Orange County EMT Accreditation Application

Transcription

1 Welcome (Step 1 of 7) Welcome Dear Applicant, Orange County EMS would like to welcome you to the Orange County EMT Accreditation application process. Make sure that you read the information and instructions for each of the following page sections and pages very carefully. EMT Accreditation Eligibility Verification Enter your intials to indicate that you either 1) Possess a valid, current State of California EMT certificate, OR 2) Are applying for your Inital EMT Certification and Orange County Accreditation at the same time. (If neither of these describe your situation, you should NOT continue with this application.) vi

2 Personal (Step 2 of 7) Applicant Demographics The information that you originally entered into your profile, such as name, address, SS#, , etc., is automatically moved into each of your applications that you complete. If you have a change of address or , you will need to return to the Login page and change your information there. First Name: Valanie Middle Name: Last Name: Ibarra Other names your records may be under (including maiden name): Address: 5833 Morrill Ave City: WHITTIER State: California Zip Code: Home Phone: - - Mobile Phone: - - Valid valanie2014@gmail.com Date of Birth: mm/dd/yyyy 05 / 18 / 1984 Identification

3 Drivers License State: California Drivers License Number: D Drivers License Expiration: mm/dd/yyyy 05 / 18 / 2017 EMS Employment Select the service for which you work (if none then select - NONE - from the list). Current Primary EMS Employer: - NONE -

4 Cert./Lic. (Step 3 of 7) Audit Advisory In order to maintain the integrity of the on-line accreditation, certification and licensure process, Orange County EMS may initiate audits of application documents. In the case of an audit, OCEMS will send out notifications only to those applicants being audited, using the contact information on file, and will require them to produce proof documents for the items claimed on their application. This may include but not be limited to original documentation of primary training and/or continuing education coursework. Application Purpose What is the purpose of this application? OC Accreditation Initial Application OC Accreditation Renewal Application Orange County Expanded Scope Training If you are a first time applicant for Orange County EMT Accreditation, please complete the information below. Failure to do so will result in an incomplete application and will not be processed. If you are a renewal candidate, you may skip this section, but you still must upload a copy of your current OC Accreditation card. Name of the agency that provided your course: Program's CE Number: Instructor's Name: Course Completion Date: mm/dd/yyyy / / Basic Life Support (CPR) Certification **Please Note** only the following are recognized by OC EMS as meeting the CPR requirement: American Heart Association - 'CPR for the Healthcare Professional' American Red Cross - 'CPR for the Professional Rescuer' YOU MUST SUBMIT BOTH SIDES of the card for it to be accepted. CPR card issued by: American Heart Association CPR for the Healthcare Professional CPR Expiration Date: 03 / 2016

5 State of California EMT Certification Since there are many different candidates applying for the Orange County Accreditation, some of the options below may not apply to you. If you are already an EMT with another county, and are only applying to be Accredited, you need your current EMT card. If you are making your Accreditation application at the same time as, or soon after, you filed your State EMT application, then you will not have a State EMT number yet. If you are a Paramedic, OCEMS recognizes you as an EMT and you may apply for Accreditation with a current Paramedic card. Failure to enter the requested information can be seen as being fraudulent and could result in a rejection of your application. CLICK HERE to visit the California Central Registry to verify the status of your certification or license within California. Current License Level (if also applying for EMT Cert., select 'EMT Certification'): EMT-Basic California EMT Certification Number (if you are a medic, enter your 'P' number): E California Certification Expiration Date: mm/dd/yyyy 03 / 31 / 2016

6 Uploads (Step 4 of 7) Document Upload Instructions Use the section below to upload all of the required documents. It is your responibility to verify that you have submitted all required documentation. Below is the list of required documents: Current Government issued photo ID (CA Driver's License or ID Card or Passport or Military ID) Proof of completion of approved OCEMS EMT Expanded Scope or EMT Accreditation course (for initial accreditation applicants only) Current Orange County Accreditation card (for renewal applicants only) Current CPR card for professional rescuers issued by American Heart Association or American Red Cross ( YOU MUST SUBMIT BOTH SIDES of the card for it to be accepted) Current California EMT Certification (you may not have this yet if you are applying as a new EMT as well) To upload: 1. Click the '+Add' button below to open the section. 2. Name your attachment using your name and the attachment name (e.g.: Peter Smith CA Driver License). 3. Click 'Browse' and locate the file you want to upload. 4. Click the '+Add' button again to finalize the attachment. 5. Repeat steps above until all documents have been attached. Edit Name File Name Valanie Ibarra CPR AHA back CPR AHA back.jpg Valanie Ibarra CPR AHA (front) CPR AHA front.jpg Valanie Ibarra CA Driver License DL.jpg Valanie Ibarra EMT Certification EMT CERT.jpg Valanie Ibarra OCEMS Expanded Scope OC EMS Cert.jpg Have you uploaded the following items to your application? Your application will NOT be processed without these: Current Government issued photo ID (CA Driver's License or ID Card or Passport or Military ID) Proof of completion of approved OCEMS EMT Expanded Scope or EMT Accreditation course (initial applicants only) Current Orange County Accreditation card (for renewal applicants only) Current HCP CPR card from AHA or American Red Cross (BOTH SIDES of the card) Current California EMT Certification (you may not have this yet if you are applying as a new EMT as well)

