Fillable Ceprovider App Continuing Education Provider (Contra Costa Health Services)

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Ceprovider App Continuing Education Provider (Contra Costa Health Services)

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  • 18 check-boxes
  • 84 other fields

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Contra Costa County EMS Agency
EMS CE Provider Application
Prehospital/EMS Continuing Education
(CE) Provider Application Packet
Submit completed application and supporting documentation to:
Contra Costa
County EMS Agency
Attn: EMS CE Provider Approval
777 Arnold Drive, Suite 110
Martinez, CA 94553
(925)608-5454 - cchealth.org/EMS
Contra Costa County EMS Agency
EMS CE Provider Application
CE Provider Checklist
Description Page #
EMS Use
Only
CE Provider Application – completed and signed
Program Director Form and resume/supporting documentation
Clinical Director Form and resume/supporting documentation
Sample Course Evaluation Form
Sample continuing education (CE) certificate (consistent with Title 22, Div 9, Ch
11, Section 100395(m))
Description of program facilities, equipment, examination security and student
record keeping
CE Provider Approval Fee
EMS Agency Use Only
Reviewed by
Date Approved
Date Expires
Contra Costa County EMS Agency
EMS CE Provider Application
CE Provider Application
Initial
Type of Entity/Organization:
Name of CE Provider:
Street Address:
City: State: Zip:
Telephone: ( ) Fax: ( )
Website:
Program Director:
Clinical Coordinator:
I certify that all information in this application packet is true and correct, to the best of my knowledge,
and that I have read and understand the responsibilities and expectations of a prehospital CE provider
program as outlined in CA Code of Regulations, Title 22, Division 9, Chapter 11 (EMS Continuing
Education).
at on
Program Director Signature City/State Date
Primary Contact Person Information
Primary Contact Person: Program Director Clinical Director See below:
Name: Title:
Organization:
Street Address:
City: State: Zip:
Phone: ( ) Email:
click to sign
signature
click to edit
Contra Costa County EMS Agency
EMS CE Provider Application
Program Director Information
(g) Each CE provider shall have an approved program director, who is qualified by education and experience in methods, materials
and evaluation of instruction, which shall be documented by at least forty hours in teaching methodology. Following, but not limited
to, are examples of courses that meet the required instruction in teaching methodology:
(1) California State Fire Marshal (CSFM) “Fire Instructor 1A and 1B”; or
(2) National Fire Academy (NFA) “Fire Service Instructional Methodology” course; or
(3) a training program that meets the U. S. Department of Transportation/National Highway Traffic Safety Administration
2002 Guidelines for Educating EMS Instructors, such as the EMS Educator Course of the National Association of EMS
Educators.
(4) Individuals with equivalent experience may be provisionally approved for up to two years by the approving authority pending
completion of the above specified requirements. Individuals with equivalent experience who teach in geographic areas where training
resources are limited and who do not meet the above program director requirements may be approved upon review of experience and
demonstration of capabilities.
(h) The duties of the program director shall include, but not be limited to:
(1) Administering the CE program and ensuring adherence to state regulations and established local policies.
(2) Approving course, class, or activity, including instructional objectives, and assigning CEH to any CE program which the C
E
provider sponsors; approving all methods of evaluation, coordinating all clinical and field activities approved for CE credit; approving
the instructor(s) and signing all course, class, or activity completion records and maintaining those records in a manner consistent with
these guidelines. The responsibility for signing course, class, or activity completion records may be delegated to the course, class, o
r
a
ctivity instructor.
(California Code of Regulations, Title 22, Division 9, Chapter 11, Section 100395)
Name: Title:
Organization:
Street Address:
City: State: Zip:
Phone: ( ) Email:
Professional License/
Certification Type:
Expiration Date:
Teaching Credential(s):
I hereby certify that I meet the qualifications for Program Director as listed above and have attached
documentation demonstrating my qualifications. I have read and understand the duties of a
prehospital CE Program Director and the requirements for a California Prehospital CE program as
specified in State regulation
(www.emsa.ca.gov/Media/Default/Word/Regulation_Chapters/Regulations_Chapter_11.0.docx) and
County EMS policies (http://cchealth.org/ems/policies.php).
in on
Signature of Program Director city/state date
click to sign
signature
click to edit
Contra Costa County EMS Agency
EMS CE Provider Application
Clinical Director Information
(i) Each CE provider shall have an approved clinical director who is currently licensed as a physician, registered nurse, physician
assistant, or paramedic. In addition, the clinical director shall have had two years of academic, administrative or clinical experience
in emergency medicine or EMS care within the last five years. The duties of the clinical director shall include, but not be limited to,
monitoring all clinical and field activities approved for CE credit, approving the instructor(s), and monitoring the overall quality of
the EMS content of the program.
(California Code of Regulations, Title 22, Division 9, Chapter 2, Section 100395)
Name: Title:
Organization:
Street Address:
City: State: Zip:
Phone: ( ) Email:
Professional License Number: Expiration Date:
MD RN Paramedic Physician Assistant
I hereby certify that I meet the qualifications for Clinical Director as listed above and have attached
documentation demonstrating my qualifications. I have read and understand the duties of a
prehospital CE Program Clinical Coordinator and the requirements for a prehospital CE program as
specified in State regulation and County EMS policies.
in on
Signature of Clinical Director city/state date
click to sign
signature
click to edit
Contra Costa County EMS Agency
EMS CE Provider Application
Description of program facilities,
equipment, examination security and
student record keeping
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Ceprovider App Continuing Education Provider (Contra Costa Health Services)

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Completed 10 January 2021

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