ࡱ> q  ,bjbjt+t+ 5AA]8 <V4(\\\;D+X)++++++$O7;O \\   l\\))  )~@)\,Ť*[)New Jersey Department of Health Office of Emergency Medical Services P.O. Box 360, Trenton, NJ 08625-0360 Basic Life SUPPORT (BLS) APPLICATION FOR Provider Recertification Mail completed application to the above address. Name of Provider ID Number FORMTEXT       FORMTEXT      Mailing Address (Required for OEMS Use Only. Must be a physical address; no PO Box or Mail Stop numbers accepted.) NJ Certification Number FORMTEXT       FORMTEXT      City, State, Zip Code Telephone Number FORMTEXT       FORMTEXT      Public Address (Optional - the Department will provide this address for requests of government records.) Cell Number FORMTEXT       FORMTEXT      City, State, Zip Code Email Address FORMTEXT       FORMTEXT      You MUST notify OEMS in writing of any changes in name and/or address. EMS Affiliation FORMCHECKBOX  Paid  FORMCHECKBOX  Volunteer  FORMCHECKBOX  Not AffiliatedType of Service  FORMCHECKBOX  FD  FORMCHECKBOX  Hospital  FORMCHECKBOX  Private  FORMCHECKBOX  Municipal  FORMCHECKBOX  US Government/Military  FORMCHECKBOX  3rd Service  FORMCHECKBOX  Other, Specify:  FORMTEXT      CPR Certification (affix card to recertification application)CPR Expiration Date(attach copy) FORMTEXT      Attach a copy of your Healthcare Provider CPR certification (Adult 1 and 2 Rescuer CPR, Adult FBOA, Child CPR, Child FboOA, Infant CPR, Infant FBOA)EMT-Basic Refresher Training (attach proof of attendance)Approved Refresher Course EMS Preparedness Training Elective Credits (24 Hours) (List courses on Page 2) (List Courses on Page 2) Total Credit Hours Course Sponsor Hours (Minimum 12 hours) Hours (Minimum 12 hours) (Minimum 48 Hours) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Certification Action and Criminal Statement1. Have you ever been charged, convicted, placed on probation, entered into a pre-trial intervention (PTI) program or entered into a plea bargain in connection with a violation of law under the laws of any state, the federal government, or any other jurisdiction, other than a minor traffic violation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No2. Have you ever been subjected to limitation, suspension, or termination of your right to practice in a health care occupation or voluntarily surrender a health care licensure in any state or to an agency authorizing the legal right to work?