Health IT Workforce Program Application
Return completed Application via US Mail or In Person to:
East Los Angeles College 1301 Avenida Cesar Chavez
Building G1 Room # 204 Monterey Park, CA. 91754
Attn: Gail Coyne
Preparing for the future……….…
Contact us at: [email protected] or http://healthit.elac.edu/
Offic e Phone # : (323) 265- 8855 Fa x#: (323) 26 5-8635
Dear Applicant:
Attached is the APPLICATION FOR ADMISSION into the Health IT Workforce Program. This innovative online and face-to-face lab program at East Los Angeles College is designed for professionals with backgrounds in Heath Information Management, Information Technology, Clinical and other Allied Health Professions preparing for the role of EHR Technical & Implementation Support Specialist for the upcoming nationwide Electronic Health Records initiative.
As part of a national consortium of colleges, East Los Angeles College will deliver a standardized curriculum designed to prepare a workforce equipped to serve the emerging needs of the healthcare industry.
Technical & Implementation Support Specialist role is needed for the ongoing support and facilitation of health IT systems across the health care industry, in organizations such as medical office practices, hospitals, health centers, long term care facilities, health information exchange organizations, state and local public health agencies and EHR vendors.
Please review the minimum entrance qualifications for enrollment in this program. Individuals applying for admission to this training MUST meet one or more of the criteria listed. If you meet one or more of the above criteria and you are a veteran spouse, you will be given priority admission:
If accepted, applicants will receive information regarding the MANDATORY orientation meeting prior to start date.
Please check all boxes that apply to you. Applications are reviewed on case-by-case basis for the skills and priority eligibility.
INFORMATION TECHNOLOGY PROFESSIONALS:
Bachelor’s Degree from a four-year college or university in Information Technology/
Computer Science with experience in information technology systems and at least one year of work experience
Associate’s of Science degree from a community college in Information Technology /Computer Science and at least one year of work experience
At least one year experience in systems development and project management of information systems.
At least one-year experience with industry certifications related to health information systems, EHRs, database management systems, or related field.
Experience with industry certifications related to information technology network systems with industry certifications.
HEALTHCARE PROFESSIONALS:
Bachelor’s Degree from a four-year college or university in Health Information
Management, Nursing/Clinicians and other allied health professions with at least one year of work experience
Associate’s of Science degree from a community college in Health Information Technology and other allied health professions with at least one year of work experience
Physician Office Manager or staff with two years experience in managing patient records and software application proficiency (i.e. Front office Medical assistants)
East Los Angeles College
APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE
Name: Gender: Male Female
Street Address:
City: State: Zip Code:
Home Phone: Work Phone:
Cell Phone #: Date of Birth:
Social Security No.: California resident for at least 1 year:
Yes No Email Address:
Please indicate your previous background experience:
Health IT IT/ Not Healthcare related Healthcare (Not IT related
Veteran Eligibility Status: Yes No (Please supply DD-214)
EDUCATION NAME OF SCHOOL AND LOCATION GRADUATION DATE
DIPLOMA/
DEGREE HIGH SCHOOL/GED
LIST ALL COLLEGES ATTENDED
HEALTHCARE, HIM and/or INFORMATION TECHNOLOGY WORK EXPERIENCE EMPLOYER
Location
JOB TITLE
Duties START DATE
END DATE
HOURS PER WEEK
Attach detailed resume to document health care or IT experience, industry training and certifications
Industry Certifications – Attach copy of license, certification, credential and awarding organization
Is your employer sending you to the training? Yes No
If yes, attach letter of verification on organization letterhead with original signature.
Race/Ethnicity Data Required:
SUBMIT THE FOLLOWING DOCUMENTS TO THE HEALTH IT PROGRAM:
Required If Applicable
Original signed application
Must include professional statement Employer Letter of Support/Commitment of Training Program (if applicable or letters of recommendation)
Detailed RESUME demonstrating work related to health information management, information technology or other health related field.
Copy of professional licensure, certification, or industry credentials only.
One copy unofficial college transcript(s) FOR EACH
COLLEGE/SCHOOL on application Copy of Veteran’s DD214 form.
Copy of Photo ID and one document indicating legal right to work: Passport, birth certificate, or permanent resident card.
**Please note the criminal background check and physical exam are at your expense if required before internship assignments in a health care facility.
Please read the following states and sign below to indicate your understanding and compliance with program:
I understand that it is my responsibility to submit all required documents within the specified timeframes set by the Health IT Training Program.
I understand that I must attend the orientation session prior to beginning the training program as a part of the criteria for entering the program.
I understand the content of the Health IT Training Program will be delivered in the hybrid format (online and Face-to-face laboratory setting).
I understand that this is an intensive six-month program and I am committed to completing the coursework as scheduled.
I understand that I may be asked for a small deposit for lab materials and this will be reimbursed upon completion of the class and return of materials.
I certify that all of the above is true and correct. Any false statements may result in the termination of my application.
Signature: __________________________________________________ Date: ______________
OFFICE USE ONLY Place an X in the appropriate box.
American Indian: (Indicate Tribe) Samoan
Asian Indian White/Caucasian
Black/African American Other Asian: (Please indicate)
Chinese Other Pacific Islander: (Please Indicate)
Filipino Hispanic, Latino, or Spanish origin
Guamamian/Chamorro No not Hispanic, Latino, or Spanish origin
Japanese Mexican, Mexican-American, Chicano
Korean Puerto Rican
Native Alaskan Cuban
Native Hawaiian Other Race: (Please Indicate)
East Los Angeles College Health IT Workforce Training PROFESSIONAL INTEREST STATEMENT
Please write a statement explaining your interest in pursuing training in
the Health IT WorkforceTraining Program. This statement should provide additional background information regarding your professional and educational experiences that are critical in evaluating your acceptance to this
program.
Signature: Date:
