Submit this form to receive your credit for the education.

*1.First name(Required.)

*2.Last name(Required.)

*3.Email Address(Required.)

*4.How clearly did your instructor explain the course material? (Required.)

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Very clearly

Somewhat clearly

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Not at all clearly

*5.Did you find the education useful in ways that could improve your patient care?(Required.)

Extremely likely

Very likely

Somewhat likely

Not so likely

Not at all likely

*6.Do you have any additional feedback on the presentation?(Required.)

*7.Are there specific topics or skills you’d like us to cover in upcoming sessions?(Required.)

*8.License Number(Required.)

*9.License State(Required.)

*10.License Level(Required.)

*11.Expiration(Required.)

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

13.NEMSID

*14.NREMT License number(Required.)

*15.NREMT License Expiration Date(Required.)