In the realm of emergency medical services, the PH 3937 form emerges as a pivotal document within the State of Tennessee, administered by the Department of Health Division of Emergency Medical Services. This comprehensive form caters to individuals seeking licensure or certification across various levels such as First Responder, EMT – IV, and Paramedic, among others. Applicants are required to furnish personal information including name, social security number, date of birth, and contact information, alongside educational background details covering high school diploma or GED completion status. Furthermore, it probes into an applicant's past, inquiring about any licensure or certification they may have had in other states or with the National Registry, and delves into legal and personal history, specifically asking about convictions other than minor traffic violations, substance abuse problems, and any disciplinary actions against previous licenses or certifications. The form also underscores the importance of honesty, warning that falsification of information could lead to the denial or revocation of the sought-after certification or license. With the inclusion of a signature line, applicants affirm the accuracy and completeness of the information provided, acknowledging the form's role as a critical step in ensuring the competency and integrity of emergency medical service providers. This process, underscored by the need to attach additional documents for certain disclosures, highlights the meticulous scrutiny applied in safeguarding the public's health and safety. Additionally, the document mentions protections afforded under HIPAA, indicating that the health information provided is shielded from public inspection, thereby ensuring the confidentiality of sensitive information, except under specific circumstances such as a subpoena or health oversight activities.
| Question | Answer |
|---|---|
| Form Name | Form Ph 3937 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | SSN, EMD, ems form, YYYY |
Office Use Only
File #
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
DIVISION OF EMERGENCY MEDICAL SERVICES
HERITAGE PLACE, METRO CENTER 227 FRENCH LANDING, SUITE 303 NASHVILLE, TENNESSEE 37243 TELEPHONE:
EMS LICENSURE/CERTIFICATION
APPLICATION
LIC/CERT LEVEL REQUESTING:
SSN:
NAME:
FIRST RESPONDER
CLASS #:
EMT – IV
DOB:
PARAMEDIC EMD
MM |
DD |
YYYY |
|
LAST |
FIRST |
MIDDLE |
(JR., II, III) |
|
MAILING ADDRESS: |
|
|
|
|
|
|
|
STREET ADDRESS |
|
||
|
|
|
|
|
|
|
CITY |
COUNTY |
|
STATE |
ZIP |
HOME TELEPHONE: ( |
) |
|
WORK TELEPHONE: ( |
) |
|
|
|
|
|
|
|
RACE:
WHITE
NATIVE
HISPANIC
|
GENDER: |
HIGH SCHOOL DIPLOMA: |
|
BLACK |
MALE |
YES |
NO |
ASIAN |
FEMALE |
GED: |
|
OTHER |
|
YES |
NO |
ARE YOU CURRENTLY OR HAVE YOU EVER BEEN LICENSED/CERTIFIED IN OTHER STATES OR WITH THE
NATIONAL REGISTRY? |
YES |
NO IF YES, LIST BELOW |
|
|
|||||
STATE: |
|
LEVEL: |
|
|
LIC/CERT #: |
EXPIRATION DATE: |
|||
|
|
|
|
|
|
|
|
|
|
STATE: |
|
LEVEL: |
|
|
LIC/CERT #: |
EXPIRATION DATE: |
|||
|
|
|
|
|
|
|
|
||
HAVE YOU EVER BEEN CONVICTED FOR A VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC |
|||||||||
VIOLATION? |
YES |
NO |
|
|
|
|
|
||
HAVE YOU EVER OR ARE YOU NOW ADDICTED TO ANY ALCOHOL OR DRUGS?
YES
NO
HAS YOUR LICENSE/CERTIFICATION TO PRACTICE IN ANY STATE EVER BEEN REPRIMANDED, SUSPENDED,
RESTRICTED, REVOKED OR IS IT UNDER THREAT OF DISCIPLINARY ACTION? |
YES |
NO |
If you answered yes to either question, give details on a separate sheet including circumstances with appropriate dates. Attach a certified copy of court records if convicted of any law violation.
I certify that all information in this form is correct and complete to the best of my knowledge. I understand that falsification of any information may be grounds for denial or revocation of my certification/license.
SIGNATURE:DATE:
"Under HIPPA, the health information you furnish on this document is protected from public inspection, absent a subpoena or for purposes of health oversight activities."
RDA 10140 |