Emergency Medical Technician (EMT) Training Program Provider Application

Name of person completing this form *

First

Last

Phone *

Email *

Program Information

Training Program Name *

Training Program Address *

Address Line 1

Address Line 2

City

State

Zip Code

Course Director *

First

Last

Clincial Coordinator *

First

Last

Program Eligibility Type

Program Eligibility

Accredited University/College or Private Postsecondary School
Medical Training Unit of a Branch of the Armed Forces or US Coast Guard
Government Agency, Including Public Safety Agency
Licensed General Acute Care Hospital

Clinical Experience Affiliation Information

Clinical Site Name

Course Date & Locations Reporting

Course Dates *

Course Location(s): *

Principal Instructor *

Course Director Information

The EMT Training Program Course Director shall be qualified by education and experience in methods, materials, and evaluation of instruction which shall be documented by at least forty (40) hours in teaching methodology. The courses include, but are not limited to the following examples: • California State Fire Marshal Instructor 1A and 1B • National Fire Academy’s Instructional Methodology • Training programs that meet the United States Department of Transportation/National Highway Trafic Safety Administration 2002 Guidelines for Education EMS Instructors such as the National Association of EMS Educators Course.

Name *

First

Last

Certification/License Type *

Certification/License Number *

Certification/License Expiration Date *

Teaching Credentials *

Course Director Resume *

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Clinical Coordinator Information

The EMT Training Program Clinical Coordinator shall be either a Physician, Registered Nurse, Physician Assistant, or a Paramedic currently licensed in California, and shall have two (2) years of academic or clinical experience in emergency medicine or prehospital care in the last five (5) years.

Clinical Coordinator Name *

First

Last

License Type *

License Number *

License Expiration Date *

Teaching Credentials *

Clinical Coordinator Resume *

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Principal Instructor Information

The EMT Training Program Principal Instructor, who may also be the Course Director or Clinical Coordinator, shall: • Be a Physician, Physician Assistant, Registered Nurse, Paramedic, AEMT, or EMT currently licensed or certified in the State of California. • Have two (2) years academic or clinical experience in emergency medicine or prehospital care in the last five (5) years. • Be qualified by education and experience in methods, materials, and evaluation of instruction which shall be documented by at least forty (40) hours in teaching methodology. The courses include, but are not limited to the following examples: o California State Fire Marshal Instructor 1A and 1B. o National Fire Academy’s Instructional Methodology. o Training programs that meet the United States Department of Transportation/National Highway Traffic Safety Administration 2002 Guidelines for Education EMS Instructors such as the National Association of EMS Educators Course.

Principal Instructor Name *

First

Last

License Type *

License/Certification Number *

License/Certification Expiration Date *

Teaching Credentials *

Principal Instructor Resume *

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Course Material

Periodic Written & Skills Examination Documents *

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Final Written & Skills Examination Documentation *

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Course Student Location(s):

Sample Course Completion Certificate *

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Description of Program Facilities, Equipment, Examination Security & Student Record Keeping *

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Provisions for EMT Course Completion by Challenge *

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Provisions for twenty-four (24) hour refresher course required for recertification *

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Description of Program Facilities, Equipment, Examination Security & Student Record Keeping *

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Attestations

Date of signature *

Electronic Signature *

First

Last

I attest that I have reviewed the S-SV EMS Agency EMT Training Program Approval/Requirements Policy (1002) and will comply with all requirements described therein. I further attest that all information contained in this application and supporting documents is true and correct to the best of my knowledge. I verify that CPR training equivalent to the current AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care at the Healthcare Provider level is a prerequisite for admission to the EMT course. I attest verifying usage of the U.S. Department of Transportation (DOT) National EMS Education Standards (DOT HS 811 077A, January 2009). I attest CPR training equivalent to the current AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care at the Healthcare Provider level is a prerequisite for admission to the EMT course