EMERGENCY MEDICAL TECHNICIAN LICENSE APPLICATION

Transcription

1 Department of Health Emergency Medical Services (EMS) Board EMERGENCY MEDICAL TECHNICIAN LICENSE APPLICATION INSTRUCTIONS: Complete all areas of the application and answer all questions. Print in ink or use typewriter. Please see instructions in enclosed guidelines before completing the sections below. A. LICENSE LEVEL APPLYING FOR - Check appropriate box. EMT-I EMT-II EMT-III If applying for a conditional license also check this box. B. PERSONAL INFORMATION Name (in full): Former Name(s): Last Name/Family Name First/Given Name Middle Name(s) Mailing Address: Civic Address (if different than mailing address): Number Street Town/City Province/Postal Code Address: Telephone Number (include area code if outside PEI): Home Work Cell C: CRIMINAL RECORD CHECK Have you ever been convicted of a criminal offence under any federal or provincial statute or do you have any outstanding charges? Yes No If Yes: A. When B. Where C. What Cause YOU MUST PROVIDE A CRIMINAL RECORD CHECK FROM A POLICE DETACHMENT OR OTHER CRIMINAL RECORD CHECK SERVICE PROVIDER.

2 D. PARAMEDIC EDUCATION - New applicants must attach copy of certificate(s). Program Graduated Date of Certification CMA Accredited PCP/EMT/P1 Yes Yes No ICP/EMT-2/P-2 Yes Yes No ACP/EMT-P/P-3 Yes Yes No Paramedic School(s) & Title of Program(s): If you have gained additional competencies above your licensure level, please indicate below all of these competencies for which you have been determined to be competent (attach copy of certificate(s). Additional Competencies Date of Certification E. PARAMEDIC EXPERIENCE - If not applicable print N/A. Where did you first obtain registration? Province/State/Country Date Were you previously licensed in PEI as an EMT? Yes No If yes: At what level? Currently employed by an ambulance service in PEI? Yes If yes: What ambulance service?_ Are you currently registered in another province or country? Yes No License Number No If yes, please provide verification of registration form of the other licensing bodies. Please list all places where currently registered: Years with this service? Total number of years experience in ambulance service work?

3 F. REGISTRATION STATUS If you answer yes to any of the following five questions attach an explanation: 1. Is your paramedic conduct or practice currently under investigation? Yes No 2. Have you ever been denied a license? Yes No 3. Have you ever been disciplined by a professional regulatory body? Yes No 4. Have you ever been suspended, dismissed or de-registered as an EMT Yes No or equivalent in PEI? 5. Has your license in another province/state ever been revoked, suspended Yes No or had conditions attached? G. CURRENCY OF KNOWLEDGE AND SKILLS -Complete either subsection 1 or subsection 2 1. RE-LICENSURE (both of the following are required): A. I have actively practiced as an EMT by participation in at least 10 emergency call-outs during the past two years preceding this application (attach verification). Yes No B. I have successfully accumulated 20 continuing education units (CEUs) within the two years preceding this application (attach documentation). Yes No 2. NEW LICENSE (one of the following is required): A. I have completed my EMT training within two years preceding this application. Yes No Date certificate granted B. I have actively practiced as an EMT by participating in at least 20 emergency call-outs during the two years preceding this application (attach verification). Yes No C. Lapsed License (1 day to less than 1 year) I have, within 60 days of being granted a conditional license, completed 10 emergency call-outs, and successfully accumulated 20 CEUs (attach documentation). Yes No D. Lapsed License (1 year to 3 years) I have, within 6 months of being granted approval of a preceptored course in emergency medical services, completed a minimum of 420 hours of preceptorship at my previous level with a minimum of 75 patient care trips of which at least 15 were emergency call-outs, and successfully accumulated 20 CEUs (attach verification). Yes No

