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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11.Educat ion Program Sponsor Criteria – This section must be completed by all applicants w ishing to provide MFR, EMT, EMT- Specialist, or Paramedic level education.

Education Program Sponsor Approval Criteria

Program Sponsorship- Required

36. ____M B S P		Provide documentation that Medical Control Authority has been informed of the program.
Course Coordinator- Recommended
37.____M B S P		C	Provide documentation of previous teaching experience
38.____M B S P		C	Provide documentation of previous field experience
39.____M B S P		C Provide documentation of license at higher level than the program
Physician Director- Required
40.____	B S P	Physician Director is identified on application and signs original signature to application.
41.____	B S P	Provide documentation that physician is licensed.
42.____	B S P	Provide documentation that physician is formally affiliated (letter of employment) or
		provide copy of contract with the program sponsor.
43.____	B S P	Provide the Physician Director's written position description (may be in contract) . When
		not in contract, this position description must be signed in acknowledgement by the
		physician.
44.____	B S P	Provide documentation that physician has clinical experience and current expertise in
		providing emergency care.
Physician Director- Recommended
45.____M		Physician Director is identified on application and signs original signature to application.
46.____M		Provide documentation that physician is licensed and has emergency care experience.
47.____M		Provide documentation that physician is formally affiliated (letter of employment) or
		provide copy of contract with the program sponsor.
48.____M		Provide the Physician Director's written position description (may be in contract) .
49.____M B S		Provide documentation that physician is knowledgeable in EMS systems.
50.____M B S P		Provide documentation that physician is Board-certified or board-eligible in emergency
		medicine.
51.____M B S P		Provide documentation that physician completed an EMS fellowship.
52.____M B S P		Provide documentation that physician is actively involved in emergency medicine or EMS
		professional organizations.
53.____M B S P		Provide documentation that the physician signs a statement assuring student competency
		at the end of the program.
54.____M B S P		Provide documentation that the physician signs a statement assuring familiarity with
		education program requirements.
55.____M B S P		Provide documentation that the physician signs a statement accepting responsibility to
		review the course curriculum for medical correctness.

BHPPA-EMS-136 (4/09)

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Clinical Resources- Recommended

78.____	B S	Demonstrate that a formal field internship program exists.
79.____	B S P	The course coordinator and/ or clinical preceptor responsible for the clinical setting has in
		place a system for demonstrating proof of the students' participation:
		a. The course coordinator/ clinical preceptor schedules the student in clinical setting.
		b. The clinical setting is advised in writing of the students scheduled.
		c. A system is maintained at the facility to record student attendance.
80.____	B S P	Demonstrate that students have access to a diverse patient mix (age/ race/ patient
		conditions) .
81.____	B S P	Provide a copy of the contract between the program and the clinical faculty.

Clinical Resources:

Hospital and Pre-Hospital Agencies Providing Clinical Contracts: (minimum one hospital and one pre-hospital)

Attach copies of all clinical contracts. (Clinical contracts must have been authorized within the last 3 years)

Student Policy/ Syllabus- Required

82.____M B S P I Provide a copy of the admissions policy.

83.____M B S P I Provide a copy of the specific grading scale and definition of successful completion.

84.____M B S P I Provide a copy of the attendance policy.

85.____M B S P I Provide a copy of the appeals policy/ procedure.

86.____M B S P I Provide a copy of the academic guidance procedure.

87.____M B S P I Provide a copy of the health and safety policy/ procedure meeting those identified required

areas in this section

88.____M B S P I Document and demonstrate how a copy of the MDCH Education Program Requirements is

made available to the students.

89.____M B S P I Provide a copy of the disclosure policy/ procedure meeting the identified required areas in

this section.

90.____M B S P I Demonstrate that a primary textbook, or resource is identified and required.

91.____M B S P I Demonstrate in the syllabus the primary instructor availability, contact phone, and class

cancellation procedure.

92.____M B S P I Provide a copy of the dress code/ hygiene policy used for the clinical setting.

93.____M B S P I Document in the syllabus that upon successful completion, students will be provided the

National Registry application, the exam reservation forms, license application and instructions for application completion.

94.____M B S P I Document in syllabus that upon successful completion, students will be provided a letter

or certificate of course completion.

95.____M B S P I Document in syllabus that students are informed that a criminal history could impact the

student's ability to participate in clinical, examinations and/ or to become licensed.

96.____M B S P I Document is syllabus that students are informed before or at the first class session that

the program sponsor is approved and the specific course has been approved.

BHPPA-EMS-136 (4/09)

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Student Teaching- Recommended

139.____	I Demonstrate in documentation that student teaching is diversified (initial training both
		didactic and skills, CE, community, etc.) .
140.____	I	Demonstrate that a formal internship program exists.
141.____	I Demonstrate that access to a diverse student population exists. (age, race, previous
		education) .
142.____	I	Provide a copy of the contract between the program and the student teaching faculty
		(supervisory) .

