AUX Proposal Submission

AUX Proposal Submission

FY18-19
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
OEMS Provider Number *
Do we have a W9 on file for you? *

Yes No
Please click on this link to access a fillable PDF. You should fill it out, save it, and email it to rscarbrough@vaems.org
Date Submitted *

Month Day Year
Date

Course Information
Which class will you be teaching? *

AHA Advanced Cardiac Life Support (ACLS) AHA Advanced Cardiac Life Support for Experienced Providers (ACLSEP) AHA Pediatric Advanced Life Support (PALS) AHA Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS) International Trauma Life Support (ITLS) Pediatric International Trauma Life Support (PITLS) Prehospital Trauma Life Support (PHTLS) Emergency Pediatric Care (EPC) Advanced Medical Life Support - Advanced Course (AMLS) EMS Safety Geriatric Education for EMS (GEMS) Principals of Ethics and Personal Leadership (PEPL) Tactical Emergency Casualty Care (TECC) Pediatric Education for Prehospital Providers (PEPP)
Full or Recert *

Full Recert
OEMS Course Number *
Upload Course Approval *

Browse Files
PDF Only Cancel of
Class Location - FIPS *

Amelia County (007) Brunswick County (025) Buckingham County (029) Charles City County (039) Charlotte County (037) Charlotte County (037) Chesterfield County (041) Colonial Heights City (570) Cumberland County (049) Dinwiddie County (053) Emporia City (595) Goochland County (075) Greensville County (081) Halifax County (083) Hanover County (085) Henrico County (087) Hopewell City (670) Lunenburg County (111) Mecklenburg County (117) New Kent County (127) Nottoway County (135) Petersburg City (730) Powhatan County (145) Prince Edward County (147) Prince George County (149) Richmond City (760) Surry County (181) Sussex County (183)
Facility Name *

Facility Street Address *

Resources/Support
Will this course will be part of a large multi-jurisdictional education event? (i.e educational expo) *

Yes No
Support for this course *

Submitting on behalf of a county-wide EMS agency Submitting on behalf of a single/stand alone EMS agency Submitting independent of an EMS agency
List Agency(ies) that are supporting this course *
Facility Resources *

Facility has dedicated educational space and equipment/space for all aspects of the course (e.g. breakout rooms) Facility does not have dedicated educations space (i.e. class held in bays) Facility does not have dedicated educations space (i.e. class held in bays)
Should be Empty: