3/23/2020
Health Sciences Department
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 a Health Sciences Counselor via
UH F
ile Drop.
We will not be
accepting in-person applications this application period.
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 docuemnts 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 temporary application submission procedures.
Fall Application Period: April 2 – July 1
Spring Application Period: July 2 – November 1
2020 Summer Application P
eriod: January 2April 30
TEMPORARY COVID-19
APPLICATION SUBMISSION PROCEDURES
Kapi`olani Community College A
d
mission Application Checklist
COMMUNITY HEALTH WORKER
Certificate of
Competence
11/4/2019
Fall Application Period: April 2 – July 1 Spring Application Period: July 2 – November 1
Summer Application Period: January 2 –April 1 Extended to April 30, 2020 (see additional application info for COVID 19)
Directions: Please complete each item carefully typewritten or neatly printed, and submit this Admission Application
Checklist and all required documents to a Health Sciences Counselor during walk-in counseling hours. 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 Health Career Counseling Center (Kauila 106) by the appropriate deadline will be accepted for
processing. Applications must be submitted in person during walk-in counseling only.
APPLICANT INFORMATION
Name: UH Numb
er/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) u
sed on documents:
(Notify the Kekaulike Information & Service Center regarding other names used on college documents.)
Semester of Application: Fall
Spring
Summer
ADMISSIONS APPLICATION CHECKLIST FOR CHW PROGRAM
1.
Attend a mandatory CHW Information Session within one year prior to application submission.
For more information visit www.kcc.hawaii.edu or pick up an Information Session schedule from K
auila 122 or
Kauila 106,
Monday – Friday during posted business hours.
Date Attended: (Month /
Day / Year)
2. Complete the online UH System Application (New, Returning or Transfer) if you are not currently enrolled at any UH
System institution during the semester you submit your application. (http://apply.hawaii.edu)
3.
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 related courses. UH
system transcripts are downloadable from the UH Portal (myuh.hawaii.edu).
4.
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 official
transcript was
sent to the Kekaulike Information & Service Center (KISC):
Institution: ___________________________ Transcript Request Date: ___________
• Institution: __________________
_________
Transcript Request Date: ___________
• Institution: __________________
_________
Transcript Request Date: ___________
Health Sciences Department
Kapi`olani Community College
COMMUNITY HEALTH WORKER (CHW) PROGRAM
Certificate of Competence
Admission Application Checklist
8/1/2019
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
5.
My Plan Initiative.” Complete reflection essays and self assessments for your program/career pathway.
6.
Self-addressed, stamped #10 (4 1/8” X 9 1/2") envelope.
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 CHW program.
I understand that if I am not accepted into the CHW 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 understand that a criminal background check and drug test may be required for entry into clinical practice. ________
(please initial)
I understand that clinical practice is required for completion of this program. ________ (please initial)
I understand that insufficiently enrolled classes may be deferred until minimum enrollment is met. _______ (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_____________
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
Health Sciences Department
Application Summary: For office use only
Date Received: _____________________ Application Complete: _____________
Counselor’s Initials: _________________ KCC GPA Verified: _______________
HI Resident: Y N
8/1/2019
Statement of Expereince & Interest - Please answer both questions
1. Why are you interested in getting a certificate in Community Health Worker?
Health Sciences Department
8/1/2019
2. What is your experience working or volunteering in the community related to health and things that
impact health, such as poverty, education level, access to care, etc.?
1/17/2019
The My Plan Self-Assessment is a counseling tool for prospective healthcare majors to help you identify and better understand
your career pathway, 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 this self-assessment by marking the appropriate boxes. All response are voluntary. This assessment
does not affect your eligibility for admission. This assessment and is used for all ten Health Academic programs, therefore there may
be some statements that do not apply to your specific program.
Knowledge of the Profession
Below
Expectations
Meets
Expectations
Exceeds
Expectations
Identifi
ed 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 serviceby 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
Demonstr
ate 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
1/17/2019
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 requir
ed for program entry and graduation or meet other requirements as directed for program admissions.
An Equal
Opportunity/Affirmative Action Institution
Kapi`olani Community College
MY PLAN
Self-Ass
essment
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:
Kelli Brandvold, ADA Coordinator for Employees and EEO/AA Campus Coordinator
Office: ‘Ilima 208
(808) 734-9575; kellib@hawaii.edu
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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