Free 52319.FH11 - Indiana

INSTRUCTIONS FOR REPORT OF BASIC EMT CONTINUING EDUCATION
Part of State Form 52319 (R2 / 1-08)

DEPARTMENT OF HOMELAND SECURITY 302 West Washington Street Indianapolis, IN 46204 Telephone: (317) 232-3980

I. II.

Certification as an emergency medical technician will be valid for a period of two years. To renew a certification, a certified emergency medical technician shall submit a report of continuing education every two (2) years that meets or exceeds the minimum requirements to take and report forty (40) hours of continuing education according to the following: A. Participate in a minimum of thirty-four (34) hours of any combination of lectures, critiques, skills proficiency examinations, continuing education courses, or teaching sessions that review subject matter presented in the Indiana basic emergency medical technician curriculum. Participate in a minimum of six (6) hours of audit and review. Participate in any update course as prescribed by the commission. Successfully complete a proficiency evaluation that tests the skills presented in the Indiana basic emergency medical technician curriculum.

B. C. D.

III.

Notwithstanding any other provisions of 836 IAC 4-4-2, a person also certified as an emergency medical technician basic advanced, emergency medical technician - intermediate, or paramedic under IC 16-31 may substitute the required continuing education credits for those of subsection II. An individual who fails to comply with the continuing education requirements described in 836 IAC 4-4-2 shall not exercise any of the rights or privileges of an emergency medical technician and shall cease from providing the services authorized by an emergency medical technician certification as of the date of expiration of the current certification. An individual requiring a valid emergency medical technician card to work should submit their continuing education document at least thirty (30) days prior to the certificates expiration date. In applying for recertification, individuals agree to comply with all recertification requirements, rules, and standards of the Indiana Emergency Medical Services Commission. The individual bears the burden of demonstrating and maintaining compliance at all times. The Indiana Emergency Medical Services Commission considers the individual to be solely responsible for his/her certification.

IV.

V.

VI.

REPORT OF BASIC EMT CONTINUING EDUCATION
State Form 52319 (R2 / 1-08)

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REGISTRANT INFORMATION

DEPARTMENT OF HOMELAND SECURITY 302 West Washington Street Indianapolis, IN 46204 Telephone: (317) 232-3980

Date of continuing education report (month, day, year) Printed name (last, first, middle initial)

Indiana certification number Provider affiliation

Drivers license / State identification number (required)

Home address (number and street, city, state, and ZIP code) Home telephone number Work telephone number E-mail address Would you be willing to assist in a disaster?

(

)

(
No 100

)

Have you been trained in NIMS?

If yes, level of NIMS / ICS training:

Yes

200

300

400

700

800

Other ___________

Yes

No

VIOLATION STATEMENT
Have you ever been charged or convicted of any crimes other than minor traffic violations?

Yes

No

If yes, have you previously reported the details of this crime(s) to the Indiana Department of Homeland Security?

Yes

No

SIGNATURE OF TRAINING OFFICER AND PROVIDER CEO (if affiliated)
Signature of training officer Printed name of training officer Signature of provider organization CEO Printed name of provider organization CEO Date (month, day, year) Telephone number

(

)

Date (month, day, year) Telephone number

(

)

SIGNATURE OF EMS REGISTRANT I, the undersigned basic emergency medical technician, hereby affirm, under the penalty for perjury, that all statements on this continuing education report are true and correct, including copies of cards, certificates, and other required documents for verification. I understand that false statements or documents may be sufficient cause for revocation by the State of Indiana Emergency Medical Services Commission. I also understand that the State of Indiana Emergency Medical Services Commission may conduct an audit of the recertification activities listed at any time.
Signature of basic-advanced EMT Date (month, day, year)

CONTINUING EDUCATION HOURS Participate in a minimum of thirty-four (34) hours of any combination of lecture, critiques, skills proficiency examination, continuing education course, or teaching sessions that review subject matter presented in the Indiana basic emergency medical technician curriculum. Only original signatures will be accepted. DATE (month, day, year) TOPIC INSTRUCTOR SIGNATURE NUMBER OF HOURS

TOTAL HOURS Page 1 of 2

BASIC EMT AUDIT & REVIEW List each program with the date, number of hours attended, and the signature of the instructor. A minimum of six (6) hours is required. Only original signatures will be accepted. If a Basic EMT cannot afford audit and review sessions, additional hours may be added to the continuing education hours to make up for those six (6) hours. DATE (month, day, year) TOPIC OF REVIEW INSTRUCTOR SIGNATURE NUMBER OF HOURS

TOTAL HOURS

SKILLS PROFICIENCY EVALUATION Successfully complete proficiency evaluation that tests the skills presented in the Indiana basic emergency medical technician curriculum. Credit may be given for skills directly observed by the EMS Medical Director or his designee either at an in-service or in an actual clinical setting. Only original signatures will be accepted. SKILLS Cardiac Arrest Management / AED Bag Valve Mask / Combi-tube Apneic Patient Oxygen Administration Spinal Immobilization, Seated Spinal Immobilization, Supine Patient Assessment, Trauma Patient Assessment, Medical Long Bone Immobilization Joint Injury Immobilization Traction Splint Immobilization Bleeding and Shock Management Mouth to Mask with Supplemental Oxygen Airway, Oxygen, Ventilation DATE OF EVALUATION (month, day, year) EVALUATOR SIGNATURE

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