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Mentor Fire Department Attendance
EMS Continuing Education Attendance Roster (Submission of this form constitutes verification of attendance)
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Email
*
Your email
Class Topic/Name:
*
Your answer
Instructor:
*
Your answer
Instructor Ohio Certification Number (If not applicable enter 0)
*
Your answer
Instructor EMS Certification Level
*
Choose
Paramedic
EMT- A
EMT- B
Outside or web-based content
Instructor Certification Level
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Choose
Continuing Education Instructor
Assistant EMS Instructor
EMS Instructor
Other or outside sourced
Class Date:
*
MM
/
DD
/
YYYY
Location:
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Total Hours:
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Pediatric Hours (enter 0 if none)
Your answer
Geriatric Hours (enter 0 if none)
Your answer
Trauma Hours (enter 0 if none)
Your answer
Cardiology Hours (enter 0 if none)
Your answer
Provide a detailed description of the training and describe any equipment, props or presentation materials used for the education. (Please be detailed as this section will be used for the Medical Director's sign-off on the class.)
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Attendee #1:
*
Your answer
Attendee #1 Email :
Your answer
Attendee #2:
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Attendee #2 Email :
Your answer
Attendee #3:
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Attendee #3 Email :
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Attendee #4:
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Attendee #4 Email :
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Attendee #5:
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Attendee #5 Email :
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Attendee #6:
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Attendee #6 Email :
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Attendee #7:
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Attendee #7 Email :
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Attendee #8:
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Attendee #8 Email :
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Attendee #9:
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Attendee #9 Email :
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Attendee #10:
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Attendee #10 Email :
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