Rev. 9/12/2019

Certificate of Achievement/ Associates in Science Degree

Oahu: Spring Application Period: June 1 – Ocotber 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 typewritten or neatly printed, and submit this Admission Application Checklist and all required documents to a Health Sciences Counselor during walk-in counseling hours. If the application deadline falls on a weekend or recognized holiday, applications will be accepted on the following business day. Only this completed program Admission Application including supplemental documentation submitted to the Health Career Counseling Center (Kauila 106) by the appropriate deadline will be accepted for processing. Applications must be submitted in person during walk-in counseling only. APPLICANT INFORMATION Name: UH Number/Username Last Name First Name M.I. Mailing Address: Street / POB City State Zip Code Phone: Cell Home Work UH SYSTEM Email 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 Identify the island that you are applying to: _____________________________

2 Attend a Mandatory MICT Program Information Session.

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

Date Attended: (Month / Day / Year)

3 Complete the online UH System Application if you are not currently enrolled at any UH System institution

during the semester you submit your application. (http://apply.hawaii.edu)

4 Prerequisite Courses must be completed with a “C” grade or higher and meet five year time limit (Anatomy & Physiology timelimit may be waived, contact Counselors for more information).

5 College transcripts for courses completed within the University of Hawai‘i System. Print out

student copy of unofficial transcripts for all course work WITHIN the UH System and highlight all prerequisite/qualification courses. UH system transcripts are downloadable from the UH Portal (myuh.hawaii.edu).

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 MOBILE INTENSIVE CARE TECHNICIAN PROGRAM

Admission Application Checklist

Rev. 9/12/2019

6 College transcripts for courses completed outside of the University of Hawai‘i System. If transferring courses from institutions outside the UH System, please list the institution and when your transcript was requested:

My external transcripts have been evaluated by KCC. Submit your transfer course report from STAR accessible via the UH Portal (myuh.hawaii.edu). My external transcripts have not been evaluated by KCC. Submit unofficial copies with this application, send official copies to the KCC Kekaulike Information & Service Center, complete Online request for Transcript Evaluation. To complete this form, you must log in with your UH Email account. Complete this form at: http://go.hawaii.edu/oxG

• Institution: ___________________________ Transcript Request Date: ___________ • Institution: ___________________________ Transcript Request Date: ___________ • Institution: ___________________________ Transcript Request Date: ___________

7 “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.

8 Submit original State of Hawai‘i Abstract of Traffic Record within 6 months from the application

deadline. 9 Submit a copy of your Hawai‘i driver’s license. 10 Submit a 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).

11 Submit copy of current Hawai‘i State Certification as an EMT. 12 Submit documents verifying prior or current work experience in the health field. Forms for work/volunteer

experience are included in the packet. 13 Submit documentation of 300 ambulance transports via EMT/MICT career ladder program verification of

work experience in the health field Part B (log sheet). 14 Submit copies of CME records beginning with the last certification period. 15 Health Immunization Form must be completed and signed by a physician, physician assistant, or

nurse practitioner confirming all immunization and/or titer dates and readings are accurate and up to date. Signed form must be submitted by your orientation date. Failure to submit completed and sign form on time may result in dismissal from program

○ Influenza, ○ Mumps ○ Rubeola ○ Varicella ○ Hepatitis B Vaccine (HBV):○ HBV-1 ○ HBV-2 ○ HBV-3 ○ Tuberculosis (TB).

__________ (initial)

M I C T A p p l i c a t i o n

Rev. 9/12/2019

16 After completing the checklist, participate in an interview with the Mobile Intensive Care Admissions Committee. An interview letter will be sent by the Department of Emergency Medical Services to notify you when your interview will be held.

