Rev. 5/19/2020

Certificate of Achievement/ Associates in Science Degree

Hawai‘i: Fall 2020 Application Deadline: June 1, 2020 Oahu: Spring Application Period: June 1 – October 1 Maui: Fall 2021 Application Deadline: June 1, 2020

Directions: Please complete each item by typing directly into the fields or neatly printing on a hardcopy, and submit this Admission Application Checklist with all required documents to the Health Sciences Counselors via UH File Drop. Only this completed program Admission Application including supplemental documentation submitted by the appropriate deadline will be accepted for processing.

To use file drop follow the directions below:

1. Scan application and all supporting documents

a. If you do not have access to a scanner, use a free smartphone app like Scannable or Scanner Pro

or Cam Scanner. Save your application and all supporting documents in PDF format.

2. From any web browser, go to https://www.hawaii.edu/filedrop

3. Log in as a UH User or Non-UH user (Non-UH Users will be sent a verification email, click on the link

in the email)

a. In the recipient field, type: hlthsci@hawaii.edu

b. Click in the drop down menu in the expiration timer, change it to 14 days

c. In the “Optional Message” field, enter FULL NAME and the PROGRAM you are applying to

d. After you’ve completed the Recipient field, extended the expiration timer, typed in the Optional

Message, click Proceed.

e. Click the Choose File button to browse for your application and supporting documents.

i. If you upload your documents in different files (i.e. application, transcripts, etc.), please

write a description of the file in the Description box.

f. Click the Start Upload button.

g. You will be redirected to a confirmation page with the link to your uploaded file. You’re

finished.

Please contact us at hlthsci@hawaii.edu or 808-734-9224 if you have any questions or need assistance with these application submission procedures.

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. 5/19/2020

APPLICANT INFORMATION

Name: UH Number/Username Last Name First Name M.I.

Mailing Address:

Street / POB City State Zip Code

Phone: Cell Home Work

Preferred 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

2

3

4

5

6

Select the island that you are applying to:

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)

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)

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

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).

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

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

Kapi`olani Community College MOBILE INTENSIVE CARE TECHNICIAN PROGRAM

Admission Application Checklist

Rev. 5/19/2020

• Institution: ______________________________________________________ • Institution: ______________________________________________________ • Institution: ______________________________________________________

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 Option 1: Submit HEMSIS and/or MEDS system reports documenting yourself listed as Crew 1 or Crew 2;

patient disposition as “treated, transported by EMS”; time frame contiguous and/or within last five years; 300+ ambulance transports. If you will not meet this criteria, but meet all others, email lcbarnes@hawaii.edu

Option 2: (For Hilo and Oahu applicants only): Submit HEMSIS and/or MEDA system reports documenting 150 transports plus the BLS Team Lead Report documenting 50 Team Leads. Option 3: (For Hilo and Oahu applicatns only): Submit BLS Team Lead Report documenting 100 Team Leads.

13 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 Rubella Varicella Hepatitis B Vaccine (HBV) HBV-1 HBV-2 HBV-3 Tuberculosis (TB).

__________ (initial)

14 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.

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

Knowledge Exam will be scheduled. 16 Schedule a EMT Psychomotor Competency Exam with your KCC EMS Training Center, using EMT-level

skill sheets found at www.nremt.org

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

Rev. 5/19/2020

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:

â These are the requirements â â Tell us what class you took to meet each requirement â

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. 5/19/2020

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 111 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

HDFS 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. 5/19/2020

Immunization/TB Clearance Record – Due by Admission Orientation

* KapCC Phlebotomy program provides a low cost titer clinic once a semester, please see the Counselors or Program Director for more information*

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)

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

Rev. 5/19/2020

Revised 05/03/2016 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. 5/19/2020

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. KapCC Phlebotomy Titer Clinic Once a semester, the KapCC Phlebotomy program puts on a titer clinic open to all current and prospective health education students. This is an opportunity for students who need proof of immunity to meet clinical experience requirements to obtain it at a greatly reduced cost. Some of the titer fees are discounted up to 90%. For more information, see a Health Sciences/EMS Counselor or speak with the Program Director.

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. 5/19/2020

Process for Run Log All Run Logs must be scanned and submitted with this application. All documents submitted are

subject to aduit and inaccurate or false reporting may be grounds for application rejection or immediate dismissal.

HEMSIS and/or MEDS system reports with the following criteria:

• Prospective MICT student listed as Crew 1 or Crew 2

• Patient disposition as ‘Treated, Transported by EMS’

• Time frame contiguous and/or within last (5) years (i.e. cannot use data from an interrupted career years

earlier)

• N > 300

To access HEMSIS reports, please contact the appropriate point person: • Hawaii Island – Stacy Domingo (Hawaii Fire) / Karlson Pong (AMR)

• Kauai – Tito Villanueva

• Maui – Mona Arcinas

• Oahu – Anthony Young (City & County) / Andy Ancheta (AMR)

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

Rev. 5/19/2020

BLS TEAM LEAD REPORT (For Oahu and Hilo applicants only)

Name:______________________________ Partner:__________________________________

MICT Applicant - please fill out your calls/ day, have your partner check off the skills performed. Please leave the score blank. You may need to make additional copies. ____________________________________________________________________________

1. Call type: _______________ Partner’s Initial: ___________________

Case number: _________________________ Date: _______________

Single system medical or trauma Yes ____ No ____ Multi-system medical or trauma Yes ____ No ____ Primary assessment performed by the EMT Yes ____ No ____ Adequate history obtained by the EMT Yes ____ No ____ Physical exam performed by the EMT Yes ____ No ____ Treatment decision performed by the EMT Yes ____ No ____ Score _____

2. Call type: _______________ Partner’s Initial: ___________________

Case number: _________________________ Date: _______________

Single system medical or trauma Yes ____ No ____ Multi-system medical or trauma Yes ____ No ____ Primary assessment performed by the EMT Yes ____ No ____ Adequate history obtained by the EMT Yes ____ No ____ Physical exam performed by the EMT Yes ____ No ____ Treatment decision performed by the EMT Yes ____ No ____ Score _____

3. Call type: _______________ Partner’s Initial: ___________________

Case number: _________________________ Date: _______________

Single system medical or trauma Yes ____ No ____ Multi-system medical or trauma Yes ____ No ____ Primary assessment performed by the EMT Yes ____ No ____ Adequate history obtained by the EMT Yes ____ No ____ Physical exam performed by the EMT Yes ____ No ____ Treatment decision performed by the EMT Yes ____ No ____ Score _____

4. Call type: _______________ Partner’s Initial: ___________________

Case number: _________________________ Date: _______________

Single system medical or trauma Yes ____ No ____ Multi-system medical or trauma Yes ____ No ____

Primary assessment performed by the EMT Yes ____ No ____ Adequate history obtained by the EMT Yes ____ No ____ Physical exam performed by the EMT Yes ____ No ____ Treatment decision performed by the EMT Yes ____ No ____ Score _____

TOTAL SCORE: _____

Rev. 5/19/2020

1.

Name: UHID:

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. Identify the question you will

answer by checking the box next to the question.

� Discuss your strengths as an EMT and your weaknesses.

� Describe what you have done to build your strengths and improve your weaknesses.

� 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. 5/19/2020

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