4 DECLARATION I hereby declare the information contained in this application and the attachments to be true and valid. I understand that (1) falsification of this application, or (2) the submission of any falsified documents to the Emergency Medical Services (EMS) Board, or (3) the submission of any falsified EMS Board documents to other agencies, may be sufficient cause for the EMS Board to withhold a license, to revoke a license, or to take other appropriate action. Date: Applicant s Signature: ADVISORY ALL applicable certificates, documentation and fee payment must be included with this application. If incomplete, the application may be returned, the application process delayed and/or if for license renewal subject to the late renewal fee. FREEDOM OF INFORMATION and PROTECTION of PRIVACY ACT - EMS BOARD COMPLIANCE STATEMENT - Personal information on this form is collected by the EMS Board under the authority of Prince Edward Island s Public Health Act (sections 25 and 38) and Emergency Medical Services Regulations (sections, 16, 17 and 18). This information will be used to determine eligibility for an EMT license and to maintain a register of licensed EMTs in the province. The collection, use or disclosure of this information must be in accordance with the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1998, c.f If you have any questions about this collection of personal information, contact the Provincial Emergency Medical Services Coordinator, Department of Health, P.O. Box 2000, Charlottetown, PE, C1A 7N8, phone: (902)

5 Department of Health Emergency Medical Services (EMS) Board EMT CONTINUING EDUCATION AND EMERGENCY CALL-OUT RECORD NAME: AMBULANCE SERVICE: EMT LICENSE #: FOR THE TWO YEAR PERIOD COMMENCING: A. CONTINUING EDUCATION UNITS (CEUs) RECORD EMTs must have accumulated 20 CEUs within the 2 years preceding application for re-licensure. Course(s) Attended: Date(s): Course Name: Course Instructor: Course Length in Hours: CEUs Earned (1 Course hour = 1CEU)* Course(s) Taught: Date(s): Course Name: Course Instructor: Course Length in Hours: CEUs Earned (1 Teaching Hour = 2 CEUs to maximum of 8 CEUs)* TOTAL CONTINUING EDUCATION UNITS EARNED: Copies of certificates to be attached. For preceptorship signed document from supervisor is required. *CEU Limitations: a) CPR and Defibrillation - maximum 2 CEUs per year for each course for recertification or teaching. b) Preceptors - no job orientations to be used; minimum 1 month to 3 months = 2 CEUs; over 3 months = 4 CEUs.

6 B. EMERGENCY CALL-OUT RECORD For re-licensure, EMTs must have participated in at least 10 emergency call-outs within the 2 years preceding application. New applicants must have participated in at least 20 emergency call-outs within the 2 years preceding application for licensure, if completion of training was more than 2 years ago and have not completed a preceptorship program. Emergency Call-Outs: Date: Ambulance Call Report Form #:

7 EMERGENCY MEDICAL SERVICES BOARD HEALTH PEI VERIFICATION OF REGISTRATION Send to each regulatory body where registered and/or licensed currently or previously. A separate form must be used for each regulatory body. Please have regulators mail completed forms to EMS Board, C/O EMS Coordinator, PO Box 2000, Charlottetown, PE C1A 7N8. Part A - To be completed by applicant Family Name: Phone #: Given Names: Address: Address: Province of Paramedic Education: Designation: Graduation Date: Registration No: Registration Date: Signature: Date: Part B - To be completes by the regulatory body Name of Regulatory Body Name of Registrant Type of Registration Granted (title) Registration Number Initial Registration Date in Jurisdiction Expiry Date of Registration Had this person s registration/license ever been denied, revoked, suspended or under review: Yes No If yes, please indicate reason on page 2. If yes, has this person s registration/license been reinstated? Yes Date: No Other Comments: Agency Seal: Contact Name Title/Phone Authorized Signature Date Personal information on this form is collected by the EMS Board under the authority of Part II of the Public Health Act, R.S.P.E.I. 1988, Cap. P-30, and the Emergency Medical Services Regulations, and according to the Agreement on Internal Trade. If you have any questions about the collection of this information, please contact the EMS Coordinator, PO Box 2000, Charlottetown, PE C1A 7N8. This information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act, R.S.P.E.I. 1998, Cap. F

