HomeMy WebLinkAboutApplication For Approval EMSHEALT STATE OF FLORIDA
DEPARTMENT OF HEALTH
BUREAU OF EMERGENCY MEDICAL SERVICES
APPLICATION FOR APPROVAL OF AN
EMERGENCY MEDICAL SERVICES (EMS) TRAINING PROGRAM
(Application must be typed)
Select only one: EMT — Basic EMT - Paramedic
Part I:
Name of sponsoring institution:
Address of Institution:
Name of Chief Executive Officer:
Instructional locations:
Name of Program Director:
Telephone number of Program Director: ( ) FAX
E-mail: @ Institution's Website (if applicable):
For Non -Public Schools: Attach copy of current license issued by the Florida Department of
Education to offer the program and evidence of compliance with any other applicable requirements.
Attach as Attachment 1.
Part 11:
1. Affiliations - for the purpose of conducting hospital and field clinical training:
1. Name of Florida Hospital(s):Attachment 2.
2. Name of Florida Advanced Life Support EMS Provider(s): Attachment 3.
3. Attach a current written agreement or contract for each hospital, facility and advanced life
support EMS provider used for clinical training of your students. Attachment 4.
2. Program of Study:
1. Document how the training program follows the most current U.S. Department of
Transportation (DOT) National Standard Curriculum? Attachment S.
DH Form 1698, October 2005
Form referenced from Section 401.2701, Florida statutes
2. Contact hours of each program component:
a. Didactic
b. Emergency Department
C. EMS Provider
d. Skills Practice Laboratory
e. Other areas
f. Contact hours of entire training program:
3. Specify all pre -requisites or co -requisites to the program: Attachment 6.
4. How do you familiarize the students with Chapter 401, F.S. and Chapter 64E-2, F.AC., which
govern emergency medical services in Florida? Attachment 7.
5. List each course and the number of hours for each course in Attachment 8.
6. Define phase one of the program. Attachment 9
7. Attach copy of the course syllabus or course outline that is used for the training program that
will document all areas of Part II, Section 2 of this application. Attachment 10.
3. Facul :
1. Medical Director.-
a.
irector:
a. Name:
b. Address:
c. Florida Physician License #: Date Issued:
d. Board certification or eligibility in:
e. Provide documentation that the training center medical director has current certifications
as required by Chapter 64E-2.004(4)(1)3., Florida Administrative Code. Attach copy of
each as Attachment 11.
f. Attach copy of current contract between the training center and the program medical
director. .Attachment 12.
2. Instructional Staff.
a. Name of Program Director:_
b. Name of Program Coordinator:
c. Name(s) of Lead Instructor(s):
d. Attach a description of the institution's qualification requirements for the position of, and
DH Form 1898, October 2005
Form referenced from Section 401.2701, Florida Statutes 2
the duties and ,responsibilities of the Program Director, Program Coordinator and Lead
Instructor(s). Attachment 13.
e. Submit a CV or resume for the Program Director, Program Coordinator and Lead
Instructor(s) as Attachment 14 demonstrating they meet the qualifications of their
positions.
4.Records:
1. Attach a list of the documents retained in a student's record that are required for completion of
the training program. These records will be reviewed during the site visit.
a. Must include records as required by Chapter 401, Florida Statutes. Attachment 15.
5. Program Policies:
1. Attach a copy of your admission requirements to the training program, catalog and any printed
advertisement. Attachment 16.
2. Specify the institutions definition of course completion. Attachment 17.
3. Attach a copy of the certificate that is issued to each graduate as proof of program completion.
Attachment 18.
6. Additional Information or Comments: Attach additional sheets as Attachment 19.
Part ill:
Important Information for the Applicant:
1. The applicant must complete all departmental requirements, to include a site visit, within 120
days of receipt of this application by the department or this application will no longer be
accepted (or considered valid). The institution has the right to reapply.
2. Once this application is deemed accepted by the department, a site visit will be scheduled. The
site visit will consist primarily of a records review and collection of documents that substantiate
that the program is in compliance with the US DOT National Standard Curriculum, all applicable
DH Form 1698, October 2005
Form referenoed from Section 401.2701, Florida Statutes 3
Florida Statutes and all applicable Florida Administrative Codes.
3. Any changes to part one or two of this application require submission of a new application and
approval. Any changes to part two of this application require written notification to the bureau
within 30 days of the change.
