Follow the steps to accurately complete your continuing education report.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your public safety identification number and Indiana public safety identification affiliation at the top of the form. Ensure that your last name, first name, and middle initial are accurate.
3. Provide your mailing address, including street, city, state, and ZIP code. Include your driver’s license number, home telephone number, email address, and cellular telephone number if applicable.
4. Address the violation statement by indicating whether you have ever been charged or convicted of a crime other than minor traffic violations. If 'yes', report it according to the instructions.
5. Get the signature of your EMS Medical Director along with their printed name, phone number, license number, and date.
6. Affirm your information by signing and dating the EMS registrant signature section, confirming that all statements are true and correct.
7. Complete sections regarding training in NIMS/ICS by selecting the appropriate options and indicating your willingness to assist in a disaster.
8. List your current affiliations, including ambulance provider organizations and supervising hospitals. Provide the necessary details and signatures as required.
9. Proceed to complete Section 1A, indicating completion of the refresher course or completing the required details if it was not completed. Ensure all signatures are original.
10. Fill out the hours and topics for each division, making sure to have the signatures of instructors for verification.
11. Attach the front copies of your current CPR and ACLS certification cards to their respective sections.
12. Complete Section 2 by noting any additional hours of continuing education, ensuring to include dates, hours, topics, and instructor signatures.
13. Conclude by filling out Section 3 for intermediate skill maintenance and acquiring instructor signatures for each skill listed.
14. Once all fields are completed, save your changes. You may choose to download, print, or share the form as needed.

Complete your Indiana Emt Continuing Education Form online today to ensure your certification stays current.