<p>Name: License Number:</p><p>This document is not required but is an optional tool to assist in tracking flexible training hours for EMT Basic standard renewal. Continuing education is a personal responsibility. You should evaluate your skills and knowledge to determine areas of weakness and plan educational opportunities in your scope of practice to improve your individual competence. </p><p>To be eligible for recertification as an EMT Intermediate Technician/AEMT, you must meet all of the following eligibility and training requirements as specified in DHS 110.07:  Complete a 42-hour EMT Intermediate Technician/AEMT refresher training between July 1, 2014, and June 30, 2016. Renewal education can be completed in the following format: a. Complete a 42-hour traditional refresher course at a Wisconsin-approved EMS Training Center. b. Complete a 30-hour traditional Basic refresher course at a Wisconsin-approved EMS Training Center AND a 12-hour EMT Intermediate Technician/AEMT refresher training at a Wisconsin-approved EMS Training Center. c. Complete an alternative flexible refresher which includes 24-hours of Basic flexible content, a six-hour mini refresher at a Wisconsin-approved EMS Training Center AND 12-hours of medical director-approved EMT Intermediate Technician/AEMT refresher based on curriculum. (The refresher must be approved by the medical director of the service where you are credentialed.)</p><p>Note: You can use portions of each described above in items a., or b. provided the full 42 hours have been met. Example: You could take a formal 30-hour traditional Basic refresher and 12 hours of medical director-approved flexible content based on the EMT Intermediate Technician/AEMT curriculum.</p><p> d. Complete an initial EMT-intermediate technician course or the didactic portion of the initial EMT-intermediate or initial EMT-Paramedic course. e. Complete the NREMT assessment examinations for this level.  Hold current CPR at the professional level by an organization specified in DHS 110.17(1).  Complete the 2016-2018 License Renewal application process by June 30, 2016.</p><p>If you have an arrest or conviction record, please include this information on your renewal application. Intermediate Technician Date of Completion Hours Topic/Course Name – CPR may not be included in any category July 1 2014 – June 30, 2016 Intermediate Technician level pharmacology 2.0</p><p>Intermediate Technician level patient assessment 2.0</p><p>IV access and medication administration 2.0</p><p>Intermediate Technician level flexible content 6.0</p><p>TOTAL 12.0</p><p>EMT-Intermediate Technician Training Record Page 1 EMT-Basic Date of Completion Hours Topic/Course Name – CPR may not be included in any category July 1 2014 – June 30, 2016 Basic level adult medical assessment and treatment 4.0</p><p>Basic level adult trauma assessment and treatment 4.0</p><p>Basic level airway – basic and advanced 2.0</p><p>Basic level pediatric medical assessment/treatment 2.0</p><p>Basic level pediatric trauma assessment/treatment 2.0</p><p>Basic level OB 1.0</p><p>Operations 2.0</p><p>WMD/Preparedness 2.0</p><p>Basic level flexible content 5.0</p><p>6-hour Basic Flexible Refresher at approved training center 6.0</p><p>TOTAL 30.0 Flexible education and training may be obtained through any format. It is highly suggested that education and training be obtained through any of the following: . Courses approved by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) . Conferences sponsored by recognized Wisconsin organizations or hospitals . In-house training approved by the EMS service medical director . You must have formal documentation verifying attendance and course completion . You must retain proof of attendance and course completion for at least 5 years. Providers are randomly audited, if selected; you are required to submit proof of education and training completion. Failure to provide proof of compliance with the requirements for renewal may result in the issuance of a conditional certificate or license, a reprimand, or the suspension or revocation of your certificate or license under Wis. Admin. Code § DHS 110.54 (12). I certify that I have completed all the above continuing education hours and that I have maintained documentation, as required. I agree to submit proof of attendance immediately upon request. ______Signature Date</p><p>EMT-Intermediate Technician Training Record Page 2</p>