DEPARTMENT OF PUBLIC HEALTH
DPH Submissions System
EMS Education Approval System
Application to Conduct EMS Training
* - Required Field
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Instructor Email Address
*
Training Agency
?
*
City or Town
*
Enter Town Name
Contact Website or Email
*
Contact Phone #
*
Type of Course
*
Course Title
Class Hours
*
Method of Education
*
Start Date
*
End Date
*
First Name
*
Last Name
*
EMS-I Certification #
EMS-I Exp. Date
Other Instructor Qualification
Medical Director Name
*
Medical Director Email
*
Medical Director Contact Phone #
*
List on OEMS Website
Yes
No
*
Private Comments
Public Comment
Affirmation EMS
Yes
?
*
Affirmation Submission
Yes
?
*
