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1. Sponsoring EMS Service

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2. EMS representative completing survey

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3. Student Name

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4. Certification Type

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5. Is the program complete?

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6. Date Program was completed

Date

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7. Exam Date

Date

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8. Has student passed the National Registry Exam?  If yes, skip to question 11

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9. If no, when is the next scheduled exam

Date

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10. If no, how many times has the National Registry Exam been attempted?

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11. If yes, you will need to start reporting monthly time per the survey monkey titled SB8 Verification of Hours every month (EMT 1 year, AEMT/Para 2 years)

T