A Non-Profit Cooperative to Improve Health Care and Reduce Member s Costs

NEW JERSEY S HOSPITAL SERVICE CORPORATION 4806 MEGILL RD. WALL TOWNSHIP, NEPTUNE, NJ 07753 PHONE: 732-919-3045 FAX: 732-919-2753 INTERNET: www.monoc.org A Non-Profit Cooperative to Improve Health Care and Reduce Member s Costs Dear Prospective Paramedic Student, Thank you for your interest in the MONOC/Ocean County College Paramedic Program. The next Paramedic training program is scheduled to start in February, 2014 and we are currently accepting applications for clinical sponsorship to the program. The didactic portion of this program will follow a hybrid format, where the majority of lecture material will be gained through independent online study with a weekly skill lab held at the MONOC Education Center in Wall Township on Thursday nights from 5pm to 9pm. Additionally, students will be required to attend two Sunday classes from 8am to 5pm. Those classes will be announced several months in advance. In order to register for the MONOC/OCC Paramedic program, each student must be at least 18 years of age, have a high school diploma or equivalent, be currently certified as an EMT with a valid CPR card, and secure clinical sponsorship (an agreement to provide clinical training once the didactic program is completed) with a New Jersey MICU program. Clinical sponsorship through MONOC is not specifically required. All candidates who choose to seek clinical sponsorship through MONOC, are required to interview and undergo written and practical skills testing before an offer of clinical sponsorship can be extended. At least one year s experience as a BLS provider in a 9-1-1 system (either paid or volunteer) is preferred, but not absolutely required. MONOC typically receives more requests for clinical sponsorship than we can accommodate; therefore, this is a competitive application process where all qualified applicants are ranked and offered sponsorship accordingly. Attached, please find an application for clinical sponsorship to the program, as well as a program reference form. The completed application and three separate references are due back to MONOC at the below address no later than November 1, 2013, along with a resume and copies of your EMT and CPR certifications. At the end of the submission period, you will be contacted by a representative from my office to schedule an appointment for a sponsorship interview. Until then, if you have any specific questions regarding the application procedure or the program itself, please do not hesitate to contact me directly. Best regards, Paul Scalzo, NREMT-P Manager, Clinical Services MONOC Mobile Health Services 4806 Megill Road Neptune, NJ 07753 office: 732.919.3045 ext 1102 fax: 732.919.2748 paul.scalzo@monoc.org Integrity, Professionalism, Excellence BAYSHORE COMMUNITY HOSPITAL CENTRASTATE MEDICAL CENTER CLARA MAASS MEDICAL CENTER COMMUNITY MEDICAL CENTER, DEBORAH HEART & LUNG CENTER JERSEY SHORE UNIVERSITY MEDICAL CENTER KIMBALL MEDICAL CENTER MONMOUTH MEDICAL CENTER NEWARK BETH ISRAEL MEDICAL CENTER OCEAN MEDICAL CENTER RIVERVIEW MEDICAL CENTER SAINT BARNABAS MEDICAL CENTER SAINT MICHAEL S MEDICAL CENTER SOUTHERN OCEAN COUNTY HOSPITAL UNIVERSITY MEDICAL CENTER AT PRINCETON

The MONOC Paramedic Intern Training Program Application for Clinical Sponsorship Name of Applicant: Last Name: First Name: MI: Address: Number/Street: Apt #: City: State: Zip Code: Contact Information: Home Phone: Cell Phone: Email: Educational Background: Have you ever attended a Paramedic Education Program Before? Yes No If yes, then where? (State/College) Date attended: Name of Didactic Program Manager: Name of Clinical Coordinator: Reason for leaving: Highest level of formal education: High School Diploma or GED Some College Associate s Degree Bachelor s Degree Master s Degree Doctoral Degree EMS Background/Experience: Total years of EMS Experience: How long have you been certified as an EMT? Years: Months: Name of Volunteer EMS Agency: Name of Paid EMS Agency: Yrs of svc: Additional Certifications: (please circle all that apply and provide copies of certificates/cards) PHTLS ITLS PEPP CEVO NREMT ICS 100 ICS 200 ICS 300 ICS 700 Other certifications: Page 1 of 5

