Certificate of Competence Maui Application · Certificate of Competence Maui Application Application Period: June 1, 2015 – October 26, 2015 (Must be postmarked by this date) ...

5/11/2015

Certificate of Competence

Maui Application Application Period: June 1, 2015 – October 26, 2015 (Must be postmarked by this date)

Directions: Please complete each item carefully and submit this complete Admissions Application Check List and all required documents to the Maui EMS Training Center located at 310 Kaahumanu Avenue in Kahului. If you are mailing your application please mail it to: Maui EMS Training Center, 310 Kaahumanu Avenue, Bldg 215, Kahului, HI 96732, ATTN: EMT Application.

Only this fully completed program Admissions Application Checklist submitted to the Maui EMS Training Center by the appropriate deadline (see above) will be accepted for processing.

APPLICANT INFORMATION

Name: UH Number/Username Last Name First Name M.I.

Mailing Address:

Street / POB City State Zip Code

Phone: Cell Home Work

Preferred Email Address:

List other name(s) used on documents: (Notify the KCC Kekaulike Information & Service Center regarding other names used on college documents.)

ADMISSIONS APPLICATION CHECKLIST FOR EMT PROGRAM 1. Attend a Mandatory EMT Program Information Session within one year of your application

submission. For more information visit www.kcc.hawaii.edu or pick up an Information Session schedule from Kauila 122 or Kauila 106 during normal business hours.

Date Attended: _______/_______/_______ (Month / Day / Year)

2. Complete a UH System Application Form (New, Returning or Transfer) OR Change of Home Institution Form (Students currently enrolled at a UH System School other than KCC) Students currently enrolled at KCC do not need either of these forms and should indicate “N/A” in the space provided.

3. Student copy of transcripts (for course work WITHIN the UH System). UH system colleges and university transcripts are downloadable from the internet (MyUH Portal). Student copies of transcripts must be submitted with this checklist.

4. Complete prerequisite courses (English 100 / Health 125) with a “C” grade or higher. For students whose prerequisites are in progress in Fall 2015 semester, your application will be contingent on successful completion of HLTH 125 and/or ENG 100, with a grade of "C" or above.

5. College transcripts for courses completed outside of the University of Hawai‘i System

Official transcript(s) should be sent to the KCC Kekaulike Information & Service Center.

• Institution: Transcript Request Date:

• Institution: Transcript Request Date:

• Institution: Transcript Request Date:

E m e r g e n c y M e d i c a l S e r v i c e s D e p a r t m e n t

Kapi`olani Community College EMERGENCY MEDICALTECHNICIAN PROGRAM

Admission Application Checklist

5/11/2015

6. “My Plan Initiative” – Complete reflection essays and self-assessments for the EMT program (see attached.)

7. Request for Transcript Evaluation Form - A request for transcript evaluation must be completed for coursework outside the UH System. Completion of this form is required in order to transfer credits to KCC. This form can be obtained at the Kekaulike Information & Service Center (‘Ilima 102) or online at: http://www.kapiolani.hawaii.edu/admissions/admissions-toolbox/%20 (see Request for Transcript Evaluation)

8. Attach an original State of Hawai‘i Abstract of Traffic Record (dated no older than 6 months from the application deadline).

9. Attach a copy of your Hawai‘i driver's license.

10. First Aid and CPR certification is required if accepted into the program. Verification of certification must be submitted 5-business days prior to the start of the program. Failure to submit documentation WILL result in your dismissal.

We only accept certifications provided by the AMERICAN HEART ASSOCIATION!!!

Certifications cannot expire prior to the end of the program you are applying to* Certification Cards must be typewritten.

First Aid and CPR can be obtained from organizations such as the following:

• KCC Office of Non-Credit Programs (KCC): 734-9288 • American Medical Response (AMR): 487-4900

□ I have completed the CPR requirement and the card is attached:

AHA Training Center Name – BLS for the Healthcare Provider Exp. Date

□ I have completed the First Aid requirement and the card is attached

AHA Training Center Name – First Aid or Heartsaver First Aid Exp. Date

□ If accepted into the program I will submit verification(s) 5-business days prior to the start of theprogram.

