Surgical Technology Application (.docx) Surgical Technology Application (.pdf) Application Checklist Student Name: Acknowledgement of Completion: Program application form Community service form Admission advisement certificate of attendance Job shadow form Criminal background check disclosure/consent form Review and self-assessment of performance standards BLS/AED certification achievement card Health certification requirements: Immunizations: MMR immunizations 1 and 2 or rubella titer Rubeola immunization or titer Chicken pox – proof of having chicken pox or chicken pox immunization per authorized medical signature or varicella titer Influenza immunization Meningitis immunization TB skin test – 1 month prior to program start Hepatitis B vaccination (series of 3) Signed verification of Hepatitis B status or declination DTAP – Diphtheria, tetanus and pertussis immunization