Northwest Region Prehospital Care Program - Certification Extension Request Form

Certification Extension Request Form

This form is intended to be completed by paramedics requesting an extension of their certification year because of being unable to complete all their Maintenance of Certification requirements by the required due date.

Name(*)

Invalid Input

Email(*)

Invalid Input

EHSN#(*)

Invalid Input

Reason you are requesting an extension

Invalid Input

What date will you complete your recertification requirements?

Invalid Input

For Office Use Only

Reviewed by

Invalid Input

Approved

YES
NO Invalid Input

Certification date extended to:

Invalid Input

Notes/Comments

Invalid Input

Forms

Self Report Form
Patch Failure Form
CME Pre-Approval Form
CME Completion Form
Certification Extension Request Form
MedicASK
SERVICE FORMS
Request for Certification (RTP)
Request for Certification
Cross Certification Form

Ontario EMS and Base Hospitals work in collaboration to ensure safe quality pre-hospital patient care is provided to every patient.