Partner application form

51��

Veterinary Technology

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Location and contact information

Organization*

Website*

Address*

Street address Address line 2 City State Zip code

Phone*

Email*

Number of current staff

Number of veterinarians*

Number of CVTs*

Number of assistants and other staff*

Practice manager*

Yes

Hours of operation

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Saturday*

Sunday*

Emergency hours*

Facility details

How would you classify your facility?*

Companion practice

Food animal practice

Research

Emergency

Mixed animal practice

Equine practice

Shelter

Referral, specialty, or other

What animals are seen at your facility*

Referral, specialty, or other*

Other (please specify)*

Is free parking available at your site?*

Yes

Is public transportation to your site available?*

Yes

Who will be 51��'s primary contact for your facility?*

Who will be supervising the student(s)?*

Do you have an existing training program for new CVTs?*

Yes

Please describe in as much detail as possible what the student veterinary technician’s learning experience at your site will be like*

Diagnostic imaging

The use of personal protective equipment such as lead shields, thyroid shields, and lead-lined gloves is required. 51�� provides student dosimetry badges.

Check all that apply*

Radiography

Digital radiography

Dental radiography

Digital dental radiography

Automatic processor

Ultrasonography

Endoscopy

Other

Other (please specify)*

Surgery

Check all that apply*

Laser surgery

AHAA-certified

Steam autoclave

Gas sterilization

Ultrasonic dental scaler

Dental unit

Other

Other (please specify)*

Please describe surgeries typically performed at this facility*

Laboratory equipment

Check all that apply*

Blood gas analyzer

Blood chemistry

Microscopy

Gram stain

Cytology

Centrifuge

Tonometry

CBC analyzer

Other

Other (please specify)*

What percent of lab work is typically sent to a commercial laboratory vs. being performed in-house?*

Anesthesia

Inhalation gases typically used*

Nitrous oxide

Sevoflurane

Isoflurane

Halothane

Other

Other (please speficy)*

Injectable agents typically used*

Propofol

Ketamine/Valium

Domitor/Antisedan

Xylazine/Yohimbine

Opioids

Barbiturates

Other

Other (please specify)*

Monitoring equipment*

Pulse oximeter

ECG

Blood pressure monitor

IV fluid pump

Ventilator

Other

Other (please specify)*

Procedures

At your facility, what procedures do technicians typically do?*

Other (please specify)*

Please describe other technician responsibilities*

51��

51�� | Portland, Oregon

Veterinary Technology