Educators

Surgical Technology – Forms and Facts

Submission Guidelines

Frequent Program Changes

President/CEO or Administrative Designee must be included on all program change submissions.



Bookmarking Protocol & Guidelines

All program submissions to the ARC/STSA must be created and sent as one seamless PDF file, with all pages upright/facing the same direction, appropriately labeled and bookmarked as indicated in the bookmarking reference below:

The ARC/STSA will not accept or process submissions that are not appropriately bookmarked. Submissions not following the guidelines will be returned to the program for correction and resubmission.  Please note that the posted document is to be used as a reference and that not all bookmark labels will apply to your submission. Bookmarks should follow the section labels provided with Self-Studies, PRRs, Findings letters or applications.


Program Director (PD) Changes

A change in Program Director (PD) should be reported to the ARC/STSA within 30 days of the change.  President/CEO or Administrative Designee must be included on all program change submissions.

Effective August 1, 2014, the following documentation should be submitted in support of the appointment:

  1. An ST Program Personnel Data Form – Program Director. This attestation form does not require the submission of additional supporting documentation unless specifically requested by the ARC/STSA.
  2. Please note: the program should retain copies of the following documents related to the appointment of the Program Director for review upon request by the ARC/STSA or during On-Site Evaluation:
    1. A current résumé indicating a minimum of five (5) years of recent scrub experience or five (5) years recent experience as an instructor in surgical technology, or a combination of both, within the past ten (10) years. The résumé should also indicate employment at the current ST program.
    2. Proof of an Associate’s Degree or above [effective for new Program Directors appointed on or after August 1, 2015]. Proof consists of submission of one of the following documents:
      • copy of Associate’s Degree diploma
      • Official college transcript
    3. Documentation indicating proficiency in instructional methodology, curriculum design, and program planning should include one(1) of the following:
      • documentation of previous teaching experience [surgical technology-related] that includes responsibilities for instructional methodology, curriculum design, and/or program planning
      • documentation of formal coursework in instructional methodology, curriculum design, and/or program planning
      • other documentation from an administrative representative how the school ensures that the candidate possesses proficiency in instructional methodology, curriculum design, and/or program planning
      • a detailed professional development plan of action and timeline for the newly appointed program director to possess proficiency in instructional methodology, curriculum design, and/or program planning
    4. Proof of a current NCCA-approved credential in surgical technology (CST™, CSFA™ or CST/CSFA™). Proof consists of submission of one (1) of the following documents:
      • A copy of the NBSTSA certification card
      • A copy of the NBSTSA certification certificate
      • A copy of the verification page from the NBSTSA website (www.nbstsa.org). [NOTE: If the Social Security number is used to access this verification, the last four digits of the Social Security number will appear on the document. If the certification number is used to access this verification, the Social Security number will not appear on the document. ]
      •  In addition, effective January 1, 2009, all newly appointed program directors are required to submit proof of attendance at an ARC/STSA-sponsored Accreditation Fundamentals for Educators (AFE) Workshop during their first year of appointment. Please contact the ARC/STSA for dates and costs for this workshop.

If an interim program director is appointed while the sponsoring institution conducts a formal search for a formal program director, please contact the ARC/STSA at info@arcstsa.org or 303-694-9262 to determine the documents required for submission in support of the interim program director appointment. At a minimum, the program should submit a plan of action, using the Plan of Action Form, and implementation timeline for the appointment of a program director, including but not limited to the projected date for the search process to conclude and for the program director’s appointment to begin.Return to Top


Clinical Coordinator (non-PD) Changes

A change in clinical coordinator (non-PD) should be reported to the ARC/STSA on the program’s next ARC/STSA Annual Report. Effective August 1, 2014, the following documentation should be attached to the Annual Report in support of the appointment:

