Submit this form to receive your credit for the education.

*1.First name(Required.)

*2.Last name(Required.)

*3.Address, City, State, Zip Code(Required.)

*4.Email Address(Required.)

*5.Course Completion Date(Required.)

*6.Course Code (Shared at the end of the presentation)(Required.)

*7.License Number(Required.)

*8.License State(Required.)

*9.License Level(Required.)

*10.Expiration(Required.)

*11.NREMT License number(Required.)

12.NREMT License Expiration Date

13.NEMSID

14.How clearly did your instructor explain the course material?

Extremely clearly

Very clearly

Somewhat clearly

Not so clearly

Not at all clearly

15.Did you find the education useful in ways that could improve your patient care?

Extremely likely

Very likely

Somewhat likely

Not so likely

Not at all likely

16.Do you have any additional feedback on the presentation?

17.Are there specific topics or skills you’d like us to cover in upcoming sessions?