Leadership Experience: (please use the space below to list any leadership positions you have held, including non-ems related positions) Employment History: (Starting with your current or most recent employer, please list your employment history, including all employers, self employment, and periods of military service. If more space is required, please supply additional information separately, using the below format) Name of Employer: Department: Address of Employer: Job Title & Description: Name & Title of Immediate Supervisor: Contact Number: Reason for Leaving: Name of Employer: Address of Employer: Job Title & Description: Department: Name & Title of Immediate Supervisor: Contact Number: Reason for Leaving: Name of Employer: Address of Employer: Job Title & Description: Department: Name & Title of Immediate Supervisor: Contact Number: Reason for Leaving: Criminal Background: (If selected for clinical sponsorship, you will be required to undergo at your cost, a criminal background check, as well as a physical and drug screen) Have you ever been charged with, or convicted of, a criminal offense other than a minor traffic violation? Y/N If yes, then please explain: Has your driver s license ever been suspended or revoked in this or any other State? Y / N If yes, then please explain: Page 2 of 5

Personal Statement: (May be typed and submitted separately) Please tell us about yourself and describe your motivation for becoming a Paramedic, including any future goals in EMS or medicine in general. Please explain why you have chosen to apply to MONOC for clinical sponsorship. Page 3 of 5

Authorization for consent and release from liability: In order to assist in evaluating my sponsorship qualifications, I authorize MONOC and/or its designated agent(s) to request and receive any information concerning me, including but not limited to reports from any persons, schools, companies, corporations, partnerships, associations, licensing agencies, and from any of my current or previous employers. I also authorize any of the aforementioned parties to furnish MONOC with any and all information concerning me. I further release MONOC and/or its designated agents from all liability and responsibility arising out of the release of such information. Realizing that the references I give, may know me by a different name, I am listing below, other names by which I have been known: Other name(s) and/or maiden name(s): I hereby affirm that my answers to the forgoing questions are true and correct, and I understand that misrepresentation or omission of facts called for in this application or any submitted records, or any information provided during the interview and screening process, shall constitute grounds for the rejection of this application or future revocation of my clinical sponsorship if accepted into the program. I understand that an offer of clinical sponsorship to the MONOC/Ocean County College Paramedic Program is contingent upon the satisfactory completion of the application form, required documents and references, and oral interview, as well as cognitive/psychomotor evaluations, criminal background check, physical and drug screening, and any other conditions set forth by MONOC. I understand that if I am extended an offer of clinical sponsorship to the MONOC/Ocean County College Paramedic Program, MONOC policies, practices, procedures, services and other materials given me are not intended to create or imply a contractual relationship between myself and MONOC except as required by law. I understand that MONOC reserves the right to amend or discontinue any policies, practices, procedures, services and other materials at any time if permitted by law. I further understand that I may terminate my sponsorship relationship with MONOC for any reason and at any time. I also acknowledge that MONOC reserves the right to terminate the sponsorship relationship at any time, and no written or oral promise of sponsorship is effective unless it is expressly set forth in a document signed by the President of MONOC. I understand that an offer of clinical sponsorship to the MONOC/Ocean County College Paramedic Program does not constitute an offer of employment with MONOC. Consent for drug screening if offer of clinical sponsorship is extended: I understand that MONOC is committed to a drug-free workplace, and has adopted a drug testing program to assist in implementing and enforcing that policy. I hereby consent, at my cost, to the taking of a urine sample by MONOC or its designated agent(s) for the purpose of testing for such substances including, but not limited to amphetamines, barbiturates, benzodiazepines (including Valium, Restoril, Xanax, and Librium), cocaine, methadone, methaqualone, marijuana, opiates, methamphetamine, phencyclidine (PCP) and Propoxyphene (Darvon). I hereby consent to the release of any reports on such samples from the laboratory to MONOC, and I release MONOC, its officers, employees, and agents from all liabilities arising from the authorized release or use of the information contained in, or derived from my test results. I understand that any sponsorship offer that may be extended to me by MONOC is based on the condition that I successfully pass the drug test. I understand that if I refuse to participate, or if my results are positive, my offer of sponsorship will be revoked. Consent for background check if offer of clinical sponsorship is extended: As part of the background check for clinical sponsorship with MONOC, I understand that MONOC and/or its agent(s) may, at my cost, conduct an investigation of my personal information. The investigation may include, but not be limited to, names and dates of current or previous employment, work experience, motor vehicle records, criminal history records from state, federal, and other agencies, military records, and names and dates of education records. I understand that these records may be used to determine eligibility for clinical sponsorship to the MONOC/ Ocean County College Paramedic Program. I authorize without reservation, the full release of these records, and for MONOC and/or its agent(s) to obtain such information. (continued) Page 4 of 5

