Free 44848.FH11 - Indiana

REPORT OF TRAINING
State Form 44848 (R3 / 9-07)

Course number

COURSES Primary instructor First Responder Basic Basic Advanced Intermediate Paramedic EVOC Extrication Instructor Update

INDIANA DEPARTMENT OF HOMELAND SECURITY

Reset Form
INSTRUCTIONS:

Submit this report to verify successful completion of training. Failure to complete any item will result in this form being rejected. Upon acceptance, this form will become a public record.
County City State ZIP code

Name of institution Address (number and street or Rural Route) Location of course Address (number and street or Rural Route) Starting date (month, day, year) Number of classes held Completion date (month, day, year) Number of classroom hours City Number of students starting State

ZIP code Number of students completing Total course hours

Number of clinical hours

Number of ambulance hours

+
Name of training institution official (please print) Signature of training institution official Name of primary instructor (please print) Signature of primary instructor Signature of Medical Director

+

=

0.00

PRIMARY INSTRUCTOR / FIRST RESPONDER / BASIC COURSES

Date signed (month, day, year)

Date signed (month, day, year) Date signed (month, day, year)

BASIC ADVANCED / INTERMEDIATE / PARAMEDIC COURSES
Name of training institution official (please print) Signature of training institution official Name of primary instructor (please print) Signature of primary instructor Name of Medical Director (please print) Signature of Medical Director Name of course coordinator (please print) Signature of course coordinator Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year)

EMERGENCY VEHICLE OPERATIONS / EXTRICATION / INSTRUCTOR COURSES
Location of driving range Signature of approved instructor Signature of approved Training Institution Official Date signed (month, day, year) Date signed (month, day, year)

(Continued on reverse side)

LIST ALL STUDENTS ENROLLED AT THE START OF THE COURSE.
Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code Name of student Address (number and street or Rural Route) City, state, and ZIP code EMS affiliation EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score EMS affiliation County Age Score County Age Score Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number Certification number Didactic hours Clinical hours Ambulance hours Driver license or state identification number