Endeavor
Health
Highland Park Hospital EMS System
Independent Data Collection Form
Please complete all fields so we can keep your EMS file current and accurate, as we transition to Vector Solutions for licensure tracking.
Personal Information
Name
*
First Name
Last Name
EMAIL
*
example@example.com
ADDRESS
*
City, State, Zip Code
*
PHONE NUMBER
*
Format: (000) 000-0000.
DATE OF BIRTH
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ORGANIZATION / DEPARTMENT
*
System Information
HPH SYSTEM NUMBER
Date of Initial EMS Licensure
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
What year did you start your EMS Career. (If you are an EMT-P list your initial EMT-B licensure date)
Licensure
EMT-P LICENSE NUMBER
EMT-P LICENSE EXPIRATION DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
EMT-B LICENSE NUMBER
EMT-B LICENSE EXPIRATION DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ECRN LICENSE NUMBER
ECRN LICENSE EXPIRATION DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
LEAD INSTRUCTOR LICENSE NUMBER
LEAD INSTRUCTOR EXPIRATION DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Certifications
BLS EXPIRATION
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ACLS EXPIRATION
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PALS EXPIRATION
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PHTLS EXPIRATION
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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