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 and submit this Admissions 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 Admissions Application Checklist submitted to the Health Career Counseling Center (Kauila 106) 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
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. Attend a MICT Program Information Session.
Oahu Applicants: For more information visit www.kcc.hawaii.edu or pick up an Information Session schedule from Kauila 121 or Kauila 106, Monday – Friday from 8:00 AM to 4:00 PM.
Maui and Hawaii Applicants: Contact your local EMS Training Center for information session schedule.
Date Attended: (Month / Day / Year)
2. Identify the island that you are applying to: _____________________________
3. Complete a UH System Application Form (New, Returning or Transfer)ORChange of Home Institution Form (Students currently enrolled at a UH System School other than KAPCC) Students currently enrolled at KAPCC do not need either of these forms.
4. Prerequisite Courses must be completed with a “C” grade or higher and meet five year time limit (Anatomy & Physiology courses may be waived, contact Counselors for more information). 5. 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.
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
6. College transcripts for courses completed outside of the University of Hawai‘i System Official transcript(s) should be sent to the KAPCC Kekaulike Information & Service Center.
• Institution: Transcript Request Date: • Institution: Transcript Request Date:
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 inorder to transfer credits to KCC. This form can be obtained at the Kekaulike Information & Service Center (‘Ilima 102) or online*.
http://kcc.hawaii.edu/page/kiscdocs (see Request for Transcript Evaluation)
8. “MICT Personal Essays.” The MICT personal essays have a minimum of 200 words and a maximum of 500 words using the template provided in this packet.
9. Submit original State of Hawai‘i Abstract of Traffic Record within 6 months from the application deadline.
10. Submit a copy of your Hawai‘i driver’s license.
11. 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 Healthcare Provider.
12. Submit copy of current Hawai‘i State Certification as an EMT.
13. Submit documents verifying prior or current work experience in the health field. Forms for work/volunteer experience are included in the packet.
14. Submit documentation of 300 ambulance transports via EMT/MICT career ladder program verification of work experience in the health field Part B (log sheet).
15. Submit copies of CME records beginning with the last certification period.
16. Health immunization records are required if accepted into the program. Verification of the following immunizations must be submitted 5-business days prior to the start of the program. Failure to submit documentation may result in your dismissal.
○ Influenza, ○ Mumps, ○ Rubeola, ○ Varicella, ○ Hepatitis B Vaccine (HBV):○ HBV-1, ○ HBV-2, ○ HBV-3,
○ Tuberculosis (TB).
17. 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.
17A. Complete EMT Placement Exam. Your KCC EMS Training Center will notify you when the EMT placement exam will be scheduled.
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 1200 3.0 Fall 2007 HPU B
HLTH 125 Survey of Medical Terminology (1) HLTH 125 3.0 SP 2008 KCC A
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 CompletionTerm of
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: _____________ HI Resident: Y N
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: ________
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.
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
1.
Name: UHID:
Please be clear and concise in your response for each reflective essay, limiting each question to a minimum of 200 words and a maximum of 500 words.
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
1.
Name: UHID:
Please be clear and concise in your response for each reflective essay, limiting each question to a minimum of 200 words and a maximum of 500 words.
M I C T A p p l i c a t i o n
Kapi`olani Community College
Personal Essay - Continued
1.
Name: UHID:
Please be clear and concise in your response for each reflective essay, limiting each question to a minimum of 200 words and a maximum of 500 words.
M I C T A p p l i c a t i o n
