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1 Kapi`olani Community College MOBILE INTENSIVE CARE TECHNICIAN PROGRAM Admission Application Checklist Certificate of Achievement/ Associates in Science Degree Island of Hawai'i: Application Periods: December 1, April 17, 2017 at 4:00 p.m. Hawai'i EMS Training Center, 200 W. Kawili St, Bldg 281, Rm 8 Directions: Please complete each item carefully and submit this Admissions Application Checklist and all required documents to Hawai'i EMS Training Center. Only this fully completed program Admissions Application Checklist submitted to Hawai'i EMS Training Center by the appropriate deadline (see above) will be accepted for processing. APPLICANT INFORMATION Name: Mailing Address: Phone: Last Name First Name M.I. UH Number/Username Street / POB City State Zip Code Cell Home Work UH SYSTEM Address: List other name(s) used on documents: (Notify the KAPCC Kekaulike Information & Service Center regarding other names used on college documents.) ADMISSIONS APPLICATION CHECKLIST FOR MICT PROGRAM 1. Attend a MICT Program Information Session. Contact Hawai'i EMS Training Center for information session time and date. Date Attended: (Month / Day / Year) 2. Complete the online UH System Application if you are not currently enrolled at any UH System institution during the semester you submit your application. ( 3. Prerequisite Courses must be completed with a C grade or higher and Anatomy & Physiology must meet the five year time limit. If your A&P course is older than five years, contact a counselor to determine if you qualify for a time limit waiver. 4. Student copy (unofficial) transcripts for course work WITHIN the UH System. UH system transcripts are downloadable from the UH Portal (myuh.hawaii.edu). Student copies of UH System transcripts must be submitted with this checklist. 5. College transcripts for courses completed outside of the University of Hawai i System. My external transcripts have been evaluated by KCC. Submit your transfer course report from STAR accessible via the UH Portal (myuh.hawaii.edu). 1 Rev. 12/20/16

2 My external transcripts have not been evaluatd by KCC. Submit unofficial copies with this application and also send official copies to the KCC Kekaulike Information & Service Center. Institution: Institution: Transcript Request Date: Transcript Request Date: Institution: Transcript Request Date: Online request for Transcript Evaluation - A request for transcript evaluation must be completed for all coursework outside the UH System. Complete this form online at: 6. MICT Personal Essay. The MICT personal essay has a minimum of 200 words and a maximum of 500 words using the template provided in this packet. 7. Original State of Hawai i Abstract of Traffic Record within 6 months from the application deadline. 8. Copy of your Hawai i driver s license. 9. Copy of your current CPR certification card. CPR certification must be full-certification, which includes Adult, Child, and Infant CPR (1 and 2 rescuer), Automatic External Defibrillator (AED), and Foreign Body Airway Obstruction, called Basic Life Support (BLS). 10. Copy of current Hawai i State Certification as an EMT. 11. Documents verifying prior or current work experience in the health field. Forms for work/volunteer experience are included in the packet. 12. Submit documentation of 300 ambulance transports via EMT/MICT career ladder program verification of work experience in the health field Part B (must use log sheet provided in this application. Make additional copies as needed). 13. Copies of CME records beginning with the last certification period. 14. Health immunization records are required if accepted into the program. Verification of the following immunizations must be submitted by your orientation date. Failure to submit documentation will result in up to dismissal. Influenza, Mumps Rubeola Varicella Hepatitis B Vaccine (HBV): HBV-1 HBV-2 HBV-3 Tuberculosis (TB). See pages 7-9 for more actual health forms that must be completed and submitted by your orientaiton date. Initial 2 Rev. 12/20/16

3 15. After completing the checklist, participate in an interview on October 21, 2016 with the Mobile Intensive Care Admissions Committee. Interview time will be scheduled in order of completed application received. 16. Complete the EMT Placement Exam. Hawai'i EMS Training Center will notify you when the EMT placement exam will be scheduled. 17. Complete the EMT Psychomotor Skills Exam with your KCC EMS Training Center, using EMTlevel skill sheets found at 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 MICT program. I understand that if I am not accepted into the MICT 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 MICT PREREQUISITES ENG 100 Composition I (3) WRI Fall 2007 HPU B 3 Rev. 12/20/16