4. Application and onsite evaluation must be completed for each location in which instruction
occurs.
5. Definitions:
a. Program Director - The Program Director is the individual responsible for course planning,
organization, operation, administration, periodic review, program evaluation, continued
development, effectiveness and approval of the program. The program should have a full-time
Program Director while the program is in progress, whose primary responsibility is to the
educational program. The program Director shall contribute an adequate amount of time to
assure the success of the program. The program director shall actively solicit and require the
cooperative involvement of the medical director of the program. The program director shall
have appropriate training and experience to fulfill the role. They shall have at least equivalent
academic training and preparation and hold all credentials for which the students are being
prepared. The program director shall have training and education in education and evaluation
and be knowledgeable in administration of education and related legislative issues for
paramedic education. The program director shall assume ultimate responsibility for the
administration of the didactic, clinical, and field intemship phases of the program. It is the
program directors responsibility to monitor all phases of the program and assure that they are
appropriate and successful.
b. Program Coordinator - The Course Coordinator is the individual responsible for coordinating
and conducting the EMT -Basic or Paramedic program. The Course Coordinator acts as the
liaison between the students, the sponsoring agency, the local medical community and the
state -level certifying or licensing agency and is responsible for assuring that the course goals
and objectives (and those set forth by any licensing, registering or certifying agency as
applicable) are met. The Course Coordinator may also serve as the Primary Instructor. This
individual shall have attended a workshop which reviews the format, philosophy and skills of the
new curriculum.
DH Forth 1698, October 2005
Form referenced from Section 401.2701, Florida Statutes 4
c. Lead Instructor - This individual is responsible for the teaching of a specific lesson(s) of the
EMT -Basic or Paramedic course. This individual shall be knowledgeable in all aspects of
prehospital emergency care, in the techniques and methods of adult education, and managing
resources and personnel. This individual shall have attended and successfully completed a
program in EMS instruction methodology and an update on this curriculum. This individual shall
be present at most, if not all, class sessions to assure program continuity and to be able to
identify that the students have the cognitive, affective, and psychomotor skills necessary to
function as an Emergency Medical Technician -Basic or Paramedic. This individual shall have
attended a workshop which reviews the format, philosophy and skills of the new curriculum.
d. Medical Director - A licensed physician meeting the applicable requirements for emergency
medical services medical directors as outlined in Chapter 401, Florida Statutes and rules of the
department. The Course Medical Director of the program should be a local physician with
emergency medical experience who will act as the ultimate medical authority regarding course
content, procedures and protocols_ All program faculty shall worts closely together in the
preparation and presentation of the program. The Course Medical Director can assist in
recruiting physicians to present materials in class, settling questions of medical protocol and
acting as a liaison between the course and the medical community. During the program the
Medical Director will be responsible for reviewing the quality of care rendered by the students in
the clinical and field setting. This Course Medical Director shall be responsible to verify student
competence in the cognitive, affective and psychomotor domains. The Course Medical Director
may also serve as the Primary Instructor. Medical direction is an essential component of out-of-
hospital training. Physician involvement shall be in place for all aspects of EMS education. The
Course Medical Director shall review all course content material and examinations. The
medical director shall periodically observe lectures and practical laboratories, field and clinical
intemships. The medical director shall participate in clinical instruction, student counseling,
psychomotor and oral testing and summative evaluation. Students shall not be awarded course
ending certificates unless the medical director and program director can assure through
documentation of completion of terminal competencies that each student has completed the full
complement of education. Documentation of completion of course competencies shall be
affixed to the student file with signatures of the medical director and program director at the
completion of the course.
6. All components of the United States Department of Transportation National Standard
Curriculum will be evaluated during the on-site visit.
DH Form 1698, October 2005
Form referenced from Section 401.2701, Florida Statutes 5
Part IV
Certification statement
We, the undersigned representatives of the sponsoring institution herein, do hereby certify that our institution
meets all the standards for a training program as provided in Chapter 401, F.S. We further understand that
any discrepancies found will subject the sponsoring institution to corrective action and possibly being denied
approval_
Name of Person Completing Application
Title
Program Director's Signature Date
Submit this completed application form with all requested attachments to:
Florida Department of Health
Bureau of Emergency Medical Services
4052 Bald Cypress Way, Bin C 18
Tallahassee, Florida 32399-1738
Attention: EMS Training Coordinator
DH Form 1698, October 2005
Form referenced from Section 401.2701, Florida Statutes 6