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

MERRTT Exam 1

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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.

Last Name: First Name: Organization Name: Org Address: City: County: State: Zip: Phone: Email Address: Mail Certificate to Organization: Off Mail Certificate to Address Below: Off Address: City_2: State_2: Zip_2: Indicate the code that best applies as your: Use QR Code below to retrieve: Position: Position_2: Position_3: Requesting Medical CEHs: Off State of license: EMT: Off EMT1: Off EMTB: Off EMTD: Off EMTInt: Off Other: Off EMT2: Off EMT CC: Off EMTP: Off EMR: Off CFR: Off AEMT: Off License or cert No: Exp Date MMDDYY: NREMT Number: Reregistration Date: