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ANESTHESIOLOGIST ASSISTANT APPLICATION
Submit
ANESTHESIOLOGIST ASSISTANT
PROGRAM APPLICATION
Submission of a current
passport photograph is
voluntary.
ANESTHESIOLOGIST ASSISTANT PROGRAM APPLICATION FORM
THIS APPLICATION MUST BE COMPLETED ON THE COMPUTER OR PRINTED LEGIBLY IN DARK INK.
ILLEGIBLE APPLICATIONS MAY BE TREATED AS INCOMPLETE AND WILL NOT BE PROCESSED.
If asked for an interview,
a photograph will be
taken at that time.
APPLICANT INFORMATION:
Name
Last
First
Middle
Maiden
Date of Birth
Mailing Address
Street Name & Number / Post Office Box / Apartment Number
City
State
Telephone
ZIP
Cell
Primary E-mail Address
Permanent Address
Street Name & Number / Post Office Box / Apartment Number
City
State
ZIP
Please call the program office if your address, phone, or e-mail changes after you submit your application.
Are you currently a student?
Full-Time
Part-Time
If yes, where are you enrolled?
No
City
Are you currently enrolled or have you ever attended South University?
State/Province
Yes
No
If yes, specify the program and provide dates of attendance
Are you currently employed?
Full-Time
Part-Time
No
Occupation
Employer
City
StateZip
Business Telephone
Please indicate how you found out about the program:
College Advisor
Other Physician/Healthcare Worker
Premed Advisor
College/Graduate School Guide
Internet
AMA Health Careers Book
Taking the GRE
Friend
Anesthetist (AA or CRNA)
Word of Mouth
AnesthesiologistTelevision/Newspaper
Other
South University is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate, baccalaureate, masters, and doctorate degrees. Contact the Commission on Colleges
at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of South University.
2
Program Technical Requirements
To undertake and successfully complete the Anesthesiologist Assistant Program, as well as to function successfully as an anesthetist
after graduation, the program requires that an individual meet certain fundamental physical, cognitive, and behavioral standards.
The requisite technical skills include, but are not limited to the following:
• Effectively communicating verbally with patients and their family members and with other healthcare professionals.
• Interacting with patients, including obtaining a history and performing a physical examination.
• Effectively communicating in writing, and by record keeping, those data and information essential to the practice of anesthesia and the care of patients.
• Reading and comprehending written parts of the medical record and other patient care documents in order to safely and effectively
participate in the practice of anesthesia.
•
Having sufficient knowledge, motor skill, and coordination to perform diagnostic and therapeutic tasks, including invasive procedures, on
patients in a timely manner so as to insure the safety and well-being of the patients. These tasks include but are not limited to peripheral
and central venous catheterization, arterial puncture and cannulation, breathing bag-and-mask ventilation, laryngeal mask airway insertion and management, endotracheal intubation.
• Having sufficient strength, motor skill, and coordination to lift, move, and position patients as required for administration of anesthesia
and performance of cardiopulmonary resuscitation.
• Having sufficient speed and coordination to quickly and safely react to emergent conditions throughout the hospital in order to assure
patient safety.
• Recognizing and differentiating colors of signals displayed on monitors; being able to work in both light and dark conditions as exist in
patient care areas (e.g., operating room, radiology suite, endoscopy suite); being able to recognize details of objects both near and far.
• Hearing, processing, and interpreting multiple conversations, monitor signals, alarms, and patient sounds simultaneously in fast-paced
patient care settings (e.g., operating room, intensive care unit, emergency room).
• Having no impairment that would preclude continuous performance of all of the above activities or any and all of the other activities that
are an integral part of an anesthesiologist assistant’s participation in the anesthesia care team.
In the space below, please list and explain any conditions that could significantly and adversely affect your ability to meet the technical requirements
of the program that are listed above. If you feel that you have any condition that may limit your ability to complete the program successfully, please
contact the program office and your specific questions will be addressed. Failure to disclose conditions that could adversely affect your ability to
function as an AA student or graduate anesthestist may result in dismissal from the application process or the educational program.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Have you ever been convicted of a crime other than a moving violation?
q Yes q No
**If yes, please explain and submit a separate attachment.
Substance Abuse
Both anesthesiologists and anesthetists are at a greater risk for substance abuse than practitioners in other medical specialties or
individuals in the general population. Handling and administering controlled substances occurs daily in the practice of anesthesia, and
current literature suggests that individuals with a history of abuse of any kind are more likely to develop a drug abuse problem if they
enter the field of anesthesiology.
Have you ever been diagnosed with or treated for any substance abuse disorder?
q Yes q No
**If yes, please explain and submit a separate attachment.
The program will contact you to discuss any information disclosed regarding substance abuse to discuss the role of addiction and
dependency in the field of anesthesia.
3
REFERENCES:
Please provide the names of at least three (3) individuals you have asked to serve as a reference:
1.
Name
Institution / Business
CityState
Telephone
E-mail Address
2.
Name
Institution / Business
CityState
Telephone
E-mail Address
3.
Name
Institution / Business
Telephone
E-mail Address
4
CityState
UNDERGRADUATE EDUCATION
Beginning with the most recent, list all undergraduate institutions which you have attended and degrees which you have or will have received within the
next six (6) months. Be sure to calculate both Overall GPA and Science GPA.
INSTITUTION
ATTENDANCE
FROM
TO
MAJOR
DEGREE
OVERALL
GPA
DATE
TRANSCRIPT
SCIENCE REQUESTED
GPA
GRADUATE EDUCATION
List all graduate and professional programs which you have attended and degrees which you have or will have received within the next six (6) months.
INSTITUTION
ATTENDANCE
FROM
TO
Have you ever been dismissed from an Academic Institution?
MAJOR
Yes
DEGREE
OVERALL
GPA
DATE
TRANSCRIPT
REQUESTED
No
**If yes, please explain and submit a separate attachment.
5
PREREQUISITE COURSEWORK
Complete the following table even though the courses appear on the transcripts that you submitted.
Note that survey courses or courses for non-science majors (except English) will not be accepted.
COURSE
NUMBER
INSTITUTION
MONTH/YEAR
COURSE
ENDED
CREDIT
BASIS
English
Q S
Gen Biology
Q S
Gen Biology Lab
Q S
Gen Biology
Q S
Gen Biology Lab
Q S
Gen Chemistry
Q S
Gen Chemistry Lab
Q S
Gen Chemistry
Q S
Gen Chemistry Lab
Q S
Org Chemistry
Q S
Org Chemistry Lab
Q S
Org Chemistry
Q S
Org Chemistry Lab
Q S
Biochemistry
Q S
Gen Physics
Q S
Gen Physics Lab
Q S
Gen Physics
Q S
Gen Physics Lab
Q S
Calculus
Q S
Statistics
Q S
GRADE
CREDIT
HOURS
Q = QUARTER and S = SEMESTER
6
ADDITIONAL COURSEWORK IN SUPPORT OF YOUR APPLICATION (optional)
If you have taken additional coursework that you feel is relevant to your graduate studies in the anesthesiologist assistant
program and that you want to bring to the attention of the admission committee, enter them here (e.g. Physiology, Anatomy, Pharmacology,
Neurosciences…)
COURSE
COURSE
NUMBER
INSTITUTION
MONTH/YEAR
COURSE
ENDED
CREDIT
BASIS
GRADE
CREDIT
HOURS
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q S
Q = QUARTER and S = SEMESTER
7
GRADUATE RECORD EXAM (South University Code is 5157)
Provide the scores you have received on the GRE general test in reverse chronological order. If you plan to retake the exam after submission
of the application, please indicate below. Scores must be sent directly to South University. Note that GRE scores that are more than 5 years
old will not be accepted. (Shaded area is for Program use only.)
DATE TAKEN
or PLANNED
SCORES
DATE THAT SCORES WERE
REQUESTED TO BE SENT
Did you participate in a formal review course for the GRE?
Yes
VERBAL
QUANTITATIVE
ANALYTICAL
No
MEDICAL COLLEGE ADMISSION TEST (MCAT)
Provide the scores you have received on the MCAT in reverse chronological order. If you plan to retake the exam after submission of the
application, please indicate below. Note that MCAT scores that are more than 5 years old will not be accepted. (Shaded area is for Program
use only.)
DATE TAKEN
or PLANNED
SCORES
DATE THAT SCORES WERE
REQUESTED TO BE SENT
Did you participate in a formal review course for the MCAT?
Yes
VERBAL
PHYSICAL
SCIENCES
BIOLOGICAL
SCIENCES
No
STAFF USE ONLY
Overall GPA
8
Prerequisite GPA
Science GPA
GRE Scores
MCAT Scores
RESEARCH EXPERIENCE
List research projects in which you have made significant contributions. (Be prepared to discuss the projects during the interview process.)
PROJECT TITLE
PRINCIPLE INVESTIGATION
INSTITUTION
DATE
PUBLICATIONS
List publications for which you have been an author and enclose reprints with the application. (Be prepared to discuss your publications
during the interview process.)
TITLE
JOURNAL CITATION
DATE
**Submit a separate attachment(s) if necessary.
9
CERTIFICATION AND LICENSURE
List any current or previous certification or licensure (e.g. EMT, RN, RRT…)
CERTIFICATION
CERTIFYING
ORGANIZATION
DATE OF EXAM
EXPIRATION
LICENSURE
LICENSING AGENCY
STATE
EXPIRATION
Have you ever been turned down when requesting licensure or certification?
**If yes, please explain and submit a separate attachment.
Have you ever had a license or certificate revoked?
**If yes, please explain below.
10
Yes
No
Yes
No
EMPLOYMENT HISTORY
Please provide your relevant work history for the past five (5) years.
EMPLOYER
DATES
Mo/Yr
From - To
DUTIES AND
RESPONSIBILITIES
FULL/PART
TIME
Full Part
Full Part
Full Part
Full Part
HONORS AND AWARDS
Please list any collegiate honors and other awards.
INSTITUTION/ORGANIZATION
DATE
AWARD
PURPOSE
11
VOLUNTARY MEDICAL EXPERIENCE
Provide a history of medical experience gained through voluntary programs.