7 Signature (Step 5 of 7) Application Signature By typing my Username and Password below, I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to EMT certification in the State of California. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as an EMT in California. Signed by Valanie Ibarra on 01/31/2016 at 3:22 PM **For OCEMS Staff** If you are completing this form on behalf of the applicant, please enter YOUR Username and Password that you used to sign in to your OC-MEDS Licensure account. Then upload a scan of Page 1 of the original signed and dated application using the section below. Edit Name File Name Valanie Ibarra CPR AHA back CPR AHA back.jpg Valanie Ibarra CPR AHA (front) CPR AHA front.jpg Valanie Ibarra CA Driver License DL.jpg Valanie Ibarra EMT Certification EMT CERT.jpg Valanie Ibarra OCEMS Expanded Scope OC EMS Cert.jpg

8 Authority (Step 6 of 7) Authority The Medical Director of the local EMS Agency may deny, suspend, revoke or place on probation any license or certificate issued under the provisions of the Health and Safety Code, Division 2.5, or Orange County Ordinances. Activities that may result in such action include: 1. Fraud in the procurement of any certificate under the law. 2. Gross negligence, repeated negligent acts, incompetence. 3. The commission of any fraudulent, dishonest, or corrupt act which is substantially related to the qualifications, functions, and duties of prehospital personnel. 4. Conviction of any crime which is substantially related to the qualifications, functions, duties of prehospital personnel. 5. A requirement under Section 290 of the Penal Code to register as a sex offender, or for any offense involving force, duress, threat, or intimidation. 6. A conviction during the preceding seven (7) years of any offense punishable as a felony and involving force, violence, threat, intimidation, or theft in either degree or currently on parole or probation for such offenses or crimes. 7. Violating or attempting to violate directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate, any provision of this division of the regulations promulgated by the EMS Authority pertaining to prehospital personnel. 8. Violating or attempting to violate any federal or state statute or regulation which regulates narcotics, dangerous drugs, or controlled substances. 9. Addiction to the excessive use of, or misuse of alcoholic beverages, narcotics, dangerous drugs, or controlled substances. 10. Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification. 11. Demonstration of irrational behavior or occurrence of a physical disability to the extent that a reasonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired. By typing my Username and Password below, I hereby acknowledge that I have read and understood the listing above, setting forth enumerated conditions and actions which may cause a certificate for EMT or Ambulance Accreditation to be denied or cause the Medical Director of the local EMS Agency to otherwise take action against any certificate issued by a local agency. I understand that certification/licensure is subject to immediate denial if a statewide criminal background check conducted by law enforcement shows any convictions which preclude an individual from working in the prehospital care system. I understand that certification/licensure is subject to immediate denial or revocation if the applicant knowingly falsifies or fails to disclose a material fact in his or her application (Health and Safety Code and Ordinance 3517). Signed by Valanie Ibarra on 01/31/2016 at 3:22 PM **For OCEMS Staff** If you are completing this form on behalf of the applicant, please enter YOUR Username and Password that you used ot sign in to your OC-MEDS Licensure account. Then make sure to upload a scan of Page 2 of the original signed and dated application using the section below. Edit Name File Name Valanie Ibarra CPR AHA back CPR AHA back.jpg Valanie Ibarra CPR AHA (front) CPR AHA front.jpg Valanie Ibarra CA Driver License DL.jpg Valanie Ibarra EMT Certification EMT CERT.jpg Valanie Ibarra OCEMS Expanded Scope OC EMS Cert.jpg

9 Thank You (Step 7 of 7) Final Step This is the last page of the application. Please take a moment to double check your application and all of the supporting documents. Once you submit your application, you will no longer be able to edit it. Only click "Submit Application" ONCE! After you click the "Submit Application" button below, a pop-up window will appear verifying that you want to submit the form. When you click "OK", the pop-up window will close and you will see this page again. DO NOT click "Submit Application" a second time. This is a large file that takes a few moments to load. Once it is saved, you will be logged out. Your next step is to pay the fee for licensing/certification/accreditation for which you are applying. When you click "Submit Application" below, you will be directed to a Check Out page where you will need to complete the payment process. Payments must be made by debit card with a Visa or MasterCard logo, or by American Express, Discover, Visa or MasterCard CREDIT CARD only and will be processed by a third party vendor. Make sure your are submitting the right application. You will NOT qualify for a refund if you submit the wrong application. **PLEASE NOTE** Your application will not be reviewed until your payment clears. You will be notified by of successful payment. DO NOT call to check on the status of your application. If there are any problems, OCEMS will contact you using the on your application. You must enter a valid address in the field of the payment processing page or you will NOT receive a receipt or further application information!