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SWORBHP Request for Training: Auxiliary Directive
Training Information
Training Information:
Auxiliary Directive:
Auxiliary Directive:
- Select -
12 Lead
PCP AIV Course
Manual Defibrillation
Other…
Enter other…
Select a preferred course date
Select a second preferred course date
Select a third preferred course date
Number of candidates
Instructor Name(s)
Service Lead Contact Email
Service Lead Contact Phone
Which type of IV Catheter does your Service use?
Equipment Required from Base Hospital
What will you be using for the final evaluation scenario?
Laptop
iPad
Other…
Please Specify
Please indicate a two-week time frame that would be preferable to book this training:
Start:
End:
Training Location Requested:
Service Contact Information
Service Contact Information:
Please provide your contact information for follow-up
Paramedic Service:
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Bruce
Essex Windsor
Grey County
Huron County
Lambton County
Medavie Chatham Kent
Medavie Elgin
Middlesex London
Oneida First Nations
Oxford County
Perth County
Name:
Email:
Paramedic Profile(s)
Paramedic Info
Paramedic 1:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 2:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 3:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 4:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 5:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 6:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 7:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 8:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 9:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 10:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 11:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 12:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 13:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 14:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 15:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Would you like to request training for another Paramedic?
- Select -
Yes
No
Paramedic 16:
First Name:
Last Name:
EHS #:
Level:
- Select -
PCP
ACP
Comments
Comments:
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