If Necessary

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					Course Coordinator                                                                                 Work Phone:                                          Sponsor Agency
Address:                                                                                           Home Phone:                                          Address:
City:                                                                                              Cell Phone:                                          City:
Zip:                                                                                               Email:                                               Zip:
                                                                                                                                                        Building/Room
                                                                                                                                                                          Meeting Dates
    T-1 M                                                                                                                                               Start Date:
                                                                                                                                                        End Date:
        MRT Initial                                                                                                                                                       Meeting Times
Medical Director Name:                                                                                                                  Check Day                Day            Start            End
                                                                                                                                                        Monday
Medical Director Signature:                                                                                                                             Tuesday
                                                                                                                                                        Wednesday
                                                                                                                                                        Thursday
EMS Coordinator Name                                                                                                                                    Friday
                                                                                                                                                        Saturday
Sponsor Hospital Affiliation                                                                             Region                                         Sunday
Estimated Number of Students                                                  Enrollment is Open to the Public: Yes or No    →                          Exam Date/Time       01/00/00            0:00
                      Additional Faculty                                  EMS-I #                  Title
                                  0                                                      Coordinator / Lead EMS-I        Note: Accommodations can be made for individuals who have already received
                                                                                                                         CPR training and / or regional training and authorization to function at the AED
                                                                                                                        level and / EPI level. Should an individual be excused from a portion of the AED
                                                                                                                        and / or EPI lessons due to other training and authorizations, it is imperative that
                                                                                                                          the Instructor check and verify all pertinent regional records for confirmation.




If Necessary, Attach a List of Additional Instructors to this Form
            FOR OFFICE USE ONLY                                      Status                    Receipt Date                 Final Decision Date                                   FOR OFFICE USE ONLY
                                                                                                                                                     Approval Number




OEMS Excel 04-08                                                                                                                                                                            T1 MR page 1 of 3
 South West      Yes
 South Central   No
 North Central

   Eastern

  North West




Not Yet Approved
Approved
Denied
Revisions Outstanding
                                                                                      Lesson                      Minimum         Meets
                Lesson Title                      Date   Start Time   End Time                     Topic Hours                                EMS-I A          EMS-I A #   EMS-I B    EMS-I B #
                                                                                       Hours                        Hrs         Standard?
Elective: NIMS (or IS 700)                                                              0:00         0:00:00
Elective: ICS for EMS (or ICS 100/200)                                                 0:00          0:00:00
Module 1: Preparatory
Introduction to Emergency Care                                                         0:00          0:00:00        0:59         FALSE
               Introduction to Emergency Care                                          0:00
Well Being of the MRT                                                                  0:00          0:00:00        0:59         FALSE
                        Well Being of the MRT                                          0:00
Medical Legal / Ethical Issues                                                         0:00          0:00:00        1:30         FALSE
Medical Legal / Ethical Issues                                                         0:00
The Human Body                                                                         0:00          0:00:00        0:59         FALSE
                              The Human Body                                           0:00
Lifting and Moving Patients                                                            0:00          0:00:00        0:59         FALSE
                    Lifting and Moving Patients                                        0:00
Evaluation and Review                                                                  0:00          0:00:00        0:59         FALSE
Module 2: Airway
Airway (Including Oxygen and Suction)                                                  0:00          0:00:00        4:00         FALSE
                                         Airway                                        0:00
                                         Airway                                        0:00
Practical Lab - Airway                                                                 0:00          0:00:00        3:00         FALSE
                         Practical Lab - Airway                                        0:00
Evaluation and Review                                                                  0:00          0:00:00        0:59         FALSE
Module 3: Patient Assessment
Patient Assessment (Including Vital Signs)                                             0:00          0:00:00        3:00         FALSE
                                                                                       0:00
                                                                                       0:00
Documentation                                                                          0:00          0:00:00        0:59         FALSE
Practical Lab - Patient Assessments                                                    0:00          0:00:00        2:00         FALSE
Evaluation and Review                                                                  0:00          0:00:00        0:59         FALSE
Module 4: Circulation                                                                                                      6         0.00
Circulation with AED                                                                   0:00           0:00          6:00         FALSE
                                                                                       0:00
                                                                                       0:00
Practical Lab - Circulation                                                            0:00          0:00:00        3:00         FALSE
Evaluation and Review                                                                  0:00          0:00:00        0:59         FALSE
                                                                                                                                            Course
                                                                      Total Classes                                                                                                  Course Approval
                                                                         (Page)
                                                                                                                 Hours (page)    0:00:00    Coordinator EMS-
                                                                                                                                                                                            #
Page Summary                                                                                   0                                            I#
MODULE 5: Illness and Injury
Medical Emergencies                                                                    0:00          0:00:00        2:00         FALSE
                                                                                       0:00
Elective: Stroke & Neurological Emergencies                         0:00        0:00:00
Medical Elective:                                                   0:00        0:00:00
Medical Elective:                                                   0:00        0:00:00
Medical Elective:                                                   0:00        0:00:00
Bleeding & Soft Tissue Injuries                                     0:00        0:00:00         1:30       FALSE
                             Soft Tissue Injuries                   0:00
Musculoskeletal Care (with Simple Splinting)                        0:00        0:00:00         2:30       FALSE
                          Musculoskeletal Care                      0:00
                          Musculoskeletal Care                      0:00
Trauma Elective:                                                    0:00        0:00:00
Trauma Elective:                                                    0:00        0:00:00
Trauma Elective:                                                    0:00        0:00:00
Practical Lab - Illness and Injury                                  0:00        0:00:00         1:30       FALSE
                                                                    0:00
Evaluation and Review                                               0:00        0:00:00         0:59       FALSE
MODULE 6: Infants and Children
Infants and Children                                                0:00        0:00:00         3:00       FALSE
                            Infants and Children                    0:00
                            Infants and Children                    0:00
Childbirth                                                          0:00        0:00:00         0:59       FALSE
Practical Lab - Children & Childbirth                               0:00        0:00:00         0:59       FALSE
             Practical Lab - Infants and Children                   0:00
             Practical Lab - Infants and Children                   0:00
Evaluation and Review                                               0:00        0:00:00         0:59       FALSE
       Module 7: OPERATIONS
EMS Operations                                                      0:00        0:00:00         0:59       FALSE
Evaluation and Review                                               0:00        0:00:00         0:59       FALSE
Elective: Hazmat                                                    0:00        0:00:00
Elective: Hazmat                                                    0:00
Elective:                                                           0:00        0:00:00
Elective:                                                           0:00        0:00:00
Elective:                                                           0:00        0:00:00
Elective: MCI                                                       0:00        0:00:00
Elective: Weapons of Mass Destruction                               0:00        0:00:00
Final Written Exam                                                  0:00        0:00:00         2:00
Final Practical Exam                                                0:00        0:00:00         3:00
                                                                                                                         Course
                                                    Total Classes                                                                                                  Course Approval
                                                       (Page)
                                                                                            Hours (page)   0:00:00   Coordinator EMS-
                                                                                                                                                                          #
Page Summary                                                               0                                                I#
Course Summary                                      Total Classes    0                        Total Hrs.   0:00:00   Expected Hours     50:00:00   Standard Met?       FALSE

