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* 1. Sponsoring EMS Service

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* 2. EMS representative completing survey

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* 3. Student Name

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* 4. Certification Type

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* 5. Is the program complete?

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* 6. Date Program was completed

Date

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* 7. Exam Date

Date

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* 8. Has student passed the National Registry Exam?  If yes, skip to question 11

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* 9. If no, when is the next scheduled exam

Date

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* 10. If no, how many times has the National Registry Exam been attempted?

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* 11. If yes, you will need to start reporting monthly time per the survey monkey titled SB8 Verification of Hours every month (EMT 1 year, AEMT/Para 2 years)

T