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MDCH USE ONLY
Received Date: __________________________________________
Michigan Dept. of Community Health
Bureau of Health Policy, Planning & Access
EMS and Trauma Systems Section
201 Townsend Street
Lansing, Michigan 48913
Returned for Correction(s): ________________________________
Corrections Received: _____________________________________
Date of Final Review: _____________________________________
Signature for Approval: ____________________________________
[email protected]
Approval # : __________________ Region: ______
NOTIFICATION OF INTENT TO CONDUCT A CONTINUING EDUCATION TOPIC
□
□
Option 1 - For use by an Instructor Coordinator offering courses independently
Option 2 - For use by an approved Initial Education Program Sponsor offering continuing education credits
during an initial education course
This notification must be received at least 30 days prior to the start of the first class. This form may be sent by
e-mail or regular US mail to the Department at the address above.
Failure to complete and submit this form as prescribed may result in an automatic disapproval.
Your application and additional documentation will be reviewed and either returned for deficiencies or approved and a copy returned
for your records. A copy will also be maintained on file with MDCH.
Responsible IC must provide proof of attendance to each individual and maintain in records, a roster of those individuals who attended
each CE session.
For further information regarding CE policies, refer to the CE Approval Guidelines for Continuing Education Programs
Education Program Sponsor (Not required for Option 1)
Bay Regional Medical Center
Street Address
1900 Columbus Ave.
City
Bay City
State
MI
Zip
48708
County
Bay
Instructor Coordinator:
Name
Phone #
E-mail:
Robert Loiselle
989-894-3124
[email protected]
Street Address
I/C#
511 S. Johnson St.
City
Bay City, MI
State
MI
Zip
48708
0629
--- --- --- --County
Bay
Notification of cancellations or changes must be provided to the Department prior to their occurrence (if possible).
I affirm that all the information submitted in this notification is true and that all presen tations will comply with MDCH
requirements and will occur as outlined in this document. I understand that any misrepresentation of the information
provided as part of this n otification may result in n on-approval or revocation of existing approval, or further action by
MDCH.
Digitally signed by Robert Loiselle
DN: cn=Robert Loiselle, o=Bay Regional Medical Center, ou=EMS, [email protected], c=US
Date: 2012.01.11 14:31:59 -05'00'
Robert Loiselle
1/11/12
Signature of I/C ___________________________________________________________________________
Date _______________
BHPPA-EMS 202 Revised 3/11
page 1 of 4
Page 2 of 4
Along with this application, you must attach the following for each class (each date)
Practical means: supervised or
a.
Lesson plan including program content and learning objectives
CE’s requested with initial education require a course schedule in lieu of an outline and objectives
critiqued hands-on practice or
b.
Name and qualifications of presenter (Not required if requested with initial education)
simulation achieving identified
c.
Sample certificate of attendance
psychomotor objectives.
d.
Evaluation tools to be used (student evaluation of course content and presenter)
Category
Category
Category
EMS Provider Categories
EMS Provider Categories
Instructor/Coordinator Categories
Code
Code
Code
1
Preparatory
5
Medical
10
Instructional Techniques
2
Airway Management and Ventilation
6
Special Considerations
11
Measurement and Evaluation
3
Patient Assessment
7
Operations
12
Educational Administration
4
Trauma
CONTINUING EDUCATION SCHEDULE
Line
Sample
1
2
Cat.
Code
4
2
2
Specific Topic Title*
Spinal Injury/Backboarding
AIrway & Ventilation
Date
1/1/05
Specific
Location
Time
1-4p
Room 101
Lake Community College
123 Main St.
Anywhere, MI
BCFD
2/28/12
2/29/12
9a-11a 1401 Center Ave.
4
5
6
2
5
5
5
Diabetic Emergencies
3/30/12
1
1
1
Practical (Hands-on or Skill)
2
2
2
IC
1
1
0
2
2
2
0
EMT-S
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Lecture
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Lecture
Lecture
Bay City, MI 48708
BCFD
Lecture
Bay City, MI 48708
BCFD
Lecture
Bay City, MI 48708
For additional classes complete another form 202.
Lecture
P
Lecture
BCFD
3/29/12
EMT
BCFD
BCFD
3/1/12 9a-11a 1401 Center Ave.
Bay City, MI 48708
3/28/12
MFR
Number of Credits
Number
Hours
Bay City, MI 48708
Bay City, MI 48708
3
Course Format
Lecture
* Refer to Conversion Document for topics under each category.
Line
7
8
9
10
11
12
13
14
15
Cat.
Code
2
5
5
4
6
4
Diabetes
Environmental
Emergencies
Head Injuries
Geriatric Patients
Date
Time
3/27/12
7p-9p
4/24/12
5/29/12
6/26/12
9/25/12
Musculoskeletal Injuries
10/23/12
1
Communicable Disease
11/27/12
Specific
Location
Auburn Williams FD
Auburn, MI
Course Format
Lecture
MFR
EMT
EMT-S
P
2
2
2
2
2
2
2
2
2
2
Lecture
Auburn Williams FD
Auburn, MI
Lecture
7p-9p
Auburn Williams FD
Auburn, MI
Lecture
7p-9p
2
2
2
2
2
Auburn Williams FD
Auburn, MI
Lecture
7p-9p
2
2
2
2
2
Auburn Williams FD
Auburn, MI
Lecture
7p-9p
2
2
2
2
2
Auburn Williams FD
7p-9p Auburn, MI
Lecture
1
1
1
1
1
1
1
1
1
1
Auburn Williams FD
7p-9p Auburn, MI
Lecture
2
2
2
2
2
Lecture
Lecture
Lecture
16
Lecture
17
Lecture
18
Number of Credits
Number
Hours
IC
Line
Cat.
Code
Date
Time
Specific
Location
Course Format
Lecture
Lecture
19
20
21
22
23
Lecture
Lecture
Lecture
Lecture
Lecture
24
Lecture
25
26
27
Lecture
Lecture
Lecture
28
Lecture
29
Lecture
30
Number of Credits
Number
Hours
MFR
EMT
EMT-S
P
IC

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