OSDH Form 666 "Distant Learning Site Data" - Oklahoma

What Is OSDH Form 666?

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

Form Details:

  • Released on May 29, 2014;
  • The latest edition provided by the Oklahoma State 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 OSDH Form 666 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 666 "Distant Learning Site Data" - Oklahoma

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Distant Learning Site Data
If you are applying for a Distance Learning class involving multiple training sites, please complete the following.
Every site through which training will be coordinated and provided must have this addendum sheet.
: __________________________
_______________
DL Course Number
Date:
DL Site Name: _______________________________________________________________________
DL Site Address: _____________________________________________________________________
(___) ____ -
(___) ____ - ___________
___________ Fax #:
Telephone #:
: [must be licensed at the level of training]
DL Site Instructors or Lab Assistants
Instructor or Assistant Name
Lic. Level Instructor #
ACLS Instructor?
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
DL Site Audio/Visual Technician: __________________________________________________
Will this person be available during this Class period
Yes
No
DL Site Clinical/Skill Arrangements: _____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List Students at this Site:
Last Name
First Name
Level
1_______________________________ _________________________________________ ______________
2_______________________________ _________________________________________ ______________
3_______________________________ _________________________________________ ______________
4_______________________________ _________________________________________ ______________
5_______________________________ _________________________________________ ______________
6_______________________________ _________________________________________ ______________
7_______________________________ _________________________________________ ______________
8_______________________________ _________________________________________ ______________
9_______________________________ _________________________________________ ______________
10______________________________ _________________________________________ ______________
11______________________________ _________________________________________ ______________
12______________________________ _________________________________________ ______________
13______________________________ _________________________________________ ______________
14______________________________ _________________________________________ ______________
15______________________________ _________________________________________ ______________
________________________________________________
Responsible DL Site Administrator:
Signature
__________________________________
DL Site Email Address:
Oklahoma State Department of Health
ODH Form 666
Emergency Medical Services
Revised 05/29/14
Distant Learning Site Data
If you are applying for a Distance Learning class involving multiple training sites, please complete the following.
Every site through which training will be coordinated and provided must have this addendum sheet.
: __________________________
_______________
DL Course Number
Date:
DL Site Name: _______________________________________________________________________
DL Site Address: _____________________________________________________________________
(___) ____ -
(___) ____ - ___________
___________ Fax #:
Telephone #:
: [must be licensed at the level of training]
DL Site Instructors or Lab Assistants
Instructor or Assistant Name
Lic. Level Instructor #
ACLS Instructor?
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
_______________________________ ________ ____________
Yes
No
DL Site Audio/Visual Technician: __________________________________________________
Will this person be available during this Class period
Yes
No
DL Site Clinical/Skill Arrangements: _____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
List Students at this Site:
Last Name
First Name
Level
1_______________________________ _________________________________________ ______________
2_______________________________ _________________________________________ ______________
3_______________________________ _________________________________________ ______________
4_______________________________ _________________________________________ ______________
5_______________________________ _________________________________________ ______________
6_______________________________ _________________________________________ ______________
7_______________________________ _________________________________________ ______________
8_______________________________ _________________________________________ ______________
9_______________________________ _________________________________________ ______________
10______________________________ _________________________________________ ______________
11______________________________ _________________________________________ ______________
12______________________________ _________________________________________ ______________
13______________________________ _________________________________________ ______________
14______________________________ _________________________________________ ______________
15______________________________ _________________________________________ ______________
________________________________________________
Responsible DL Site Administrator:
Signature
__________________________________
DL Site Email Address:
Oklahoma State Department of Health
ODH Form 666
Emergency Medical Services
Revised 05/29/14