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you answered Yes to the either of the above questions, you must provide official documentation that fully describes the offense, current status, and disposition of the case. I hereby affirm that the above statements and information is true and correct, including the completion of the continuing education hours for this certification period, and that I am eligible for recertification. Signature of Provider Date FORMTEXT       Name of Provider NJ Certification Number FORMTEXT       FORMTEXT       Direct Verification of Skill Maintenance Q/A:Q/I Observation OtherPatient Assessment  Medical and Trauma FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Ventilatory Management Skills/Knowledge (simple adjuncts, O2 delivery, BVM) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Cardiac Arrest Management/AED FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Hemorrhage Control and Splinting Procedures FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Spinal Immobilization FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX OB/Gynecologic Skills/Knowledge FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Communications and Documentation Skills FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Other related Skills/Knowledge (i.e., report writing and documentation) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  As the EMS Training Officer or designee, I do hereby affix my signature attesting to the continued competence in all the skills outlined in the above verification.Print Name of EMS Training Officer or Designee FORMTEXT      Signature of EMS Training Officer or Designee Date FORMTEXT       Affix BLS Card Here Name of Provider NJ Certification Number FORMTEXT       FORMTEXT      Details of Recertification TrainingDate CompletedTopic of Training/ Course NameSponsor and Location of CourseHours Rec dCategory Type: R=Refresher P=Preparedness E-Elective FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Proof of attendance MUST be retained by provider and is subject to audits from OEMS. BASIC LIFE SUPPORT APPLICATION FOR Provider Recertification (Continued) EMS-57 JUL 12 Page  PAGE 2 of 3 Pages. EMS-57 JUL 12 Page  PAGE 1 of 3 Pages.  DEij  &(*468:Z"VXlnpz|~ľģľľģľľģľľrģjb5OJQJUj5OJQJUjv5OJQJU CJOJQJj5OJQJUmHj5OJQJU 5OJQJj5OJQJU CJOJQJ6CJOJQJ;CJOJQJ5;CJOJQJ CJOJQJ5CJOJQJ, Ej8:h8>$$THp4F@)$  $ ($$TH4)$  x $ x $  Ej *48:TVpz~"$>HLNn : < V ` d f    ( , . F H   < >        U:TV~Ш~V($$TH4)>$$THp4F@)$  $ ($$TH 4)$   "$&:<>HJLNn < > R T V ` b d f h | ~     j5OJQJUj:5OJQJUj5OJQJU6CJOJQJjN5OJQJUj5OJQJUmHj5OJQJUj5OJQJU CJOJQJ CJOJQJ 5OJQJ1"$LNn: < d f ~($$TH 4)$ >$$THp4F@)$  $    , . ר~wO($$TH4)$ $xd>$$THp4F@)$  $ ($$TH4)    ( * , . ( * F H J | ~     < > @ b d üͼrdjtCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJU CJOJQJjCJOJQJU CJOJQJ56CJOJQJ CJOJQJ 5OJQJj5OJQJUmHj5OJQJUj&5OJQJU& pH]Z $($$TH4) $ ($$TH4)$ 3$$THp40) $   J L h j l prߵߧߙxqiq6CJOJQJ CJOJQJ CJOJQJ CJOJQJ 5OJQJjCJOJQJUmHj8 CJOJQJUjCJOJQJUjLCJOJQJUjCJOJQJUj`CJOJQJU CJOJQJjCJOJQJUjCJOJQJU$ h j prv@A,-: *48:T^bd~u dfDF-   `prv@A׈b_װ $3$$TH 40 )8$ $ ($$TH4) $   ($$TH4) @A-.89  &(*468:<PRT^`bdfz|~j 5OJQJUj 5OJQJUj 5OJQJUj$ 5OJQJU CJOJQJ CJOJQJ CJOJQJ6CJOJQJj5OJQJUmHj 5OJQJU 5OJQJj5OJQJU/A,-8:bdP$  $ ($$TH04) $  X! whc;|c($$TH4) hP<$ .!V%($$THp4) $\$$THp4֞ 8 Xx!)u  fh|~ʬʥyrʚdjJ5OJQJU CJOJQJj5OJQJUmHj 5OJQJU 5OJQJj5OJQJU CJOJQJ6j^ CJOJQJUj CJOJQJU CJOJQJjr CJOJQJUj CJOJQJU CJOJQJjCJOJQJU'u\$  $ ($$TH4)$ H$xxx($$TH4)dfz$  $ )$$TH44)$$ >$$TH 4Fp)~BDF@AQRSažž۬{۾s۬CJH*OJQJj"CJOJQJUjCJOJQJUj6CJOJQJU CJOJQJjCJOJQJU CJOJQJ CJOJQJ5CJOJQJj5OJQJU CJOJQJ 5OJQJj5OJQJUmHj5OJQJU+DFwnddddd $$ $  $ ($$TH4) $ ,"' $ ,"'?$$THH44F@) -QRdewx $$ $  $ \$$TH4֞p H$%) -QRabdetuwx "#2356EFHI_`oprs+,./>?ABQRTUt babceftuvxy !#$234߼ߧߙߋ߼}ojCJOJQJUj\CJOJQJUjCJOJQJUjpCJOJQJUjCJOJQJU CJOJQJ CJOJQJjCJOJQJUjCJOJQJU CJOJQJjCJOJQJUjCJOJQJU+` $$ $  $ \$$TH4֞p H$%)"#56HI_`rs@ $$ $  $ \$$TH4֞p H$%)467EFGHI_`aopqst+~j CJOJQJUjCJOJQJUj CJOJQJUjCJOJQJUj4CJOJQJUjCJOJQJU CJOJQJ CJOJQJjHCJOJQJUjCJOJQJU CJOJQJ/h$  $ \$$TH4֞p H$%) $$  ./ABT $$ $  $ \$$THp4֞p H$%)+,-/0>?@BCQRSTU{|}߼ߧߙߋ߼}wi}jF5OJQJU 5OJQJj5OJQJUCJjCJOJQJUjZCJOJQJUjCJOJQJU CJOJQJ CJOJQJjnCJOJQJUjCJOJQJU CJOJQJjCJOJQJUjCJOJQJU(TUt $$ $  $ \$$TH4֞p H$%) |} xz|~,.VX ( @ f r ~ !:!b!!!!!","T"|"~""""#F#H#p####$$:$b$$$$$%,%T%|%%%%%&F&n&p&&&&'8':'b'     ^|}~uMXB $ ($$TH4)$ H$$$TH4)xx$\$$TH4֞p H$%)  z~.0DFHRTVXZnpr|~ !Ϳڱ͕ͣyq5CJOJQJj5CJOJQJU5CJOJQJ CJOJQJj5OJQJUj25OJQJU CJOJQJ CJOJQJj5OJQJU 5OJQJ CJOJQJ CJOJQJ CJOJQJj5OJQJUj5OJQJUmH(xz|~\I>$$TH 4Fp)$ ($$TH4)$ H$3$$TH 40) $ ,.VX$  $ )$$TH44)$$ $$THt4    $  ( @ f r ~ <u l$  $$ ($$TH4) ($ ,"'?$$THH44F@) !:!b!!!$ T$$TH4rX") l$ !!!!!!!(!*!,!6!8!:!25CJOJQJU+((()F)n)))))*8*`*b****+*+$ T$$TH04rX"))))))))))))))))))))))))** ****&*(***4*6*8*:*N*P*R*\*^*`*b*d*x*̵̥̅̕ujP75CJOJQJUj65CJOJQJUjd65CJOJQJUj55CJOJQJUjx55CJOJQJU CJOJQJ5CJOJQJj5CJOJQJUmHj5CJOJQJUj55CJOJQJU,x*z*|***********************++++++&+(+*+,+.+B+D+F+P+R+T+V+j+̼̬̜̌̅uj:5CJOJQJU CJOJQJj95CJOJQJUj(95CJOJQJUj85CJOJQJUj<85CJOJQJU5CJOJQJj5CJOJQJUmHj5CJOJQJUj75CJOJQJU+*+,+T+|+++++P,c,,,,,, !)$$ $$$ T$$TH04rX")j+l+n+x+z+|+~++++++++++++++++++++++P,,,,,,,,̼̬̜̕~wjaj0JCJOJQJj0JCJOJQJU CJOJQJCJ5;CJOJQJ56CJOJQJ CJOJQJj;5CJOJQJUjv;5CJOJQJUj;5CJOJQJU5CJOJQJj5CJOJQJUmHj5CJOJQJUj:5CJOJQJU#,,,,,,,,,,,,,,,,56CJOJQJ CJOJQJ0JCJOJQJj0JCJOJQJU0JCJOJQJmH,,,,,,,,,,,,,$ !) 3 0&P1h/R / =!"#@$%@vDText23vDText16vDText23vDText16vDText23vDText16vDText23vDText16vDText23vDText16vDeCheck20vDeCheck22vDeCheck23vDeCheck20vDeCheck22vDeCheck23vDeCheck29vDeCheck30vDeCheck31vDeCheck32vDText24vDText17vDText17vDText17vDText17vDText17vDeCheck24vDeCheck25vDeCheck24vDeCheck25vDText18vDText23vDText16vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDeCheck26vDeCheck27vDeCheck28vDText25vDText18vDText23vDText16vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31vDText26vDText27vDText28vDText29vDText31 [8@8 NormalCJ_HaJmH sH tH 6@6 Heading 1$$@&a$CJ6@6 Heading 2$$@&a$CJ 88 Heading 3$$@&a$5\B@B Heading 4$$@& CJ(<< Heading 5$$@&a$ 5CJ\66 Heading 6$@& 5CJ\<< Heading 7$$@&a$ 5CJ\8@8 Heading 8 <@&6]D @D Heading 9 $@& 5CJOJQJ<A@< Default Paragraph Font,", Caption$a$CJ @T@@ Block Text $ CJOJQJ,@,Header  !, @",Footer  !