"Emergency Medical Services (EMS) Systems Examination Application" - Illinois

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Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
INSTRUCTIONS FOR EMS EXAMINATION APPLICATION
ALL COURSEWORK AND FINAL EXAMS MUST BE COMPLETED PRIOR TO APPLICATION. Online application and fee
payment can be completed at www.continentaltesting.net. Provide all applicable information requested. Missing information
will result in a delay of testing and licensure. Applications must be received by Continental Testing Services at least 15
days prior to the test date.
Part I - Application Category (Required)
1. Enter profession name.
EMT-Basic
EMT-Intermediate
EMT-Paramedic
Trauma Nurse Specialist (TNS)
2. Check profession code (required).
600 for EMT-Basic
601 for EMT-Intermediate
602 for EMT-Paramedic
603 for TNS
3. Enter applicable fee. The fee must be in the form of money order, cashier’s check or organizational check and made
payable to Continental Testing Services Inc.
No cash or personal checks accepted.
$20 for EMT-Basic
$30 for EMT-Intermediate
$40 for EMT-Paramedic
$25 for TNS
If an unexcused absence occurs, testing fee is forfeited and will not be refunded.
4. Check appropriate information regarding application.
First application
Second application
Third application
Other, and provide explanation
Part II - Applicant Identifying Information
1. Full name (required)
2. Social Security number (required)
3. Permanent mailing address (required)
4. Employment (check current employment related to this profession, if applicable.)
5. Maiden name (if applicable)
6. Driver’s license number
7. Driver’s license state
8. Race (optional)
9. Place of birth, city, state, county (required)
10. Date of birth (required)
11. Gender (required)
12. Telephone numbers (required)
13. E-mail address
IOCI 12-0232
Page 1 of 5
Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
INSTRUCTIONS FOR EMS EXAMINATION APPLICATION
ALL COURSEWORK AND FINAL EXAMS MUST BE COMPLETED PRIOR TO APPLICATION. Online application and fee
payment can be completed at www.continentaltesting.net. Provide all applicable information requested. Missing information
will result in a delay of testing and licensure. Applications must be received by Continental Testing Services at least 15
days prior to the test date.
Part I - Application Category (Required)
1. Enter profession name.
EMT-Basic
EMT-Intermediate
EMT-Paramedic
Trauma Nurse Specialist (TNS)
2. Check profession code (required).
600 for EMT-Basic
601 for EMT-Intermediate
602 for EMT-Paramedic
603 for TNS
3. Enter applicable fee. The fee must be in the form of money order, cashier’s check or organizational check and made
payable to Continental Testing Services Inc.
No cash or personal checks accepted.
$20 for EMT-Basic
$30 for EMT-Intermediate
$40 for EMT-Paramedic
$25 for TNS
If an unexcused absence occurs, testing fee is forfeited and will not be refunded.
4. Check appropriate information regarding application.
First application
Second application
Third application
Other, and provide explanation
Part II - Applicant Identifying Information
1. Full name (required)
2. Social Security number (required)
3. Permanent mailing address (required)
4. Employment (check current employment related to this profession, if applicable.)
5. Maiden name (if applicable)
6. Driver’s license number
7. Driver’s license state
8. Race (optional)
9. Place of birth, city, state, county (required)
10. Date of birth (required)
11. Gender (required)
12. Telephone numbers (required)
13. E-mail address
IOCI 12-0232
Page 1 of 5
Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
Part III - Education Information
1. Check “yes” or “no” for high school graduate or GED and provide any additional education information.
2. Name of last school attended
3. Last school location (city and state)
4. Date of graduation (month and year)
Part IV - Record of Licensure Information
Individuals licensed in a U.S. jurisdiction, foreign country or province MUST state whether or not they
have ever held licensure (either temporary or permanent) to practice as an EMS professional.
Part V - Record of Examination
This information is REQUIRED if you have taken the exam for the same level of this profession from National Registry or
another state. Failure to disclose examination attempt(s) may result in denial of your application or other appropriate action.
