Form EMS-44 "Emergency Medical Technician-Education Program Application for Accreditation" - New Jersey

What Is Form EMS-44?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2013;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form EMS-44 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form EMS-44 "Emergency Medical Technician-Education Program Application for Accreditation" - New Jersey

Download PDF

Fill PDF online

Rate (4.3 / 5) 37 votes
New Jersey Department of Health
Office of Emergency Medical Services
P. O. Box 360
Trenton, NJ 08625-0360
EMERGENCY MEDICAL TECHNICIAN-EDUCATION PROGRAM
APPLICATION FOR ACCREDITATION
I. SPONSORING INSTITUTION
Name
Federal Tax ID Number
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Web Address
II. RESOURCES
Personnel: Include the name, address, telephone number, email address, level of certification and resume for each of the
following positions. Submit a letter of agreement from each individual agreeing to fulfill the roles and responsibilities of their
positions as listed in N.J.A.C. 8: 40A.
Name of Program Director
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
Name of Program Coordinator
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
Name of Program Medical Advisor/Director
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
EMS-44
JUN 13
Page 1 of 4 Pages.
New Jersey Department of Health
Office of Emergency Medical Services
P. O. Box 360
Trenton, NJ 08625-0360
EMERGENCY MEDICAL TECHNICIAN-EDUCATION PROGRAM
APPLICATION FOR ACCREDITATION
I. SPONSORING INSTITUTION
Name
Federal Tax ID Number
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Web Address
II. RESOURCES
Personnel: Include the name, address, telephone number, email address, level of certification and resume for each of the
following positions. Submit a letter of agreement from each individual agreeing to fulfill the roles and responsibilities of their
positions as listed in N.J.A.C. 8: 40A.
Name of Program Director
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
Name of Program Coordinator
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
Name of Program Medical Advisor/Director
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
EMS-44
JUN 13
Page 1 of 4 Pages.
APPLICATION FOR THE ACCREDITATION OF
EMERGENCY MEDICAL TECHNICIAN-BASIC TRAINING SITE
(CONTINUED)
Name of Lead EMT Instructor
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
EMS ID Number
EMT Instructional Staff: Attach a list of all EMT Instructors and Instructor Aides affiliated with this educational site. Include
the name, mailing address, physical address, telephone number, EMS ID number and level of certification for each staff
member.
Records: Identify the storage location of the EMT Instructional Staff records:
Attendance/instructional records (Lecture vs. practical)
Instructor evaluations (student, peers, coordinator)
Counseling records
Grievance records
Competency verification/evaluations
Instructor Policies and Procedures (provide a copy)
Certification records
Facilities: Identify each training site to be used by the accredited education agency. Attach letter(s) of agreement from each
facility. Each letter of agreement shall include a statement that the facilities are educationally conducive to the learning
process and that any alteration of the physical plant must be disclosed to the EMT educational agency first.
Facility Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Web Address
Facility Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Web Address
EMS-44
JUN 13
Page 2 of 4 Pages.
APPLICATION FOR THE ACCREDITATION OF
EMERGENCY MEDICAL TECHNICIAN-BASIC TRAINING SITE
(CONTINUED)
Clinical Affiliations: List the hospitals and/or mobile intensive care units which will provide the required clinical training
experiences to students from this site.
Facility Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Facility Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Facility Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Telephone Number
Fax Number
Name of Contact Person
Title
Email Address
Curriculum:
Provide a copy of the education program’s goals, objectives and lesson plans for each of the following areas:
Cognitive Domain
Psychomotor Domain
Affective Domain)
List the textbooks, workbooks and, if applicable, web-based learning management system that will be used in the
delivery of the EMT education program.
Class Capacity: Indicate the minimum and maximum number of students that will be enrolled per class with the available
physical plant and instructional personnel:
Minimum: __________
Maximum: __________
EMS-44
JUN 13
Page 3 of 4 Pages.
APPLICATION FOR THE ACCREDITATION OF
EMERGENCY MEDICAL TECHNICIAN-BASIC TRAINING SITE
(CONTINUED)
Student Records:
Identify the storage location of the student records listed below. Attach the policy on control of access to student
records that is in accordance with the Family Educational Rights and Privacy Act of 1974 and all related New Jersey
Department of Health regulations:
Attendance
Counseling
Student Contract
Grievance
Clinical Experience
Quiz/Examination Results
Course Registration
Interviews
Workbook
Evaluation Forms
Examination Results
Course Prerequisites
Provide a copy of the program’s policy and procedure manual.
Equipment: Attach an inventory of all equipment, including quantities, required for the conduct of EMT educational progrm.
Indicate if the equipment is owned, leased or borrowed, and whether it will be stored on site or transported to each class.
(Equipment must be available during site inspection.)
Evaluations: Summarize the evaluation process to be used for students, staff, and overall program performance. Copies of
all evaluation instruments must be submitted and approved prior to the initial education program. Student evaluation
instruments must include all module tests, both cognitive and psychomotor, as appropriate.
Mentoring: Any program conducting its first course utilizing the National EMS Education Standards must establish an
agreement with a pilot program coordinator (contact OEMSSSSS for this list) to mentor the new educational provider.
Confirmation of this agreement should be sent by the mentor directly to OEMS.
III. VERIFICATIONS
By our signatures we verify that all of the above information is true and accurate to the best of our knowledge.
Signature of Sponsor Contact Person
Date
Signature of Medical Advisor/Director
Date
Signature of Program Director
Date
Signature of Program Coordinator
Date
Signature of Lead EMT Instructor
Date
EMS-44
JUN 13
Page 4 of 4 Pages.
Page of 4