HomeMy WebLinkAboutalcoems-emt-trainingprogram-application-03282018Alameda County EMS Page 1 of 7
EMT TRAINING PROGRAMS Program Approval
Initial Application Renewal Program Change
TRAINNG PROGRAM FEES: Agencies of Government, Hospitals, and Community Colleges $1,500.00
Private Programs $3,000.00
EMT TRAINING PROGRAM NAME:
PROVIDER LOCATION (County of primary headquarters): ________________________________________
MAILING ADDRESS: ______________________________________ _______________ ____ _________
Street City State Zip
PHONE NUMBER: ____________________ FAX NUMBER: ____________________
PROGRAM DIRECTOR:____________________________________________________________
CLINICAL COORDINATOR: ____________________________________________________________
APPLYING FOR: Full program with refresher Refresher only Certifying Entity
ELIGIBILITY:
Accredited universities and colleges including junior and community colleges, school districts, and
private post-secondary schools
Medical training units of a branch of the Armed Forces or the Coast Guard of the United States
Licensed general acute care hospitals
Agencies of government including public safety agencies
Local EMS Agency's (LEMSA's)
STUDENT ELIGIBILITY: Employees only Open to the public
LOCAL EMS AGENCY AUTHORITY: All EMT training programs located in Alameda County, regardless of where headquartered or approved, are required to submit on an on-going basis, up-to-date training
program information, including program director, clinical coordinators, principle instructors, class schedules,
and rosters; and may be audited for compliance with regulations. Title 22, Division 9, Chapter 2, Article 1, § 100057 – 58, Article 3, § 100066, 100071 & 100077, Article 4, § 100082.
I certify that I have read and understand the requirements in Title 22, Chapter 2, Article 3 to be an approved EMT Training Program and Chapter 11 to be a Continuing Education 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 requirements in Title 22 may result in revocation
of this program approval.
Program Director Signature: Date:
For Alameda County EMS Use Only
Application Received Application Incomplete - Returned Application Approved Expiration Date Reviewed By
_________________________________________________________________________________
Comments: __________________________________________________________________________
Revised: October 16, 2017
Alameda County EMS Revised: October 16, 2017 Page 2 of 7
EMT TRAINING PROGRAM
Application Check-list
The following material must be submitted with your initial or renewal application. Failure to provide the required
material within the required timeframe will delay your approval or re-approval as an EMT Training Program.
Material to be submitted: Full program Program Refresher only Only agency
Application
Program Fees
Program Director Documentation
Program Clinical Coordinator Documentation
Principal Instructor(s) Documentation
Teaching Assistants Documentation
A signed statement identifying which EMT curriculum is used
A signed statement attesting to the number of course hours (broken down by didactic and skills,
and ambulance and/or emergency room)
A course outline
Sample lesson plans 1
plan
A signed statement identifying transport providers and /or hospitals used for clinicals
Signed statements describing the facilities and equipment, and provisions for examination
security and student record keeping
Sample tamper resistant course completion certificate
Sample copy of a final skills verification
examination
Sample copy of a final written examination
A signed statement of provisions for course
completion by challenge exam
A signed statement of provisions for a refresher
course
A calendar of courses given in the past year
Not Required
2plans2plans 1
Alameda County EMS Page 3 of 7
EMT TRAINING PROGRAM
PROGRAM DIRECTOR INFORMATION SHEET
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications - Each EMT training program shall have an approved program director that shall be qualified by
education and experience in methods, materials, and evaluation of instruction. Duties of the program director, in
4.Coordinating all clinical and field activities related to the course.
7.
Experience: Submit a resume including licenses/certificates, job and/or clinical experience and demonstration of your
education and experience in methods, materials, and evaluation of instruction.
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
I certify that I have read and understand the requirements in Title 22, Chapter 2, Article 3 regarding the duties
of Program Director, and in approving Principal Instructors and Teaching Assistants, 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:
Revised: October 16, 2017
Alameda County EMS Page 4 of 7
EMT TRAINING PROGRAM
PROGRAM CLINICAL COORDINATOR INFORMATION SHEET
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications: Each training program shall have an approved program clinical coordinator that shall be either a
physician, registered nurse, physician assistant, or a paramedic currently licensed in California, and who shall have two
(2) years of academic or clinical experience in emergency medicine or prehospital care in the last five (5) years. Duties
2.Approval of the qualifications of the principal instructor(s) and teaching assistant(s).
California License: (submit a copy)
Physician
Registered nurse
Physician assistant
Paramedic
Experience: submit a resume including licenses/certificates; job and/or clinical experience documentation of at least
two years in emergency medicine or prehospital care within the last five (5) years in at least one of the following areas -
Academic
Clinical
I certify that I have read and understand the requirements in Title 22, Chapter 2, Article 3 regarding the duties
of Clinical Coordinator, 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:
Program Director Signature: Date:
Revised: October 16, 2017
Alameda County EMS Page 5 of 7
EMT TRAINING PROGRAM
PRINCIPAL INSTRUCTOR(s)
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
California License/Certificate: (submit a copy)
Physician
Registered nurse
Physician assistant
Paramedic
EMT
Teaching Experience:
director in coordination with the program clinical coordinator as qualified to teach the topics to which s/he is assigned,
who shall be qualified by education and experience in methods, materials, and evaluation of instruction. Check one and
California State Fire Marshal (CSFM) "Fire Instructor 1A and 1B"
National Fire Academy (NFA) "Fire Service Instructional Methodology" course or equivalent
Traffic Safety Administration 2002 Guidelines for Educating EMS Instructors, such as the EMS Educator
Experience: (submit a resume including licenses/certificates, job and/or clinical experience documentation of at least
two years 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
Clinical
I certify that I have read and understand the requirements in Title 22, Chapter 2, Article 3 regarding the duties
of Principal Instructor, 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:
Program Director Signature: Date:
Clinical Coordinator Signature: _________________________________________ Date:
Duplicate page for additional principal instructors
Revised: October 16, 2017
Alameda County EMS Page 6 of 7
TEACHING ASSISTANTS &
EMT SKILLS COMPETENCY VERIFICATION
Name: _______________________________________________________________________ _________
Qualifications: California EMT / PARAMEDIC / RN / Other: __________________________________________
License /Certificate Number : Authorized to verify skills & sign (circle)? Yes No
Signature (only if authorized):
Name: _______________________________________________________________________ _________
Qualifications: California EMT / PARAMEDIC / RN / Other: __________________________________________
License /Certificate Number : Authorized to verify skills & sign (circle)? Yes No
Signature (only if authorized):
Name: _______________________________________________________________________ _________
Qualifications: California EMT / PARAMEDIC / RN / Other: __________________________________________
License /Certificate Number : Authorized to verify skills & sign (circle)? Yes No
Signature (only if authorized):
Name: _______________________________________________________________________ _________
Qualifications: California EMT / PARAMEDIC / RN / Other: __________________________________________
License /Certificate Number : Authorized to verify skills & sign (circle)? Yes No
Signature (only if authorized):
Name: _______________________________________________________________________ _________
Qualifications: California EMT / PARAMEDIC / RN / Other: __________________________________________
License /Certificate Number : Authorized to verify skills & sign (circle)? Yes No
Signature (only if authorized):
Notify ALCO EMS in writing, in advance when possible, and in all cases within thirty (30) calendar days of any changes to this list.
Duplicate page if needed
EMS stamp date received
Revised: October 16, 2017
Program or
Clinical/Coordinator: _____________________________ _____________________________ _______________ Name Signature Date (MM/DD/YYYY)
Alameda County EMS Page 7 of 7
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
Revised: October 16, 2017