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Program Approval
CONTINUING EDUCATION PROVIDER APPLICATION
Initial Application Renewal Program Change
CE PROVIDER FEES: Agencies of Government, Hospitals, and Community Colleges $1,000.00
Private Programs $2,000.00
CE PROVIDER NAME:
PROVIDER LOCATION (County of primary headquarters): ________________________________________
MAILING ADDRESS: ______________________________________ _______________ ____ _________
Street City State Zip
PHONE NUMBER: ____________________FAX NUMBER: ____________________
PROGRAM DIRECTOR:____________________________________________________________
CLINICAL DIRECTOR:____________________________________________________________
TYPE OF AGENCY (Check One):
PREHOSPITAL SERVICE PROVIDER AGENCY
BASE HOSPITAL
OTHER HOSPITAL
EMT TRAINING PROGRAM
EMT-P TRAINING PROGRAM
OTHER SCHOOL
INDIVIDUAL
OTHER:
ESTIMATED NUMBER OF CE COURSES TO BE OFFERED PER YEAR: ___________________________
I certify that I have read and understand the requirements in Title 22, Division 9, Chapter 11, to be an approved CE provider and will comply with the requirements as described. I certify that all information on this application, to the best of my knowledge, is true and correct. I understand that failure to comply with the
Program Director Signature: Date:
For Alameda County EMS Use Only
Packet Received Incomplete - Returned Approval Date Expiration Date Provider Number Reviewed By
Comments: __________________________________________________________________________
Revised: March 15, 2018
Revised: March 15, 2018 Page 2 of 4
CE PROVIDER PROGRAM
Application Check-list
The following material must be submitted with your initial or renewal application form. Failure to provide the
required material will delay your approval or re-approval as a CE Provider. Shaded boxes not required.
If the application is for a program or clinical director change, the application and appropriate resume form are
only required.
Material to be submitted: EMS agency use
Application form
Program Director Resume Form
Clinical Director Resume Form
A statement identifying the types of CE classes to be offered
and delivery format
Sample tamper resistant course completion certificate
A calendar of anticipated classes to be offered in the coming year
A calendar of classes given in the past year showing the
name of the class, dates, and numbers of students
Not Required
Please return this application to:
Kreig Harmon, Paramedic
Prehospital Care Coordinator
Alameda County EMS
1000 San Leandro Blvd., 2nd floor
San Leandro, CA 94577
(510)667-7984
Alameda County EMS
Alameda County EMS Revised: March 15, 2018 Page 3 of 4
CONTINUING EDUCATION PROGRAM
PROGRAM DIRECTOR INFORMATION SHEET
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications: (1) Administering the CE program and ensuring adherence to state regulations and established local
policies. (2) Approving course, class, or activity, including instructional objectives, and assigning CE hours to any CE
program which the CE provider sponsors; approving all methods of evaluation, coordinating all clinical and field
activities approved for CE credit; approving the instructor(s) and signing all course, class, or activity completion records
and maintaining those records in a manner consistent with these guidelines. The responsibility for signing course, class,
or activity completion records may be delegated to the course, class, or activity instructor
California State Fire Marshal (CSFM) "Fire Instructor 1A and 1B"
National Fire Academy (NFA) "Fire Service Instructional Methodology" course or equivalent
A training program of at least 40 hours of teaching methodology that meets the U.S. DOT/National Highway
Traffic Safety Administration 2002 Guidelines for Educating EMS Instructors, such as the EMS Educator
course of the National Association of EMS Educators
Equivalent experience - Note: Individuals with equivalent experience may be provisionally approved for up to
two years by the approving agency pending completion of the specified requirements above. Submit
documentation of the equivalent experience
I certify that I have read and understand the requirements in Title 22, Chapter 11, including the duties of the
Program Director, delivery formats and limitations, and CE Provider requirements, and will comply with the requirements as described. I certify that all information on this application, to the best of my knowledge, is
true and correct.
Signature: Date:
Alameda County EMS Revised: March 15, 2018 Page 4 of 4
CONTINUING EDUCATION PROVIDER
CLINICAL DIRECTOR INFORMATION SHEET
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications: 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
California License: (submit a copy)
Physician
Registered nurse
Physician assistant
Paramedic
Experience: (submit documentation (may be on resume) of at least two years experience in emergency medicine or
prehospital care within the last five (5) years in at least one of the following areas - check all that apply).
Academic
Administrative
Clinical
I certify that I have read and understand the requirements in Title 22, Chapter 11, including the duties of the Clinical Director, delivery formats and limitations, and CE Provider requirements, and will comply with the
requirements as described. I certify that all information on this application, to the best of my knowledge, is
Signature: Date: