Inova Phlebotomy School – Online Application

You must have JavaScript enabled to use this form. Application for Admission – Inova Phlebotomy School Inova Health System, an Equal Opportunity Employer, shall not because of race, color, religion, age, sex, national origin or handicap, fail or refuse to hire qualified applicants. First Name Middle Initial Last Name Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Email Have you previously applied? Yes No If yes, indicate date Are you authorized to work in the U.S.? Yes No NOTE: All applicants must be legally eligible to work in the United States. Documentation must be provided for verification. Education High School/GED Years Attended Example: 2015 to 2019 School Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Did you graduate? Yes No College Address of College City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Years Attended Example: 2017 to 2021 Did you graduate? Yes No Degree Other Institution Address of Institution City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Years Attended Example: 2019-2021 Did you graduate? Yes No Degree References Please list two individuals whom you have asked to submit a letter of recommendation for you. Prefer professional/educational references. Submit references to InovaPhebSchool@inova.org. Full Name, Reference One Relationship Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Full Name, Reference 2 Relationship Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Submit references to InovaPhebSchool@inova.org. Previous Employment (if any) Company 1 Please enter the name of the employer.  Phone Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Supervisor Job Title Perod of Employment Example: 2019 to 2021 Responsibilities Reason for Leaving May we contact your previous supervisor for a reference? Yes No Company 2 Please enter the name of the employer.  Phone Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Supervisor Job Title Perod of Employment Example: 2019 to 2021 Responsibilities Reason for Leaving May we contact your previous supervisor for a reference? Yes No Phlebotomy Information How did you first learn about the Phlebotomy School and when did you first become interested in this career field? Why do you want to be a Phlebotomist? Have you had an opportunity to work in a related field? Provide a brief description of this experience. In what ways do you think you can make a contribution to Inova Phlebotomy School or healthcare? Provide a brief personal statement. In the space below, list or describe any additional information about yourself, your training or experience that you feel may be important in considering your application for admission. (Email additional documentation if needed) Essential Functions for Admission to Inova Phlebotomy School Prior to admission each student must agree that they can, and are prepared to meet these requirements with or without reasonable accommodation. Inova Phlebotomy School is an equal opportunity employer. Inova does not discriminate on the basis of gender, age, race, color, creed, religion, pregnancy, or related medical conditions, marital status, national origin, mental or physical disability or any other characteristic protected by applicable federal, state, or local law. The School will provide reasonable accommodations to otherwise qualified students with disabilities. The following is a list of the technical abilities and skills required: 1. Manual Dexterity Be able manipulate objects precisely that require fine or gross motor skills using good eye-hand physical coordination. Be able to carry objects weighing up to 20 pounds and have the stamina to perform program functions over an 8 hour day including standing, walking or sitting. Be able to maneuver freely in the clinical laboratory setting and in a patient-care setting. 2. Vision Be able to distinguish colors, and clarity. Corrected vision to 20/20 3. Communication Skills Be able to communicate in English, both verbally and in writing to all, team members, students, patients, and other healthcare workers 4. Intellectual and Critical Thinking Skills Be able to solve problems and apply critical thinking under normal and stressful situations. 5. Ethical Standards Exercise ethical judgement, integrity, honesty, dependability, patient confidentiality and adhere to the academic and professional code. 6. Safety Be able to recognize and respond to safety issues, including recognizing emergency situations and taking appropriate actions. Be able to adhere to the regulations of accrediting agencies, comply with safety regulations of the laboratory and maintain a safe environment for themselves and others. 7. Internal and External Customer Service Demonstrate excellent customer service to all patients, students and Inova team members they encounter. Fully participate in lecture and internship requirements. Please read the above listed technical standards carefully, and then complete the statement below. A diploma, GED or transcript must be submitted to InovaPhebSchool@inova.org. Disclaimer and Signature I attest that I have read and understood the technical standards of the program in the Inova Phlebotomy School. Further, I believe that I am able, and am prepared to, meet these requirements. I certify that my answers are true and complete to the best of my knowledge. If this application leads to appointment to the Inova Phlebotomy School I understand that false or misleading information in my application or interview may result in my release. Applicant Electronic Signature Sign above Date Applicant Data Record Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, medical condition or disability. Government agencies require periodic report on sex, ethnicity, disable and veteran status of applicants. As an employer, we comply with government regulations and Affirmative Action responsibilities. Solely to help us comply with government record keeping, reporting or other legal requirements, please fill out the Affirmative Action Survey on this page. This data is for periodic government reporting and Affirmative Action only. It will be detached from the Application to the Inova Phlebotomy School and kept in a separate, confidential file. We appreciate your cooperation. Providing this information is voluntary. Refusal to provide this information will NOT affect your consideration for the Inova Phlebotomy School in any way. Name Check One Male Female Check One White African American American Indian Asian/Pacific Islander Hispanic Unknown Other… Enter other… Note: Submit completed attachments to InovaPhebSchool@inova.org. With this application please submit the non-refundable $50 application fee online at: https://www.inova.org/phlebotomy-school-payments