PNCCT Renewal Policy The PNCCT certificate and renewal are

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					                               PNCCT Renewal Policy
The PNCCT certificate and renewal are valid for three years. To receive a new wallet card, the
following steps must be followed:

   •     Complete the Renewal Request form, in this packet.

   •     Enclose copies of the following current certifications:
                                EMT-P/RN/MD license
                                PNCCT (card or certificate)
                                NRP
                                PALS/PEPP/ or ENPC*
                                BLS Health Care Provider-CPR.

   •     Provide documentation of sixteen (16) credits of pediatric and/or neonatal continuing
         education (CE) with an emphasis in critical care.

         Documentation of hours may be:
            o in the form of a letter on agency letterhead, signed by the Training Officer or
              Medical Director. The letter must include your name, PNCCT number (if
              available), number of CE hours and topics covered.

            o a copy of your state CE printout, provided that the printout includes your name,
              address, identification number, number of hours and dates of the courses
              completed. You must highlight the courses that you would like considered for
              your renewal.

            o certificates that are dated and signed, with topic content and time frame.

            o documented in-service training and/or PICU/NICU clinical rotations, on-line CE,
              or EIGHT (8) hours from ONE (1) of the following:
                         APLS, PBTLS, STABLE, NALS, PALS*/PEPP*/ or ENPC*
              (*the same certification cannot be used for the above certification and CE credits).

   •     Forward your Renewal Request form, documentation, and $35.00 renewal fee to:

                                      UMBC
                                      Professional Education and Training
                                      Academic IV – B-Wing – 4th Floor
                                      1000 Hilltop Circle
                                      Baltimore, Maryland 21250

   •     Renewal Requests postmarked from the first to the end of the month are processed by the
         end of the following month.



5/2005
                                     PNCCT Renewal Request
Name:            ___________________________________________                             Date: ___________________

Address:         ___________________________________________

                 ___________________________________________

Phone (Home):    ________________________                     Phone (Work):              _________________________

Email:           ________________________                     Phone (Alternate):         _________________________

                                        Date & Location of
Student number (if known): ____________ Original PNCCT Course: ______________________________

I am requesting renewal of my PNCCT certificate:                    ________________________________
                                                                                 (signature)

Provide documentation of sixteen (16) credits of pediatric and/or neonatal continuing education (CE) with an emphasis in
critical care. Documentation of hours may be:

o   in the form of a letter on agency letterhead, signed by the Training Officer or Medical Director. The letter must include
    your name, PNCCT number (if available), number of CE hours and topics covered.
o   a copy of your state CE printout, provided that the printout includes your name, address, identification number, number
    of hours and dates of the courses completed. You must highlight the courses that you would like considered for your
    renewal.
o   certificates that are dated and signed, with topic content and time frame.
o   documented in-service training and/or PICU/NICU clinical rotations, on-line CE, or EIGHT (8) hours from ONE (1) of
    the following:
                             APLS, PBTLS, STABLE, NALS, PALS*/PEPP*/ or ENPC*
                 (*the same certification cannot be used for the above certification and CE credits).
o   You may list CE course information in the table below (PLEASE PRINT) and have the information verified and signed
    by your training officer or medical director.


Topic                     Hours                       Date & Location




Training/Medical Director’s Name: ____________________________________            ___________________
                                                      (please print)                 telephone number
                                         ____________________________________ ___________________
                                                         signature                          date
Please find enclosed current copies of my:
            EMT-P/RN/MD license                       CPR—BLS Healthcare Provider Card
            PALS/PEPP or ENPC Card                    NRP
      I have enclosed my $ 35.00 check or money order (made payable to UMBC)
      Please charge my Visa or Mastercard $ 40.00 (please circle)
     ($ 35.00 renewal plus a $ 5.00 convenience processing fee)

Card Number: ______________________________ Exp date: _________________ V-code: __________________
                                                                    last three digits on back of card
__________________________________________            ___________________________________________
    please print name as it appears on the card               signature as it appears on card         5/2005
                         Certifications

  Paramedic/RN/MD License                 PNCCT Card




            NRP                       PALS/PEPP/ENPC




BLS-Health Care Provider-CPR
UMBC – PROFESSIONAL EDUCATION AND TRAINING                                                                       UMBC EHS/PACE
ACADEMIC IV, B-WING-4TH FLOOR, 1000 HILLTOP CIRCLE, BALTIMORE, MD 21250 (410) 455-3780 FAX: (410) 455-1344       PNCCT COURSE ORDER FORM
                                                                                                                                          ORDER INFORMATION
                                                                                                                                 Date:
                                                                                                                                 Print Name:
                                                                                                                                 Address:



                                                                                                                                 Phone:
                                                                                                                                 Alt. Phone:
                         ITEMS                                                           ITEMS                                   Email:
                                                                                                                                 Student# or Course location:
                     PNCCT - Pin                                                          PNCCT Patch                            CREDIT CARD PURCHASES:
                                                                                                                                 Indicate type of credit card:
                                                                                                                                             MasterCard       Visa
                                                                                                                                  There is a $ 5.00 convenience processing fee
                     ¾ inch x 1 inch electroplated metal                                  4 x 3½ inch embroidered patch
                                                                                                                                 Card Number:
                                                                                                                                 Expiration           V-Code:
                              Each        #        Cost                                                 Each     #        Cost   Date:                (last three digit on back)
                              $ 3.00                                                                    $ 3.00                   Amount Charged:
                                                                                                                                 Signature:


                     UMBC Pin                                                             UMBC Patch                             SHIPPING & HANDLING FEE:
                                                                                                                                      All packages sent USPS Priority Mail
                                                                                                                                           With Delivery Confirmation
                     ¾ inch x ¾ inch electroplated metal                                  3½ x 4 inch embroidered patch          Minimum shipping fee:                    $ 5.00
                                                                                                                                   st
                                                                                                                                 1 item ------------------------------- $ 5.00
                              Each        #        Cost                                                 Each     #        Cost   Each additional ten (10) patches/pins--- $ 1.50
                              $ 5.00                                                                    $ 3.00                         (Up to ten patches equal one item)


                                                                                    SUB-TOTAL FROM THIS COLUMN
                                                                                   SUB-TOTAL FROM FIRST COLUMN
                                                                                             TOTAL BOTH COLUMNS
                                                                                             SHIPPING & HANDLING
                                                                     CREDIT CARD CONVENIENCE PROCESSING FEE
       SUB-TOTAL FROM FIRST COLUMN                         MAKE CHECKS PAYABLE TO “UMBC”               TOTAL DUE                  Images of the patch and pin are available on our website
                                                                                                                                  (http://ehs.umbc.edu/ce/ccemt-p/)                5/2005

				
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