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OVERVIEW & ELIGIBILITY APPLICATION FOR MASSACHUSETTS DPH APPROVAL

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APPLICATION FOR MASSACHUSETTS DPH
APPROVAL FOR CONTINUING EDUCATION PROGRAM
DPH/OEMS 200-46
ConEd App
01/2016
OVERVIEW & ELIGIBILITY
This application is to be used by non-accredited training providers to apply for OEMS continuing education approval, in
accordance with 105 CMR 170.964. Along with the application, a program (course) outline with objectives and instructor
qualifications must be attached for each program for which the applicant is seeking approval. The application is to be
submitted at least 3 week prior to program start date. No program may be advertised or occur prior to receiving approval. This
application is to be sent to the applicable Regional EMS Council if the program sponsor’s primary place of business is within
Massachusetts. Program sponsors who have a primary place of business outside Massachusetts are to submit the application
directly to OEMS. At the discretion of OEMS, state agencies may apply directly to OEMS for program approval.
APPLICATION CHECKLIST - SPONSOR
□ APPLICATION Complete the application for OEMS continuing education approval of an EMS training
program.
□ OUTLINE Include an outline that clearly identifies program objectives and subject matter. Please
refer to Administrative Requirement (AR) 2-212, EMS Continuing Education Standards
for what topics are not eligible to receive approval for continuing education credit
hours. This can be found on our website: http://mass.gov/dph/oems. Following the
application is a recommended outline sample.
□ INSTRUCTOR QUALIFICATIONS Identify name and phone number of primary instructor (even if the program sponsor is
the primary instructor). Include qualifications such as “EMT”, “Paramedic”, “I/C”, “RN”,
“MD”, etc. Identify additional instructors along with their credentials (include resume
information for each) on attached course outline.
Submit the complete packet to the regional EMS council based on sponsor’s mailing address:
Region 1:
Western Mass EMS
168 Industrial Park Drive
Northampton, MA 01060
wmems@wmems.org
www.wmems.org
Region 2:
Central Mass EMS Corp.
361 Holden Street
Holden, MA 01520
ConEd@cmemsc.org
www.cmemsc.org
Region 3:
Northeast EMS, Inc
20A DelCarmine Street
Wakefield, MA 01880
education@neems.org
www.neems.org
Region 4:
Metro Boston EMS Council
25 B Street
Burlington, MA 01803
regionIVconed@mbemsc.org
www.mbemsc.org
Region 5:
Southeastern Mass EMS Council
12 Wareham Street
Middleboro, MA 02346
ems@semaems.com
www.semaems.com
OEMS:
(For out of state sponsors)
99 Chauncy Street, 11
th
Floor
Boston, MA 02111
oems.coned@state.ma.us
www.mass.gov/dph/oems
Please check your application for completion and legibility. If your application is incomplete or illegible, it will be returned and
program approval will be delayed.
As a reminder, in accordance with AR 2-212, course completion documentation must be provided to the EMT at the completion of
the course. Program sponsors shall issue course completion certificates or provide attendees with a copy of the roster signed by the
instructor and student. The program sponsor is responsible for retaining the original signed roster for seven years. If personnel have
Massachusetts EMT certification, they are to use that certification number on the attendance roster, and not another state or
NREMT certification number. Please reference AR 2-212 for what a course completion certificate must contain.
APPLICATION FOR MASSACHUSETTS DPH
APPROVAL FOR CONTINUING EDUCATION PROGRAM
DPH/OEMS 200-46
ConEd App
01/2016
1) GENERAL INFORMATION: (Type or print legibly in black or blue ink)
TITLE OF PROGRAM
NAME OF SPONSOR
SPONSOR’S EMAIL
SPONSOR’S MAILING ADDRESS (STREET)
CITY
STATE
NAME OF PRIMARY INSTRUCTOR
INSTRUCTOR’S CERTIFICATION # (if applicable)
PRIMARY INSTRUCTOR’S EMAIL
INSTRUCTOR’S PHONE #