17 Complete EMT Knowledge Exam. Your KCC EMS Training Center will notify you when the EMT

Knowledge Exam will be scheduled. 18 Schedule a EMT Psychomotor Competency Exam with your KCC EMS Training Center, using EMT-level

skill sheets found at www.nremt.org

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) I understand that priority selection is given to Hawai‘i State residents for tuition purposes and that non-residents will be considered after all qualified residents have been accommodated per Board of Regents Policy. ________ (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 1200 3.0 Fall 2007 HPU B

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

M I C T A p p l i c a t i o n

Rev. 9/12/2019

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 Institution Name Grade

MICT PREREQUISITES

ENG 100 Composition I (3) or ESL 100 Composition I (3)

HLTH 125 Survey of Medical Terminology (1)

EMT 110 Emergency Medical Technician (10.5)

EMT 120 Emergency Medical Technician - ALS Assist (1.3) EMT 125 Emergency Medical Technician - ALS Practicum (3.8)

MATH 103 College Algebra (3) or higher

BIO 130 & BIO 130 L Anatomy & Physiology & Lab (4+1) OR PHYL 141 & PHYL 141L Human Anatomy & Physiology I & Lab (3+1) AND PHYL 142 & PHYL 142L Human Anatomy & Physiology II & Lab (3+1)

*Five year time limit – may be waived, contact Counselors for more information*

PROGRAM SUPPORT COURSES Not required for admission

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 KapCC GPA Verified: _______________

M I C T A p p l i c a t i o n

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

Kapi‘olani Community College, Health Sciences and Emergency Medical Services Departments 4303 Diamond Head Road, Kauila 106 ♦ Honolulu, Hawai’i 96816-4421 ♦ Telephone: (808) 734-9224

Website: www.kapiolani.hawaii.edu An Equal Opportunity/Affirmative Action Institution

Rev. 9/12/2019

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.

EMT/MICT CAREER-LADDER PROGRAM WORK VERIFICATION FORM

PLEASE PRINT

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.

M I C T A p p l i c a t i o n

Rev. 9/12/2019

NAME

EMT/MICT CAREER LADDER PROGRAM

VERIFICATION OF WORK EXPERIENCE IN THE HEALTH FIELD FORM

(PART B-log sheet)

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.

M I C T A p p l i c a t i o n

Rev. 9/12/2019

Immunization/TB Clearance Record – Due by Admission Orientation (Form 12)

Name of Applicant: UH ID:

This page must be completed and signed by a physician in order for your application to be complete.

Immunization Type and Date AND Titer and Date Mumps TITER IS REQUIRED (See Below)

Diphtheria, Pertussis, and Tetanus (DPT)

Influenza

*Rubeola (Measles) 1st Dose TITER IS REQUIRED (See Below)

2nd Dose

*Rubella TITER IS REQUIRED (See Below) *Varicella (Chicken Pox) TITER IS REQUIRED (See Below)

**Hepatitis B

Shot 1 Date: Shot 2 Date: Shot 3 Date:

TB Clearance ***Skin Test (2-Step) Required OR Chest X-Ray Date and Results Date and Results

1st 1st Shot Date

1st Read Date

2nd 2nd Shot Date:

2nd 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) Revised 05/03/2016

M I C T A p p l i c a t i o n

Rev. 9/12/2019

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 1st 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.

M I C T A p p l i c a t i o n

Rev. 9/12/2019

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 re-administration of the entire vaccination series.

M I C T A p p l i c a t i o n

The University of Hawai‘i does not discriminate on the basis of race, sex, age, color, national origin, or disability. For inquiries regarding our nondiscrimination policies, please contact the Kapiolani Community College designees:

Deneen Kawamoto, ADA Coordinator for Students Office: ‘Ilima 107 (808) 734-9522; deneenk@hawaii.edu

UHCC offers Career and Technical Education (CTE) Programs of Study leading to Associate of Science (AS) and Associate of Applied Science (AAS) degrees, as well as postsecondary certificates, in career fields such as arts and communications, business, health careers, industrial and engineering technology, natural resources, and public and human services. For more information, visit our website at http://uhcc.hawaii.edu/programs/index.php. UHCC applies an open access policy, with program admission based upon the completion of applicable course/testing prerequisites. The lack of English skills will not be a barrier to admission and participation in CTE programs.

