SWORBHP College Request for Training: Student Certification

THIS FORM IS TO BE COMPLETED BY A COLLEGE.

If you are from a Paramedic Service and wish to request training, please complete the following form: https://webforms.lhsc.on.ca/form/sworbhp-service-request-for-trai

Please note, the Student/College will be required to submit payment prior to training via cheque to LHSC as per the following:
PCP: $350
ACP: $500

COLLEGE CONTACT INFORMATION

Please provide your contact information for follow-up.

Name:

Email:

College:

STUDENT PROFILE

Student 1:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has NOT been taught:

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 2

Student 2:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives_2

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 3

Student 3:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 4

Student 4:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 5

Student 5:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives 5

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 6

Student 6:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives 6

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE 7

Student 7:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives 7

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE

Student 8:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives 8

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE

Student 9:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives 9

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

Would you like to add another Paramedic?

STUDENT PROFILE

Student 10:

First Name:

Last Name:

Student Identifier:

First three characters of the college code (ie. FAN) / ‘P’ or ‘A’ to identify PCP or an ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)

Student Email:

Level:

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Start:

End:

Preceptor Name:

Service:

Have you contacted someone at this service?

Contact Name:

Contact Email:

Has the student been taught all ALS PCS Core Medical Directives

Yes

Please list which directives have not been taught

Please check all of the ALS PCS Auxiliary Medical Directives the student has been taught

IV and Fluid Therapy

Cardiogenic Shock

CPAP

Supraglottic

Nausea/Vomiting

Electronic Control Device Probe Removal

Assessment of Patients with Potential COVID-19

COMMENTS

Please feel free to provide additional comments/information: