Free 53513.FH11 - Indiana

STATEMENT OF REMEDIATION OF EMT-BA CURRICULUM
State Form 53513 (2-08) DEPARTMENT OF HOMELAND SECURITY

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Remediation must be completed prior to the third attempt of the written certification examination.

We hereby verify that __________________________________________________________________ has been remediated in ALL
Name of candidate

areas of the EMT-BA curriculum. We have spent ____________ hours, which either meets or exceeds the EMS Commission required twelve (12) hours of remediation.
Name of training institution Course number

Signature of primary instructor

Date (month, day, year)

Signature of training institution official

Date (month, day, year)

Signature of candidate

Date (month, day, year)