HomeMy WebLinkAboutalco-paramedic-precptor-renewal-application-ver201907ALAMEDA COUNTY PARAMEDIC PRECEPTOR RENEWAL APPLICATION
Version 7.2019
NAME:
AGENCY:
PARAMEDIC LICENSE #: EXPIRATION DATE:
PRECEPTOR EXPIRATION DATE:
INTERNS IN THE LAST TWO YEARS
P-PASS F-FAIL R –REMEDIATE D – STUDENT DROPPED
(CIRCLE ONE)
CONTINUING EDUCATION
8 SUPPLEMENTAL HOURS OF EMS EDUCATION CEU (INCLUDING CEUs AWARDED FOR
PROVIDING AN INTERNSHIP)
ALAMEDA COUNTY PARAMEDIC PRECEPTOR RENEWAL APPLICATION
Version 7.2019
Have you had any reported clinical issues in the last two years? Y N
If yes, please give date, details, and outcome:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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My signature below attests that all information submitted is true and represents the request to
continue my role as a paramedic preceptor as described by the Alameda County EMS
Paramedic Preceptor Program Policy.
Signature below represents the recommendation and support by your department/agency for
the paramedic listed above to continue his/her role as a paramedic preceptor as described by
the Alameda County EMS Paramedic Preceptor Program Policy.