Free 44737.FH11 - Indiana

INSTRUCTIONS FOR REPORT OF EMT BASIC-ADVANCED CONTINUING EDUCATION
Part of State Form 44737 (R6 / 1-08) DEPARTMENT OF HOMELAND SECURITY

I. II.

Certification as an emergency medical technician basic-advanced will be valid for a period of two years. To renew a certification, a certified emergency medical technician basic-advanced shall submit a report of continuing education every two (2) years that meets or exceeds the minimum requirements to take and report fifty-six (56) 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 ten (10) hours of any combination of lectures, critiques, skills proficiency examinations, or teaching sessions that review subject matter presented in the Indiana emergency medical technician basic-advanced curriculum. Participate in a minimum of twelve (12) 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 and the Indiana emergency medical technician basic-advanced curriculum.

B.

C. D. E.

III.

An individual who fails to comply with the continuing education requirements for the emergency medical technician basicadvanced certification shall not exercise any of the rights or privileges of an emergency medical technician basic-advanced or administer advanced life support to any emergency patient as of the date of expiration of the current certificate. An individual requiring a valid emergency medical technician basic-advanced certification 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.

REPORT OF EMT BASIC-ADVANCED CONTINUING EDUCATION
State Form 44737 (R6 / 1-08) DEPARTMENT OF HOMELAND SECURITY

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REGISTRANT INFORMATION
Date of continuing education report (month, day, year) Printed name (last, first, middle initial) 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? Indiana certification number Provider affiliation Drivers license / State identification number (required)

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No 100

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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 offenses, that have not been previously reported?

Yes

If you answered yes, you must attach official documentation that fully describes the No offense, current status, and disposition of the case.

SIGNATURE OF EMS MEDICAL DIRECTOR AND PROVIDER CEO As the EMS Medical Director, I do hereby affix my signature attesting to the continued competence in all skills outlined in this document.
Signature of physician Printed name of physician Signature of provider CEO Printed name of provider CEO Certification / license number License number Date (month, day, year) State Date (month, day, year) Telephone number

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SIGNATURE OF EMS REGISTRANT I, the undersigned basic-advanced 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 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 instructor signatures will be accepted. DATE (month, day, year) TOPIC INSTRUCTOR SIGNATURE NUMBER OF HOURS

TOTAL HOURS Page 1 of 2

BASIC-ADVANCED EMT COURSE RELATED LECTURES List each program with the date, number of hours attended, and the signature of the instructor. A minimum of ten (10) hours is required. DATE (month, day, year) LESSON TOPIC INSTRUCTOR SIGNATURE NUMBER OF HOURS

TOTAL HOURS BASIC-ADVANCED EMT AUDIT & REVIEW List each program with the date, number of hours attended, and the signature of the instructor. A minimum of twelve (12) hours is required. DATE (month, day, year) TOPIC OF REVIEW INSTRUCTOR SIGNATURE NUMBER OF HOURS

TOTAL HOURS BASIC-ADVANCED EMT SKILLS PROFICIENCY EVALUATION (In addition to the Basic EMT Skills Proficiency Evaluation) List each program with the date, number of hours attended, and the signature of the instructor. 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 Intravenous Therapy Page 2 of 2 DATE OF EVALUATION (month, day, year) EVALUATOR SIGNATURE