Intermediate/99 Recertification Form 2010 - The National Registry Of Emergency Medical Technicians

ADVERTISEMENT

THE NATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS
EMT - Intermediate/99 Recertification Form 2010
Please read instructions enclosed
Registry
Social Security
I
Number
Number
Last
First
Mid.
Name
Name
Init.
Mailing
Address
City
State
Zip + 4
Email
Home Phone
Area Code
FELONY STATEMENT
YES
NO
Since your last certification, have you been convicted of a felony?
YES
NO
Since your last certification, have you ever been subject to limitation, suspension from, or under revocation or
probation of your right to practice in a health care occupation or voluntarily surrendered a health care licensure
in any state or to any agency authorizing the legal right to work?
If you answered “yes” to either question, you must provide official documentation that fully
describes the offense, current status, and disposition of the case.
EMPLOYER INFORMATION
FOR OFFICE
INACTIVE STATUS REQUEST
USE ONLY
Organization in which you currently serve as an
F
F
Request inactive status*
EMT-Intermediate/99:
50
50
Agency: __________________________________________________
A
A
I f t h i s i s y o u r f i r s t t i m e t o
B
B
Address: _________________________________________________
recertify, you must have worked at
2
2
least 6-months performing as an
City ____________________ State _________Zip Code ___________
(EMT-Intermediate 99) and using
3
3
your skills in either the emergency
Training Officer ____________________________________________
ambulance/rescue or patient/
S
S
health care setting. You will need
T.O.
T.O.
Daytime Phone # ___________________________________________
to submit proof of employment.
$$
$$
61
By completing this section you are indicating you are currently performing EMT-Intermediate
99 skills in either the emergency ambulance/rescue or patient/health care setting.
EMT INTERMEDIATE/99 REFRESHER TRAINING - (36 HOURS REQUIRED)
Submit course completion certificate of state approved DOT National Standard EMT Intermediate/99 Refresher completed within
this recertification cycle
OR
Official letter from your Training Officer/Medical Director verifying completion of all mandatory and flexible core content including
completion dates and hours and method used
OR
Use the summary sheet outlining Core Content by applying dates, hours & method used in the respective areas. Attachment
must be verified with the EMS Professional’s signature and must include copies of all certificates that make up the refresher
components
CPR CERTIFICATION
As the EMS Professional’s CPR Instructor/Training Officer, I hereby verify the EMS Professional has been examined and performed
satisfactorily so as to be deemed competent in each of the following:
Adult 1 & 2 Rescuer CPR
Child Obstructed Airway
Adult Obstructed Airway
Infant CPR
CRR Instructor/Training Officer Verifying Signature
Child CPR
Infant Obstructed Airway
Submit copy of card and/or verify with appropriate signature.
Month
Year
EMT’s CPR EXP DATE
Page 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 4