  1. An ST Program Personnel Data Form – Clinical Coordinator. This attestation form does not require the submission of additional supporting documentation unless specifically requested by the ARC/STSA. Please note: the program should retain copies of the following documents related to the appointment of the Clinical Coordinator for review upon request by the ARC/STSA or during On-Site Evaluation:
    1. A current résumé indicating a minimum of three (3) years of recent scrub experience or three (3) years recent experience as an instructor in surgical technology, or a combination of both, within the past five (5) years. The résumé should also indicate employment at the current ST program.
    2. Proof of a current NCCA-approved credential in surgical technology (CST™, CSFA™, or CST/CSFA™). Proof consists of submission of one of the following documents:
      • A copy of the NBSTSA certification card
      • A copy of the NBSTSA certification certificate
      • A copy of the verification page from the NBSTSA website (www.nbstsa.org). [NOTE: If the Social Security number is used to access this verification, the last four digits of the Social Security number will appear on the document. If the certification number is used to access this verification, the Social Security number will not appear on the document.]

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Program Faculty (non-PD, non-CC) Changes

A change in program faculty (non-PD, non-CC) who teach core surgical technology content should be reported to the ARC/STSA on the program’s next ARC/STSA Annual Report. Effective August 1, 2014, the following documentation should be attached to the Annual Report in support of the appointment:

  1. An  ST Program Personnel Data Form – Core Instructor. This attestation form does not require the submission of additional supporting documentation unless specifically requested by the ARC/STSA. Please note: the program should retain copies of the following documents related to the appointment of the Core Instructor for review upon request by the ARC/STSA or during On-Site Evaluation:
    1. A current résumé indicating a minimum of two (2) years of recent scrub experience or two (2) years recent experience as an instructor in surgical technology, or a combination of both, within the past five (5) years. The résumé should also indicate employment at the current ST program.
    2. Proof of a current NCCA-approved credential in surgical technology (CST™, CSFA™, or CST/CSFA™). Proof consists of submission of one of the following documents:
      • A copy of the NBSTSA certification card
      • A copy of the NBSTSA certification certificate
      • A copy of the verification page from the NBSTSA website (www.nbstsa.org). [NOTE: If the Social Security number is used to access this verification, the last four digits of the Social Security number will appear on the document. If the certification number is used to access this verification, the Social Security number will not appear on the document. ]

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Institutional Administrator Changes (President/CEO and Dean)

A change in an institutional administrator directly related to the Surgical Technology program (President/CEO or Dean – or comparable appointments) should be reported to the ARC/STSA within 30 days of the change. The following documentation should be submitted in support of the appointment:

  1. For a change in President/CEO [or comparable appointment]:
  2. For a change in Dean [or comparable appointment]:

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Program Advisory Committee (PAC) Membership Change

Changes to the membership of the Program Advisory Committee (PAC) should be reported to the ARC/STSA on the program’s next ARC/STSA Annual Report. The following documentation should be attached to the Annual Report in support of the appointment: Program Advisory Committee (PAC) Form Please note:

  1. The public member appointed to the Program Advisory Committee (PAC) holds a duty to represent the interests of the patient that may come under the care of the surgical technologist and therefore has a vested interest in the proper education of the surgical technologist for quality patient care. The public member must not be:
    • A current or former employee of the sponsoring institution
    • A current or former employee of any clinical affiliate associated with the program
    • A current of former student of the surgical technology program
    • A current or former healthcare provider
  2. Please include the current NBSTSA certification number for the committee member representing the Practicing CST on the ARC/STSA Program Advisory Committee (PAC) Form and submit proof of certification and currency. This proof can consist of one (1) of the following:
    • A copy of the NBSTSA CST certification card
    • A copy of the NBSTSA CST certification certificate
    • A copy of the verification page from the NBSTSA website (www.nbstsa.org). [NOTE: If the Social Security number is used to access this verification, the Social Security number will appear on the document. Please black out the social security number on the document prior to submission. If the certification number is used to access this verification, the Social Security number will not appear on the document. ]

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Maximum Enrollment Capacity (MEC) Changes

Proposed changes to the program’s maximum enrollment capacity must be reported to the ARC/STSA for review and approval of sufficiency of program resources by the ARC/STSA Board of Directors using the Maximum Enrollment Capacity (MEC) Attestation Form.

