EMS Program Instructor Application

EMS Program Instructor Application
Note: This is not the VCU application for a part-time position. This collects information for all EMS program instructors - part-time or contractors.

The application for the part time position is here: https://vcu.csod.com/ux/ats/careersite/1/home/requisition/1392?c=vcu
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 / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Class/Role
Primary Location*
Program*

EMTAEMTParamedic
Instructor Type*

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

Understood
Experience
EMS/Healthcare Level*
VA EMS Cert Number*
Total Years in EMS*
Input 0 if none
Years as an educator*
Input 0 if none
Instructor Certifications

VA EMS ECNAEMSE INAEMSE IINAEMSE SkillsNCEEACLS InstPALS InstBLS InstNAEMT InstFire InstructorVAVRSOther
Briefly describe your EMS experience*
Describe any teaching/education experience you have:*
Describe any clinical (i.e. in hospital) experience.*
Reference
Please provide two (2) professional references of individuals who can comment on your professionalism and teaching abilities.
Please provide a professional reference of individuals who can comment on your professionalism and prehospital patient care,
Reference

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

First NameLast Name
Reference Email 2
example@example.com
Reference Phone Number 2
Please enter a valid phone number.
Attachements
VA Provider Cert/License*

PDF only
Cancelof
VA EMS Ed Coord*

PDF only
Cancelof
Other INSTRUCTOR certifications*

PDF only
Cancelof
Resume/CV*

Cancelof
Professional Headshot

Cancelof
Any other relevant Certifications

Cancelof
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:

EMS Program Instructor Application

Personal Information

Class/Role

Experience

Reference

Attachements

Independent Contractor