10. Submit “Work/Volunteer Experience in the Health Field” form (see attached).

11. “Verification of Work or Volunteer Experience in the Health Field” forms (see attached) must be received by application deadline (see attached).

12. After completing the application, participate in an interview with the Admissions Committee. Interviews will be on November 5, 2015 & November 6, 2015. Upon completion of your application, you will be assigned an interview time based on the order of completed application received. Interview will be approximately 15 minutes.

E m e r g e n c y M e d i c a l S e r v i c e s D e p a r t m e n t

5/11/2015

WORK/VOLUNTEER EXPERIENCE IN THE HEALTH FIELD

To be completed and submitted by the applicant. If experience involves direct patient contact, please fill out the VERIFICATION OF WORK OR VOLUNTEER EXPERIENCE IN THE HEALTH FIELD form):

Agency: Date: from to (month/day/year) (month/day/year) Contact Person: Title: Telephone # Duties:

Agency: Date: from to (month/day/year) (month/day/year) Contact Person: Title: Telephone # Duties:

Agency: Date: from to (month/day/year) (month/day/year) Contact Person: Title: Telephone # Duties: I CERTIFY THAT THE ANSWERS AND RESPONSES PROVIDED FOR ALL ITEMS IN THIS SUPPLEMENTAL APPLICATION FORM ARE TRUE TO THE BEST OF MY KNOWLEDGE AND SUBJECT ME TO THE REQUIREMENTS AND/OR DISCIPLINARY MEASURES AS PROVIDED UNDER THE UNIVERSITY'S STUDENT CONDUCT CODE.

SIGNATURE: Date: (month/day/year)

5/11/2015

VERIFICATION OF WORK OR VOLUNTEER EXPERIENCE IN THE HEALTH FIELD FORM If you have work or volunteer experience in the health field which you wish to have evaluated for consideration in the application process for the EMT program at Kapi'olani Community College, complete the top portion of the Work/Volunteer Verification Form and take or send it to your employer or volunteer supervisor. Have the employer or volunteer supervisor complete the bottom portion of the form and submit it directly to the Department of Emergency Medical Services at the address given below. ALL FORMS MUST BE RECEIVED BY THE APPLICATION DEADLINE. Note to applicant: Reproduce extra copies of this form as needed. Please also provide agency with addressed + stamped envelope. Please inform recipient this verification has to be POST MARKED by the date due.

FOR APPLICANT USED - PLEASE PRINT CLEARLY

NAME: Last First MI Name of agency:

Position with agency:

Dates of employment or volunteer service: From: To: (month/day/year) (month/day/year) Did you work directly with patients (circle one) YES / NO Duties (if additional space is needed – please use the back of this page)

FOR AGENCY USE:

□ I verify that the above information is accurate □ I am unable to verify the above information.

Comments: (if additional space is needed – please use the back of this page) Form completed by: Print Name Signature Position of respondent: Date: (month/day/year) When this form is completed, please return to:

MAUI EMS Training Center 310 Kaahumanu Avenue, Bldg 215

Kahului, HI 96732 ATTN: EMT Application Verification Form

The deadline for receipt of this Work or Volunteer Verification Experience Form is: October 26: For Spring Emergency Medical Technician applicants

6/12/2015

APPLICANT CERTIFICATIONS:

I certify that the answers and responses provided for all of the items on this Admissions Application/Check List are true to the best of my knowledge and belief. I understand that providing incorrect or false information will subject me to the requirements and/or discipline measures as provided under the University’s Student Conduct Code. I understand that if I am not accepted into the program of application, I must submit a new application and all required documents for any subsequent semester. I also allow KISC to change my major and home institution if I am accepted into the EMT program. I understand that if I am not accepted into the EMT program, my home institution and major will not change.

