CTCCE Instructor Application

CTCCE Instructor Application
Note: This is not the VCU application for a part-time position. This collects information for people interested in becoming CTCCE instructors.
Personal Information
Legal Name
First Name
Last Name
Suffix
Preferred Name
PreferredName
Suffix
FullNameBuilder
FilingName
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contacts

Rows	Name (First and Last)	Phone	Relationship
Contact 1
Contact 2

Class/Role
Primary Location
Desired Teaching Areas

Other
You have selected the desire to be an instructor in the Paramedic Program (includes EMT, AEMT, and Paramedic). Please select if you want to be considered for as lead instructor, lab instructor, and/or clinical instructor.
Instructor Type
To be considered for a lead instructor for EMS Initial education, candidates may have additional requirements such as an interview and/or teaching demonstration.
Experience
Calculation
Degree/Licensure

Other
Years of experience in healthcare
EMS Experience
EMS/Healthcare Level
VA EMS Cert Number
Total Years in EMS
Input 0 if none
Current EMS agency
If unaffiliated, write "Unaffiliated"
EMS Education Coordinator
Years as an EMS Education Coordinator
Include years as ALS-C and/or EMT Instructor
Regulatory
If violation is > 5 years, select No violations
Current Instructor Certifications
EMS Related Instructor Certifications

Other
Current AHA Instructor
AHA Instructor Number
Current Affiliated AHA Training Center
Will you request to change primary affiliation to VCU?
Current NAEMT Instructor
Years as an Educator/Instructor
Input 0 if none
Briefly describe your healthcare experience
Describe any teaching/education experience you have:
Describe any clinical (i.e. in hospital) experience.
References
Please provide two (2) professional references of individuals who can comment on your professionalism and teaching abilities.
Please provide a professional reference of individual who can comment on your professionalism and patient care.
Reference

First NameLast Name
Reference Email
example@example.com
Reference Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Reference
Reference 2

First NameLast Name
Reference Email 2
example@example.com
Reference Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Reference 2
Attachements
Resume/CV

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Professional Headshot

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Please provide a copy of your current {degreelicensure} license(s)/certification(s).
Healthcare Provider License/Certification

PDF only
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VA EMS Education Coordinator

PDF only
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BLS Instructor

PDF Only
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ACLS Instructor

PDF Only
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PALS Instructor

PDF Only
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Please provide a copy of your current {naemtInstructor} instructor certifications.
NAEMT INSTRUCTOR certifications

PDF only
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Please provide a copy of your current {typeA9} instructor certifications.
Other INSTRUCTOR certifications

PDF only
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Any other relevant Certifications

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Independent Contractor
Select the scenario that best describes your current relationship with VCU.
Previous contractor with CTCCE
Last Independent Contractor Agreement (ICA)
Should be Empty:

CTCCE Instructor Application

Personal Information

Class/Role

Experience

EMS Experience

Current Instructor Certifications

References

Attachements

Independent Contractor