Download Advanced Life Support Provider Recertification Application and more Lecture notes Economics in PDF only on Docsity! EMS-60 JUL 12 Page 1 of 3 Pages. New Jersey Department of Health Office of Emergency Medical Services P.O. Box 360 Trenton, NJ 08625-0360 ADVANCED LIFE SUPPORT APPLICATION FOR PROVIDER RECERTIFICATION Name of Provider Social Security No. (Last 4 Digits Only) Mailing Address (Required for OEMS Use Only. Must be a physical address; no PO Box or Mail Stop numbers accepted.) NJ Certification Number City, State, Zip Code Telephone Number Public Address (Optional - the Department will provide this address for requests of government records.) Cell Number City, State, Zip Code Email Address Provider Level MICP MICN ACM/FP ACM/FN MICU Program Certification Expiration Dates ACLS Expiration BCLS Expiration PALS or PEPP-Advance (attach copy) (attach copy) (attach copy) RN License Expiration Continuing Education Hours Airway, Breathing Medical Traumatic OB and Pediatric Operational Tasks TOTAL and Cardiology Emergencies Emergencies Emergencies (ICS/WMD/HAZMAT) (Minimum 48 Hrs) Certification Action and Criminal Statement 1. Have you ever been charged, convicted, placed on probation, entered into a pre-trial intervention (PTI) program or entered into a plea bargain in connection with a violation of law under the laws of any state, the federal government, or any other jurisdiction, other than a minor traffic violation? Yes No 2. Have you ever been subjected to limitation, suspension, or termination of your right to practice in a health care occupation or voluntarily surrender a health care licensure in any state or to an agency authorizing the legal right to work? Yes No If you answered “Yes” to the either of the above questions, you must provide official documentation that fully describes the offense, current status, and disposition of the case. I hereby affirm that the above statements and information is true and correct, including the completion of the continuing education hours for this certification period, and that I am eligible for recertification. Signature of Provider Date ADVANCED LIFE SUPPORT APPLICATION FOR PROVIDER RECERTIFICATION (CONTINUED) EMS-60 JUL 12 Page 2 of 3 Pages. Name of Provider NJ Certification Number TO BE COMPLETED BY MICU MEDICAL DIRECTOR Verification of Skill Maintenance Q/A:Q/I Direct Other Patient Assessment and Management Ventilatory Management Skills / Knowledge Cardiac Arrest Management Hemorrhage Control and Splinting Procedures IV and IO Therapy, and Medication Administration Spinal Immobilization OB/Gynecologic Skills / Knowledge Communications and Documentation Skills As the MICU Medical Director, I do hereby affix my signature attesting to the continued competence in all the skills outlined in the above verification. Signature of Medical Director Date TO BE COMPLETED BY EMS DIRECTOR I certify that the above-named pre-hospital ALS care provider has demonstrated clinical competence, is actively affiliated with this MICU, and to the best of my knowledge has met all requirements for recertification. Signature of EMS Director Date Signature of EMS Educator Date Recertification forms are due to OEMS by the 30th of the month preceding the expiration date. Copies of ACLS, BLS and PALS or PEPP-Advanced cards must be attached.
