HomeMy WebLinkAboutparamedic-preceptor-applicationAlameda County EMS Revised: October 16, 2017 Page 1 of 1
ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY
Paramedic Preceptor Application
Name: ____________________________________ Last First MI
Address: Street City State Zip County
Home Phone: _______________________ Cell Phone: _______________________ Email:
Employer: ________________________________________________________________________________________________________
Who is your EMS Coordinator?
Number of years of experience as a paramedic: (two years total required): In Alameda County:
Date promoted to a level 3 paramedic? (one year minimum required)
(MM/DD/YYYY)
EDUCATION
Paramedic School attended: __________________________________________________ Date graduated: _____________________
(MM/DD/YYYY)
Field Preceptor Training Workshop attended: Date completed: _____________________
(MM/DD/YYYY)
significant teaching experience
(see Paramedic Preceptor Requirements Policy, section 3.4.1 - attach proof of completion)
Education higher than high school? Yes No If yes, what degree/subject matter:
EXPERIENCE
Did you work as an EMT before attending paramedic school? Yes No If yes, for how many years?
California Paramedic License #: Expiration Date:
ADDITIONAL CERTIFICATIONS
Are you currently certified in all required Core Courses? Yes No
CPR ACLS BLS PEPP PALS or BTLS or PHTLS
Are you a certified instructor for any of the Core Courses? Yes No
CPR ACLS BLS PEPP PALS BTLS PHTLS
This section to be completed by the applicant
I understand that all the information on this application is subject to verification. I certify that the information provided is true and correct to the best of my ability.
Sign here: Date:
This section to be completed by the provider agency EMS Coordinator I hereby recommend this individual for approval as a preceptor in Alameda County. This individual meets all requirements and has no documented incidents requiring remediation during the past calendar year.
Sign here: Date:
Printed Name: _________________________________________________________________