HomeMy WebLinkAboutalcoems-psfa-trainingproviderapplicationAlameda County EMS Revised: May 25, 2018 Page 1 of 3
PUBLIC SAFETY FIRST AID (PSFA) TRAINING PROGRAM APPLICATION
Initial Application Renewal Program Change
PSFA TRAINING
PROGRAM FEES:
PSFA 75$,1,1*352*5$0 NAME:B_____________________________________________________
PRIMARY LOCATION OF TRAINING PROGRAM: _____________________________________________
MAILING ADDRESS:_______________________________ _______________ ____ _________
Street City State Zip
PHONE NUMBER: ____________________ FAX NUMBER:____________________
NAME OF PROGRAM DIRECTOR:_______________________________________________________
TYPE OF AGENCY (Check One):
EMS PROVIDER
PUBLIC SAFETY AGENCY
HOSPITAL
EMT TRAINING PROGRAM
PARAMEDIC TRAINING PROGRAM
OTHER SCHOOL
INDIVIDUAL
OTHER:
ESTIMATED NUMBER OF PSFA COURSES TO BE OFFERED PER YEAR: ______________________
I certify that I have read and understand the requirements in Title 22, Division 9, Chapter 1.5, to be an approved Public Safety First Aid (PSFA) 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 or providing false information may result in withdrawal of PSFA
Provider approval.
Program Director Signature: Date:
For Alameda County EMS Use Only
Packet Received Application Incomplete - Approval Date Expiration Date Reviewed By
Agencies of Government, Hospitals, and Community Colleges. . . . . $1,500.00
Private Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$3,000.00
Revised: May 25, 2018 Page 2 of 3
PSFA TRAINING PROGRAM APPLICATION
Application Check-list
The following material must be submitted with your initial or re-approval application form. Failure to provide the
required material will delay your approval or re-approval as a PSFA Provider.
Any person or agency conducting a training program shall notify the Alameda County Emergency Medical
Services District (“District”) in writing within thirty (30) calendar days of any changes in the program.
The District may request additional materials or documentation as a condition of course approval.
Material to be submitted:
Application Form
Program Director Resume
Name and Credentials of Instructor(s)
Instructor Requirements/Maintenance
Detailed Initial Course Outline (21 hours min)
Detailed Retraining Course Outline (8 hours min)
Update Training Plan
Final Written Examination with Pre-established Scoring Standards
Skill Competency Testing Criteria, with Pre-established Scoring Standards
Course Evaluation Form/Method
Sample of Tamper Resistant Course Completion Certificate
Grievance Procedures
Please return this application to:
Alameda County EMS
Attn: Training Programs Unit
1000 San Leandro Blvd., 2nd floor
San Leandro, CA 94577
(510)618-2050
Alameda County EMS
Alameda County EMS Revised: May 25, 2018 Page 3 of 3
PSFA TRAINING PROGRAM APPLICATION
LIST OF INSTRUCTORS
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)
Name: _______________________________________________________________________ _________
Employer:
Qualifications: EMT -P / RN / Other: ________________________________________________________________
License Number : (submit a copy)