Endeavor Health
Highland Park Hospital EMS System
EMT - B 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
Date
ORGANIZATION / DEPARTMENT
*
System Information
HPH SYSTEM NUMBER
*
INITIAL LICENSURE DATE
*
-
Month
-
Day
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
Date
LEAD INSTRUCTOR LICENSE NUMBER
LEAD INSTRUCTOR EXPIRATION DATE
-
Month
-
Day
Year
Date
Driver's License
DRIVER'S LICENSE #
*
DRIVER'S LICENSE EXPIRATION
*
-
Month
-
Day
Year
Date
Certifications
CPR EXPIRATION
*
-
Month
-
Day
Year
Date
ACLS EXPIRATION
-
Month
-
Day
Year
Date
BLS EXPIRATION
-
Month
-
Day
Year
Date
PHTLS EXPIRATION
-
Month
-
Day
Year
Date
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