Part VI - Personal Information (Required Under 210 ILCS 50)
1. Felony conviction? (check “yes” or “no”) If yes, provide the documentation requested on the application.
2. Denied or disciplined for a professional license or permit? (Check “yes” or “no”) If yes, provide circumstances.
Part VII - Examination Coding Information (Required)
1. Enter test code center for the chosen test site/date.
(Test schedule available at www.continentaltesting.net or www.idph.state.il.us/ems)
2. Enter your training program site code. (This code is provided by the instructor or EMS system).
3. Record the number of times this level exam has been taken.
4. Special accommodations. (check “yes” or “no”) If yes, attach a completed Special Accommodations Form.
(Available at www.continentaltesting.net or www.idph.state.il.us/ems)
Part VIII - Child Support Information
This information is required by the Illinois Administrative Procedure Act [5 ILCS 100/10-65]. The application will
not be processed without a child support status appropriately checked.
Part IX - Certifying Statement
1. The application must be signed and dated by the applicant. Signature certifies that all information is true and correct.
THE COMPLETED APPLICATION AND TESTING FEE SHOULD BE SUBMITTED TO YOUR EMS SYSTEM
COORDINATOR OR TRAUMA NURSE SPECIALIST COURSE COORDINATOR (WHICHEVER IS APPLICABLE).
2. Signatures of the EMS system coordinator or TNS course coordinator (whichever applies) and the EMS medical director
are required.
APPLICATIONS WITHOUT ALL REQUIRED SIGNATURES WILL NOT BE PROCESSED.
Online applications can be done at www.continentaltesting.net. If applying online, notify your EMS system coordinator or
TNS course coordinator to provide authorization to the testing service.
Upon completion of the application, Continental Testing Services will send a confirmation letter to each individual sched-
uled to test. The confirmation letter and a government issued photo ID (driver’s license or state identification card) are
needed for entry into the exam.
The status of an application can be reviewed at www.continentaltesting.net.
Test results are posted at www.continentaltesting.net approximately five business days after the test date.
Continental Testing will send a test result letter to each test candidate.
IOCI 12-0232
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Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
IMPORTANT NOTICE: Completion of this form is necessary for consideration for testing and
FOR OFFICIAL USE ONLY
.
licensure under the Illinois Emergency Services Medical Systems Act [210 ILCS 50]
The following materials are required to complete application for
Carefully follow all steps outlined on the INSTRUCTION SHEET.
certification and licensure.
In addition, note the following:
1. Three page APPLICATION FOR EMS EXAMINATION.
A. Type or print legibly with black ink only.
2. SUPPORTING DOCUMENTS, forms, and/or any other docu-
B. FEES ARE NOT REFUNDABLE.
mentation you may be required to submit with your application.
C. Disclosure of U.S. Social Security number is mandatory in ac-
3. If the name shown on your supporting documents is different
cordance with the Illinois Administrative Procedure Act [5 ILCS
from that shown on your application, you must submit PROOF
100/10-65]. The Social Security number may be provided to
OF LEGAL NAME change - copy of marriage license, divorce
the Illinois Department of Healthcare and Family Services to
decree, affidavit or court order.
identify persons who are more than 30 days delinquent in com-
plying with a child support order.
PART I: Application Category Information
1. PROFESSION NAME
3. FEE
$
0.00
2. PROFESSION CODE
4. CHECK BOX INDICATING THE APPROPRIATE INFORMATION REGARDING YOUR APPLICATION
600 EMT – Basic
$20
This is the first time I have made application for this profession in Illinois.
601 EMT – Intermediate
$30
This is the second time I have made application for this profession in Illinois.
602 EMT – Paramedic
$40
This is the third time I have made application for this profession in Illinois.
603 TNS
$25
Other
Explain:__________________________________________________________________________
________________________________________________________________________________
PART II: Applicant Information – You must notify the Illinois Department of Public Health, Division of EMS
and Highway Safety, and/or Continental Testing Services in writing, of any address changes
after you file this application in order to receive any further information.
