New Jersey Department of Health

EMERGENCY MEDICAL TECHNICIAN

Continuing Education Documentation

Issued to (Last, First Name)

Certification or Provider No.

Date of Birth *

_____ / _____ / _____
Course Title

Course Number

Date Conducted

Total Elective Credits **

Session Location

Credits *:

*Trauma/Medical:

*Other:
State

County *

Region *

Certification Level *

Name of Coordinator/Instructor (Print)

Signature of Coordinator/Instructor

Date

* Fields marked with an “*” are required for PA providers.

** Fields marked with an “**” are required for NJ providers.

All other fields are mandatory for both states.

Pennsylvania providers must submit a copy of this document directly to their Regional EMS Council for addition to their continuing education records.

New Jersey providers must retain this document as part of their personal recertification records.
EMS-28a

SEP 15

EMS-28A EMT Continuing Education Documentation

EMS-28A, EMT, CONTINUING EDUCATION

ewhite

2013-04-11

NJDOH