INSTITUTION
DATES Mo/Yr
From - To
DUTIES AND RESPONSIBILITIES
ANESTHESIA SHADOWING EXPERIENCE
Provide a history of anesthesia shadowing experience gained through voluntary programs.
INSTITUTION
12
DATES & Hours
of participation
Brief explain of experience at this institution.
ARBITRATION
Every student and South University agrees that any dispute or claim between the student and South University (or any company affiliated
with South University, or any of its officers, directors, trustees, employees or agents) arising out of or relating to a student’s enrollment
or attendance at South University whether such dispute arises before, during, or after the student’s attendance and whether the dispute
is based on contract, tort, statute, or otherwise, shall be, at the student’s or South University’s election, submitted to and resolved by
individual binding arbitration pursuant to the terms described herein. This policy, however, is not intended to modify a student’s right, if
any, to file a grievance with any state educational licensing agency.
Either party may elect to pursue arbitration upon written notice to the other party. Such notice must describe the nature of the controversy
and the remedy sought. If a party elects to pursue arbitration, it should initiate such proceedings with JAMS, which will serve as the
arbitration administrator pursuant to its rules of procedure. JAMS can be contacted as follows: JAMS, 45 Broadway, 28th Floor, New
York, NY, 10006, www.jamsadr.com, 800-352-5267. This provision does not preclude the parties from mutually agreeing to an alternate
arbitration forum or administrator in a particular circumstance. If either party wishes to propose such an alternate forum or administrator,
it should do so within twenty (20) days of its receipt of the other party’s intent to arbitrate.
South University agrees that it will not elect to arbitrate any undividable claim of less than the relevant jurisdictional threshold that a
student may bring in small claims court (or in a similar court of limited jurisdiction subject to expedited procedures). If that claim is
transferred or appealed to a different court, however, or if a student’s claim exceeds the relevant jurisdictional threshold South University
reserves the right to elect arbitration and, if it does so, each student agrees that the matter will be resolved by binding arbitration
pursuant to the terms of this Section.
IF EITHER A STUDENT OR SOUTH UNIVERSITY CHOOSES ARBITRATION, NEITHER PARTY WILL HAVE THE RIGHT TO A JURY TRIAL, TO ENGAGE
IN DISCOVERY, EXCEPT AS PROVIDED IN THE APPLICABLE ARBITRATION RULES, OR OTHERWISE TO LITIGATE THE DISPUTE OR CLAIM IN ANY
COURT (OTHER THAN IN SMALL CLAIMS OR SIMILAR COURT, AS SET FORTH IN THE PRECEDING PARAGRAPH, OR IN AN ACTION TO ENFORCE
THE ARBITRATOR’S AWARD). FURTHER, A STUDENT WILL NOT HAVE THE RIGHT TO PARTICIPATE AS A REPRESENTATIVE OR MEMBER OF
ANY CLASS OF CLAIMANTS PERTAINING TO ANY CLAIM SUBJECT TO ARBITRATION. THE ARBITRATOR’S DECISION WILL BE FINAL AND
BINDING. OTHER RIGHTS THAT A STUDENT OR SOUTH UNIVERSITY WOULD HAVE IN COURT ALSO MAY NOT BE AVAILABLE IN ARBITRATION.
The arbitrator shall have no authority to arbitrate claims on a class action basis, and claims brought by or against a student may not be
joined or consolidated with claims brought by or against any other person. Any arbitration hearing shall take place in the federal judicial
district in which the student resides. Upon a student’s written request, South University will pay the filing fees charged by the arbitration
administrator, up to a maximum of $3,500 per claim. Each party will bear the expense of its own attorneys, experts and witnesses,
regardless of which party prevails, unless applicable law gives a right to recover any of those fees from the other party. If the arbitrator
determines that any claim or defense is frivolous or wrongfully intended to oppress the other party, the arbitrator may award sanctions
in the form of fees and expenses reasonably incurred by the other party (including arbitration administration fees, arbitrators’ fees, and
attorney, expert and witness fees), to the extent such fees and expenses could be imposed under Rule 11 of the Federal Rules of Civil
Procedure.
The Federal Arbitration Act (FAA), 9 U.S.C. §§ 1, et seq., shall govern this arbitration provision. This arbitration provision shall survive the
termination of a student’s relationship with South University.
Signature
13
ANESTHESIOLOGIST ASSISTANT PROGRAM
709 Mall Boulevard
Savannah, GA 31406
Phone (912) 201-8083 Fax (912) 790-4199
TO THE APPLICANT: Complete the following information and send it to the person who has agreed to complete it for you.
Include a stamped envelope addressed to the Program Office at the above address.
APPLICANT REFERENCE FORM
Applicant’s Name
Date
Reference’s Name
NOTE TO APPLICANT AND REFERENCE REGARDING CONFIDENTIALITY: Under the Family Educational Rights and Privacy ACT of 1974, students are given
the right to inspect their educational records, including letters of recommendation. The applicant may waive that right if desired. Please select one of the
following options and sign and date to indicate your selection.

