New Jersey Department of Health

Office of Emergency Medical Services

P.O. Box 360

Trenton, NJ 08625-0360

ADVANCED LIFE SUPPORT

APPLICATION FOR Provider Recertification

Name of Provider	Social Security No. (Last 4 Digits Only)
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
Provider Level
MICP MICN ACM/FP ACM/FN
MICU Program
Certification Expiration Dates
ACLS Expiration	BCLS Expiration	PALS or PEPP-Advance

(attach copy)	(attach copy)	(attach copy)	RN License Expiration
Continuing Education Hours
Airway, Breathing	Medical	Traumatic	OB and Pediatric	Operational Tasks	TOTAL

and Cardiology	Emergencies	Emergencies	Emergencies	(ICS/WMD/HAZMAT)	(Minimum 48 Hrs)
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
TO BE COMPLETED BY MICU MEDICAL DIRECTOR
Verification of Skill Maintenance	Q/A:Q/I	Direct	Other
Patient Assessment and Management
Ventilatory Management Skills / Knowledge
Cardiac Arrest Management
Hemorrhage Control and Splinting Procedures
IV and IO Therapy, and Medication Administration
Spinal Immobilization
OB/Gynecologic Skills / Knowledge
Communications and Documentation Skills
As the MICU Medical Director, I do hereby affix my signature attesting to the continued competence in all the skills outlined in the above verification.
Signature of Medical Director	Date
TO BE COMPLETED BY EMS DIRECTOR
I certify that the above-named pre-hospital ALS care provider has demonstrated clinical competence, is actively affiliated with this MICU, and to the best of my knowledge has met all requirements for recertification.
Signature of EMS Director	Date
Signature of EMS Educator	Date
Recertification forms are due to OEMS by the 30th of the month preceding the expiration date.

Copies of ACLS, BLS and PALS or PEPP-Advanced cards must be attached.
ATTACHMENTS

Affix ACLS Card Here

Affix BLS Card Here

Affix PALS or PEPP-Advance Card Here

ADVANCED LIFE SUPPORT

APPLICATION FOR Provider Recertification

(Continued)

EMS-60

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

EMS-60, Advanced Life Support, Application for Provider Recertification

EMS-60, application for provider recertification, recertification, ALS, advanced life support, EMS, emergency medical services

EWhite

2004-04-06

NJDOH