“Health care students are required to complete University prescribed academic requirements that involve practice in a University affiliated health care facility setting with no substitution allowable for the completion required clinical practice. Failure of a student to complete the prescribed clinical practices shall be deemed as not satisfying academic program requirements. It is the responsibility of the student to satisfactorily complete any background checks and drug testing that may be required by the affiliated health care facility to which he/she is assigned for clinical practice in accordance with procedures and timelines as prescribed by that affiliated health care facility.”

I have read and understand the notification that a background check and drug test may be required for entry into clinical practice. I also understand that clinical practice is required for completion of this program. __________ (please initial)

I certify that the answers and responses provided for all items in this supplemental application form are true to the best of my knowledge and subject me to the requirements and/ or disciplinary measures as provided under the University’s student conduct code. ________ (please initial)

Print Name ____________________________ Signature ________________________ Date_____________

EXAMPLE of how to complete the application:

These are the requirements Tell us what class you took to meet each requirement

Course Alpha

Credits Term of

Completion

Where Completed

(i.e., Institution Name)

Grade

EMT PREREQUISITES

ENG 100 Composition I (3) WRI 1200 3.0 Fall 2007 HPU B

HLTH 125 Survey of Medical Terminology (1) HLTH 125 3.0 SP 2008 KCC A

E m e r g e n c y M e d i c a l S e r v i c e s D e p a r t m e n t

6/12/2015

CRITERION FOR ACCEPTANCE:

Qualification is based on a rating system, grades for completed prerequisites, support courses, supplemental documents, and interview. Selection is based on total qualifying scores in rank order from the highest score until admission quota is met for the EMT program.

EMT PREREQUISITES

EFFECTIVE FALL 2014

Course Alpha/Test

Score Credits

Term of Completion

Where Completed

(i.e., Institution Name)

Grade

ENG 100 Composition I (3)

HLTH 125 Survey of Medical Terminology (1)

COMPASS Placement Test Score of MATH 24 or higher (within last two years)

MICT PREREQUISITES Course Alpha Credits Term of

Completion

Where Completed

(i.e., Institution Name)

Grade

MATH 103 College Algebra (3) or higher

BIO 130 & BIO 130 L Anatomy & Physiology & Lab (4+1) OR (WITHIN 5 YEARS)

ZOOL 141 & ZOOL 141L Human Anatomy & Physiology I & Lab (3+1) AND

ZOOL 142 & ZOOL 142L Human Anatomy & Physiology II & Lab (3+1) (WITHIN 5 YEARS)

MICT PROGRAM SUPPORT COURSES

Course Alpha Credits Term of

Completion

Where Completed

(i.e., Institution Name)

Grade

FAMR 230 Human Development (3cr)

AS Arts & Humanities Course (3cr)

Application Summary: For office use only Date Received: _____________________ Ethnic Code: ____________ Counselor’s Initials: _________________ Application Complete: _____________ HI Resident: Y N KCC GPA Verified: _______________

E m e r g e n c y M e d i c a l S e r v i c e s D e p a r t m e n t

Total Coursework Score: ________ Supplemental Documents Score: ________ Total Interview Score: ________ Total Score: ________

Name: _____________________________________  UHID: ________________________________ 

Program: _______________________________________________________________ 

Please be clear and concise in your response for each reflective essay, limiting each question to 300 words. 

Career Pathway Preparation 

1. In a brief statement describe your career goals in this pathway.  Where do

you see yourself in this career pathway in the next three years? 

H e a l t h S c i e n c e s D e p a r t m e n t

Kapi`olani Community College MY PLAN

Reflection Essays

Career Pathway Attributes 

2. In viewing “Health Careers at a Glance”, what are your strongest and

weakest “professional qualities” in your chosen career pathway?  Please

describe these attributes; how do you plan to overcome your challenges,

how do you plan to improve on your strengths?

H e a l t h S c i e n c e s D e p a r t m e n t

Career Pathway Outlook 

3. Describe any personal obstacles you face that may impact your current

academic success and how you plan to overcome these challenges? (I.e.

transportation, financial obligations, child care, time management).  What

support systems do you have in place to overcome them?