2. U.S. SOCIAL SECURITY NO. (Required)
1. NAME
LAST
FIRST
MIDDLE
3. PERMANENT MAILING ADDRESS
STREET
CITY
STATE
ZIP CODE
COUNTY
4. EMPLOYMENT
VOLUNTEER
FIRE DEPT
HOSPITAL
PRIVATE
INDEPENDENT
TRAUMA CENTER
NON-TRAUMA
(If Applicable)
5. MAIDEN NAME (If Applicable)
6. DRIVER’S LICENSE NUMBER
7. STATE OF DRIVER’S LICENSE
8. RACE (Optional)
African American
Native American
Asian
Caucasian
Hispanic
Other
9. PLACE OF BIRTH
CITY
STATE/COUNTY
10. DATE OF BIRTH
11. GENDER
Female
__ __ / __ __ / __ __ __ __
Male
Month
Day
Year
12. TELEPHONE NUMBER(S) WHERE YOU MAY BE REACHED
13. E-MAIL ADDRESS (Required)
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
Work:
Home:
(Area Code)
(Area Code)
IOCI 12-0232
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Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
PART III: Education Information
1. PRELIMINARY EDUCATION (Check Appropriate Box)
High School Graduate
Yes
No
OR
GED
Yes
No
2. NAME OF LAST SCHOOL ATTENDED
3. LAST SCHOOL LOCATION (City and State)
4. DATE OF GRADUATION
__ __ / __ __ __ __
Month
Year
5. Additional Education (Check Highest Level)
Diploma Nurse
ADN
BS
BSN
MS/MSN
Doctorate
PART IV: Record of Licensure/Certification Information
If you have ever been licensed to practice the profession for which you are now making application, or held a related
license, complete the information requested below.
DATE OF
LICENSE STATUS
STATE / COUNTY
PROFESSION NAME
LICENSE NUMBER
ISSUANCE
(Active, Lapsed, etc.)
(If additional space is needed, attach a separate sheet.)
PART V: Record of Examination
If you have ever taken a licensure examination in Illinois or any other state for the profession for which you are now making
application, you must complete the information requested below. EACH EXAMINATION ATTEMPT MUST BE SHOWN.
Failure to disclose an examination attempt may result in the denial of your application or other appropriate action.
EXAM RESULTS
NAME OF EXAMINATION
STATE
MONTH/YEAR
(Passed, Failed, Absent)
(If additional space is needed, attach a separate sheet.)
IOCI 12-0232
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Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Examination Application
PART VI: Personal History Information (Required Under 210 ILCS 50)
YES
NO
1. Have you been convicted of a felony? If yes, attach a statement, in your own words, of the circumstances
surrounding the incident. An additional fee and authorization for release of information must be submitted to the
Department to obtain a criminal history report from the Illinois State Police or other law enforcement agency.
2. Have you ever had disciplinary action brought against you or a license you have held in Illinois or other state?
If yes, provide an explanation of the circumstances for the action.
PART VII: Examination Coding Information (This part is for examination applicants only.)
Complete the following:
1. Select the examination site you desire and enter test center code.
(Provided on test schedules)
2. Enter your training program site code.
(Provided by instructor or EMS system)
3. Record the number of times you have taken this exam in Illinois or any other state.
(Required)
4. Do you require any special accommodations as required under the American Disabilities Act?
Yes
No
If yes, attach completed special accommodations request form and any other necessary documentation to application.
PART VIII: Child Support Information (Every applicant is required by law to respond to the following question)
In accordance with five Illinois Compiled Statutes 100/10-65(c) of the Illinois Administrative Procedure Act, applications for a
license/certification shall include the applicant’s Social Security number. The applicant shall certify, under penalty of perjury his/her
status in complying with a child support order. FAILURE TO CERTIFY SHALL RESULT IN DENIAL OF LICENSE.
FALSIFICATION MAY RESULT IN DISCIPLINARY ACTION AND/OR CONTEMPT OF COURT.
Are you more than 30 days delinquent in complying with a child support order?
1.
No
2.
Yes
3.
Not Applicable
(NOTE: If you are not subject to a child support order, answer “Not Applicable.”)
PART IX: Certifying Statement
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connec-
tion therewith, and to the best of my knowledge, they are true, correct and complete.
I UNDERSTAND THAT TESTING FEES FOR UNEXCUSED ABSENCES ARE NONREFUNDABLE.
______________________________________________________________________
_________________________________
Signature of Applicant
Date
This section for authorization by EMS medical directors, EMS system coordinators and/or TNS course coordinators ONLY.
The EMS system coordinator or TNS course coordinator is responsible for final verification of examination eligibility.
I certify that the above applicant is expected to successfully complete the approved training program, including the
written and practical exams.
____________________________________________________
____________________________________________________
Signature of EMS Medical Director (Required)
Signature of EMS System Coordinator (Required for EMT)
____________________________________________________
____________________________________________________
Signature of TNS Course Coordinator (Required for TNS)
Date
IOCI 12-0232
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