4 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 MICT program. Course Alpha Credits Term of Completion Where Completed (i.e., Institution Name) Grade MICT PREREQUISITES ENG 100 Composition I (3) HLTH 125 Survey of Medical Terminology (1) EMT 100 Pre-Hospital Emergency Care (10cr) EMT 101 Pre-Hospital Emergency Care Practicum (3cr) MATH 103 College Algebra (3) or higher BIO 130 & BIO 130 L Anatomy & Physiology & Lab (4+1) OR ZOOL 141 & ZOOL 141L Human Anatomy & Physiology I & Lab (3+1) AND ZOOL 142 & ZOOL 142L Human Anatomy & Physiology II & Lab (3+1) *Five year time limit may be waived, contact Counselors for more information* PROGRAM SUPPORT COURSES 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: Y N HI Resident: : Y N KCC GPA Verified: Total Coursework Score: Supplemental Documents Score: Total Interview Score: Total Score: 4 Rev. 12/20/16

5 VERIFICATION OF WORK EXPERIENCE IN THE HEALTH FIELD If you have work experience in the health field, which you wish to have evaluated for consideration in the application process for the MICT programs at Kapi'olani Community College, complete the top portion of the Work Verification Form and take or send it to your employer. Have the employer complete the bottom portion of the form and submit it with the MICT application. Note to applicant: You may reproduce extra copies of this form as needed. PLEASE PRINT EMT/MICT CAREER-LADDER PROGRAM WORK VERIFICATION FORM NAME: UH ID # Last First MI Name of employing agency: Position with agency: Dates of employment: From: To: Duties: ******************************************************************************** For employing agency's use: I verify that the above information is accurate. I am unable to verify the above information. Comments: Employer's name: Form completed by: Print Name Signature Position of respondent: Date: When this form is completed, please submit with the MICT application. 5 Rev. 12/20/16

6 NAME EMT/MICT CAREER LADDER PROGRAM VERIFICATION OF WORK EXPERIENCE IN THE HEALTH FIELD FORM (Applications must use this log sheet. Make additional copies if necessary) Work experience as an EMT is required prior to entrance into the MICT field program. At least 300 ALS or BLS ambulance transport calls are required. Please list the information requested below for the cases in which you served as the EMT. Verification from a MICT is required. HEMSIS records are also acceptable. Date Type of Call Patient Diagnosis MICT Signature (Emergency, for verification Transfer, etc.) I verify that the above information is true and accurate. Printed name Signature To applicant: Photocopy extra copies of this form as needed. When this form is completed, please submit with the MICT application. 6 Rev. 12/20/16

7 Name of Applicant: Immunization/TB Clearance Record Due by Admission Orientation (Form 12) UH ID: This page must be completed and signed by a physician in order for your application to be complete. Mumps Diphtheria, Pertussis, and Tetanus (DPT) Influenza Immunization Type and Date AND Titer and Date TITER IS REQUIRED (See Below) *Rubeola (Measles) 1st Dose TITER IS REQUIRED (See Below) 2nd Dose *Rubella *Varicella (Chicken Pox) TITER IS REQUIRED (See Below) TITER IS REQUIRED (See Below) **Hepatitis B Shot 1 Date: 1st Shot 2 Date: Shot 3 Date: TB Clearance ***Skin Test (2-Step) Required OR Chest X-Ray Date and Results Date and Results 1 st Shot Date 1 st Read Date 2 nd 2 nd Shot Date: 2 nd Read Date: *Rubeola, Rubella, and Varicella Immunization/Titer: For students in the DMS, MLT, MLT-P, PTA, RAD, RESP, EMT, and MICT programs, titers indicating the student's state of immunity to measles, rubella and chicken pox are required. If titers are negative, must show proof of receiving the appropriate boosters on this sheet. **Hepatitis B Vaccination: Hepatitis B vaccination is strongly recommended. Health Education students are offered the Hepatitis B series through University of Hawaii at Manoa, Student Health Services (see enclosed memo). Students may refuse the Hepatitis B vaccine; if they do, they must sign a refusal statement at the time of program advising for registration. If titers are negative, must show proof of receiving the appropriate boosters on this sheet. ***TB Clearance: If clearance is by skin test, the 2-STEP TEST IS REQUIRED for students in the DMS, MLT, MLT-P, OTA, PTA, RAD, RESP EMT & MICT programs. The State Department of Health Provides this service free of charge but you must identify yourself as a Health Sciences or EMS student from Kapi'olani Community college and that you are required to take the 2-step TB skin test. (IMPORTANT NOTE: The test must be completed no later than 1 year prior to the end of class. Skin tests are valid for only 1 year.) Physician s Name (printed) Physician s Signature Date Address (printed) 7 Rev. 12/20/16

