Emerg ency Medical Services Dep artment Certificate of Competence Oahu: Fall Application Period: December 1 June 1 / Spring Application Period: June 2 October 1 Maui: Application Periods: TBA, Contact Maui EMS Training Center 808-244-4063 Hawai i: Application Periods: TBA, Contact Hawai i EMS Training Center 808-935-8002 Directions: Please complete each item carefully and submit this Admission Application Check List and all required documents to a Health Sciences Counselor during office hours at the Health Career Counseling Center in Kauila 106. Only this fully completed program Admission Application Checklist submitted to the Health Career Counseling Center in person to Kauila 106 by the appropriate deadline will be accepted for processing. APPLICANT INFORMATION Kapi`olani Community College EMERGENCY MEDICALTECHNICIAN PROGRAM Admission Application Checklist Name: Mailing Address: Phone: Last Name First Name M.I. UH Number/Username Street / POB City State Zip Code 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. 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: Institution: Institution: Transcript Request Date: Transcript Request Date: Transcript Request Date: 10/5/2015
Emergency Medical Services Department 6. 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) 7. My Plan Initiative Complete reflection essays and self-assessments for the EMT program (see attached.) 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 and verification must be submitted with this application. We only accept certifications cards (not certificates) provided by the AMERICAN HEART ASSOCIATION!!! Certification cards (certificates are not accepted) cannot expire prior to the end of the program you are applying to. Certification cards (certificates are not accepted) must also be typewritten. First Aid and CPR card (not certificates) can be obtained from organizations such as the following: KCC Office of Non-Credit Programs (KCC): 734-9211 American Medical Response (AMR): 487-4900 I have attached a copy of the front and back of my AHA HEALTHCARE PROVIDER CPR card: AHA Training Center Name BLS for the Healthcare Provider Exp. Date I have attached a copy of the front and back of my First Aid Card. AHA Training Center Name First Aid or Heartsaver First Aid Exp. Date 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 checklist, participate in an interview with the Emergency Medical Technician Admissions Committee. An interview letter will be sent by the Department of Emergency Medical Services to notify you when interview will be held. 10/5/2015
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 Contact Person: Title: Telephone # Duties: Agency: Date: from to Contact Person: Title: Telephone # Duties: Agency: Date: from to 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: 10/5/2015
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: 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: When this form is completed, please return to: Date: Health Sciences Counselor Kapi'olani Community College 4303 Diamond Head Road, Kauila 106 Honolulu, HI 96816-4421 The deadline for receipt of this Work or Volunteer Verification Experience Form is: June 1: For Fall Emergency Medical Technician applicants October 1: For Spring Emergency Medical Technician applicants 10/5/2015
Emerg ency Medical Services Dep artment 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 Circle Points EMT PREREQUISITES Course Alpha Credits Term of Completion Where Completed (i.e., Institution Name) Grade Points A B C ENG 100 Composition I (3) WRI 1200 3.0 Fall 2007 HPU B 12 9 6 HLTH 125 Survey of Medical Terminology (1) HLTH 125 3.0 SP 2008 KCC A 4 3 2 10/5/2015
Emergency Medical Services Department 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 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) Total Coursework Score: Supplemental Documents Score: Application Summary: For office use only Date Received: Ethnic Code: Total Interview Score: Counselor s Initials: Application Complete: Total Score: HI Resident: Y N KCC GPA Verified: 10/5/2015
Health Sciences Department Kapi`olani Community College MY PLAN Reflection Essays 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?
Health Sciences Dep artment 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?
Health Sciences Dep artment 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?
