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| All fields are required. Please enter n/a if not applicable. |
| Instructor’s Name:
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| Address:
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| City
State
Zip
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| Daytime Telephone:
E-mail Address:
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| Is this program (Check One)
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If this program is Hospital-based or College-affiliated, provide the name, address, telephone number and website of
the institution: |
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If this program is College-affiliated, please provide a link to the program information from your college’s web site.
If unavailable, please mail hard copies of the course syllabi to IAHCSMM Headquarters, ATTN: PDRC.
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This program is designed to provide instruction to students who are:
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How is instruction in this program delivered? (Check all that apply.)
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If this program includes students who are new to the field of CS, explain what plan is in place to provide the required
hands-on experience component. (i.e. clinical affiliations with local hospitals, etc.)
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If this program is hospital-based, explain what plan is in place to insure that students receive hands-on experience
in the
curriculum areas that are not a part of the student’s routine work assignments. (i.e. cross-training, etc.)
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| If this program includes students who are new to the field of CS and does not include a hands-on field experience
component, those students must be informed of the need for 400 hours hands-on experience in writing at the onset
of the class.
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This curriculum requires that each student have a copy of the current IAHCSMM textbook and workbook study guide.
How do students obtain their course materials? (Check One)
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What additional references do you provide for your students? (i.e. reference texts, videos, industry publications,
computer-based learning modules, internet access, etc.)
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What audio-visual equipment is available for your use in the classroom? (i.e. computer, computer projector,
overhead projector, VCR, write on board, flip charts, easel, etc.)
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Do you provide all instruction for the program? If not, explain how teaching duties are divided and what criterion is used to establish other instructor’s qualifications.
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| What is the length of this course?
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Independent and Hospital-based programs: List the hours of scheduled class time and the approximate length of the course from beginning to end. (For example, 160 hours delivered over 9 months, followed by 400 hours of hands-on experience.)
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College-affiliated programs: List the number of credits assigned to this program. Separate the number of lecture and lab credits if applicable, and indicate the number of hours spent on clinical internship (if provided).
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Please list any additional information that you wish to share about your program in the space below.
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Please Note: This form must be updated every two years or when major changes in the program occur.
IAHCSMM membership number
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| All fields are required. Please enter n/a if not applicable. |
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| Telephone Number:
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| IAHCSMM I.D. Number:
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Educational Background:
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CS-Related Experience: (List include facility address, telephone number and contact person)
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Teaching Experience:
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Professional Affiliations:
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Publications: (List published articles, papers, etc.)
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Speaking/Presentations: (List seminars, workshops, etc. that you have presented)
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Honors/Awards/Professional Accomplishments:
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| *As a condition of approval as an IAHCSMM Instructor, I agree to follow the requirements listed below: |
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I will keep IAHCSMM notified of changes in my contact information. |
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I will keep IAHCSMM informed of changes in the curriculum or in the instructors that assist me with the course. |
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I will not duplicate copyrighted IAHCSMM materials. |
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I will follow the most current version of the curriculum designed specifically by IAHCSMM. |
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I will use the most current edition of the IAHCSMM Instructors’ Guide for my course(s). |
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As an IAHCSMM-approved Instructor, I will not teach other Central Service/Sterile Processing curriculums that
are not IAHCSMM-approved. |
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I will attend one entire Instructors’ Update Meeting and complete Annual IAHCSMM Meeting every two years. |
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I will update Part 1 and 2 of the Instructor Application information every two years. |
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I will maintain a current CRCST status. If I am teaching through a college academic appointment and do not
have CRCST status, I will maintain an Associate membership in IAHCSMM. |
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It will be my responsibility to regularly visit the Instructors’ Section of the IAHCSMM web site
(http://www.iahcsmm.org/instructors.htm) to keep current with Instructor news and information. |
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I understand that failure to comply with IAHCSMM Instructor Requirements will result in the loss of my approval
as an IAHCSMM Instructor. |
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I certify that, to the best of my knowledge and belief, all of the information on and attached to this application
is true, correct, complete and made in good faith. I understand that any information I give may be researched.
Further, I agree to comply by the rules and regulations set forth by the Instructor’s guide and any addenda
published thereafter, as well as the Association’s Bylaws as applicable to current members. |
| Enter your IAHCSMM membership number to Electronically Sign this document.
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Thank you for taking the time to fill out this form, you will be contacted by
IAHCSMM within 4 weeks.
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