                                                                                    sum
                                                                               recommeded   190:45:00
                                                                                   hours
     sum
recommeded   190:45:00
    hours
Circulation with AED Awareness
Circulation with AED
                                               SIGNATURE, VERIFICATION, AND CHECKLIST SHEET


 I certify that I, as the primary EMS-Instructor, have completed and submitted all three pages of this "T-1M" MRT Application to Conduct Training, and that this represents a true and
 accurate record of the topics to be covered during the MRT Program as well as the dates, times, and instructor(s) for each lesson. I certify that this course meets the most recently
published AHA Guidelines, National Standard Training Curriculua, as approved by the United States Department of Transportation, National Highway Traffic Safety Administration, and
                                            will adhere in the form and content, to all applicable Office of Emergency Medical Services Policies.




      Primary EMS-Instructor Signature                      Primary EMS-Instructor Name, Printed                 EMS-I Certification #          Certification Expiration Date
                                                                  T-1 M Checklist and Verifcation Area
    Use the Checklist below to verify that all portions of ths Application have been completed and that all required adjunct documentst have been

             Verify that all course information on the top of Page 1 has been entered correctly.                                             Initial:

             Verify that Date/ Time Scheduled and instructor information is completed for each topic on Pages 2-3.                           Initial:

             Verify that the Primary EMS-I has signed on page 2 through 3, and included current EMS-I
                                                                                                                                             Initial:
             Certification Number

             Attach names and titles of additional faculty/instructors not included on Page 1.                                               Initial:

             Assure that the Course Medical Director has signed Page 1 (if AED course)                                                       Initial:

             E-mail an electronic version of this form, with a file name of your name, MRT Course and start
                                                                                                                                             Initial:
             date for the class to the Regional EMS Office in which the course is to be held.

             Mail a hard copy of this application to: The Regional Coordinator's Office for the Region in which the
                                                                                                                                             Initial:
             course is to be conducted.




        OEMS Excel 04-08                                                                                                                                T1 MRT Page 5 of 5
                       Course            Receipt    Final Decision                                         Coure
Instructor   EMS-I #            Status                   Date
                                                                     Course        Start Date   End Date           Region   email   Work Phone
                       Number             Date                                                             Open?
    0         00000      0        0      01/00/00     01/00/00       MRT Initial    01/00/00    01/00/00     0       0        0         0
Sponsor
          Place   Town   Exam Date   Exam Time   #Students   Proctor
Agency
   0        0      0      01/00/00     0:00:00       0

				
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