Health Information Technology (HIT) Program Application

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1 Health Information Technology (HIT) Program Application Capital Community College Division of Continuing Education, Economic & Community Development Today s Date Last Name First Name Middle Initial Home Address Address City State Zip County of Residence Day Phone ( ) Evening Phone ( ) Male Female Yes, I certify I am a legal resident of Connecticut and have met the 12-month residency requirements No, I am not a legal resident of Connecticut. State of legal residence: I am currently employed. My employer is I am currently unemployed Please check highest level of education: General Education Degree High School Diploma Some College 2 Year College Degree 4 Year College Degree Masters Degree Doctorate Degree Please provide a brief response to the following questions: 1) Please describe your experience in the IT or health care field. Number of years in IT or health care years 2) Why are you interested in the HIT program? 3) Please select a concentration track: Practice Workflow & Information Management Redesign Specialist / Clinical Consultant This person assists healthcare providers in analyzing workflow processes, integrates information technology into workflows, designs processes and information flows, assists in the selection of vendors and software and ensures quality measurement and improvements that result in the meaningful use of electronic health records. Technical / Software Support This person maintains systems in clinical and public health settings, including patching and upgrading of software. This person interacts with end users to diagnose IT problems and implement solutions, documents IT problems and evaluates the effectiveness of problem resolution, and supports systems security and standards. I can attend classes at night, during the day.

2 Completion of this application does not guarantee enrollment in the program. You will be notified of your acceptance by May 12th. If you are accepted and you enroll in the program you must follow the attendance policy. Students who do not complete the Health Information Technology Program will be held financially responsible for the course. Instruction and handouts will be provided at no cost. Students will be required to purchase their own textbook.

3 Capital Community College Health Information Technology Training Program Registration Information Process: A complete Registration Form and Release Form are required to register.

4 A complete Registration Form and a signed Release Form are required for the Registration Please Print. Name (Last, First, Middle) Fall/Spring Part I: Personal HIT Information Registration Form Date Current Home Address (Street, City, State, Zip ) Home Telephone (include area code) Work Telephone (include area code) Mobile Telephone (include area code) (required for course confirmation) Date of Birth (MM/DD/YYYY) (required for college registration) Social Security Number (required for college registration) Gender Connecticut Resident U. S Citizen If not a citizen, Alien Registration Number Female Male Yes No Yes No Race (select one) Black White Asian Hispanic Native American Other Part II: Employment Information Are you currently employed? Yes No If no, please see section below, Dislocated Workers Current/Previous Employer Dates Employed (mm/yyyy ) / to / Current/Previous Employer Address (Street, City, State & Zip) Position Title Position Hours Dates In Position (mm/yyyy) / to / Current/Previous Salary/Hourly Wage (Required information) Part Time Full Time $ Part III: Education (Highest Level of Education) General Education Degree High School Diploma Some college 2 Year College Degree 4 year College Degree Masters Degree Doctorate Degree Dislocated Workers Have you been certified as a dislocated worker by the CT Department of Labor? Yes No Check the concentration track you are registering for (choose only one): Practice Workflow & Information Management Redesign Specialist / Clinical Consultant Technical / Software Support Students who do not complete the Health Information Technology Program will be held financially responsible for the course. Instruction and handouts will be provided at no cost. Students will be required to purchase their own textbook. Contact: (860) or (860)

5 Capital Community College Authorization to Release Personally Identifiable Student Information In order to comply with federal grant reporting, the College is asked by the Grant Administrator (Tidewater Community College) to report on individual student registration and participation in programs supported by the Office of the National Coordinator, Department of Health and Human Services. To do so accurately and in compliance with FERPA (Family Education Rights and Privacy Act), we need your authorization. After reading this document, sign below acknowledging the release of your training records to Tidewater Community College for the purpose of compliance with federal program requirements related to the HIT program. I, the undersigned, authorize or Capital Community College to disclose the following information: Registration records, academic history, social security number, date of birth, mailing address, and other personally identifiable information to Tidewater Community College for the purpose of compliance with federal requirements of the HIT grant. Student Name (Print): Address: DOB: Student Banner ID#: (If you do not know your Banner ID#, it will be filled in for you) Student Signature: Date: Capital Community College 950 Main Street Hartford, CT This project is funded by Office of the National Coordinator, Department of Public Health and Human Services, Grant Number 90CCC00801/10.

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