MLSGO Student Evaluation Form

Do you hereby waive and renounce all rights of access, including those established by the Family education rights and privacy act of 1974, to any letter or letters of reference or confidential letters of recommendation to be hereafter written on your behalf by the evaluator's name you provide on this form?

Yes No

Fill out the form below

Applicant Name

Current University

Personal Email Address

Signature of Waiving Party (Applicant)

Date

Who is being asked to write the recommendation?

Full Name

Email Address

Furthermore, I grant the above named person permission to release specific and personally identifiable information about me from my educational record in order that he/she may fulfill my request to complete this academic evaluation form. He/she may release my information electronically, or verbally to the party or parties listed below:

any such information he/she may release only the information on this form.

This waiver is not operative and becomes null and void if at any time said recommendations are used for any purpose other than these which are specifically intended. My specific intention is.

respecting admission to an educational agency or institution other

If Other, please specify

When the indicated evaluator above submits your reference, it will be emailed to the Program Director(s) of the School(s) of Medical Technology you applied to as indicated below

Comanche County Memorial Hospital Laboratory; Stacey Paryag-Stevens, MPA, AHI(AMT), MLS(ASCP)CM; Program Director; Stacey.Paryag@ccmhhealth.com; 3401 West Gore Boulevard, Lawton, OK 73505; Mobile/Work: (580) 704-7650; Fax: (580) 585-5462

Mercy Hospital Ada Laboratory; Leah Babcock, MSHR, MT(ASCP); Program Director; Leah.Babcock@Mercy.Net; 430 North Monte Vista, Ada, OK 74820; Phone: (580) 421-1596; Fax: (580) 421-1525

Saint Francis Hospital Laboratory; Austin B. Reed, MS, MLS(ASCP); Program Director; ABReed@saintfrancis.com; 6161 South Yale Avenue, Tulsa, OK 74136-1902; Phone: (918) 494-1343; Fax (918) 494-1497

Signature of Waiving Party (Applicant)

Date

Admission

Effective 2018: All applications can ONLY be submitted online via this website.

MLSGO Student Academic Evaluation Form

Evaluation Form Deadline: By November 1st 2025

Permission to release personally identifiable and/or waiver of right to inspect or review confidential letter of recommendation. (Family education rights and privacy act of 1974 as amended)

Fill out the form below

Who is being asked to write the recommendation?

This waiver is not operative and becomes null and void if at any time said recommendations are used for any purpose other than these which are specifically intended. My specific intention is.

When the indicated evaluator above submits your reference, it will be emailed to the Program Director(s) of the School(s) of Medical Technology you applied to as indicated below

This page to be completed by instructor/advisor

Scholastic Ability

Personal Appraisal

Rate the applicant on the following qualifications, in comparison to other students in classes. (5 = Outstanding; 3 = Average; 1 = Poor)

Psychomotor

Cognitive

Affective

Overall Recommendation

Evaluator Information