Health Sciences Department Kapi`olani Community College MY PLAN Self - Assessment 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 selfassessment and reflective essays with a counselor to understanding how they support your academic and career goals. Academic Strength Below Meets Exceeds Cumulative GPA Prerequisite Course GPA Completed prerequisites Completed support courses Writing ability Letters of evaluation Awards/Achievements Knowledge of the Profession Below Meets Exceeds 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 Meets Exceeds 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
Program Dental Assisting (DENT) HEALTH CAREERS COUNSELING CENTER HEALTH CAREERS @ A GLANCE FOR HEALTH SCIENCES/EMS Health Services Occupational Cluster Therapeutic Dental Professional Qualities Professional Attitude Time Management Compassion Flexibility Adapt to Changes Ability to Multitask Starting Semester Application Period Fall Dec 1 - June 30 Selection Process Selection Criteria Prerequisites Qualifying Placement Tests COMPASS Reading score of 74 or higher ENG 100 or ESL 100 Math 100 (or higher) Prerequisites SP 151 ZOOL 141 + 141L UPDATED: 06/2015 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. Suggested Degree Support Courses (Credits) CA:39 Emergency Medical Technician (EMT) Therapeutic Direct Patient Care Integrity Empathy Self Motivation Appearance & Hygiene Self Confidence Time Management Teamwork & Diplomacy Respect Patient Advocacy Fall Spring Dec 1 - June 1 June 2 - Oct 1 Prerequisites, Supplemental Application Requirements, & Interview COMPASS MATH 24 or higher or evidence of completion English 100 Health 125 MATH 24 or Equivalent coursework CC:13 Medical Assisting (MEDA) Therapeutic Patient Care, Health Info & Diagnostic Compassion Attention to Detail Ability to Multitask, Organizational Skills, Good Verbal & Written Adaptability & Flexibility Fall Dec 1 March 1 Qualifying Scores/ Courses COMPASS ENG 22 or higher & COMPASS MATH 24 or higher, or evidence of completion of both ENG 100 MATH 100 ZOOL 141 + 141L FAMR 230 AS/AH CC:33 AS:64 Medical Laboratory Technician (MLT) Diagnostic Laboratory Attention To Detail Integrity Dependability Good Verbal & Written Self-Starter Ability To Multi-Task Spring June 1 Sept 1 Prerequisites & Support Courses ENG 100 or ESL 100 MATH 103 or higher CHEM 161 + 161L MLT 100 BIOL 130 or BIOL 171 or ZOOL 141 & ZOOL 142 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 Critical Thinking * Problem Solving Skills Teamwork & Diplomacy Respect Patient Advocacy Spring June 1 Oct 1 (every other year) Best Qualified Prerequisites, Supplemental Application Requirements, & Interview ENG 100 HLTH 125 MATH 103 EMT 100 EMT 101 BIO 130 + 130L or ZOOL 141,141L, & 142,142L FAMR 230 AS CC:44 AS:69 Information is subject to change without notice. Updated: 7/9/2015
HEALTH CAREERS COUNSELING CENTER HEALTH CAREERS @ A GLANCE FOR HEALTH SCIENCES/EMS UPDATED: 06/2015 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. Program Health Services Occupational Cluster Personal Qualities Starting Semester Application Period Selection Process Selection Criteria Qualifying Placement Tests Prerequisites Suggested Support Courses Degree (Credits) Occupational Therapy Assistant (OTA) Therapeutic Rehabilitation Able to Relate & Engage With People; people person Self Motivated & Responsible Organizational Skills Commit To Rigorous Study Critical Thinking Skills Creative & Adaptability Teamwork Skills Fall April 1 May 31 Qualifying Scores/ Courses COMPASS ENG 100, & COM- PASS MATH 24 or higher, or evidence of completion of both ENG 100 or ESL 100 MATH 100 or higher BIOL 130, 130L or ZOOL 141,141L + 142,142L HLTH 125 OTA 110 OTA 119 AS/AH FAMR 230 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 Prerequisites & Observation Reference Score ENG 100 or ESL 100 MATH 103 or higher SP 181 FAMR 230 ZOOL 141,141L, 142,142L PTA 101W HLTH 120 HLTH 125 HLTH 290, 290L A.S. Humanities Course AS:72 Radiologic Technician (RAD) Diagnostic Imaging Compassion Hand-Eye Coordination and Visualization Acute Problem Solving Skills/ Ability to Adapt Function Under Pressure Good Work Ethic Fall Apr 1 May 31 Prerequisites & Support Courses, & A 2 Exam HESI A 2 Exam ENG 100 or ESL 100 MATH 135 or higher HLTH 125 BIOL 130 + 130L or ZOOL141,141L, 142,+142L AS/AH AS/SS AS: 89-92 Respiratory Care Practitioner (RESPI) Therapeutic Direct Patient Care Compassion and Caring Culture Competence Ability to Adapt Ability to Multitask Organizational Skills Problem Solving Skills Integrity Teamwork & Diplomacy Good Work Ethic Fall April 1 May 30 Prerequisites, Interview, Essay, & Evidence of Degree Earned ENG 100 or ESL 100 MATH 100 or higher HLTH125 or HLTH110 PSY100 or FAMR230 CHEM100 or higher ZOOL141,141L, 142,+142L MICR 130 or MICR 135 MICR 140 A.S. Humanities Course AS: 67-68 Information is subject to change without notice. Updated: 7/9/2015