EMS-28 NJ-PA EMT Continuing Education Documentation
|[pic] |New Jersey Department of Health | |
| |EMERGENCY MEDICAL TECHNICIAN | |
| |Continuing Education Documentation | |
|Issued to (Last, First Name) |Certification or Provider No. |Date of Birth * |
| | |_____ / _____ / _____ |
|Course Title |Course Number |
| | |
|Date Conducted |Total Elective Credits ** |
| | |
|Session Location |Credits *: |
| |*Trauma/Medical: |
| |*Other: |
|State |County * |Region * |Certification Level * |
| | | | |
|Name of Coordinator/Instructor (Print) |Signature of Coordinator/Instructor |Date |
| | | |
|* Fields marked with an “*” are required for PA providers. |Pennsylvania providers must submit a copy of this document directly to their |
|** Fields marked with an “**” are required for NJ providers. |Regional EMS Council for addition to their continuing education records. |
|All other fields are mandatory for both states. |New Jersey providers must retain this document as part of their personal |
| |recertification records. |
EMS-28
SEP 15
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