Curriculum Vitae and Job Description

APPENDIX C-Supplemental CV Form

– Curriculum Vitae and Job Description

Complete this form for any other paid faculty members (no support course faculty). Give this form a unique file name, and save it to the Appendix C folder.

Other Paid Faculty Information

How long have you been serving in the present position with the program? Are you currently certified as a paramedic? Yes No Have you ever been a paramedic? Yes No

Provider/Instructor Information (check all that apply):

Ever been certified? Currently Certified? Advanced Cardiac Life Support Provider Yes No Yes No Advanced Cardiac Life Support Instructor Yes No Yes No Advanced Trauma Life Support Provider Yes No Yes No Advanced Trauma Life Support Instructor Yes No Yes No Advanced Pediatric Life Support (APLS) Provider Yes No Yes No Advanced Pediatric Life Support (APLS) Instructor Yes No Yes No Pediatric Advanced Life Support (PALS) Provider Yes No Yes No Pediatric Advanced Life Support (PALS) Instructor Yes No Yes No Pediatric Education for Prehospital Professionals Provider Yes No Yes No Pediatric Education for Prehospital Professionals Instructor Yes No Yes No International Trauma Life Support Provider Yes No Yes No International Trauma Life Support Instructor Yes No Yes No Pre-Hospital Trauma Life Support Provider Yes No Yes No Pre-Hospital Trauma Life Support Instructor Yes No Yes No

Duties / Responsibilities (check all that apply):

Average # of work hours/week while class in session Hours Didactic Lecture Yes No % of time Laboratory Instructor Yes No % of time Hospital Preceptor Yes No % of time Field Preceptor Yes No % of time Have you been evaluated by your supervisor? Yes No Date of most recent evaluation?