2017.AREMT.NREMT.Recertification
TheAustralasianRegistryOfEmergencyMedicalTechnicians
EMTRecertificationForm2017
Name / Date of
Birth / Registry
Number
Mailing
Address / PhoneNumber / Email
Payment / Payment
Amount / PaymentStatus
Employer / Employer
Address / EmployerPhone
Number
Certifications
CPR / ACLS
AstheEMSProfessional'sCPRInstructor/TrainingOfficer,Ihereby
verifytheEMSProfessionalhasbeenexaminedandperformed
satisfactorilysoastobedeemedcompetentineachofthefollowing:
•Adult12RescuerCPR
•AdultObstructedAirway
•ChildCPR
•ChildObstructedAirway
•InfantCPR
•InfantObstructedAirway
VerifyingSignature:
______
Submitcopyofcardand/orverifywithappropriatesignature
EMT'sCPRExpirationDate: / ExpirationDate:
Submitacopyofcard.
VerificationOfSkillCompetence
Q/A:Q/I / DirectObservation / Other
PatientAssessment/Management / • / MedicalandTrauma
VentilatoryManagementSkills/Knowledge / • / Simpleadjuncts
• / Supplementaloxygendelivery
• / Advanced airway management
•
•
•
Professional Statement / AREMT Status
If you have not already completed Privacy
Verification document, PLEASE see attached
Sinceyourlastcertification,haveyoubeensubjectto
limitation,probation,suspension,orrevocationofyourright
topracticeinahealthcareoccupationorvoluntarily
surrenderedahealthcarelicenseinanystateortoany
agencyauthorizingthelegalrighttowork?
2017.AREMT.NREMT.recertification
EMTContinuingEducation(24HoursRequired)CourseName / Sponsor/Provider / Date
Completed / Methodof
Instruction / Hours
Received
EMTRefresher/Ongoing Employment/Training(24HoursRequired)
TopicsofTraining / Hours
Required / CourseName / Sponsor / Date
Completed / Methodof
Instruction / Hours
Received
24 / 48
TotalHours / 48
SubmitcoursecompletioncertificateofstateapprovedAREMTNationalStandardParamedicRefresher programcompletedwithinthis
recertificationcycle.
AND
SubmitanOfficialLetterfromyourEmployer/TrainingOfficerorMedicalDirectorverifyingcompletionofallmandatoryandflexiblecore
contentincludingcompletiondatesandhoursandmethodsused.
OR
UsethesummarysheetoutliningCoreContentbyapplyingdates,hoursmethodusedintherespectiveareas.Attachmentmustbe
verifiedwiththeEMSProfessional'ssignatureandmustincludecopiesofallcertificatesthatmakeuptherefreshercomponentsand
submittedwiththerecertificationform.
VerificationOfSkillCompetence
Q/A:Q/I / DirectObservation / Other
CardiacArrestManagement / • / BasicECGRecognition,where required
• / Updated guidelines
• / Monitor/Defibrillatorknowledge(set-up,
routinemaintenance,pacing)
HemorrhageControlSplintingProcedures / Review procedures
IVTherapyIOTherapy / • / Only where authorised
SpinalImmobilization / • / Seatedlyingpatients
OB/GynecologicSkills/Knowledge / Review procedures
OtherRelatedSkills/Knowledge / • / Protocols
• / EPCR Reportwritingdocumentation
2017.AREMT.NREMT.recertification
AsPhysicianMedicalDirector/Training ManagerofEMTtraining/operations,Idoherebyaffixmysignatureattestingtocontinuedcompetenceinallskills
outlinedabove.
______/ ______/ ______
PhysicianMedicalDirectorSignature(mustbeoriginal
signature) / Title / DateSigned
IherebyaffirmthatallstatementsontheAEMTRecertificationFormaretrueandcorrect,includingthecopiesofcards,certificatesand
AREMTEMTrefresherattachment.ItisunderstoodthatfalsestatementsordocumentsmaybesufficientcauseforrevocationbyAREMT.
ItisalsounderstoodthatAREMTmayconductanauditoftherecertificationactivitieslistedatanytime.
______/ ______
YoursignatureDatesigned / SignatureofTrainingOfficer/Supervisor
(mustbeotherthanEMSProfessional
mustbeanoriginalsignature) / DateSigned
Thisapplicationmustbemailedandpostmarkednolaterthan______2017.
DEBIT MY CREDIT CARD ($150.00 INCLUSIVE OF GST, 1.5% ON-LINE MERCHANT FEE (PLUS Amex, Paypal 3.5% trackeable post $15 Australia OR $30 overseas,)
Card InformationCARD TYPEVisaMasterCardAmerican ExpressBankard
CARD NUMBEREXPIRATION
MMYYYYLAST THREE (3) DIGITS ON THE BACK OF THE CARD
SIGNATURE
MMDDYYYY
OVERSEAS BANK TRANSFER TO: AUSTRALASIAN REGISTRY OF EMERGENCY MEDICAL TECHNICIANS
SWIFT CODE > Metwau4b ACCOUNT NUMBER > 027555O75 BSB >484-799 BANK -Suncorp Metway Brisbane
PAY ONLINE USING PAYPAL. UNDER "REGISTRATION" PAGE. EXCLUDES trackeble postage fee…A$150.00
AustralasianRegistryofEmergencyMedicalTechnicians
POBox3007
West Ipswich Queensland 4305
(617)32815654
EMTContinuingEducation
CourseName / Sponsor / Date
Completed / Methodof
Instruction / Hours
Received
*Someorallofthiscourse'shourswerenotcountedtowardsthistopic,becauseoneormoreearlier
courseshavealreadyfulfilledtherequirednumberofhours. / TotalHours / 24
2017.AREMT.NREMT.recertification