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
Mailing Address (Required for OEMS Use Only.

Must be a physical address; no PO Box or Mail Stop numbers accepted.)	NJ Certification Number
City, State, Zip Code	Telephone Number
Public Address

(Optional - the Department will provide this address for requests of government records.)	Cell Number
City, State, Zip Code	Email Address
You MUST notify OEMS in writing of any changes in name and/or address.

EMS Affiliation
Paid Volunteer Not Affiliated
Type of Service
FD Hospital Private Municipal US Government/Military 3rd Service

Other, Specify:
CPR Certification (affix card to recertification application)
CPR Expiration Date(attach copy)
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)
Certification Action and Criminal Statement
1.	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?	Yes	No
2.	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?	Yes	No
If 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

Name of Provider	NJ Certification Number
Direct

Verification of Skill Maintenance	Q/A:Q/I	Observation	Other
Patient Assessment – Medical and Trauma
Ventilatory Management Skills/Knowledge

(simple adjuncts, O2 delivery, BVM)
Cardiac Arrest Management/AED
Hemorrhage Control and Splinting Procedures
Spinal Immobilization
OB/Gynecologic Skills/Knowledge
Communications and Documentation Skills
Other related Skills/Knowledge

(i.e., report writing and documentation)

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
Signature of EMS Training Officer or Designee	Date

Affix BLS Card Here

Name of Provider	NJ Certification Number
Details of Recertification Training
Date

Completed	Topic of Training/

Course Name	Sponsor and

Location of Course	Hours

Rec’d	Category Type:

R=Refresher

P=Preparedness

E-Elective
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 2 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

EMS-57, Basic Life Support, Application for Provider Recertification

EMS-57, application for provider recertification, recertification, BLS, basic life support, EMS, emergency medical services

EWhite

2012-05-21

NJDOH