Clinical Resources for Student Teaching:

Hospital and Pre-Hospital Agencies Providing Clinical Contracts: (minimum one hospital and one pre-hospital)

Attach copies of all clinical contracts. (Clinical contracts must have been authorized within the last 3 years)

Student Policy/ Syllabus- Required
143.____M B S P I		Provide a copy of the admissions policy.
144.____M B S P I Provide a copy of the specific grading scale and definition of successful completion.
145.____M B S P I		Provide a copy of the attendance policy.
146.____M B S P I		Provide a copy of the appeals policy/ procedure.
147.____M B S P I		Provide a copy of the academic guidance procedure.
148.____M B S P I		Provide a copy of the health and safety policy/ procedure meeting those identified
		required areas in this section
149.____M B S P I	Document and demonstrate how a copy of the MDCH Education Program Requirements
		is made available to the students.
150.____	I	Document in the syllabus that students will be provided a copy of:
		a. the Michigan EMT Education Program Requirements (Objectives) .
		b. the Michigan Education Program Approval Packet (forms and packet)
		c. the current Michigan EMS legislation (P.A. 368 of 1978 as amended)
151.____M B S P I		Provide a copy of the disclosure policy/ procedure meeting the identified required areas
		in this section.
152.____M B S P I Demonstrate that a primary textbook, or resource is identified and required.
153.____M B S P I	Demonstrate in the syllabus the primary instructor availability, contact phone, and class
		cancellation procedure.
154.____M B S P I		Provide a copy of the dress code/ hygiene policy used for the clinical setting.
155.____M B S P I	Document in the syllabus that upon successful completion, students will be provided
		the National Registry application, the exam reservation forms, license application and
		instructions for application completion.
156.____M B S P I	Document in syllabus that upon successful completion, students will be provided a
		letter or certificate of course completion.
157.____M B S P I	Document in syllabus that students are informed that a criminal history could impact
		the student's ability to participate in clinical, examinations and/ or to become licensed.
158.____M B S P I	Document is syllabus that students are informed before or at the first class session that
		the program sponsor is approved and the specific course has been approved.
BHPPA-EMS-136 (4/09)		page 12 of 17

Operational Policy/ Procedures- Required

159.____M B S P I Student records will be maintained for minimally five years and contain:

a.all academic information such as grades

b.copies of student course-end evaluations (didactic, practical, affective & clinical)

c.copies of all student clinical attendance verifications

d.any student incident report or counseling record

e.student vaccination history (if not found in other facility record)

160.____M B S P I Provide an example of each final evaluation tool that will be used to evaluate the

student inthe cognitive, psychomotor, affective domains.

161.____M B S P I Provide a policy that directs how evaluation tools will be developed and evaluated after

use to improve validity and reliability, if needed.

162.____M B S P I Demonstrate "fairness in advertising" in all course information. Provide a copy of the

course announcement for this criteria.

Program Evaluation- Required

163.___M B S P I By policy, describe how the program will utilize the data obtained from the comparison of the course outcomes to the success of students on the NREMT and State of Michigan exams.

164.___M B S P I By policy, direct what data is included in the final report that is made by the primary I C or course coordinator to the program sponsor and/ or the Advisory Committee, and is maintained in course records. This final report includes:

a.a summary of each course's evaluations (from # 101)

b.facts on student attrition (number of students enrolled/ completing)

c.the comparison of course outcomes to NREMT and State of Michigan exam (# 103)

d.the action plan for implementing necessary changes (from # 104.)

Program Evaluation- Recommended

165.___M B S P I Evaluate the effectiveness of the program in developing competencies consistent with the needs of the graduates' employers.

166.___M B S I C Document how instructor competency is demonstrated and how their education is extended.

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14.I affirm that all information submitted in response to this application is true and that the EMS education programs under our sponsorship are consistent with the Michigan Department of Community Health education program requirements and written and practical performance objectives. I also affirm that all program instructors possess the knowledge and skills appropriate to their area of instruction and that all classes will be taught in an appropriate educational environment .

I affirm that all course completion certificates and continuing education credits awarded will be under the direction of this program approval and any documentation of CE completion will exhibit Program Sponsor approval number and the signature of the Program Course Coordinator.

I affirm that as an approved EMS CE Program Sponsor all attendance records will be maintained a minimum of four years and that all requests for CE attendance verification by the Department will be returned within 10 days of receipt of verification request .

The Michigan Department of Community Health, or its designated representatives, reserves the right to request copies of all documentation relevant to the conduct of this program and upon which approval is granted and to make an initial on-site evaluation visit and follow-up monitoring visits as the Department shall deem appropriate.

I certify that I am the authorized representative of the Program Sponsor, and that I am authorized to sign this application on the Program Sponsor’s behalf. I affirm by my signature that this program will follow all course requirements as set forth and approved by MDCH and that any changes from the information submitted herein will be submitted to MDCH for approval before they are implemented. I understand that any misrepresentation of the information provided as part of this application may result in non- approval or revocation of existing approval.

Printed Name of Program Sponsor Representative

Original Signature of Program Sponsor Representative

Date

15.I affirm my commitment to serve as Course Coordinator and to comply with all MDCH requirements as the course coordinator Printed Name if Program Course Coordinator

Original Signature of Program Course Coordinator

Date

16.I affirm my commitment to serve as Physician Director and to comply with all MDCH requirements as the physician director Printed Name of Physician Director

Original Signature (Please indicate M.D. or D.O.)		Date
Attachments:	Course Schedule Form
	I nstructional Faculty Form
	Advisory Committee Member Form

Documentation of compliance w ith all required approval criteria must be on file or physically present at the course site and available for verification during the on- site evaluation or at the request of the regional coordinator. I t is suggested that documentation of compliance w ith recommended criteria also be made available at the on- site evaluation.

See Program Explanation and Criteria document for detail of requirements.

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COURSE SCHEDULE

Program Sponsor: __________________________	Course Level: _________________________	# Clinical Hours: ________
Field I nternship Hours: ____________________	Course Location: ______________________	Hospital: ________
		Pre- Hospital: ________

Attach course schedule( s) to application. Schedule must include topics and hours required in MDCH Education Program Requirements.