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.

Emergency Contacts*

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

Class/Role
Primary Location*
Desired Teaching Areas*

BLSACLSPALSATLSPHTLSAMLSTNCCEMTFCCSAEMTParamedicMHROOther
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*

Lead InstructorAssistant/Lab InstructorClinical Instructor
To be considered for a lead instructor for EMS Initial education, candidates may have additional requirements such as an interview and/or teaching demonstration.*

Understood
Experience
Calculation
Degree/Licensure*

MD/DORNNPPAEMSPolice OfficerOther
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

NAEMSE INAEMSE IINAEMSE SkillsNCEEFire InstructorVAVRSOther
Current AHA Instructor

BLSACLSPALS
AHA Instructor Number*
Current Affiliated AHA Training Center*
Will you request to change primary affiliation to VCU?*

YesNo
Current NAEMT Instructor

PHTLSAMLSEPCTECCEMS SafetyGEMSMHRO
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.
Relationship to Reference*
Reference 2

First NameLast Name
Reference Email 2
example@example.com
Reference Phone Number 2
Please enter a valid phone number.
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.*

I hold a part time position with the CTCCE.I am an employee of VCU Health (not VCU school).I am an employee of VCU (state position), not VCU Health.I am neither an employee of VCU nor VCU Health.
Previous contractor with CTCCE*

I have never been paid as an independent contractor by VCU (school).I HAVE been previously paid as an independent contractor by VCU.
Last Independent Contractor Agreement (ICA)*

Within the past 12 months.1-2 years ago.Longer than 2 years.I am not sure.
Should be Empty:

CTCCE Instructor Application

Personal Information

Class/Role

Experience

EMS Experience

Current Instructor Certifications

References

Attachements

Independent Contractor