EMERGENCY MEDICAL TECHNICIAN CONTINUING …
EMERGENCY MEDICAL TECHNICIAN CONTINUING EDUCATION DOCUMENTATION
Issued to (Last, First Name) Course Title Date Conducted Session Location
State
County *
Name of Coordinator/Instructor (Print)
Certification or Provider No. Date of Birth * _____ / _____ / _____
Course Number
Total Elective Credits **
Region *
Credits *: *Trauma/Medical: *Other:
Certification Level *
Signature of Coordinator/Instructor
Date
* Fields marked with an "*" are required for PA providers. ** Fields marked with an "**" are required for NJ providers. All other fields are mandatory for both states.
EMS-28 JAN 12
Pennsylvania providers must submit a copy of this document directly to their Regional EMS Council for addition to their continuing education records.
New Jersey providers must retain this document as part of their personal recertification records.
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