Cross Certification Request - Service

PART A: PARAMEDIC INFORMATION

Original Submission ID

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Paramedic Information

Name

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Email

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EHS#

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Work History

Please select all RBHP you have worked for in the past 10 years

Previous Employment

{ccr1-cepcp-services:value} {ccr1-CPER-services:value} {ccr1-HSNCPC-services:value} {ccr1-NWRPCP-services:value} {ccr1-RPPEO-services:value} {ccr1-Sunnybrook-services:value} {ccr1-SWORBH-services:value} {ccr1-ornge-service:value} Invalid Input

PART B: RELEASE OF INFORMATION

I authorize the release of information to the Regional Paramedic Program for Eastern Ontario from other Base Hospitals and/or Certifying Bodies regarding my certification status and skills as a Paramedic

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Part C: Certification Referal Information

Referring Service

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Level of Certification

Primary Care
Advanced Care
Critical Care Invalid Input

Initial Certification Date(*)

...

Please select the date

Last Annual Certification Date:(*)

...

Please select a date

Has this Paramedic ever been Deactivated/Decertified by a Medical Director in the previous 10 years, not including absence from clinical practice:(*)

Yes
No Invalid Input

If Yes, list date(s) and reason(s):

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PART D: AUXILIARY DIRECTIVES CERTIFICATION

Select all that apply(*)

Adult Intraosseous ACP
Analgesia ACP/PCP
Cardiogenic Shock PCP AIV
Central Venous Access Device ACP
Continuous Positive Airway Pressure ACP/PCP
Cricothyrotomy ACP
Electronic Control Probe Device ACP/PCP
Emergency Trach Reinsertion ACP/PCP
Intravenous and Fluid Therapy PCP AIV

Nasotracheal Intubation ACP
Nausea/Vomiting ACP/PCP
Procedural Sedation ACP
Supraglottic Airway ACP/PCP
Minor Abrasions ACP/PCP
Minor Allergic Reaction ACP/PCP
Musculoskeletal Pain ACP/PCP
Headache ACP/PCP

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PART E: REFERRING BASE HOSPITAL CONFIRMATION

Name

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Title

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Phone #

Please enter a valid phone number

Email Address

Please enter a valid email address

Submit