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S-SV EMS Agency
Butte, Colusa, Glenn, Nevada, Placer, Shasta, Siskiyou, Sutter, Tehama & Yuba Counties
(916) 625-1702
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EMS Continuing Education (CE) Provider Application
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Program Information
CE Provider/Individual Name
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CE Provider Number (Renewal Applicants Only)
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Program Director
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Clinical Director
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Program Director Information
Each CE provider shall have an approved program director, who is qualified by education and experience in methods, materials and evaluation of instruction, which shall be documented by at least 40 hours in teaching methodology. Following, but not limited to, are examples of courses that meet the required instruction in teaching methodology: • California State Fire Marshal (CSFM) "Fire Instructor 1A and 1B"; or • National Fire Academy (NFA) "Fire Service Instructional Methodology" course; or • A training program that meets the U. S. DOT/NHTSA 2002 Guidelines for Educating EMS Instructors, such as the EMS Educator Course of the National Association of EMS Educators. • Individuals with equivalent experience may be provisionally approved for up to two (2) years pending completion of the above specified requirements. Individuals with equivalent experience who teach in geographic areas where training resources are limited and who do not meet the above program director requirements may be approved upon review of experience and demonstration of capabilities.
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Program Director Resume
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Program Director License/Certifications
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Applicable Instructor Training Completion Documentation
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Clinical Director Information
Each CE provider shall have an approved clinical director who is currently licensed as a physician, registered nurse, physician assistant, or paramedic. In addition, the clinical director shall have had two years of academic, administrative or clinical experience in emergency medicine or EMS care within the last five years. The duties of the clinical director shall include, but not be limited to, monitoring all clinical and field activities approved for CE credit, approving the instructor(s), and monitoring the overall quality of the EMS content of the program.
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License Number
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Applicable Certifications/Licenses
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Clinical Director Resume
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Course Material
Sample CE Certificate
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Applicants Name signature
Attestations
Date of signature
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Electronic Signature
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I attest that I have reviewed the S-SV EMS Agency EMS CE Provider Approval/Requirements Policy (1001) 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.
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