tdent Inoation o odla eency esponse adioloical anspotation ainin · tdent Inoation o odla eency...

Student Information Form Modular Emergency Response Radiological Transportation Training Indicate the position code(s) that apply: 1-Fire Department, 2-Law Enforcement, 3-EMS, 4-Emergency Management, 5-Regulatory/Compliance, 6-Other, 7-Local Government, 8-Hospital Staff, 9-Tribal Rep. This form must be filled out for each student. Please PRINT all information. If the student is requesting CAPCE Continuing Education Hours, all boxes marked with ( * ) must be filled out. *Last Name: *First Name: *Org. Address: *County: *City: *State: *Zip: Phone: *Email Address: Mail Certificate to Organization Address: City: State: Zip: * Indicate the code that best applies as your employment status: 1- Paid Full-Time 2- Paid Part-Time 3- Volunteer * Position Code: * Position Code: * Position Code: Requesting Medical CEH’s *State of license: * License or cert. No: * Exp. Date (MM/DD/YY): National Registry EMTs complete the following: NREMT Number: Re-registration Date: * Level of License: EMT EMT-2 EMT-1 EMT CC EMT-B EMT-P EMT-D EMR EMT-Int CFR Other AEMT Check Appropriate Class: Compressed MERRTT Full MERRTT Train the Trainer Partial MERRTT Course Start date: Course End date: Test score: Instructor 1 & Organization Course location City: State: By signing this sheet, I hereby certify that the information is true and accurate and the student, if requesting, is entitled to receive the Continuing Education Hours (CEH). Instructor Signature *Basic* 1 Radiological Basic 5 Initial Response 2 Biological Effects 6 Patient Handling 3 RAM Shipping Packages 10 DOE Shipping and Resource 4 Hazard Recognition 11 Waste Isolation Pilot Plant *Operational* 7 Incident Control 8 Radiological Survey Instruments and Dosimetry Devices 9 Decontamination, Disposal and Documentation 12 Pre-Hospital Practices 13 Transportation of Safeguard Material 14 Transportation by Rail Practical 1 Instrumentation 15 Case Histories Practical 2 Patient Handling 16 Public Information Officer Practical 3 Package Integrity Practical 4 Contamination Survey Practical 5 Picture Card Practical Note: Modules and Practical’s listed above are equal to 0.5 CEH CEH’s Awarded per category: Basic Operational CAPCE Activity Number: 16-CECB-F2-0696 Instructor 2 & Organization Instructor 3 & Organization Mail Certificate to Address Below FEMA SID number: *Organization Name: Use QR Code below to retrieve your SID number

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Transcript of tdent Inoation o odla eency esponse adioloical anspotation ainin · tdent Inoation o odla eency...

Page 1: tdent Inoation o odla eency esponse adioloical anspotation ainin · tdent Inoation o odla eency esponse adioloical anspotation ainin Indicate the position code(s) that apply: 1-Fire

Student Information FormModular Emergency Response Radiological Transportation Training

Indicate the position code(s) that apply: 1-Fire Department, 2-Law Enforcement, 3-EMS, 4-Emergency Management, 5-Regulatory/Compliance, 6-Other, 7-Local Government, 8-Hospital Staff, 9-Tribal Rep.

This form must be filled out for each student. Please PRINT all information.If the student is requesting CAPCE Continuing Education Hours, all boxes marked with (*) must be filled out.

*Last Name: *First Name:

*Org. Address:

*County:*City:

*State: *Zip: Phone:

*Email Address:

Mail Certificate to Organization

Address: City: State: Zip:

*Indicate the code that best applies as your employment status:

1- Paid Full-Time2- Paid Part-Time3- Volunteer

*Position Code:*Position

Code:*Position Code:

Requesting Medical CEH’s *State of license:

*License or cert. No: *Exp. Date (MM/DD/YY):

National Registry EMTs complete the following:NREMT Number: Re-registration Date:

*Level of License:EMT EMT-2EMT-1 EMT CCEMT-B EMT-PEMT-D EMREMT-Int CFROther AEMT

Check Appropriate Class:Compressed MERRTT

Full MERRTT Train the Trainer

Partial MERRTT

Course Start date:

Course End date:

Test score:

Instructor 1 & Organization

Course location City: State:

By signing this sheet, I hereby certify that the information is true and accurate and the student, if requesting, is entitled to receive the Continuing Education Hours (CEH).

Instructor Signature

*Basic*1 Radiological Basic 5 Initial Response 2 Biological Effects 6 Patient Handling 3 RAM Shipping Packages 10 DOE Shipping and Resource 4 Hazard Recognition 11 Waste Isolation Pilot Plant

*Operational*7 Incident Control 8 Radiological Survey Instruments and Dosimetry Devices9 Decontamination, Disposal and Documentation12 Pre-Hospital Practices 13 Transportation of Safeguard Material 14 Transportation by Rail Practical 1 Instrumentation15 Case Histories Practical 2 Patient Handling16 Public Information Officer Practical 3 Package Integrity Practical 4 Contamination Survey

Practical 5 Picture Card Practical

Note: Modules and Practical’s listed above are equal to 0.5 CEH

CEH’s Awarded per category: Basic Operational

CAPCE Activity Number: 16-CECB-F2-0696

Instructor 2 & Organization

Instructor 3 & Organization

Mail Certificate to Address Below

FEMA SID number:

*Organization Name:

Use QR Code below to retrieve your SID number

Page 2: tdent Inoation o odla eency esponse adioloical anspotation ainin · tdent Inoation o odla eency esponse adioloical anspotation ainin Indicate the position code(s) that apply: 1-Fire

MERRTT Exam1

TEPP Course Evaluation

You have participated in a program that has received Commision on Accreditation for Pre-Hosipatal Continuing Education (CAPCE) approval for continuing education credit. If you have any comments regarding the quality of this program and/or your satification with it, please contact CAPCE at: CAPCE, 12300 Ford Road Suite 350, Dallas, TX 75234, (972) 247-4442.