2) METHOD OF INSTRUCTION (SELECT ONLY ONE): (Refer to AR 2-212 for definition of instructional methods)
T1 –
In Person, Single
Occurrence
T2 –
In Person, Blanket
(Multiple Occurrences)
T3 – Distributive
Education (DE)
T4 – Pre-Identified
Standardized Courses (To be
issued by OEMS)
T5 – Virtual Instructor
Led Training (VILT)
3) PROGRAM TYPE (SELECT ONLY ONE):
30 Hour Paramedic NCCR
20 Hour EMT/AEMT NCCR
Continuing Education Program Hours:
**Please note, when entering number of hours do not include breaks or topics that are not eligible for credit hours in accordance with AR 2-212. You may
apply for half and quarter hours**
4) DATES AND LOCATION OF PROGRAM:
START DATE: (MM/DD/YY)
START TIME:
END DATE: (MM/DD/YY)
END TIME:
ADDITIONAL DATES AND TIMES
CAN EMTs OUTSIDE YOUR AGENCY ATTEND?:
Yes No
PHYSICAL LOCATION ADDRESS (STREET)
CITY
STATE
5) AFFIRMATIONS:
a. The applicant hereby affirms that they comply with, and will continue to comply with, all relevant federal and state laws, including but not
limited to, federal and state anti-discrimination statutes, M.G.L. c. 111C; regulations, including but not limited to 105 CMR 170.000 and 105
CMR 700.000, and the Department’s Administrative Requirements, the Statewide Treatment Protocols, policies and advisories.
b. The applicant hereby affirms that the information on this application is true and correct and that the course will conform with the standards
set forth in the attached outline.
NOTE: The individual whose name appears below is the listed official representative of the applicant, and must have authority to sign all necessary
program documents.
Sponsor’s Official Representative: (Print)
Signature:
Date:
OFFICIAL USE ONLY:
Regional Council or OEMS Reviewer: (Print)
Regional Council or OEMS Reviewer: (Signature)
Approval Number:
_____ - R__ - _____ - T__
Date Approved:
APPLICATION FOR MASSACHUSETTS DPH
APPROVAL FOR CONTINUING EDUCATION PROGRAM
DPH/OEMS 200-46
ConEd App
01/2016
Recommended Format for a Continuing Education Outline
1. TOPIC - Write a brief descriptive title of the program/subject to be covered
2. PREREQUISITE - These are the minimum requirements (if any) for participation in the program (e.g., if
there is a prior course EMTs must attend or prior sessions of a multi-session program)
3. PURPOSE - State why the program is being offered
4. OBJECTIVES - List what you expect the student to be able to do or know after s/he has completed the
program. Objectives should be stated explicitly to the students at the beginning of the course and also
serve to determine what the instructor will evaluate at the end of the program. Examples: “The
student will demonstrate appropriate application of a traction splint.” “The student will explain the
pathophysiology of COPD versus CHF.”
5. COURSE FORMAT - Indicate how the course will be delivered (e.g. lecture, group discussion, skills
sessions)
6. FACULTY - Identify the lead instructor’s qualifications and any assisting instructors or guest speakers
with credentials
7. REFERENCES - List the material(s) that the instructor used to plan the course (e.g., textbooks, journal
articles, online references)
8. RESOURCES - List teaching aides to be used (e.g., slides, videos, EMS equipment, manikins)
9. EVALUATION - Indicate how the course objectives will be measured with examples to review (e.g.,
written exam/quiz, verbal evaluation through question/answer, skills demonstration)
10. CONTENT - Provide details outlining the material to be presented and give the exact times devoted to
each section to ensure the course content will meet the desired learning objectives. Outlines should be
sufficiently detailed so that the range of material to be covered is clear and logically presented.
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OVERVIEW & ELIGIBILITY APPLICATION FOR MASSACHUSETTS DPH APPROVAL

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Completed 3 March 2021

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