8 Explanation for the practitioner s license being Denied: Revoked: Suspended: Under Review:

9 EMERGENCY MEDICAL SERVICES BOARD EMT RE-LICENSING INSTRUCTIONS All re-licensing applications must include the following: 1. Completed Emergency Medical Technician License Application form. Note: An Emergency Medical Care Certificate is not required as a copy is on file. 2. Valid and subsisting certificate in Cardiopulmonary Resuscitation (CPR) at the basic rescuer level in accordance with the standards of the Canadian Heart Foundation. 3. Valid and subsisting Drivers Abstract from the Department of Motor Vehicles. The Drivers Abstract will be required to be updated every 2 year period. The applicant must: - have a valid provincial Class 4 driver s license or equivalent, that authorizes the applicant to drive an ambulance; and - not have more than 6 demerit points in either of the 2 years preceding the application 4. Currency of Knowledge and Skills as indicated by both of the following: (a) Applicant has actively practised as an EMT by participating in at least 10 emergency call-outs during the 2 years preceding this application. Required documentation: Complete emergency call-out portion of EMT Continuing Education And Emergency Call-out Record form provided and submit with completed application and other supporting documentation. and (b) Applicant has successfully completed 20 continuing education units (CEUs) within the 2 years preceding this application. Required documentation: Complete continuing education portion of EMT Continuing Education And Emergency Call-Out Record form provided and submit with completed application and other supporting documentation including copy of certificate(s). Note: An EMT who has been licensed for less than 2 years will have both requirements (a and b) pro-rated based on the length of time of his/her current license. 5. $20 license fee. If paying by cheque, make payable to the Provincial Treasurer. An application will not be processed without the fee. Note: An application or fee received after the due date will be charged a late renewal fee of $10 in addition to the $20 fee

10 6. Criminal record check. 7. Scored 80% or higher on Provincial Exam for EMT I and EMT III. Payment must be received for the exam before marks and licensure are released. 8. If applying for EMT III, you must provide proof of a valid ACLS certificate.

11 EMERGENCY MEDICAL SERVICES BOARD EMT LICENSING INSTRUCTIONS - NEW APPLICANT - All new applications must be accompanied with the following: 1. Completed Emergency Medical Technician License Application form. 2. Valid and subsisting Emergency Medical Care Certificate indicating successful completion of training, including both classroom and practical experience, given in a community college or comparable program in emergency medical services that is accredited, at the time of the applicant s graduation, by the Canadian Medical Association s conjoint committee on accreditation of allied health services. 3. Valid and subsisting certificate in cardiopulmonary Resuscitation (CPR) at the basic rescuer level in accordance with the standards of the Canadian Heart Foundation. 4. Valid and subsisting Drivers Abstract from the Department of Motor Vehicles, and a photocopy of driver s license. Note: The applicant must: - have a valid provincial Class 4 driver s license or equivalent, that authorizes the applicant to drive an ambulance; and - not have more than 6 demerit points in either of the 2 years preceding the application. 5. Currency of Knowledge and Skills as indicated by one of the following (a or b): (a) (b) Successfully completed training within the two years preceding this application. Required documentation: copy of EMT Certificate; or As an EMT, participated in at least 20 emergency call-outs during the 2 years preceding this application. Required documentation: Complete emergency call-out portion (Section B) of EMT Continuing Education And Emergency Call-out Record Form provided and submit with completed application and other supporting documentation. 6. $20 license fee. If paying by cheque, make payable to the Provincial Treasurer. Applications will not be processed without the fee. 7. Criminal record check. 8. Scored 80% or higher on Provincial Exam for EMT I and EMT III. Payment must be received for the exam before marks and licensure are released. 9. If applying for EMT III, you must provide proof of a valid ACLS certificate.