SPECIALTY COURSE ANNOUNCEMENT: Certified Lab Instructor (CLI)

Transcription

1 W e s t c h e s t e r R e g i o n a l E M S C o u n c i l Est SPECIALTY COURSE ANNOUNCEMENT: Certified Lab Instructor (CLI) The Westchester Regional EMS Council (REMSCO) has scheduled a Certified Lab Instructor (CLI) program for Summer Class Size/ Composition The class will be maximized at twenty-four (24) students. All applications must be submitted by a Course Sponsor Administrator. Please note: Per REMSCO policy, each of the eight (8) Course Sponsors located in the Westchester Region will automatically be allotted two (2) seats in this class. Priority in the CLI Class will be given to those applicants who plan to teach in programs based within the Westchester Region. Secondary priority will be given to those candidates recommended by the Hudson Valley and New York City Regional Course Sponsors, respectfully. Additional candidates from any NYS Course Sponsor will be accepted, as seats remain available. Candidate Eligibility To be accepted as a student in this program, a candidate must have: Current NYS EMT/AEMT Certification Verification of a grade of 85% or greater on the last certification exam NOTE: This exam must have been for the most recent certification / recertification. If a candidate has been participating in the NYS CME Recertification Program, he or she must have taken a NYS exam to obtain a grade for this application. Verification from an officer of an EMS organization indicating current practice as a provider, and a minimum of two (2) years experience as an EMT in a prehospital setting within the last three (3) years. A letter from the recommending Course Sponsor Administrator indicating his or her intention to allow the candidate to fulfill the internship requirement of the CIC program under his or her supervision/employ should they successfully finish the class.

2 W e s t c h e s t e r R e g i o n a l E M S C o u n c i l Est Pre-Screenings All candidates are required to pass a pre-screening for this course. The following dates have been scheduled for the CLI Pre-screenings: Prescreening Date Day Time *June 4, 2009 Thursday *NOTE: If there are not enough applicants to hold the prescreening, it will be cancelled. CLI Course Dates Once the candidates have successfully passed the prescreening, the dates for the CLI course are. Course Date Day Time June 19, 2009 Friday June 20, 2009 Saturday June 27, 2009 Saturday **NOTE: Students MUST attend every session and fully participate in all the exercises in order to successfully complete this course. Failure to do so will result in expulsion from the class. Application Submission Application paperwork needed to for this course can be found on the Westchester Regional EMS Council website, Course Sponsor Administrators should submit original, complete applications to the Westchester Regional EMS Office by Friday, May 29, A $50.00 refundable appearance deposit must accompany each application or the candidate will not be scheduled for the prescreening. Applications submitted by someone other than a NYS DOH EMS Course Sponsor Administrator, faxed, ed, or otherwise found to be incomplete, will not be accepted and will be returned to the Course Sponsor. If you have any questions, please contact the Westchester Regional EMS Office at Issued by: Daniel Olmoz Program Administrator, Westchester Regional EMS Office

3 T R A I N I N G & E D U C A T I O N C O M M I T T E E 4 Dana Rd., Valhalla, NY PHONE FAX Application for Instructor Course: CLI Pre-Screening (Please Type or Print Legibly) Level of Certification (check one) EMT-Paramedic EMT-Intermediate EMT- Critical Care EMT Basic NYS EMS Certification # Expiration Date / / Applicant Information Last Name First Name M.I. Birthdate / / Male Female Address City State Zip Primary Phone ( ) Secondary Phone ( ) Course Sponsor Information Name NYS Course Sponsor # Course Administrator Contact # EMS Experience (List EMS Providers within the past three (3) years) Agency Name Job Title Dates Employed/Member Supervisor Name Certification Requirements (If you are unable to meet these requirements, admission to the CLI Prescreening and CLI Course will be denied. If you have any questions, please contact the Regional Office.) 1. Current NYS EMT/AEMT Certification 2. Verification you have achieved an 85% or greater on the last certification exam 3. Verification from an officer of an EMS organization indicating that you currently practice with them as an EMS provider, and have a minimum of two (2) years experience as an EMT in a prehospital setting within the last three (3) years 4. A letter of sponsorship from a current NYS EMS Course Sponsor, recommending you for the CLI course and indicating their intention to allow you to complete your CLI internship under their supervision/employ. I hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as the applicant. I do affirm that I have not been convicted, nor am I currently charged with any crime(s) related to: murder, manslaughter, assault, sexual abuse, theft, robbery, drug abuse or the sale of drugs. Applicant s Signature: Date / / WREMSCO CLI Pre-Screening Application - feb05.doc

4 T R A I N I N G & E D U C A T I O N C O M M I T T E E 4 Dana Rd., Valhalla, NY PHONE FAX Course Sponsor s Instructor Candidate Checklist Please type or print legibly: Submission Date Course Sponsor Information Name NYS Course Sponsor # Sponsor Administrator Contact # Checklist for: CLI CIC Note: Documents in the shaded areas will be completed the first night of class. Candidate Order of Preference 1 Candidate Name Prescreening Application (CLI Only) CLI Certificate (CIC Only) Copy of EMT/AEMT Card NYS Certification Exam Score Verification Agency Verification Course Sponsorship Letter NYS Application for Instructor Certification NYS Instructor Sheet FOR WESTCHESTER COURSE SPONSORS ONLY: Unless otherwise directed, the first two (2) candidates listed on this form will be guaranteed admission to the program, provided all appropriate documentation is submitted and any prescreenings have been successfully completed (if a CLI Course). WREMSCO CLI- CIC candidate checklist - v feb05.doc

5 TRAINING & EDUCATION COMMITTEE Dono Rd" Valhalla, NY PHONE FAX Application for Instructor Course: Verification of EMS Affiliation Instructor Course (check one) D Instructor Coordinator (CIG) o Lab Instructor (CLI) (Please Type or Print Legibly) Applicant Information Last Name First Name M.I. Birthdate D Male D Female EMS Agency Information Name NYS Agency Code SupervisorJCaptainfChief Contact # Level of Service (check one) D EMT Paramedic 0 EMT-Intermediate 0 EMT - Basic County EMS Region I hereby certify that the applicant is currently an active employee / member of the above named organization. Per agency records, this applicant has provided prehospital patient care with from to -, Name ofagency Date Date constituting a minimum of two (2) years experience as an EMT within the last three (3) years I hereby certify that all of the information provided is true and correct and that the signature below is mine. Supervisor/Captain/Chief Signature: Date, / VVREMSCO Verification of EMS Afflialion (ClI-CIC) - feb05.doc