H e a l t h S c i e n c e s D e p a r t m e n t

The purpose of the self-assessment is to discover your strengths and areas of focus. Working in healthcare requires a combination of academic skills, social skills, and a commitment to public service. As you plan, find ways to make your strengths shine and to improve your weaker areas. Consider discussing your self-assessment and reflective essays with a counselor to understanding how they support your academic and career goals.

Academic Strength Below

Expectations Meets

Expectations Exceeds

Expectations

Cumulative GPA Prerequisite Course GPA Completed prerequisites Completed support courses Writing abilityLetters of evaluation Awards/Achievements

Knowledge of the Profession Below

Expectations Meets

Expectations Exceeds

Expectations

Relevant experience – volunteer Relevant experience – for credit Relevant experience – paid Relevant Public service/Service Learning Understanding of current healthcare issues Comfort with bodily fluids Comfort with illness Comfort with injury Comfort with death Comfort with physical contact with people Ability to multitask and adapt to change

Personal Characteristics Below

Expectations Meets

Expectations Exceeds

Expectations

Commitment to public service Empathy/altruism Moral/ethical integrity Emotional maturity Responsibility Leadership Dedication/hard-working Commitment to life-long learning Ability to work as a team Personal interests & experience

H e a l t h S c i e n c e s D e p a r t m e n t

Kapi`olani Community College MY PLAN

Self - Assessment

Information is subject to change without notice. UPDATED: FALL 2015

HEALTH CAREERS @ A GLANCE FOR NURSING

HEALTH CAREERS COUNSELING CENTER

Program Health Services

Occupational Cluster

Professional Qualities Starting

Semester Application

Period Selection Process

Selection Criteria

Qualifying Placement Tests Prerequisites Support Courses

Required to Apply Degree

(Credits)

Dental Assisting (DENT)

Therapeutic Dental

Professional Attitude Time Management

Compassion Flexibility

Adapt to Changes Ability to Multitask

Fall Dec 1 - June 30 Best Qualified, First Accepted

Cumulative Score from Completed

Prerequisites None English 100

Math 100 (or higher) SP 151 ZOOL 141,141L None CA:39

Emergency Medical Technician (EMT)

Therapeutic Direct Patient Care

Integrity Empathy

Self Motivation Appearance & Hygiene

Self Confidence Time Management

Communication Skills Teamwork & Diplomacy

Respect Patient Advocacy

Fall Spring

June 1 - Oct 1 Dec 1 - Apr 1

Best Qualified, First Accepted

Cumulative Score from Completed

Prerequisites, Sup-plemental Applica-

tion Requirements, & Interview

COMPASS MATH 24 or higher or evidence of com-pletion

English 100 Health 125

None CC:13

Health Informatics (HI)

Health Information Fall Dec 1—Apr 30 First Qualified, First Accepted

Qualifying Scores/Courses

COMPASS ENG 22 or higher & COMPASS MATH 24 or higher, or evidence of com-pletion of both

None None CC:30 AS: 71

Medical Assisting (MEDA)

Therapeutic Patient Care, Health Info & Diagnostic

Compassion Attention to Detail Ability to Multitask,

Organizational Skills, Good Verbal & Written Communication Skills

Adaptability & Flexibility

Fall Dec 1—Mar 1

Best Qualified, First Accepted

Qualifying Scores/Courses

COMPASS ENG 22 or higher & COMPASS MATH 24 or higher, or evidence of com-pletion of both

None None CC:33 AS:64

Medical Laboratory Technician (MLT) Diagnostic Laboratory

Attention To Detail Integrity

Dependability Good Verbal & Written Communication Skills

Self-Starter Ability To Multi-Task

Spring June 1—Sept 1 Best Qualified, First Accepted

Cumulative Score from Completed Prerequisites &

Support Courses

None

Recommended: CHEM 162 + 162L

MICR 130 MICR 161

AS SS AS AH

AS:70-73

Mobile Intensive Care Technician (MICT)