&)@1& Page Number2>@B2Title$5CJOJQJIItt ~a4+!!"#$%&'()x*j+,, #%(+.258<ACDEGHJLMOPRS: pAT !$n&(*+,,!"$')*,-/034679;=>?@BFINQT -b',&1:K  $*u %7GXh{ams3?EHTZ]ior~    '   % ( 4 : 2 B E U X h &@PScfv "2~1=CFRX!#/57CIKW]_kqt !')5;>JPR^dfrxz(.0<BDPVXdjmy  ".47CIKW]_kqs !')5;=IOQ]cfrxz'-0<BDPVXdjlx~FFFFFFFFFFG$G$G$G$G$G$G G G G FFFFFFG$G$G$G$FFFG$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF\ce!!8@0(  B S  ?Text23Text16Check20Check22Check23Check29Check30Check31Check32Text24Check24Check25Check26Check27Check28Text25Text26Text27Text28Text29Text31vY| 1EYm  !i CWk~AE-1dg!0  be j m , / y{knfuewhiteQ\\dhss-ha-99\Home\ewhite\FORMS\EMS- BLS Provider Recertification Application.dotewhiteoC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of EMS-57 BLS Provider Recertification Application.asdewhiteoC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of EMS-57 BLS Provider Recertification Application.asdewhiteoC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of EMS-57 BLS Provider Recertification Application.asdewhiteR\\dhss-ha-99\Home\ewhite\FORMS\EMS-57 BLS Provider Recertification Application.dotewhiteR\\dhss-ha-99\Home\ewhite\FORMS\EMS-57 BLS Provider Recertification Application.dotewhiteR\\dhss-ha-99\Home\ewhite\FORMS\EMS-57 BLS Provider Recertification Application.dotewhite)\\dhss-ha-99\home\ewhite\FORMS\EMS-57.dotewhiteNC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of EMS-57 (NJDOH).asdewhite1\\dhss-ha-99\home\ewhite\FORMS\EMS-57 (NJDOH).dot@  a  )@@ 0@000 0 00 @00(@004@00 0"0$0&0(0*0X@GzTimes New Roman5Symbol3& zArial"qhb'33u *z ٖ4#r0d7DEMS-57, Basic Life Support, Application for Provider Recertification{EMS-57, application for provider recertification, recertification, BLS, basic life support, EMS, emergency medical servicesEWhiteewhiteOh+'0@       (08EEMS-57, Basic Life Support, Application for Provider RecertificationiMS-EWhite |EMS-57, application for provider recertification, recertification, BLS, basic life support, EMS, emergency medical servicesMS-EMS-57 (NJDOH).dot ewhite(3hiMicrosoft Word 8.0 @G@[@t4w7@[u՜.+,D՜.+,t0 hp  NJDOH * 71 EEMS-57, Basic Life Support, Application for Provider Recertification Title 6> _PID_GUIDAN{F3BA78B9-87A4-11D8-B1CE-00105A219C26}  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUWXYZ[\]^_`abcdefghijklmnopqrstvwxyz{|}~Root Entry Fnw7Pg*[Data Vb<1Tableu WordDocument5SummaryInformation(DocumentSummaryInformation8CompObjjObjectPoolPg*[Pg*[  FMicrosoft Word Document MSWordDocWord.Document.89q