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MICT 2021 Application V2 (Kapiolani Community College)

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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.
Emergency Medical Services Department
Kapi`olani Community College
MOBILE INTENSIVE CARE TECHNICIAN PROGRAM
Admission Application Checklist
Rev. 5/19/2020
APPL
ICANT INFORMATION
Name: UH
Number/Username
Last Name First Name M.I.
Mailing
Address:
Street / POB City State Zip Code
Phon
e:
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
MICT Application
Kapi`olani Community College
MOBILE INTENSIVE CARE TECHNICIAN PROGRAM
Admission Application Checklist
Oahu
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
MICT Application
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
MICT Application
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: _______________
MICT Application
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
1
st
Shot Date
1
st
Read Date
2
nd
2
nd
Shot Date:
2
nd
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)
MICT Application
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 1
st
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.
MICT Application
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.
MICT Application
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. 6/12/2020
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:
The first set of steps are to obtain the 300 call run log in Webcur:
Open Webcur (see attached pdf Webcur_E5)
Select E5 Reports from tabs
Select Activity by on the Reports pulldown
Select Provider
Select Provider from the popup list showing all the provider
Select a start and end time date
Run Report
Download the report by clicking the Excel icon in the top right corner
Once the report comes up in Excel delete the following columns:
Patient name
Patient address
The only columns (see Example_Call Log) that need to be listed are:
Date
Trip no.
Crew
Outcome/Receiving Agency
Nature of call
Print the 300 call report. Complete the attached form letter and:
Have a unit supervisior initial the call report to verify its authenticity
Make appointment with EMS 1 (call Chanda Kuriyama at 723-7906) or AMR manager
Obtain verbal permission to apply for MICT class
Have EMS 1 or AMR manager confirm authenticity of data collected
Receive EMS 1's or AMR manager’s signature on attached form letter (MICTCandidate_EntryLtr)
Scan and submit with KCC MICT electronic application
If you have any questions, feel free to contact us – Mark Kunimune (markkuni@hawaii.edu) or Leaugeay
Barnes (lcbarnes@hawaii.edu)
MICT Application
Tab le 1
Activity Report by Provider Report
City and County of Honolulu EMS
Date Range: 05/02/2020 - 06/02/2020
Date
Trip No.
Crew
Outcome / Receiving Agency
Nature of Call
5/5/2020
1822179
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queen's Medical Center
ALS
5/8/2020
1822762
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queen's Medical Center
ALS
1822813
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queen's Medical Center
ALS
5/10/2020
1823132
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queens Medical Center West
ALS
1823141
Lennox, Gabrielle; McGregor, Theresa
Patient Treated, Transported by EMS / Queens Medical Center West
BLS
1823155
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queens Medical Center West
ALS
1823177
Lennox, Gabrielle; McGregor, Theresa
Patient Treated, Transported by EMS / Queens Medical Center West
BLS
1823182
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queens Medical Center West
ALS
1823193
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queen's Medical Center
ALS
1823219
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Queens Medical Center West
ALS
1823232
McGregor, Theresa; Lennox, Gabrielle
Patient Treated, Transported by EMS / Kapiolani Medical Center - Pali Momi
ALS
5/13/2020
1823772
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Kuakini Medical Center
ALS
5/14/2020
1823992
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Straub Clinic and Hospital
ALS
1825728
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Straub Clinic and Hospital
ALS
1826489
Kam, Mitchell; Lennox, Gabrielle
Patient Treated, Transported by EMS / Straub Clinic and Hospital
ALS
5/18/2020
1824901
Lennox, Gabrielle; Kam, Mitchell
Patient Treated, Transported by EMS / Straub Clinic and Hospital
BLS
5/22/2020
1825706
Lennox, Gabrielle; Kam, Mitchell
Patient Treated, Transported by EMS / Straub Clinic and Hospital
BLS
1
__________________
Date
To Kapi’olani Community College MICT Program,
____________________ has permission from Honolulu C&C EMS1/AMR Ops Manager to
(Candidate Name)
Apply for this upcoming ______ MICT program. I have also reviewed the data pulled from
(Year)
Webcur and confirm that it is authentic.
_____________________________________ ____________________________
(Print Name) (Title)
_____________________________________ ____________________________
(Signature) (Date)
MICT Application
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?
MICT Application
Kapi`olani Community College
Personal Essay
MICT Program
Rev. 5/19/2020
2.
Name: UHID:
MICT Application
Kapi`olani Community College
Personal Essay
MICT Program
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