Rev. 9/12/2019

1.

Name: UHID:

Please answer one of the three essay questions below. Please be concise in your response for each reflective essay. Limit 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?

M I C T A p p l i c a t i o n

Kapi`olani Community College Personal Essay MICT Program

Rev. 9/12/2019

2.

Name: UHID:

M I C T A p p l i c a t i o n

Kapi`olani Community College Personal Essay MICT Program

3/25/2019

The purpose of the My Plan Self-Assessment is a counseling tool for prospective healthcare majors to identify and better understand your career pathway including your strengths and areas of focus. Working in healthcare requires a combination of academic and professional knowledge and skills and a commitment to public service. As you plan, find ways to make your strengths shine and to improve your weaker areas. Please complete areas of this self-assessment by marking the boxes. All response are voluntary. Consider discussing your self-assessment with a counselor/advisor to understanding how they support your academic and career goals.

Knowledge of the Profession Below Expectations

Meets Expectations

Exceeds Expectations

Identified career goals in my health pathway Identified career alternatives in my health pathway Relevant experience – by volunteer experiences Relevant experience – by servicing learning experiences Relevant public service – by paid work experiences Understand “professional qualities” of health pathway(s) Understanding of current healthcare issues Comfort with bodily fluids or personal patient care Comfort with illness Comfort with injury Comfort with death Comfort with physical contact with people Ability to multitask and adapt to change Ability to accept constructive feedback Ability to handle occupational crises, challenges or problems Ability to move forward to achieve the goals and outcomes Ability to follow safety guidelines and standards of practice

Personal Characteristics Below Expectations

Meets Expectations

Exceeds Expectations

Demonstrate commitment to public service Demonstrate empathy/altruism Demonstrate moral/ethical integrity Demonstrate emotional maturity Demonstrate good interpersonal relationships Accept responsibility Ability to work independently to achieve the goal/task Collaborate and teamwork to achieve the goal/task Accept and demonstrate leadership Be dedicated/hard-working healthcare practitioner Committed to life-long learning

Kapi`olani Community College MY PLAN

Self – Assessment

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

3/25/2019

Academic Strength Below Expectations

Meets Expectations

Exceeds Expectations

+Completed prerequisites of health program of study +Completed support courses of health program of study Achieved minimum cumulative GPA for program entry Achieved prerequisite course GPA for your program entry Effective verbal and nonverbal communication skills Ability to utilize technology effectively for learning

Established Support Systems to Succeed in Health Pathway Program

Below Expectations

Meets Expectations

Exceeds Expectations

Established support for transportation to externships Established support for financial assistance prior to entry Established support for nonacademic responsibilities Established support for personal and time management skills Established support for continuous professional learning Established opportunities to balance personal, family, & school Established support for campus and community resources

+As required for program entry and graduation or meet other requirements as directed for program admissions.

An Equal Opportunity/Affirmative Action Institution

Kapi`olani Community College MY PLAN

Self-Assessment

The University of Hawai‘i does not discriminate on the basis of race, sex, age, color, national origin, or disability. For inquiries regarding our nondiscrimination policies, please contact the Kapiolani Community College designees:

Kelli Brandvold, ADA Coordinator for Employees and EEO/AA Campus Coordinator Office: ‘Ilima 208 (808) 734-9575; kellib@hawaii.edu

Deneen Kawamoto, ADA Coordinator for Students Office: ‘Ilima 107 (808) 734-9522; deneenk@hawaii.edu

UHCC offers Career and Technical Education (CTE) Programs of Study leading to Associate of Science (AS) and Associate of Applied Science (AAS) degrees, as well as postsecondary certificates, in career fields such as arts and communications, business, health careers, industrial and engineering technology, natural resources, and public and human services. For more information, visit our website at http://uhcc.hawaii.edu/programs/index.php. UHCC applies an open access policy, with program admission based upon the completion of applicable course/testing prerequisites. The lack of English skills will not be a barrier to admission and participation in CTE programs.

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