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PARAMEDIC TRAINING PROGRAM Program Approval
Initial Application Renewal Program Change
TRAINNG PROGRAM FEES: Agencies of Government, Hospitals, and Community Colleges $2,250.00
Private Programs $4,500.00
PARAMEDIC TRAINING PROGRAM NAME:
PROVIDER LOCATION (County of primary headquarters): ________________________________________
MAILING ADDRESS: ______________________________________ _______________ ____ _________
Street City State Zip
PHONE NUMBER: ____________________ FAX NUMBER: ____________________
PROGRAM DIRECTOR:_______________________________________________________
PROGRAM MEDICAL DIRECTOR: _______________________________________________________
ELIGIBILITY (Provide Documentation):
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 -
STUDENT ELIGIBILITY: Employees only Open to the public
CONTINUING EDUCATION PROVIDER: Training Programs wishing approval as a Continuing Education
Provider should complete Continuing Education Provider Application. CE provider requirements can be
found in Title 22, Division 9, Chapter 11.
LOCAL EMS AGENCY AUTHORITY: 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.
I certify that I have read and understand the requirements in Title 22, Chapter 4, Article 3 to be an approved Paramedic Training Program, 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
PARAMEDIC TRAINING PROGRAM
Application Check-list
The following material must be submitted with your initial or renewal application form. Failure to provide the required material within the
required timeframe will delay your approval or re-approval as a Paramedic Training Program. Shaded areas not required.
Material to be submitted: Initial
program
Program
Renewal EMS agency use
Application Form
Eligibility Documentation
Program Fees
Program Director documentation
Program Medical Director Documentation
Principal Instructor(s) documentation
Teaching Assistants documentation
Written agreement(s) with paramedic service provider(s)
for student field internships
Written agreement(s) with licensed general acute
hospital(s) for student clinicals
A statement identifying which Paramedic curriculum is used (equivalent to the U.S.
DOT EMT-P National Standard Curriculum HS 808 862 March 1999)
(broken down by didactic and skills, and hospital clinical
An outline of course objectives
Performance objectives for each skill
evaluating students and monitoring of preceptors in the
Student evaluation criteria and standardized forms for evaluating students and monitoring of preceptors in a
field internship setting
Sample of tamper resistant course completion certificate
Samples of skills examinations for periodic testing and a
copy of a final written examination
provisions for examination security and student record
The location of courses and proposed start dates
A statement of the anticipated submission date of
materials to CoAEMSP for CAAHEP accreditation
Copies of the pre-enrollment letter provided to applicants
explaining the CAAHEP accreditation process
A calendar of courses given in the past year showing dates of courses
Not Required
Alameda County EMS Revised: October 16, 2017 Page 3 of 7
PARAMEDIC 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 Paramedic Training Program shall have an approved Program Director who shall be qualified:
•By education and experience in methods, materials, and evaluation of instruction
•And shall have a minimum of one year experience in an administrative or management level position
And have a minimum of three years academic or clinical experience in prehospital care education within the
last five years
Check one and submit documentation verifying one of the following
Physician
Registered nurse with a baccalaureate degree
Paramedic with a baccalaureate degree
An individual who holds a baccalaureate degree in a related health field or in education
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.
I certify that I have read and understand the requirements in Title 22, Chapter 4, Article 3, § 100149 regarding
the duties of the Course Director 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: October 16, 2017 Page 4 of 7
PARAMEDIC TRAINING PROGRAM
PROGRAM MEDICAL DIRECTOR INFORMATION SHEET
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications - Each Paramedic Training Program shall have an approved Program Medical Director, licensed in
California, who has two years experience in prehospital care in the last five years and who is qualified by education and
experience in methods of instruction.
Experience: Submit a resume including licenses/certificates, job and/or medical experience and demonstration of your
education and experience in methods, materials, and evaluation of instruction.
I certify that I have read and understand the requirements in Title 22, Chapter 4, Article 3, § Section 100149 regarding the duties of the Program Medical Director 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: October 16, 2017 Page 5 of 7
PARAMEDIC TRAINING PROGRAM
PRINCIPAL INSTRUCTOR(s)
Name:
Last First MI
Agency:
Address:
Street City State Zip
Home Phone: _________________ Cell Phone: Fax: _________________
E-mail:_________________________________________________________________________________
Qualifications – Principle Instructors must be approved by the Program Director and Medical Director and shall:
•Be qualified by education and experience in methods, materials, and evaluation of instruction
•Have two years experience in ALS prehospital care and be knowledgeable in the course content of the U.S.DOT EMT-P National Standard Curriculum HS 808 862 March 1999)
•Have six years experience in an allied health field or related technology and an associate degree
•Or have two years experience in an allied health field or related technology and a baccalaureate degree
Check one and submit documentation verifying one of the following:
Physician
Registered nurse
Physician assistant
Paramedic – License # _____________________
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.
I certify that I have read and understand the requirements in Title 22, Chapter 4, Article 3, § 100149 regarding
the duties of the 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:
(Make copies for additional Principal Instructors)
Alameda County EMS Revised: October 16, 2017 Page 6 of 7
PARAMEDIC TRAINING PROGRAM
TEACHING ASSISTANTS
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)
Duplicate page for additional teaching assistants
Alameda County EMS Revised: October 16, 2017 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