recommend you wait to get

one during the fall semester when new flu vaccinations are made available.

Immunity Requirements: please do not submit this form until all requirements

are met* and data are provided.

Radiography Program Information/Application Packet

7 Minnesota State College Southeast Radiography Program www.southeastmn.edu Updated 5.27.22

Radiography Program Essential Abilities Form (pages 7-8)

The Radiography program essential abilities listing is to make you aware of the physical, cognitive, and mental capabilities

you may encounter once employed in a radiography position. These abilities are typical of the demands of a radiographer in

the work setting. The curriculum requires demonstrated proficiency in a variety of cognitive, problem-solving, manipulative,

communicative and interpersonal skills. If you have any questions regarding these, you should contact the Program Director

or the Admissions advisors. Please sign and turn in this completed form with your checklist.

Physical Activity Requirements

Occasional

• Crouching - positioning patients for exams and stocking supplies

• Repetitive motions - entering computer data

• Grasping - positioning patients for exams and procedures

• Pulling - moving items that can weigh as much as 100 pounds

Frequent

• Pushing - transporting patients in wheelchairs or on carts using up to 50 pounds of force. Moving portable and C-

arm equipment with up to 50 pounds of force to areas of the hospital.

• Pulling - assisting and moving patients off and onto carts using 8 to 40 pounds of force.

• Lifting - moving patients (who can weigh more than 50 pounds) from wheelchair/cart or stretcher off and onto exam

tables.

• Fingering - entering computer data and setting radiographic exposure techniques for exams.

• Carrying - carrying imaging cassettes that can weigh as much as 25 pounds.

Routine

• Stooping - positioning of exams and assisting patients in and out of wheelchairs.

• Reaching - positioning patients and manipulating portable equipment.

• Standing - all clinical assignments require standing.

• Walking- transporting and assisting patients into dressing/exam rooms. Walking to other areas of the department

and hospital to do exams or have images interpreted.

• Talking - must be able to communicate verbally in an effective manner with patients, co-workers, and physicians.

• Hearing - perceiving the nature of sounds during auscultation (listening) and percussion (tapping on a surface to

determine the underlying structure).

• Feeling - perceiving attributes of patients and objects such as when positioning patients for procedures or palpating

veins for IV insertion.

Visual & Hearing Acuity Requirements

• During clinical assignments, students are required to use a computer console and select the proper exposure

techniques on the x-ray equipment.

• Clinical assignments require critiquing (evaluation) of radiographs.

• Clinical assignments require working with printed and/or written documentation.

• Students must be able to assess patient’s condition, i.e., color, respiration, motion, etc.

• Students must be able to hear in order to communicate with patients while taking a history, giving positioning

instructions, or interacting with other team members.

• Students must be able to hear instructions from doctors under conditions such as: in a darkened fluoroscopy room &

in surgical attire.

(Form continued next page)

Radiography Program Information/Application Packet

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Intellectual and Emotional Requirements

• Students must be able to critique (evaluate) radiographs and determine diagnostic quality.

• Students must be able to make adaptations and respond with precise, quick and appropriate action during

emergency situations.

• Students must maintain patient confidentiality.

• Students must be able to maintain a high standard of courtesy and cooperation in dealing with co-workers, patients,

and visitors with satisfactory performances despite the stress of a hospital/clinic work environment.

• Students must be able to learn to analyze, synthesize, solve problems and reach evaluative judgment.

• Students are expected to be able to learn and perform routine radiographic procedures. In addition, students must

have the mental and intellectual capacity to calculate and select proper technical exposure factors according to the

individual needs of the patent and the requirements of the procedure with speed and accuracy.

• Students must be able to accept criticism and adopt appropriate modifications in their behavior.

• Students must demonstrate appropriate emotional health required for utilization of intellectual abilities and exercise

good judgment.

Clinical Situations

• Students may be subjected to electrical, radiant energy, and chemical hazards.

• Students may be subjected to trauma situations or surgical experiences.

• Persons in the radiologic sciences have been identified as having the likelihood of occupational exposure to blood or

other potentially infectious materials and, therefore, are included in the OSHA Exposure Control Plan with its

specifications to prevent contact with the above materials.

If you have a documented disability, there may be accommodations that can be made to assist in your successful completion

of the program, please see a college counselor.

Yes No I have read and understand the Program Essential Abilities relative to the Radiography Program.

The inability to meet all of the Program Essential Abilities will in no way prohibit your acceptance to the Radiography

Program.

The Americans with Disabilities Act bans discrimination of persons with disabilities, and in keeping with this law, Minnesota

State College Southeast makes every effort to ensure quality education for all students. It is our obligation to inform students

of the essential abilities demanded by the program and of the occupation. Students with documented disabilities which

require accommodations or special services to meet the Essential Abilities of the program should contact Disability Services

(507-453-1443) for assistance, advising and arrangement of appropriate accommodations.

Sign and turn in this completed form with your checklist.

Student Signature____________________________________________________________________________________

Name (print)________________________________________________________________________________________

Date ______________________________________________

Radiography Program Information/Application Packet

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Radiography Program Criminal Background Check Form (Page 9)

DISCLOSURE – PREPARATION OF A CONSUMER REPORT

To process your application with Minnesota State College Southeast, a background check will be conducted by NetStudy 2.0. In accordance

with the U.S. Fair Credit Reporting Act SS 606, we notify you of the following: A background check report may contain information bearing

on your character, general reputation, personal characteristics, mode of living and credit standing, information may include, but is not

limited to: employment history, education, criminal records, credit history, motor vehicle records, personal references, and any data

provided on this application, or during the interview process.

lease read the following and, if acceptable, authorize us to order an investigative report to be prepared by NetStudy 2.0.

AUTHORIZATION – TO PREPARE INVESTIGATIVE, CONSUMER REPORT

I authorize the appropriate individuals, companies, institutions or agencies to release information required for the preparation of an

investigative report on me and to respond to all inquiries necessary for the same.

Legal Last Name Legal First Name Legal Middle Name

_____

Complete Street Address Email address

City County State Zip Code

Phone Number Driver License # and expiration date dd/mo/yyyy

Please list out of state address you have lived in during the past 5 years:

Street Address City State Zip Code Years Start to End

Please list other names you have used and dates changed, if applicable, in the past 5 years:

Name Date Changed Name Date Changed

Race Sex Eye Color Hair Color

Height Weight Birth State Date of Birth

AUTHORIZE A PHOTOCOPY AND/OR AN ELECTRONIC COPY OF THIS AUTHORIZATION TO BE ACCEPTED WITH THE SAME

AUTHORITY AS THE ORIGINAL AND IF EMPLOYED BY THE ABOVE NAMED COMPANY THIS AUTHORIZATION WILL REMAIN

IN EFFECT THROUGHOUT MY EMPLOYMENT.

Signature Social Security Number Date

Parent/Legal Guardian Signature is required for applicants under 18 years of age Date