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Kapi`olani Community College EMERGENCY MEDICALTECHNICIAN PROGRAM lication Checklist (Kapiolani Community College)

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12/19/2019
Certificate of Competence
Maui Fall 2020 EMT Program: January 6 – May 22, 2020 (all applications must be RECEIVED by deadline)
Directions: Please complete each item carefully typewritten or neatly printed, and submit this Admission Application
Checklist and all required documents. 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 Maui EMS Training Center by
the appropriate deadline will be accepted for processing. Due to COVID-19 precautions, COMPLETED
original applications may be turned in at UH Maui College Mailroom Box 75, or mailed to MAUI EMS
TRAINING CENTER, 310 Kaahumanu Ave, Bldg 215, Kahului, HI 96732.
APPLICANT INFORMATION (clearly print or type)
Name: UH
Number & UH 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 EMT PROGRAM
1. Attend a MANDATORY EMT Information Session within one year of your application
submission. If you have not attended an info session, the Maui EMS Training Center will offer a
session on January 7, 2020 from 8:30 – 10:30 a.m. Please call 808-244-4063 to sign-up to attend.
Date Attended: _______/_______/_______ (Month / Day / Year)
2. Complete the online UH System Application and apply to Kapiolani Community College if
you are not currently enrolled at any UH System institution during the semester you
submit this application. (http://apply.hawaii.edu)
3. Prerequisite courses (ENG 100/HLTH 125) must be completed with a “C” grade or higher by
the application deadline.
4. Math qualification must have been completed (course or qualifying exam) within the last two
years. No exceptions.
5. Copy of Accuplacer placement report if using placement for math qualification. Accuplacer
placement report may be obtained free from the Testing Center where you took the Accuplacer
Kapi`olani Community College
EMERGENCY MEDICALTECHNICIAN PROGRAM
Admission A
pp
lication Checklist
12/19/2019
exam. If you are using completion of a math course to meet math qualification criteria,
Accuplacer placement report is not required as couse should be reflected on your transcript.
6. College transcripts for courses completed within the Univeristy of Hawai‘i System. Print out
student copy of unofficial trnascripts for all course work WITHIN the UH Systme and highlight
all qualification courses. UH system transcripts are downloadable from the UH Portal
(myuh.hawaii.edu).
7. College transcripts for courses completed outside of the University of Hawai‘i System.
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: ___________
8. Original State of Hawai‘i Abstract of Traffic Record (dated no older than six months from the
application deadline).
9. Copy of current Hawai‘i driver's license.
10. First Aid and American Heart Association (AHA) CPR certification is required. Verification of
AHA certification must be submitted with this application. Failure to submit documentation
WILL result in an incomplete application. Sample cards are on page six of this application.
We only accept CPR certifications provided by the AHA!!!
Certifications cannot expire prior to the end of the program you are applying to. Certification
Cards must be typewritten.
On Maui, First Aid and CPR certification may be obtained from:
Leo Domingo, 808-283-6401, ldomingo69@gmail.com
American Medical Response, amr-hawaii.enrollware.com, 808-487-4900
My CPR (AHA BLS or AHA Healthcare Provider) card is attached:
_____
AHA Training Center Name Exp. Date
My First Aid (First Aid or Heartsaver First Aid) card is attached:
_____
Training Center Name Exp. Date
11. Submit “Work/Volunteer Experience in the Health Field” form (see attached).
12/19/2019
12. “Verification of Work or Volunteer Experience in the Health Field” forms (see attached) must be
received by application deadline (see attached).
13. “My Plan Initiative” – Complete self-assessments for the EMT program (see attached.)
14. You are required to participate in an interview with the EMT Selection Committee, interviews
will be on May 26 & 27, 2020. Your time of interview will be in the order of completed
application received by the Maui EMS Training Office on or before the application deadline of
May 22, 2020. Your EMT application must be completed including all supplemental documents
to participate in the interview.
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
12/19/2019
APPLICANT CERTIFICATIONS
:
I certify that the answers and responses provided for all of the items on this Admissions Application/Checklist 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)
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
EMT 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
12/19/2019
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 EMT program.
EMT PREREQUISITES
Course
Alpha/Test
Score
Credits
Term of
Completion
Institution
Name
Grade
GPA Points
(see box
below for
point values):
ENG 100 Composition I (3)
HLTH 125 Survey of Medical Terminology (1)
ENG 100 + HTLH 125 GPA Points Awarded:
4.0 = 25 / 3.99-3.75 = 23 / 3.74-3.5 = 21 / 3.49-3.25 = 19 / 3.24-3.0 = 17 / 2.99-2.75 = 15 / 2.74-2.5= 13 / 2.49-2.25 = 11 / 2.24-2.0 = 10
Accuplacer score of 250+ in the Arithmetic or
higher domain or completion of MATH 75X or
higher within the last two years (placement into
MATH 75x does not meet qualification criteria)
Yes No
MICT SUPPORT COURSES
(not required to apply for EMT
program)
MATH 103 College Algebra (3) or higher
Y
es No
5 0
BIOL 130 & BIOL 130 L Anatomy & Physiology
& Lab (4+1) OR (WITHIN 5 YEARS)
PHYL 141 & PHYL 141L Human Anatomy &
Physiology I & Lab (3+1) AND
PHYL 142 & PHYL 142L Human Anatomy &
Physiology II & Lab (3+1) (WITHIN 5 YEARS)
Y
es No
5 0
FAMR 230 Human Development (3cr)
Y
es No
5 0
Total points (GPA points + Support
Coures Points)
/40
Application Summary: For office use only
Date Received: _____________________
Counselor’s Initials: _________________ Application Complete: Y N
HI Resident: Y N
KCC GPA Verified: _______________
Total Coursework Score: ________
Supplemental Documents Score: ________
Total Interview Score: ________
Total Score: ________
12/19/2019
Affix copy of Current Driver’s License here:
Affix copy of current American Heart Association CPR (Healthcare Provider or BLS) front and back here:
(Card must be typewritten – no hand written cards will be accepted.)
(Card cannot expire prior to December for Fall admits, May for Spring admits, and August for Summer admits).
Affix copy of current first-aid card here:
(Card must be typewritten – no hand written cards will be accepted.)
(Card cannot expire prior to December for Fall admits, May for Spring admits, and August for Summer admits).
12/19/2019
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
(month/day/year) (month/day/year)
Contact Person: Title:
Telephone #
Duties:
Agency: Date: from to
(month/day/year) (month/day/year)
Contact Person: Title:
Telephone #
Duties:
Agency: Date: from to
(month/day/year) (month/day/year)
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:
(month/day/year)
12/19/2019
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:
(month/day/year) (month/day/year)
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: Date:
(month/day/year)
When this form is completed, please return to:
Maui EMS Trianing Center
Kapiolani Community College
c/o 310 Kaahumanu Ave, Bldg 215
Kahului, HI 96732
The deadline for receipt of this Work or Volunteer Verification Experience Form is:
Fall 2020: May 22, 2020
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
Identif
ied 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
Demonst
rate 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
Health Sciences Department
Reset
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 E
qual 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:
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.
Health Sciences Department
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