Get Massachusetts Department Of Public Health Office Of Emergency

This guide provides clear instructions to assist users in completing the Massachusetts Department of Public Health Office of Emergency Medical Services Basic EMT Examiner Application form online. By following these steps, you can ensure that your application is filled out correctly and submitted efficiently.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to access the Basic EMT Examiner Application. This will allow you to open the form for completion.
2. Begin filling in the Application Date field with the date you are submitting the application. Then, provide your full name, including your last name, first name, and middle initial.
3. Input your primary occupation. Additionally, fill out your home and work addresses. Make sure to include your Social Security number, home phone number, and work phone number.
4. Enter your current Massachusetts EMT certification number and its expiration date. Then, check the appropriate box to indicate your EMT level, whether Basic, Intermediate, or Paramedic.
5. Summarize any certifications or registrations you hold in other states by providing the state, level of certification/registration, certification/registration number, and expiration date.
6. Answer the question regarding any lapses, suspensions, restrictions, or revocations of your EMT certification by selecting 'Yes' or 'No.' If 'Yes,' attach a separate letter detailing the circumstances.
7. List your employment as an EMT providing direct patient care, including the organization name, your position, the address, and the duration of your employment.
8. Indicate the frequency of use of your emergency medical care skills, specifying whether it is daily, weekly, monthly, or other. Describe in what capacity you utilize these skills.
9. Detail your educational background, starting with where you were initially trained as a Basic EMT. Provide the institution address, course coordinator, completion date, and instructor’s name.
10. Indicate whether you have received advanced EMT training. If so, provide details including the course name, institution, and completion date.
11. Complete questions related to CPR/BLS Instructor training, including the institution, course coordinator, and completion dates of both initial and most recent recertifications.
12. Provide further educational background if applicable and whether you instruct in other related courses. Indicate your current involvement in EMT training in Massachusetts, including role and region.
13. Outline any other relevant certifications or affiliations related to allied health or EMS, and detail your last three jobs, including reasons for leaving and job descriptions.
14. List three personal references with their name, signature, contact details, and state how long they have known you.
15. Sign the application confirming the accuracy of information provided, and note the date. Make sure all accompanying documents are ready for submission.
16. Once completed, save your changes, download or print the application, and share it as necessary.

Complete your application online today to ensure a smooth submission process.