Survey for Prospective Students
Interested in the
 Internet BS Medical Technology Program

Fill out this form on-line and submit, we will assess your qualifications and be in touch with you.

Are you interested in obtaining a BS degree in medical technology?  Yes No

What level of certification do you have?

MLT    CLT    MT    CLS   None
Other - (Type in Box)

What is your certification agency?

ASCP     AMT      NCA      ISCLT 
HEW/HHS 

What is your job title?

Technician      Technologist   Supervisor
Manager         Other - (Type in Box)       

What are your job responsibilities? (Check all that apply)

Chemistry          Blood Bank        Supervision
Generalist           Hematology        Microbiology
Other - (Type in Box)  

How many years of experience do you have in Clinical Laboratories?

Less than 2 years   2-5 years           More than 5 years 

Which do you know how to use? (Check all that apply)

Computer          E-mail            Word Processor
The Internet/The Web

Do you have a computer with Internet access at home?

Yes No

Do you have a computer with Internet access at work?

Yes No

Are you within 2 hours driving time of a State of Georgia?

Two or four year college               University                
Technical School    

What is the name of the school that is within 2 hours driving time?

Could you complete the prerequisites for the program by the end of Summer Semester 2004?

Yes No

If you cannot finish the prerequisites by Summer Semester 2004, when can you finish. Month/Year?

Could you spend the time needed to participate in a distance program?

Yes No

Could you complete the program in 6 consecutive semesters (two years)?

Yes No

Could you attend 3 workshops per semester at a facility within 2 hours driving time?

Yes No

Would your supervisor allow you to do 11 hours per week of clinical internship at your work site each semester?

Yes No

Would your supervisor allow you to do 11 hours per week of clinical internship at a different work site?

Yes No

Who at your work site would be a contact person for the Department receiving exams, etc. for you?

I f you are not interested in a degree, would you be interested in taking any of the courses for continuing education credit?

Yes No

Which course would you be interested in taking for continuing education credit?

Chemistry      Blood Bank    Microbiology
Hematology   Immunology

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