Health Informatics and Information Management Program
Application 2016-2017 Academic Year
Application available: January 12, 2016
Application DUE: April 17, 2016 (post marked)
r A.A.A.S. in Health Information Technology
Requires Shoreline General Education Core Requirements, program prerequisites and program courses. Program prerequisites: ENGL& 101, English Composition, MATH 098, Intermediate Algebra I (previously MATH 080, Beginning Algebra) and BIOL& 170, Human Biology must be completed or currently enrolled prior to application submission.
r Certificate of Proficiency as Medical Coding and Reimbursement Specialist
Requires Shoreline General Education Core Requirements, program prerequisites and program courses.
Program prerequisites: ENGL& 101, English Composition, MATH 098, Intermediate Algebra I (Previously MATH 080, Beginning Algebra) and BIOL& 170, Human Biology must be completed or currently enrolled prior to application submission.
DIRECTIONS:Submit one complete packet by the April 17, 2016 deadline.
Judy Proffitt
SCC – HIIM Program
Hope Division
16101 Greenwood Avenue N
Shoreline, WA 98133
Shoreline Community College provides equal opportunity in education and employment and does not discriminate
on the basis of race, color, religion, national origin, gender, sexual orientation, age, marital status, or disability.
DIRECTIONS:
Apply to Shoreline Community College to obtain a Student ID number http://new.shoreline.edu/Steps/Apply.aspx
Complete all items listed below - SUBMIT ALL REQUESTED ITEMS IN A SINGLE PACKET.
ü / Submit this checklist with HIIM Program application. Check off items as completed.I attended HIIM Program Information Meeting on ______/______/______or reviewed online ______
Non-refundable check or money order for $15.00 made payable to Shoreline Community College
Completed HIIM Program Application form
Official COMPASS placement Math score if you tested placement above MATH 098, Intermediate Algebra I
Provide transcripts of all relevant college work completed at other colleges that you would like to be considered for transfer.
One (1) set of official transcripts are required when relevant course work has been completed at other colleges
YOU must submit sets in your Application Packet
Course Descriptions: for courses not using Washington Common Course Numbering. Only syllabi or copies of the official college course catalog will be accepted
Provide unofficial transcript of all SCC coursework
Copy of current Winter registration form to document courses being taken at the time of application
Curriculum Plan: for students transferring into SCC program as a Second Year Health Information Technology (HIT) student
I understand that:
(For all applicants)
Initial / Not completing or submitting requested items will delay or disqualify my application to the HIIM Program.Initial / HIT students must be available to accept facility placement for up to 3 continuous weeks (97.5 hours) for the HIIM Professional Practice Experience (PPE) course.
Initial / HIT students will be required to submit to and pay for immunizations, titers and health tests as required by their clinical facility prior to the start of the HIIM 234 Professional Practice Experience (PPE) course.
Initial / HIT students will be required to apply, pay for and pass a criminal background check prior to visiting sites for the HIIM 234 Professional Practice Experience (PPE) course. Students who do not pass this check may have difficulty finding sites for their PPE. It is common practice for health care facilities to require criminal background checks for any potential employee prior to hire.
Initial / HIT students who live more than 30 miles from Shoreline Community College will be required to identify and provide contact information for sites for the HIIM 234 PPE course. The HIIM program will generate the Affiliation contracts between the PPE site and the school and, assist where ever possible.
SHORELINE COMMUNITY COLLEGE
APPLICATION for ADMISSION to the Health Informatics and Information Management Program - 2016-2017
SCC Student I.D.:Please Print / Required
Name:
Last Name / First Name / Initial / Other Name(s) on Transcripts
E-mail:
Daytime Phone No
Address:
Street / Apt No. / Evening Phone No.
City / State / Zip Code
I am applying for: / More than one can be selected
o A.A.A.S. Degree, Health Information Technology
o Certificate of Proficiency, Medical Coding and Reimbursement Specialist
I wish to attend school o Full Time (12 or more credits per quarter) o Part time (less than 12 credits per quarter)
1. Date of birth _____-_____-_____ Age______
2. Gender: o Female o Male
I have completed high school as follows:
(check one) / I have completed college as follows:
(check one)
o 1. Did not complete high school / o 1. Have not completed college
o 2. Still in high school / o 2. Short-term training, private vocational school or other
o 3. High school graduate / o 3. One-year certificate from a community college
o 4. GED / o 4. Associate degree
o 5. Alternative high school diploma / o 5. Bachelor’s degree
o 6. Master’s degree
o 7. Doctorate or professional degree
Please check one or more boxes. (This information is Voluntary: / o 5. Filipino Asian
o 1. White, Non-Hispanic / o 6. Chinese, East Indian, Japanese, and Korean
o 2. African American, Non-Hispanic / o 7. Other Asian
o 3. American Indian/Alaskan / o 8. Hispanic
o 4. Samoan, Southeast Asian, and Pacific Islander / o 9. Other Ethnicity ______
Is English your first (native) language? o Yes o No
I certify that all statements on this application are complete and true. I also understand that If I am admitted and do not enroll for
the term to which I am admitted, I will need to reapply for admission. No submitted materials will be returned and/or duplicated.
I have enclosed the $15.00 non-refundable application fee (check or money orders only please).
Signature Date
Shoreline Community College provides equal opportunity in education and employment and does not discriminate
on the basis of race, color, religion, national origin, gender, sexual orientation, age, marital status, or disability.
Application HIIM Program
Education, Training and Experience
(Failure to complete this section will result in your application being disqualified)
HIIM Applicant NameDirections: List colleges/universities that you have attended and dates enrolled if transferring credits. Be sure to submit official transcripts and course descriptions of college coursework you wish to have evaluated for transfer to Shoreline Community College.
College/University / Dates Enrolled / Degree Earned / Major / Transcripts SentPlease describe your personal computer abilities including MS Windows, MS Word, Excel, PowerPoint, Access, e-mail, e-mail attachments, internet searching, etc. If you have taken classes, please identify.
______
______
______
Please list any additional training or education you have had.
______
______
Please identify any health care experience you have had.
______
HIIM Program Application
Coursework to be evaluated
(Failure to complete this section will result in your application being disqualified)
Applicant NameAll courses considered must have a grade of 2.0 or higher and accompanied with official transcripts.
If your grade is not shown as decimal on your transcript, we use the following:
A=4.0, B=3.0, C=2.0, less than 2.0 not considered
If Currently Enrolled
If currently enrolled in a required class, please indicate which quarter you are enrolled and provide a copy of the registration form.
Shoreline Course / Cr / College Where Course Taken / Equivalent Course Number on transcript / Qtr. Taken / Grade / Currently Enrolled / forHIIM use
only
ENGL& 101, English Composition 1
Program Prerequisite
MATH 098 Intermediate Algebra I (Previously MATH 080) or COMPASS score showing equivalency
Program Prerequisite
Multicultural or Diversity
Course (for HIT)
Human Relations
BUS 104 or 105
(for MCRS)
BIOL& 170 Human Biology (for MCRS and HIT) – taken within past 10 years)
(Program Prerequisite)
HIIM 134 Medical Terminology (for MCRS and HIT) - taken within past 10 years
CIS 105 Computer applications – taken within past 5 years
BUSTC 170 Access (for HIT) – taken within past 5 years
BUSTC 150 Excel (for HIT) – taken within past 5 years
HIIM Application 2016-2017 Page 1 of 5