Free 18220.FH11 - Indiana

INSTRUCTIONS FOR REPORT OF EMT- PARAMEDIC CONTINUING EDUCATION
Part of State Form 18220 (R11 / 12-07) DEPARTMENT OF HOMELAND SECURITY

I. II.

Certification as an emergency medical technician-paramedic will be valid for a period of two years. To renew a certification, a certified paramedic shall submit a report of continuing education every two (2) years that meets or exceeds the minimum requirements below. A. An applicant shall report a minimum of seventy-two (72) hours of continuing education consisting of the following: 1. Section IA - Forty-eight (48) hours of continuing education through a formal paramedic refresher course as approved by the commission or forty-eight (48) hours of supervising hospital-approved continuing education that includes the following: a. b. c. d. e. 2. Sixteen (16) hours in airway, breathing, and cardiology Eight (8) hours in medical emergencies Six (6) hours in trauma Sixteen (16) hours in obstetrics and pediatrics Two (2) hours in operations

Section IB - Attach a current copy of cardiopulmonary resuscitation certification for the professional rescuer. The certification expiration date shall be concurrent with the paramedic certification expiration date. Section IC - Attach a current copy of advanced cardiac life support certification. The certification expiration date shall be concurrent with the paramedic certification expiration date. Section II - Twenty-four (24) additional hours of emergency medical services related continuing education; twelve (12) of these hours shall be obtained from audit and review. The participation in any course as approved by the commission may be included in this section. Section III - Skill maintenance (with no specified hour requirement) - All skills shall be directly observed by the emergency medical service medical director or emergency medical service educational staff of the supervising hospital, either at an in-service or in an actual clinic setting. The observed skills include, but are not limited to, the following: a. b. c. d. e. f. g. h. i. Patient medical assessment and management Trauma assessment and management Ventilatory management Cardiac arrest management Bandaging and splinting Medication administration, intravenous therapy, intravenous bolus, and intraosseous therapy Spinal immobilization Obstetrics and gynecological scenarios Communication and documentation

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REPORT OF EMT- PARAMEDIC CONTINUING EDUCATION
State Form 18220 (R11 / 12-07) DEPARTMENT OF HOMELAND SECURITY

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REGISTRANT INFORMATION
Public safety identification number Printed name (last, first, middle initial) Home address (number and street, city, state, and ZIP code) Have you been trained in NIMS / ICS? If yes, level of NIMS / ICS training: Would you be willing to assist in a disaster? Indiana certification number Home telephone number Drivers license number E-mail address

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Yes

No

100

200

300

400

700

800

Other ___________

Yes

No

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

Yes

No

If you answered yes, you must attach official documentation that fully describes the offense, current status, and disposition of the case.

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

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Date (month, day, year)

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SIGNATURE OF EMS REGISTRANT

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I, the undersigned paramedic, 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 Indiana Department of Homeland Security and the Emergency Medical Services Commission. I also understand that the Indiana Department of Homeland Security and the Emergency Medical Services Commission may conduct an audit of the recertification activities listed at any time.
Signature of paramedic Date (month, day, year)

CURRENT AFFILIATIONS - AMBULANCE PROVIDER ORGANIZATIONS
Name of provider Street address (number and street, city, state, and ZIP code) Signature of Chief Executive Officer Name of provider Street address (number and street, city, state, and ZIP code) Signature of Chief Executive Officer Date (month, day, year) Provider certification number Date (month, day, year) Telephone number Provider certification number Telephone number

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CURRENT AFFILIATIONS - SUPERVISING HOSPITAL
Name of hospital Street address (number and street, city, state, and ZIP code) Signature of EMS Coordinator Name of hospital Street address (number and street, city, state, and ZIP code) Signature of EMS Coordinator Date (month, day, year) Date (month, day, year) Telephone number

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Telephone number

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SECTION IA: EMT - PARAMEDIC REFRESHER TRAINING 1. If a formal EMT-Paramedic Refresher course was completed, please attach a copy of the certificate of completion. 2. If a formal EMT-Paramedic Refresher course was not completed, Section I must be completed in its entirety. All signatures must be original. 3. All in-services and refresher courses must be done at or approved by your Supervising Hospital. 4. Lecture hours can only be assigned to one category of in-service credit in Section I. DATE (month, day, year) NUMBER OF HOURS TOPIC INSTRUCTOR'S SIGNATURE Division I - Airway, Breathing, and Cardiology Required: 16 hours

Division II - Medical Emergencies

Required: 8 hours

Division III - Trauma

Required: 6 hours

Division IV - Obstetrics & Pediatrics

Required: 16 hours

Division V - Operational Tasks

Required: 2 hours

SECTION IB: CPR CERTIFICATION

SECTION IC: ACLS CERTIFICATION

Attach a copy of the front of your current provider card or certification.

Attach a copy of the front of your current provider card or certification.

CPR and ACLS certification hours may be added to the appropriate divisions in Sections I and II. Page 2 of 4

SECTION II: 24 ADDITIONAL HOURS OF CONTINUING EDUCATION 12 hours must be obtained as AUDIT & REVIEW DATE (month, day, year) NUMBER OF HOURS TOPIC

INSTRUCTOR'S SIGNATURE

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SECTION III: VERIFICATION OF SKILL COMPETENCE 1. No specific amount of time must be spent on each skill or combination thereof. 2. All skills must be directly observed by the EMS Medical Director or EMS educational staff of the Supervising Hospital, either at an in-service or in an actual clinical setting. All signatures must be original. SKILL A. Medical Assessment / Management DATE (month, day, year) INSTRUCTOR'S SIGNATURE

B.

Trauma Assessment / Management

C.

Ventilatory Management

D.

Cardiac Arrest Management

E.

Bandaging and Splinting

F.

Medication Administration, IV Therapy, IV Bolus, and IO Therapy

G.

Spinal Immobilization

H.

Obstetrics and Gynecological

I.

Communication and Documentation

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