EMS Course Completion Verification Form



Mark the appropriate boxes for both course type and level of course.Course Type: ? Initial Course ? Refresher CourseFor IV therapy and stand-alone SGA courses please also submit a copy of each course of completion certification (COC) with the EMT credential number listed on the COC to the Department of Health. Course Level:? Emergency Medical Responder? EMT (Includes RN to EMT)? EMT with Supraglottic Airway ? Intravenous Therapy? Supraglottic Airway (standalone class)? Advanced EMT? Paramedic? EMS Evaluator (ESE)? SEI WorkshopSend completed document to:HSQA.EMS@DOH.OrEMS Education and TrainingP.O .Box 47853Olympia, WA 98504-7853Phone: 360-236-2840Training Program Name: FORMTEXT ?????Course Approval Credential Number: FORMTEXT ????? (TRNG.ES.XXXXXXXX-COURSE) DOH Course Number: FORMTEXT ????? (IYY-XX-XXX)Course Completion Date: FORMTEXT ?????Approval Signatures:Training Program Director: ________________________________ -OR-Senior EMS/*Lead Instructor: _____________________________________We hereby attest that those individual(s) listed below have successfully completed the course have met the course requirements as defined in RCW 18.7 or 18.73.* EMR and EMT courses require a DOH approved SEI. For other course instructor qualification requirements, see the EMS Training Program and Instructor Manual.Last NameFirst NameM.I.EMT credential number (IV Therapy or Standalone Supraglottic Airway endorsement courses only)NotesCourse CompletionPass or Fail1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????16. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????17. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????18. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????19. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????20. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????22. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????23. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????24. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????25. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????27. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????28. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????29. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????30. FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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