8 Guidelines for Rubeola/Rubella/Mumps/Varicella Clearance Documentation of a positive titer result is required. Explanation of Titer Results and Required Actions: Positive Titer: Titers that indicate a positive immunity against the designated disease are acceptable and do not require any further action. Equivocal Titer: Titers that indicate an equivocal immunity against the designated disease must be accompanied by documentation of two administered immunity booster shots. Negative Titer: Titers that indicate a negative immunity against the designated disease must be accompanied by documentation of two administered immunity booster shots. Guidelines for Tetanus/Diphtheria Clearance Documentation of a booster shot within ten years and/or the immunization or booster date is required. Guidelines for Influenza Clearance Valid Duration: Documentation of the current seasonal influenza immunization is required. Influenza season can be present from October to March. Typically, an influenza vaccination that was received on or after September 1 st of the current season is acceptable. Requirements for Tuberculosis (TB) Clearance Valid Duration: Skin Test: A negative 2-step TB skin test must be obtained and dated within one year of the last day of the scheduled clinical shift. This process usually consists of a TB skin test injection on one arm with a second TB skin test occurring seven days later on the other arm. If a 1-step TB skin test was performed within one year, then another 1-step TB skin test can be performed and qualify as a 2-step exam, provided documentation of examination can be provided for both days. If a 2-step TB skin test was performed in the past, a 1-step TB skin test is acceptable, but must be dated within one year of the last day of the scheduled clinical shift and must accompany all proper documentation. Chest X-Ray: If a previous skin test had a positive result, then a chest x-ray must be performed. The negative chest x-ray results can be accepted if the procedure was performed within one year of the last day of the scheduled clinical shift, and if it accompanies the date of positive skin test with result size. The provider of the TB skin test (usually a personal physician or the Department of Health) may have applicable records. 8 Rev. 12/20/16

9 Guidelines for Hepatitis-B Clearance Validity: Documentation of a positive titer result, or documentation of a completed series of vaccinations is required. Explanation of Immunization requirements, Titer Results and Required Actions: Three Immunization shots: Documentation of a completed series of three shots is acceptable and does not require any further action. Positive Titer: Titers that indicate a positive immunity against Hepatitis-B are acceptable and do not require any further action. Equivocal Titer: Titers that indicate an equivocal immunity against Hepatitis-B must be accompanied by documentation of a single administered immunity booster shot. Negative Titer: Titers that indicate a negative immunity against Hepatitis-B must be accompanied by documentation of readministration of the entire vaccination series. 9 Rev. 12/20/16

10 Kapi`olani Community College Personal Essay MICT Program Name: UHID: Please answer one of the three essay questions below. Be clear and concise, limiting your response to a minimum of 200 words and a maximum of 500 words. Please identify which question you will answer. 1. Discuss your strengths as an EMT and your weaknesses. 2. Describe what you have done to build your strengths and improve your weaknesses. 3. What have you done to prepare yourself for MICT class? 10 Rev. 12/20/16

11 Kapi`olani Community College Personal Essay - continued MICT Program Name: UHID: 11 Rev. 12/20/16