I expressly waive my rights to have access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law regulation or policy.

I do NOT waive my right to access this letter of recommendation.
Signature of Applicant
Date
TO THE INDIVIDUAL PROVIDING REFERENCE: This individual is applying for admission to a Master of Medical Science degree program that will prepare him/her for a career delivering anesthesia for the complete range of patient ages and degree of health for, all types of surgical procedures, as
a member of the Anesthesia Care Team. This is a highly responsible position providing direct patient care during surgical procedures. The program is
an intensive 28 months of classroom, laboratory and clinical activities. As a student, and after graduation as a practitioner, the applicant must have
unquestionable integrity. Please complete the following assuming that someday this applicant may be delivering anesthesia to one of your family. Your
candid evaluation of this applicant is greatly appreciated.
PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION (Chair if Committee evaluation):
NameDegree
Title
Institution or Business
Address
Daytime Telephone Number
E-mail Address
How long have you known the applicant?
In what capacity have you known the applicant?
14
Please mark the following analog scale (with a solid dot or an X) for each category indicating this applicant’s position relative to other students’ who
you have known who entered into health professions that required direct patient care responsibilities. Leave blank those categories for which you
have no knowledge about the applicant.
AVERAGE
WORST I HAVE
EVER KNOWN
BEST I HAVE
EVER KNOWN
INTELLECTUAL ABILITY
WORK EFFECTIVELY WITHIN A TEAM
VERBAL COMMUNICATION
COMPASSION AND EMPATHY
WRITING ABILITY
CREATIVITY
SELF-STARTER
ACCEPTANCE OF RESPONSIBILITY
MATURITY
DEPENDABILITY
COMMON SENSE
LEVEL OF ORGANIZATION
PERSISTENCE
PLEASE MARK THE FOLLOWING INDICATING YOUR OVERALL IMPRESSION:
 RECOMMEND AS EXCEPTIONAL  RECOMMEND HIGHLY  RECOMMEND
 RECOMMEND WITH RESERVATIONS  RECOMMEND WEAKLY  CANNOT RECOMMEND
 Please have a Program Director call me concerning this applicant.
 I have attached an additional page to help with your evaluation of this applicant.
 This is a composite committee evaluation.  This is an individual’s evaluation.
SignatureDate
Telephone Number
Best time to call
15
ANESTHESIOLOGIST ASSISTANT PROGRAM
709 Mall Boulevard
Savannah, GA 31406
Phone (912) 201-8083 Fax (912) 790-4199
TO THE APPLICANT: Complete the following information and send it to the person who has agreed to complete it for you. Include a
stamped envelope addressed to the Program Office at the above address.
APPLICANT REFERENCE FORM
Applicant’s Name
Date
Reference’s Name
NOTE TO APPLICANT AND REFERENCE REGARDING CONFIDENTIALITY: Under the Family Educational Rights and Privacy ACT of 1974, students are given
the right to inspect their educational records, including letters of recommendation. The applicant may waive that right if desired. Please select one of the
following options and sign and date to indicate your selection.