In addition, I release and discharge MONOC and/or its agent(s) and associates from any expenses, losses, damages, liabilities, or any other charges or complaints that may arise from the investigative process. I also authorize full release of the information described above, without reservation, throughout the duration of my clinical sponsorship with MONOC. I also certify that all information provided is correct, and I understand that misrepresentation or omission of facts called for in this application or any submitted records, or any information provided during the interview and screening process, shall constitute grounds for revocation of my clinical sponsorship. This authorization shall remain valid until such a time as it is revoked in writing, by the undersigned. Full Name: (please print) Place of Birth: Signature: Date signed: Driver s License #: Social Security #: Page 5 of 5

The MONOC Paramedic Intern Training Program Clinical Sponsorship Reference This reference will become part of the applicant s admission file Name of Applicant: Date: Applicant Instructions: This reference should only be returned by the person supplying it. Please provide the person supplying the reference with a stamped envelope addressed to: Paul Scalzo, NREMT-P Manager, Clinical Services MONOC Mobile Health Services 4806 Megill Road Neptune, NJ 07753 Please sign one of the below statements before giving this form to the person supplying the reference. I waive my right to see this reference once completed: I do not waive my right to see this reference, once completed: Person providing the reference: The above named individual is applying to MONOC for clinical sponsorship to the MONOC/Ocean County College Paramedic Program. Letters of reference are essential in assisting in the evaluation and selection of candidates. We welcome your comments and opinions, and ask that you answer the questions contained in this reference form, as candidly and completely as possible. Your cooperation in completing and returning this form by November 1, 2013, is greatly appreciated. If you have any questions, please feel free to contact my office directly at (732) 919-3045 ext 1102, or paul.scalzo@monoc.org Thank you, Paul Scalzo, NREMT-P Manager, Clinical Services MONOC Mobile Health Services

The MONOC Paramedic Intern Training Program Clinical Sponsorship Reference Name of Applicant: How long have you known the applicant? In what capacity do you know the applicant? Please circle all that apply As an EMS provider As a member of a church or civic group As a personal friend As a coworker As a supervisor or employer Please rate the applicant using the following scale, and provide additional comments if appropriate: 5 = Exceptional 4 = Above Average 3 = Average 2 = Needs Improvement 1 = Poor NA = Not Applicable How would you rate the applicant s efficiency and effectiveness as an EMS provider? How would you rate the applicant s ability to feel and express sympathy for others? How would you rate the applicant s ability to work with, and relate to others? How would you rate the applicant s ability to express him/her self, and effectively communicate with others? How would you rate the applicant s leadership ability? How would you rate the applicant s ability to analyze situations and utilize critical thinking skills? How would you rate the applicant s personal character and emotional maturity?

The MONOC Paramedic Intern Training Program Clinical Sponsorship Reference Please indicate how you would recommend the applicant for clinical sponsorship to this Paramedic program: Highly Recommend Recommend Recommend with reservation Do not recommend Is there anything else you would like us to know about the applicant? Please print your name and title: Please sign and date the reference: Daytime telephone number: Date: Email address: