Northwest Region Prehospital Care Program - Request for Certification (RTP)

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Request for Certification (RTP)

Northwest Region Prehospital Care Program
290 Munro St., Suite 2400, Thunder Bay, ON P7A 7T1
Phone: (807)684-7950 Fax: (807)683-3211

Request for Certification

Return to Practice

First day of LOA

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Return to Practice Date

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BLS Successful Completion Date

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SECTION A

(to be completed by the Employer Requesting Certification)

Paramedic Name

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Phone Number

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Address

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EHS Number

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Employment Status

NAOTEMS NWEMS RRDPS SNEMS - City SNEMS - District Invalid Input

EMPLOYER SUPPORTING CERTIFICATION

The above paramedic meets all qualifications for employment under the Ontario Regulation 257/00 under the Ambulance Act(*)

YES NO Input required

The above paramedic is physically capable of performing all duties within their scope of practice with no restrictions. (*)

YES NO Please select Yes or No

Name of submitter(*)

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Submitter's EMail Address

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Please check the box below as your signature verifying that all the information provided is true and accurate. (*)

All information provided is true and accurate This is required to continue. If the information is incorrect or false please close this page.

Forms

Self Report Form
Patch Failure Form
CME Pre-Approval Form
CME Completion Form
Certification Extension Request Form
SERVICE FORMS
Request for Certification (RTP)
Request for Certification
Cross Certification Form
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Ontario EMS and Base Hospitals work in collaboration to ensure safe quality pre-hospital patient care is provided to every patient.

Northwest Region Prehospital Care Program
290 Munro St. Suite 2400
Thunder Bay, Ontario
P7A 7T1

Phone: (807) 684-7950
Fax: (807) 683-3211
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
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