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

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

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: __________
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	●	Quiz/Examination Results	●	Clinical Experience

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

Application for the Accreditation of

Emergency Medical Technician-Basic Training Site

(Continued)

3

EMS-44

JUN 13	Page 4 of 4 Pages.

JUN 13	Page 1 of 4 Pages.

EMS-44, Application for Accreditation of Emergency Medical Technician-Basic Training Sites

EMS-44, emt, education program, accreditation, application for accreditation, emergency medical services, EMS

EWhite

2013-06-18

NJDOH