Free EMS Training Center Application, DPH 7482 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7482 (09/05)

STATE OF WISCONSIN Chapter 110, 111, 112, 113, Wis. Admin. Code (608) 266-1568

EMS TRAINING CENTER CERTIFICATION APPLICATION
This form is authorized under s. 146.50, Wis. Stats. and Chapters 110, 111, 112 and 113, Wis. Admin. Code. Completion of this form is mandatory for certification as an EMS Training Center in Wisconsin. Personally identifiable information requested on this form will only be used for certification purposes.

INSTRUCTIONS: Type or print legibly. Complete all sections of this application, sign, and return it to the address listed below. This application is to be used to apply for certification or update EMS Training Center Certification in Wisconsin. Attach information required in the accompanying checklists for each level of EMS training that is provided or is being applied for. Failure to complete all sections of this application and attaching the requested documentation will result in the application being returned unapproved. RETURN COMPLETED FORM TO: DIVISION OF PUBLIC HEALTH BUREAU OF LOCAL HEALTH SUPPORT & EMS P.O. BOX 2659 MADISON, WI 53701-2659

Type of application:

Initial

Update/Renewal

Level(s) of training requested for approval (check all that apply):
First Responder First Responder Ref. Basic Basic Refresher Basic IV Basic IV Refresher Intermediate (1999) Intermediate (1999) Refresher Paramedic Paramedic Refresher

APPLICANT INFORMATION
Training Center Name Address Mailing Address (if different than above) City Name of Person Completing Application Telephone Number FAX Number E-mail Address State Zip Code County

Name of EMS Program Contact (program assistant, secretary, etc.) Telephone Number FAX Number E-mail Address

TRAINING CENTER MEDICAL DIRECTOR INFORMATION
Medical Director Name Address Mailing Address (if different than above) Physician License Number

City Telephone Number FAX Number

State

Zip Code E-mail Address

County

Attach a copy of the medical director's curriculum vitae.

DPH 7482 (09/05) Page 3

SUPERVISORY CHAIN OF COMMAND: List the supervisory chain of command within your training center beginning with the agency head (i.e. District Director) through to the Instructor / Coordinator level. Name Title Telephone Number and / or Email

Attach additional sheets if necessary.

INSTRUCTOR / COORDINATORS: List the certified EMS Instructor / Coordinators employed at this facility. A resume or curriculum vitae, current CPR and ACLS (if teaching ALS levels) certification, current EMT licensure and / or National Registry of EMTs certification and current Instructor / Coordinator certification approval must be on file with your institution for our review. All requested information must be attached to this application for any instructor / coordinators seeking certification approval. Name License Number License Level Approved Teaching Levels (check all that apply) FR FR FR FR FR FR FR FR FR FR FR FR FR Attach additional sheets if necessary. B B B B B B B B B B B B B IV IV IV IV IV IV IV IV IV IV IV IV IV INT INT INT INT INT INT INT INT INT INT INT INT INT P P P P P P P P P P P P P

DPH 7482 (09/05) Page 3

PRECEPTORS: List the preceptors used by your facility. A resume or curriculum vitae, current CPR and ACLS (if teaching ALS levels) certification, and current licensure information must be on file with your institution for our review. Years Pre-hospital Name License Number License Type Experience

Attach additional sheets if necessary.

ADJUNCT FACULTY (Teaching Assistants, etc.): List the adjunct faculty employed by your facility. A resume or curriculum vitae, current CPR and ACLS (if teaching ALS levels) certification, current EMT licensure and/or National Registry of EMTs certification must be on file with your institution for our review. Name License Number License Level

Add additional sheets if necessary.

DPH 7482 (09/05) Page 4

TRAINING LOCATIONS: List the locations at which EMS training is commonly conducted. Address

City

Attach additional sheets if necessary.

I,
(Print Name)

, as the administrator/supervisor/dean of the Emergency agree that all training provided
(Name of Training Center)

Medical Services discipline of

by this training center will be conducted in direct compliance with all administrative rules, regulations, policies and guidelines established by the current edition of the U.S. Department of Transportation, the EMS Section of the Bureau of Local Health Support and EMS, and the Wisconsin Technical College System Board (where applicable).

SIGNATURE - Administrator/Supervisor/Dean

Title

Date Signed