Northwest Region Prehospital Care Program

INSTRUCTIONS FOR USE

The CME Completion Form is to be completed by Paramedics following the completion of any approved clinical CME activity. This form is to be submitted to NWRPCP prior to the CME deadline date as outlined in the CME Program and Catalogue; December 15th or next business day. Please complete in as much detail as possible to provide context for full analysis. Note: please don’t include any patient health information (PHI) in your entries.

Name(*)

Invalid Input

Email(*)

Invalid Input

EHSN#

Invalid Input

Date of CME

Invalid Input

Hours Attended

Invalid Input

Title of CME Event

Invalid Input

Education Methods

Invalid Input

Please describe

Invalid Input

Summary of Clinical Value/Knowledge Gained

Invalid Input

Did this event include Patient Contact(s)

Yes Invalid Input

Add 2nd patient contact?

No
Yes Invalid Input

Patient 1 Demographics & Working Dx

Invalid Input

Patient 1 Care Performed

Invalid Input

Add 3rd patient contact?

No
Yes Invalid Input

Patient 2 Demographics & Working Dx

Invalid Input

Patient 2 Care Performed

Invalid Input

Patient 3 Demographics & Working Dx

Invalid Input

Patient 3 Care Performed

Invalid Input

Were your goals/objectives met?

Yes
No Invalid Input

Please explain

Invalid Input

Would you recommend this CME activity to other Paramedics?

Yes
No Invalid Input

Suggestions for improving this CME activity: (If Applicable)

Invalid Input

Please attach your certificate or other supporting document.

Invalid Input

For Office use only

Date Approved (D/M/Y - 01/01/2020)

Invalid Input

Approved by

Invalid Input

Clinical Hours Approved

Invalid Input

Certification Extension Request Form

INSTRUCTIONS FOR USE

For Office use only

Forms