This form will replace the documentation previously required for a MEC change. Please note: support documentation must be maintained at your campus to verify sufficiency of the program’s resource to address any needs related to the proposed MEC change, including but not limited to:

  • Classroom equipment
  • Laboratory instrumentation
  • Supplies and equipment
  • Computer resources
  • Instructional aides

(See Standard III.A.- physical resources, Standard III.B. – faculty resources, and Standard III.C. – curriculum resources and clinical case requirement.)

ARC/STSA will contact you if additional documentation is needed.

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ST Facilities Changes

Proposed changes to the program’s facilities – classroom or laboratory facilities – should be reported to the ARC/STSA for review and approval by the ARC/STSA Board of Directors. The following documentation should be submitted in support of approval of the facilities change:

  • A blueprint or floor plan showing the surgical technology classrooms, laboratory space, and faculty offices, including  measurements, and photographs of these areas
  • An updated list of laboratory furnishings, equipment, and supplies
  • Publications: Any changes in contact information – telephone number, fax number, address, etc.

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ST Curriculum Changes

Proposed changes to the curriculum offered by a CAAHEP-accredited program come under two categories:

  • curriculum changes that include curriculum content found in the Core Curriculum for Surgical Technology, 6e [CCST6e] – Core Content
  • curriculum changes that involve curriculum content not found in the CCST6e, such as general education courses not used to teach CCST6e content – Non-Core Content

Core Content Curriculum Changes Documentation in support of Core Content curriculum changes typically includes the following:

  • A narrative indicating the nature of the change, including date of effectiveness
  • Proof of institutional accreditor and state approval agency [if applicable] review and approval of the curriculum change
  • Program Advisory Committee minutes indicating review of the proposed curriculum change
  • A completed ARC/STSA Curriculum Sequencing [C-1] Form
  • A master curriculum list of all courses required for program completion
    [Please note that a master curriculum list includes the course designation, course title, clock hours, and time increment (quarter, semester, trimester, etc.) of instruction.]
  • Copies of proposed [new] syllabi [and/or companion documentation, if applicable] that have changed
    [Please note that a comprehensive syllabus and/or companion document includes the course designation, course title, clock hours, time increment (quarter, semester, trimester, etc.) of instruction, course faculty, course schedule, course overview, course objectives, method of teaching, course content outline, outcomes assessment methods, and grading scale. ]
  • A completed ST Curriculum Attestation Form
  • A completed ST Core Curriculum Outline Comparison Form
  • Copies of publications, draft publications, or a plan of action to update publications to reflect the proposed curriculum change

Non-Core Content Curriculum Changes

Submit the ST Curriculum Change Attestation Form – Associate Degree for Non-Core Content, degree-level curriculum changes, from a certificate or diploma to an associate degree.

Other Non-Core Content curriculum changes may be reported on the next Annual Report. Please note that curriculum changes submitted and/or approved outside of the Annual Report should not be included in the Annual Report.

If assistance is required to determine whether a curriculum change is considered Core or Non-Core, please contact the ARC/STSA at info@arcstsa.org or 303-694-9262.

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Findings Letter/Program Change Letter Submissions

When submitting a findings letter or program change to the ARC/STSA, please use the following guidelines when preparing your submission:

  1. A cover letter, on institutional letterhead, should include a reference to the purpose for the documentation submission (for example: “…response to a findings letter from the ARC/STSA dated October 11, 2013…”).
  2. A copy of ARC/STSA communication(s) related to the submission (e.g., findings letter, CAAHEP letter, etc.), if applicable.
  3. If the submission is related to a findings letter, for each Standard citation:
    1. Section I – Narrative Response
      • List the Standard, finding and request from the findings letter.
      • Insert the program’s narrative response

      Note: If supporting documentation is included to demonstrate compliance or to clarify a change, please insert the supporting documentation in an appendix, labeled numerically, following the complete narrative response. Please reference the appendix number and page number in the narrative.)

