Form Bhppa Ems 136 – Fill Out and Use This PDF

	Michigan Department of Community Health
		EMS and Trauma Systems Section
		201 Townsend Street
		Lansing, Michigan 48913
MDCH USE ONLY
Date Received at MDCH:	________________________		Date Amendments Requested: _____________________
Date Rec’d by Regional Coordinator: _________________			Date Amendments Received: _____________________
Date Reviewed by Regional Coord.: __________________			Date of On-Site: ________________________________
			Date Report form sent to MDCH: ____________________
Recommended Approval:	฀ Yes	฀ No
Regional Coordinator Signature:

PROGRAM SPONSOR

APPLICATION FOR INITIAL APPROVAL

This application is to be completed jointly by the Program Sponsor’s Course Coordinator and a representative of the Program Sponsor. Tw o complete copies, one w ith original signatures, and all attachments must be received by MDCH at least 60 days prior to the planned start of the first course to be offered. Approval of an education program for emergency medical services personnel is predicated upon completion and submission of this application as prescribed by PA 368 of 1978, as amended, and applicable Rules, and compliance with Program Requirements for the respective program type and level. The courses may not start until the application is approved. I f the application does not meet approval criteria 30 days following the evaluation, or 7 days prior to course or continuing education start date, the application becomes null and void.

Program approval is for up to three years. For all additional course offerings within the approval period, the sponsor must submit the appropriate form; I nterim Application form BHPPA-EMS-136a and attachments electronically to MDCH; CE Application BHPPA-EMS-202c to the Regional Coordinator at least 30 days prior to date of the class.

Paramedic program sponsors with accreditation from Joint Review Committee on Educational Programs for EMT-Paramedic must submit this application with a copy of verification of accreditation from JRC and must complete questions 1-7 (attachments not required for questions 5, 6 & 7). Programs with current JRC accreditation will be approved for all four levels of EMS education. For additional course offerings, form BHPPA-EMS-136a must be submitted as noted above.

Refer to the Program Explanation and Criteria document for detailed instructions on application requirements.

1.

	Education Program Sponsor
	Address
	City	State	Zip	County
2.
	Type of Program applying for:
	__________	EMS Education Program Sponsor ( Check appropriate level) : _____ MFR			_____ EMT
	__________	I C Education Program Sponsor		_____ EMT-Specialist	_____ Paramedic
	__________	EMS CE Program Sponsor

BHPPA-EMS-136 (4/09)

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8.

Start date( s) and end date( s) of first course to be offered at each level:

MFR	____________________	-	____________________
EMT	____________________	-	____________________
EMT-Specialist	____________________	-	____________________
Paramedic	____________________	-	____________________
I C	____________________	-	_____________________

( Attach schedule of each course listed above, follow ing attached format)

9.

Course Location( s) ( building, room # , street address, city, zip)

10.General Program Sponsor Criteria – This section must be completed by all initial applicants. I f you are currently an approved program sponsor and are seeking an additional program type, you do not need to complete this section, proceed to specific program type criteria

Program Sponsor Approval Criteria

See text for detailed explanation of criteria, documentation required, and re-approval documentation required.

NOTE:Criteria are divided into required and recommended categories.

M- criteria for MFR program	B- criteria for Basic EMT program
S- criteria for EMT- Specialist program	P- criteria for Paramedic program
I - criteria for I C program	C- criteria for CE program

General Criteria for all applicants

Program Sponsorship- Required

1. ____M B S	I C	Provide documentation that verifies sponsor facility type. Programs must be sponsored
		by a facility that is either a post -secondary school (such as a university or a college), a
		high school or vocational/ technical school, or proprietary school licensed by the
		Michigan Department of Labor and Economic Growth; an adult education center; a
		licensed life support agency, a hospital, or a United States Military Service.
		or
2. ____	P	Provide documentation that verifies sponsor facility type. Programs must be sponsored
		by a facility that is either a post -secondary school, a high school or vocational/ technical
		school, or proprietary school licensed by the Michigan Department of Labor and
		Economic Growth; an adult education center, or a hospital.

3.____M B S P I C Provide a sponsor representative contact that is other than the course coordinator or primary I C.

4.____M B S P I C Provide a written statement outlining sponsor responsibilities.

5.____M B S P I C Provide an action plan that documents how the sponsor will provide oversight to all classes.

BHPPA-EMS-136 (4/09)

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Course Coordinator- Required

6.____M B S P I C Course Coordinator for the program is identified on application.

7.____M B S P I C Show proof of Michigan I C licensure and EMS provider licensure.

8.____M B S P I C Provide documentation of formal affiliation with program (employment verification letter) or copy of contract with sponsor.

9.____M B S P I C Provide written Course Coordinator position description.

10.____M B S P I C Assure a licensed I C is present during all classes with the exception of the presence of

a qualified instructor or subject matter expert approved according to MDCH policy.

Course Coordinator- Recommended

11.____M B S P I C Provide documentation of previous experience as a Course Coordinator

12.____M B S P I C Provide documentation of previous coordination experience

13.____M B S P I C Provide documentation of previous general administrative experience

14.____M B S P I C Provide documentation of academic credentialing, e.g. B.S., M.S., Ph.D., etc.

I nstructional Faculty- Required

15.____M B S P I C Provide documentation that demonstrates instructors are proficient in the subject

material presented. I f an EMS provider, instructor must be licensed at level of course or higher.

16.____M B S P I C Provide Curriculum Vitae for instructors that identifies credentials, including copy of

EMS license for each instructor, if applicable.

17.____M B S P I C Provide documentation that demonstrates instructor formal affiliation(employment

verification letter) or copy of contract with program sponsor 18.____M B S P I C Provide instructor's written position description (generic) .

I nstructional Faculty- Recommended

19.____M B S P I C Provide documentation that instructors are licensed I / C(s) in State of Michigan

20.____M B S P I C Provide documentation that instructors have academic credentialing.

21.____M B S P I C Provide documentation that instructors have previous EMS field experience.

22.____M B S P I C Provide documentation that instructors have previous teaching experience.

Financial Resources- Required

23.____M B S P I C Provide a written statement from the sponsor that states there is financial support for

the program.

Financial Resources- Recommended

24.____M B S P I C Provide a course budget and written statement from the sponsor financially supporting

the program.

Facility- Required ( See facility requirements attachment)

25.____M B S P I The facility meets all requirements in the attached appendix.

Facility- Recommended ( See facility recommendations)

26.____M B S P I The facility meets some recommendations in the attached appendix.

BHPPA-EMS-136 (4/09)

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