Preparing for the future.

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1 Health IT Workforce Program Application Return completed Application via US Mail or In Person to: East Los Angeles College 1301 Avenida Cesar Chavez Building G1 Room # 204 Monterey Park, CA Attn: Gail Coyne Preparing for the future. Contact us at: or Office Phone #: (323) Fax#: (323)

2 Dear Applicant: Attached is the APPLICATION FOR ADMISSION into the Health IT Workforce Program. This innovative online and face-to-face lab program at East Los Angeles College is designed for professionals with backgrounds in Heath Information Management, Information Technology, Clinical and other Allied Health Professions preparing for the role of EHR Technical & Implementation Support Specialist for the upcoming nationwide Electronic Health Records initiative. As part of a national consortium of colleges, East Los Angeles College will deliver a standardized curriculum designed to prepare a workforce equipped to serve the emerging needs of the healthcare industry. Technical & Implementation Support Specialist role is needed for the ongoing support and facilitation of health IT systems across the health care industry, in organizations such as medical office practices, hospitals, health centers, long term care facilities, health information exchange organizations, state and local public health agencies and EHR vendors. Please review the minimum entrance qualifications for enrollment in this program. Individuals applying for admission to this training MUST meet one or more of the criteria listed. If you meet one or more of the above criteria and you are a veteran spouse, you will be given priority admission: If accepted, applicants will receive information regarding the MANDATORY orientation meeting prior to start date. Please check all boxes that apply to you. Applications are reviewed on case-by-case basis for the skills and priority eligibility. INFORMATION TECHNOLOGY PROFESSIONALS: Bachelor s Degree from a four-year college or university in Information Technology/ Computer Science with experience in information technology systems and at least one year of work experience Associate s of Science degree from a community college in Information Technology /Computer Science and at least one year of work experience At least one year experience in systems development and project management of information systems. At least one-year experience with industry certifications related to health information systems, EHRs, database management systems, or related field. Experience with industry certifications related to information technology network systems with industry certifications. HEALTHCARE PROFESSIONALS: Bachelor s Degree from a four-year college or university in Health Information Management, Nursing/Clinicians and other allied health professions with at least one year of work experience Associate s of Science degree from a community college in Health Information Technology and other allied health professions with at least one year of work experience Physician Office Manager or staff with two years experience in managing patient records and software application proficiency (i.e. Front office Medical assistants) Other employees with a minimum of one year experience directly related to health information processes, database management or information technology in a hospital, clinical, physician office. (May include PA, Nurse practitioners, software trainers, those certified from AHIMA or the AAPC). APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE 2

3 East Los Angeles College APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE Name: Gender: Male Female Street Address: City: State: Zip Code: Home Phone: Cell Phone #: Social Security No.: Address: Work Phone: Date of Birth: California resident for at least 1 year: Yes No Please indicate your previous background Veteran Eligibility Status: Yes No experience: (Please supply DD-214) Health IT IT/ Not Healthcare related Healthcare (Not IT related EDUCATION NAME OF SCHOOL AND LOCATION GRADUATION DIPLOMA/ DEGREE HIGH SCHOOL/GED LIST ALL COLLEGES ATTENDED HEALTHCARE, HIM and/or INFORMATION TECHNOLOGY WORK EXPERIENCE EMPLOYER Location JOB TITLE Duties START END HOURS PER WEEK Attach detailed resume to document health care or IT experience, industry training and certifications Industry Certifications Attach copy of license, certification, credential and awarding organization Is your employer sending you to the training? Yes No If yes, attach letter of verification on organization letterhead with original signature. APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE 3

4 Race/Ethnicity Data Required: American Indian: (Indicate Tribe) Asian Indian Black/African American Chinese Filipino Guamamian/Chamorro Japanese Korean Native Alaskan Native Hawaiian Place an X in the appropriate box. Samoan White/Caucasian Other Asian: (Please indicate) Other Pacific Islander: (Please Indicate) Hispanic, Latino, or Spanish origin No not Hispanic, Latino, or Spanish origin Mexican, Mexican-American, Chicano Puerto Rican Cuban Other Race: (Please Indicate) SUBMIT THE FOLLOWING DOCUMENTS TO THE HEALTH IT PROGRAM: Required Original signed application Must include professional statement Detailed RESUME demonstrating work related to health information management, information technology or other health related field. One copy unofficial college transcript(s) FOR EACH COLLEGE/SCHOOL on application Copy of Photo ID and one document indicating legal right to work: Passport, birth certificate, or permanent resident card. If Applicable Employer Letter of Support/Commitment of Training Program (if applicable or letters of recommendation) Copy of professional licensure, certification, or industry credentials only. Copy of Veteran s DD214 form. **Please note the criminal background check and physical exam are at your expense if required before internship assignments in a health care facility. Please read the following states and sign below to indicate your understanding and compliance with program: I understand that it is my responsibility to submit all required documents within the specified timeframes set by the Health IT Training Program. I understand that I must attend the orientation session prior to beginning the training program as a part of the criteria for entering the program. I understand the content of the Health IT Training Program will be delivered in the hybrid format (online and Face-to-face laboratory setting). I understand that this is an intensive six-month program and I am committed to completing the coursework as scheduled. I understand that I may be asked for a small deposit for lab materials and this will be reimbursed upon completion of the class and return of materials. I certify that all of the above is true and correct. Any false statements may result in the termination of my application. Signature: Date: OFFICE USE ONLY Start Date: Cohort #: Completed Date: Deferred to Cohort: Dropped by Program Withdrawn APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE 4

5 East Los Angeles College Health IT Workforce Training PROFESSIONAL INTEREST STATEMENT Please write a statement explaining your interest in pursuing training in the Health IT WorkforceTraining Program. This statement should provide additional background information regarding your professional and educational experiences that are critical in evaluating your acceptance to this program. Signature: Date: APPLICATION FOR ADMISSION INTO HEALTH IT WORKFORCE 5

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