    2. Section II – Supporting Documentation – on the pages following the complete narrative response, insert any supporting documentation that provides evidence of compliance with the Standards. Note: For a findings letter with more than two (2) citations, each citation/response should be listed on a table of contents that includes the Standard and the page of the narrative where the response is located. Citations with the same Standard number should be listed separately (e.g.: III.A. – Resources – Budget and III.A. – Resources – Computers). [Please note that any plans of action submitted in the response should be submitted using the Plan of Action Form.]
  4. All submissions should be submitted in electronic/digital (CD-ROM, DVD, flash drive) form, using PDF (preferred) format. The electronic/digital copy must be a single, continuous “seamless” document – all files and folders combined into one, continuous document saved as a PDF document. NOTE: Please do not e-mail large documents (more than 20 pages) to the ARC/STSA.
  5. Documentation should be submitted to:
    Ron Kruzel
    Executive Director ARC/STSA
    6 West Dry Creek Circle, Suite 110
    Littleton, CO 80120

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On-Site Evaluation Documents

When an On-Site Evaluation is scheduled, two common documents used to support the visit are:

  1. List of On-Site Visit Materials – Surgical Technology and On-Site Evaluation specific – provided by the ARC/STSA and used by the program to prepare on-site documentation for the visitors to review. Each On-Site Evaluation [Initial, Random/Continuing, Consultative/Comprehensive, Focused] uses a List of Materials specific to that type of evaluation. Please be sure to use the applicable List of Materials, which will be sent with your notification letter, to prepare for your program’s evaluation. (Click here for sample lists for  Required On-Site Visit Materials – Initial On-Site Evaluation – ST  and  Required On-Site Visit Materials – Random/Continuing On-Site Evaluation – ST )
  2. On-Site Evaluation Schedule – Surgical Technology and Evaluation specific – completed and submitted to the ARC/STSA separate from any additional documentation (not bound into the Self-Study, etc.).

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ST FORMS

If you are unable to locate a specific form requested by the ARC/STSA in the list below, please contact us at info@arcstsa.org or 303-694-9262 for further assistance.

Please note that copies of standardized ARC/STSA forms should be saved to your computer before completing each form.

Clinical Sufficiency Survey Form

Required On-Site Visit Materials – Initial On-Site Evaluation – ST 

Required On-Site Visit Materials – Random/Continuing On-Site Evaluation – ST

On-Site Evaluation Schedule – Random/Continuing ST

Fair Practices Form – ST

Program Advisory Committee (PAC) Form – ST

Clinical Affiliate Attestation Form – ST

Clinical Affiliation Site Reporting Form – ST

Program Data Sheet

Program Personnel Data Form – President

Program Personnel Data Form – Dean

Program Personnel Data Form – Program Director

Program Personnel Data Form – Clinical Coordinator

Program Personnel Data Form – Core Instructor

Faculty Schedule of Responsibilities Form-ST

A-1 – ARC/STSA Budget Form

A-2 – Methods of Didactic and Laboratory Evaluation Form – ST

A-3 – Methods of Clinical Evaluation Form – ST

C-1 – Curriculum Sequencing Form – ST

C-2 – Didactic and Laboratory Courses – Summary Form – ST

C-3 – Clinical Courses – Summary Form – ST

ARC/STSA Curriculum Attestation Form – CCST6e

Core Curriculum Outline Comparison Form 

Curriculum Change Attestation Form – Associate Degree

Sample Program Effectiveness Plan (PEP) – ST

ARC/STSA Plan of Action Form

  • (click here for instructions for completing this form andsample of a completed form)

ARC/STSA Outcomes Tracking Tool (1-25)

ARC/STSA Outcomes Tracking Tool (1-40)

[Either of the above is required for use for tracking ARC/STSA-established outcomes for all cohorts enrolled on or after August 1, 2014 and upon request by the ARC/STSA]

  • (click here for instructions for completing this form and a sample of a completed form)

ST Graduate Survey Tool
This Graduate Survey Tool is used for graduates who completed the program on or after August 1, 2016 and may be administered immediately upon completion of the program.

ST Employer Survey Tool
This Employer Survey Tool is used for graduates who completed the program on or after August 1, 2016 and may be administered immediately upon placement.

Standard I.A./I.B./I.C. – Sponsoring Attestation Form

* Please contact the ARC/STSA office at info@arcstsa.org or 303-694-9262 for forms marked with an asterisk above.

If you are unable to locate a specific form requested by the ARC/STSA in the list above, please contact us at info@arcstsa.org or 303-694-9262 for further assistance.

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