Intermediate/99 Recertification Form 2010 - The National Registry Of Emergency Medical Technicians Page 2

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ADDITIONAL EMS RELATED CONTINUING EDUCATION - (36 HOURS REQUIRED)
Date
Method of Hours Date
Method of Hours
Comp.
Topics of Training
Instruction Rec’d Comp.
Topics of Training
Instruction Rec’d
*MUST BE FILLED IN
*DO NOT LEAVE BLANK
* DO NOT MAIL IN
CERTIFICATES FOR THIS
SECTION UNLESS AUDITED
TOTAL HOURS
VERIFICATION OF SKILL COMPETENCE
Q/A:
Direct
Other
Q/I
Observation
1.
PATIENT ASSESSMENT/MANAGEMENT:
Medical and Trauma
2.
VENTILATORY MANAGEMENT SKILLS/KNOWLEDGE: Simple adjuncts
Supplemental oxygen delivery
Alternative airways* (PTL, Combi-tube, ET)
Endotracheal Intubation (adult & pediatric)
3.
CARDIAC ARREST MANAGEMENT: Megacode & ECG Recognition, Therapeutic Modalities
Monitor/defibrillator knowledge (set-up & routine maintenance)
4.
HEMORRHAGE CONTROL & SPLINTING PROCEDURES
5.
IV THERAPY & IO THERAPY*: Medication Administration
6.
SPINAL IMMOBILIZATION: Seated & lying patients
7.
OB/GYNECOLOGIC SKILLS/KNOWLEDGE
8.
OTHER RELATED SKILLS/KNOWLEDGE: Radio communications
Report writing & documentation
*If applicable in your area.
As the Physician Medical Director of EMT-Intermediate/99 training/operations, I do hereby affix my signature attesting to the continued
competence in all the skills outlined above.
Physician Medical Director Signature (must be original signature)
Title
Date Signed
I hereby affirm that all statements on the EMT-Intermediate/99 Recertification Form are true and correct, including the copies of cards,
certificates and NREMT Intermediate refresher attachment. It is understood that false statements or documents may be sufficient cause
for revocation by NREMT. It is also understood that NREMT may conduct an audit of the Recertification activities listed at any time.
Your Signature
Date Signed
Signature of Training Officer/Supervisor
Date Signed
(must be original signature)
(Must be other than EMS Professional & must be an original signature)
Page 2

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