I expressly waive my rights to have access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law regulation or policy.

I do NOT waive my right to access this letter of recommendation.
Signature of Applicant
Date
TO THE INDIVIDUAL PROVIDING REFERENCE: This individual is applying for admission to a Master of Medical Science degree program that will prepare him/her for a career delivering anesthesia for the complete range of patient ages and degree of health for, all types of surgical procedures, as
a member of the Anesthesia Care Team. This is a highly responsible position providing direct patient care during surgical procedures. The program is
an intensive 28 months of classroom, laboratory and clinical activities. As a student, and after graduation as a practitioner, the applicant must have
unquestionable integrity. Please complete the following assuming that someday this applicant may be delivering anesthesia to one of your family. Your
candid evaluation of this applicant is greatly appreciated.
PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION (Chair if Committee evaluation):
NameDegree
Title
Institution or Business
Address
Daytime Telephone Number
E-mail Address
How long have you known the applicant?
In what capacity have you known the applicant?
16
Please mark the following analog scale (with a solid dot or an X) for each category indicating this applicant’s position relative to other students’ who
you have known who entered into health professions that required direct patient care responsibilities. Leave blank those categories for which you
have no knowledge about the applicant.
AVERAGE
WORST I HAVE
EVER KNOWN
BEST I HAVE
EVER KNOWN
INTELLECTUAL ABILITY
WORK EFFECTIVELY WITHIN A TEAM
VERBAL COMMUNICATION
COMPASSION AND EMPATHY
WRITING ABILITY
CREATIVITY
SELF-STARTER
ACCEPTANCE OF RESPONSIBILITY
MATURITY
DEPENDABILITY
COMMON SENSE
LEVEL OF ORGANIZATION
PERSISTENCE
PLEASE MARK THE FOLLOWING INDICATING YOUR OVERALL IMPRESSION:
 RECOMMEND AS EXCEPTIONAL  RECOMMEND HIGHLY  RECOMMEND
 RECOMMEND WITH RESERVATIONS  RECOMMEND WEAKLY  CANNOT RECOMMEND
 Please have a Program Director call me concerning this applicant.
 I have attached an additional page to help with your evaluation of this applicant.
 This is a composite committee evaluation.  This is an individual’s evaluation.
SignatureDate
Telephone Number
Best time to call
17
ANESTHESIOLOGIST ASSISTANT PROGRAM
709 Mall Boulevard
Savannah, GA 31406
Phone (912) 201-8083 Fax (912) 790-4199
TO THE APPLICANT: Complete the following information and send it to the person who has agreed to complete it for you. Include a
stamped envelope addressed to the Program Office at the above address.
APPLICANT REFERENCE FORM
Applicant’s Name
Date
Reference’s Name
NOTE TO APPLICANT AND REFERENCE REGARDING CONFIDENTIALITY: Under the Family Educational Rights and Privacy ACT of 1974, students are given
the right to inspect their educational records, including letters of recommendation. The applicant may waive that right if desired. Please select one of the
following options and sign and date to indicate your selection.

I expressly waive my rights to have access to this letter of recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law regulation or policy.

I do NOT waive my right to access this letter of recommendation.
Signature of Applicant
Date
TO THE INDIVIDUAL PROVIDING REFERENCE: This individual is applying for admission to a Master of Medical Science degree program that will prepare him/her for a career delivering anesthesia for the complete range of patient ages and degree of health for, all types of surgical procedures, as
a member of the Anesthesia Care Team. This is a highly responsible position providing direct patient care during surgical procedures. The program is
an intensive 28 months of classroom, laboratory and clinical activities. As a student, and after graduation as a practitioner, the applicant must have
unquestionable integrity. Please complete the following assuming that someday this applicant may be delivering anesthesia to one of your family. Your
candid evaluation of this applicant is greatly appreciated.
PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION (Chair if Committee evaluation):
NameDegree
Title
Institution or Business
Address
Daytime Telephone Number
E-mail Address
How long have you known the applicant?
In what capacity have you known the applicant?
18
Please mark the following analog scale (with a solid dot or an X) for each category indicating this applicant’s position relative to other students’ who
you have known who entered into health professions that required direct patient care responsibilities. Leave blank those categories for which you
have no knowledge about the applicant.
AVERAGE
WORST I HAVE
EVER KNOWN
BEST I HAVE
EVER KNOWN
INTELLECTUAL ABILITY
WORK EFFECTIVELY WITHIN A TEAM
VERBAL COMMUNICATION
COMPASSION AND EMPATHY
WRITING ABILITY
CREATIVITY
SELF-STARTER
ACCEPTANCE OF RESPONSIBILITY
MATURITY
DEPENDABILITY
COMMON SENSE
LEVEL OF ORGANIZATION
PERSISTENCE
PLEASE MARK THE FOLLOWING INDICATING YOUR OVERALL IMPRESSION:
 RECOMMEND AS EXCEPTIONAL  RECOMMEND HIGHLY  RECOMMEND
 RECOMMEND WITH RESERVATIONS  RECOMMEND WEAKLY  CANNOT RECOMMEND
 Please have a Program Director call me concerning this applicant.
 I have attached an additional page to help with your evaluation of this applicant.
 This is a composite committee evaluation.  This is an individual’s evaluation.
SignatureDate
Telephone Number
Best time to call
19
NARRATIVE STATEMENT (Please be sure to address the following questions)
1. The goal or intent of your undergraduate major.
2. If you changed majors as an undergraduate, explain why.
3. What are you specifically looking for in a career as an Anesthesiologist Assistant?
APPLICANT NAME: ________________________________________________________________________
20
ANESTHESIA LITERATURE SUMMARY
All applicants are required to read and summarize, on this page, an article of their choice from the current anesthesia literature. The
article may be a clinical investigation, laboratory investigation, or a review article, but not a case report. Please choose an article from
one of the following journals (You may be charged a fee for an article):
1. ANESTHESIOLOGY published by Lippincot Williams and Wilkins Website http://www.anesthesiology.org
2. ANESTHESIA AND ANALGESIA published by Lippincot Williams and Wilkins Website http://www.anesthesia-analgesia.org
3. JOURNAL OF CLINICAL ANESTHESIA published by Elsevier Science Website http://elsevier.com/locate/jcaonline
Be prepared to discuss the article that you chose during the interview process.
APPLICANT NAME:______________________________________________________________
Journal Name__________________________________________________________________
Volume Number______________________ Month_________________ Year____________ Pages
Title of the Article_______________________________________________________________
21
DOCUMENTATION OF EXPOSURE TO ANESTHESIA PRACTICE IN THE OPERATING ROOM
All applicants are required to spend at least 8 hours in the operating room to observe the practice of surgical anesthesia. The purpose
of this activity is to expose the applicant to the patient anesthetist interaction, technology involved in anesthesia delivery, manual
skills associated with anesthesia care and the level of responsibility for the patient. The applicant is responsible for contacting a local
anesthesiologist and arranging to spend at least 8 hours with the anesthesiologist, an anesthesiologist assistant or a nurse anesthetist.
These requirements may be satisfied by an individual who has worked in an anesthesia department or has had an anesthesia rotation
as part of previous clinical training.
APPLICANT NAME:________________________________________________________________________
How are you satisfying the requirement for exposure to anesthesia practice?

I have worked/volunteered in an anesthesia department
• Time spent in anesthesia department:___________ Months__________________Years
• Job Title_______________________________________________________

I have had a rotation in an anesthesia department as part of my clinical training in:
• Program Date(s)_________________________________________________
• At (Institution)___________________________________________________
• City ___________________________________ State___________________

I have spent at least 8 hours with an anesthesiologist or anesthetist in the operating room observing the
administration of anesthesia on: DATE ________________________________
Complete the information below regardless of which box was checked. Ask the person who supervised your experience to sign and date the verification below.
Name:________________________________________________________ Title:_______________________________________
Institution:_______________________________________________________________________________________________
City: _________________________ State:____________________________ Zip:________________________________________
Signature:_____________________________________________________ Date:_______________________________________
Daytime Telephone Number:___________________________________________________________________________________
E-mail Address:___________________________________________________________________________________________
22
CONSENT TO OBTAIN RESULTS OF CRIMINAL BACKGROUND CHECK
APPLICANT NAME:
Due to the nature of the practice of anesthesia, which includes responsibility for the lives and well being of patients and having continual access
to controlled substances, individuals with criminal records are generally not suitable candidates for participation in the Anesthesiologist Assistant
Program. Applicants must complete, date and sign the release form below and submit with their completed application. Results from the background
check will be used in evaluating the applicant’s eligibility for admission.
I, (print full name),
hereby give permission to South University through its agents and employees to access data resulting from a criminal background check that I will
provide. Further, I give permission to South University to share the information gained from said background check with the Anesthesiologist Assistant
program for use in evaluating eligibility for admission and participation, and to provide to any of its clinical education sites for purposes of fulfilling
participation requirements with said clinical education sites.
Signature:_______________________________________________________
Date:___________________________________________________________
I WITNESS HEREOF_________________________________________________
DATE:__________________________________________________________
NOTARY SEAL:
**BACKGROUND CHECK MUST BE PERFORMED THROUGH www.advantagestudents.com. OR www.psibackgroundcheck.com
THE COST IS THE RESPONSIBILITY OF THE APPLICANT.**
23
APPLICANT’S ATTESTATION TO THE ACCURACY OF THE INFORMATION PROVIDED ON THE APPLICATION FORM,
PERMISSION TO RELEASE INFORMATION AND PENALTY FOR FALSIFICATION.
APPLICANT NAME: ________________________________________________________________________
I have read and understood all sections of the program description and application for admission to the anesthesiologist assistant program at South
University. I declare that all information that I have provided is complete and true. I hereby consent and permit agents of South University to contact
those persons and entities whose names are set forth as references or otherwise specified in the application, to verify the information that I have
provided. I hereby consent to the provision/release to South University of such information by those persons and entities who may be contacted in
these regards, and I hereby release any such persons/entities from any claims that I may have with regard to such information and further agree and
covenant not to sue such persons/entities on account of any disclosure by them of this information. I agree that, if accepted to this South University
Anesthesiologist Assistant program I will abide by all rules and regulations of South University. Furthermore, I understand and agree that providing
false or incomplete information in this application, or in support of this application, is just cause for disqualification of (failure to further consider) my
application or in the case of my acceptance into the program, for immediate dismissal from South University.
Signature:_______________________________________
Date:___________________________________________
24
APPLICATION CHECKLIST
It is the applicant’s responsibility to inform the office of any change in address or telephone numbers, including the effective dates of the change.
The program office will not be responsible for lost or missed communications due to the failure of the applicant to provide a change of address or
telephone numbers and their effective dates.
PLEASE USE THIS CHECKLIST TO CONFIRM THE STATE OF YOUR APPLICATION. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED
FOR INTERVIEWS.

Application form is complete in all parts

Check for application fee of $ 50.00 has been enclosed.

Three reference forms have been sent/ given to appropriate persons.

GRE score reports have been sent to South University (South University Code is 5157).
OR

MCAT scores from www.MCATTESTSCORES.com

Official transcripts have been requested from all colleges/universities that you attended.

All GPA’s (Science and Overall) have been calculated

Narrative statement has been enclosed.

Anesthesia literature summary has been enclosed.

Documentation of exposure to surgical anesthesia has been completed and enclosed.

Completed criminal background check done through
OR

Notarized consent form to obtain results of completed criminal background check

Applicant’s attestation has been signed and enclosed.

Arbitration agreement is signed
25
South University, Savannah
Anesthesiologist Assistant Program
709 Mall Boulevard
Savannah, GA 31406-4805
912.201.8080
912.790.4199 fax
www.southuniversity.edu/anesthesiologistassistant
South University is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate, baccalaureate, masters, and doctorate degrees.
Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of South University.
See SUprograms.info for program duration, tuition, fees, and other costs, median debt,
federal salary data, alumni success, and other important info.
www.southuniversity.edu
© 2012 by South UniversitySM
10/29/12