Therapeutic Direct Patient Care

Integrity Empathy

Self Motivation Appearance & Hygiene

Self Confidence Time Management

Communication Skills Critical Thinking * Problem

Solving Skills Teamwork & Diplomacy

Respect Patient Advocacy

Spring June 1—Oct 1 (every other year)

Best Qualified, First Accepted

Cumulative Score from Completed

Prerequisites, Sup-plemental Applica-

tion Requirements, & Interview

None HLTH 125 ENG 100 BIOL 130 + 130L

None CC:44 AS:69

ENG 100 or ESL 100; MATH 103 or higher; BIOL 130 or BIOL 171 or ZOOL 141 & ZOOL 142; CHEM 161 & 161L; MLT 100

All programs give priority seating to qualified Hawai`i state residents. Each student should develop a “My Plan” with the Health Sciences/Nursing Counselor(s) for their intended program/career pathway. UPDATED: 05/2014

Information is subject to change without notice.

UPDATED: 5/2015HEALTH CAREERS @ A GLANCE FOR NURSING

HEALTH CAREERS COUNSELING CENTER

Program Health Services

Occupational Cluster

Personal Qualities Starting

Semester Application

Period Selection Process

Selection Criteria

Qualifying Placement Tests Prerequisites Support Courses

Required to Apply Degree

(Credits)

Occupational Therapy Assistant

(OTA)

Therapeutic Rehabilitation

Able to Related & Engage With People,; “people person” Self Motivated & Responsible

Organizational Skills Commit To Rigorous Study

Communication Skills Critical Thinking Skills Creative & Adaptability

Teamwork Skills

Fall Dec 1—May 30 First Qualified, First Accepted

Qualifying Scores/Courses

COMPASS ENG 100, & COMPASS MATH 24 or higher, or evi-dence of comple-tion of both

None None Recommended:

ENG 100 MATH 100

CC: 5 AS:70-72

Physical Therapist Assistant (PTA)

Therapeutic Rehabilitation

Accountability Altruism

Compassion and Caring Culture Competence

Duty Integrity

Social Responsibility Communication Problem Solving

Fall Apr 1—May 25 Best Qualified, First Accepted

Cumulative Score from Completed

Prerequisites & Ob-servation

Reference Score

None

ENG 100 MATH 103 or higher HLTH 120 SP 181 ZOOL 141,141L,142,+142L

PTA 101W FAMR 230 HLTH 125 HLTH 290 + HLTH 290L A.S. Humanities Course None AS:72

Radiologic Technician

(RAD) Diagnostic Imaging

Communication Skills Compassion

Hand-Eye Coordination and Visualization

Acute Problem Solving Skills/Ability to Adapt

Function Under Pressure Good Work Ethic

Fall Apr 1—May 31 Best Qualified, First Accepted

Cumulative Score from Completed Prerequisites &

Support Courses, & A2 Exam

HESI A2 Exam ENG 100 MATH 135 or higher HLTH 125

BIOL 130 + 130L or ZO-OL141,141L,142,+142L

AS/AH AS/SS AS:89-92

Respiratory Care Practitioner (RESPI)

Therapeutic Direct Patient Care

Communication Skills Compassion and Caring

Culture Competence Ability to Adapt

Ability to Multitask Organizational Skills

Problem Solving Skills Integrity

Teamwork & Diplomacy Good Work Ethic

Fall Dec 1—May 30 Best Qualified, First Accepted

Cumulative Score from Completed

Prerequisites, Inter-view, Essay, & Evi-

dence of Degree Earned

None

ENG 100 MATH 100 or higher HLTH125 or HLTH110 PSY 100 or FAMR230 CHEM 100 or higher

ZO-OL141,141L,142,+142L MICR 130 or MICR 135 MICR 140 A.S. Humanities Course None AS:67-68

All programs give priority seating to qualified Hawai`i state residents. Each student should develop a “My Plan” with the Health Sciences/Nursing Counselor(s) for your intended program/career pathway.