TEMPORARY EMR REGISTRATION INSTRUCTIONS

Transcription

1 REGISTRATION INSTRUCTIONS Please ensure you read all of the instructions completely before submitting your application for registration. All sections of the Temporary EMR Registration Form must be completed. In order to become registered under the EMT Regulation of the Health Disciplines Act and use the protected title Emergency Medical Responder EMR, you must complete all items in the checklist. NOTE: If you have successfully completed the Provincial Registration Examination, you must complete the New Practitioner Registration Form to apply for registration. If you have taken and failed any portion of the Provincial Registration Examination, you are not eligible to apply for temporary registration. Temporary EMR registration checklist Have you completed the Temporary EMR Registration Form in full? Have you completed and signed (if necessary) the payment area? The College does not accept personal cheques. Do not send cash through the mail. You may also pay by debit card at the College office. Have you signed and dated the declaration? Have you included an original certificate of graduation or official transcript from your training program with your application? Photocopies, faxes or statements of marks will not be accepted. The official transcripts or graduation certificates must clearly state graduated from the training program or successfully completed the training program within a year of graduation date. If your graduation date is over a year, in addition to your initial training certificate, you must also provide an original certificate of completion or an official letter from a refresher program stating that you have successfully completed the program. Have you included the following with your application? A copy of a valid level C CPR, HCP or BLS instructor card issued within two years immediately preceding the date of application. Cards issued on or after Oct. 1, 2012 must be from the following providers: Canadian Red Cross, St. John Ambulance, Lifesaving Society, Canadian Ski Patrol System, and Heart and Stroke Foundation of Canada. Have you provided a Character and Reputation Reference Form to two eligible referees? Forms are the last two pages of this application package. Eligible referees are listed on the form, and cannot be related to you. Forms must be completed and mailed with your application to the Alberta College of Paramedics. (Continued on page 2) Page 1 of 5

2 REGISTRATION INSTRUCTIONS Have you included an original security clearance with a Vulnerable Sector Check from your local policing agency with your application? The clearance must be dated within one year of your application. The clearance must clearly state that a Vulnerable Sector Check has been performed or the College will be unable to accept your application. If you have a criminal record, you must submit an original Summary of Convictions which specifies the date of the conviction, the nature of the conviction and the resultant disposition. If you cannot obtain the documentation locally, you will have to request the documentation from Ottawa, which is done through a finger print check (this can take from four to six months). In addition, the Registration Committee requires that you provide a written summary of the circumstances surrounding the conviction(s). If you would like your original documents returned, please enclose a self-addressed stamped envelope with your application. Once you have completed the Temporary EMR Registration Form, gathered all necessary supporting documents and signed the declaration, you are ready to submit your application. Please allow up to three weeks for processing. If you successfully complete the Provincial Registration Examination you will be automatically registered and your new registration card will be mailed to you. If you fail either portion of the exam, your temporary registration will be immediately revoked. Alberta College of Paramedics # Broadmoor Blvd Sherwood Park, AB T8H 2W7 Ph: Toll-Free: Page 2 of 5

3 REGISTRATION FORM Personal information (please print clearly) Office Use Only RO# Female Male Legal name: Last First Middle Maiden/former name(s): If Applicable Mailing address: Street City Prov. Postal Code Birth date: mm/dd/yyyy address: Phone: Home Cell Work Proof of valid certifications as indicated Have you included your original graduation certificate or original transcript (no photocopies or faxes)? Have you included a copy of level C CPR or HCP card dated within previous two years, or a copy of your BLS instructor card (e.g. if issued Sept. 1, 2012 will expire Sept. 1, 2014)? Yes Date of issue: mm/dd/yyyy Registration and conduct * If your answer is yes to any of the following questions, please provide full particulars on a separate sheet of paper and attach to this form. 1. Have you ever been convicted of a criminal offense? (Mandatory to check one or the other) *Yes No If you have selected yes, please review the College s Applicants with Criminal Records policy before submitting your application. This Policy is found on the website under Resources. 2. Have you obtained any professional registration(s), licensure(s) or successfully completed any other certification from a provincial or national organization? (List all) Yes No Regulatory Body: License/Reg. No. Regulatory Body: License/Reg. No. Expiry Date: mm/dd/yyyy Expiry Date: mm/dd/yyyy Page 3 of 5

4 REGISTRATION FORM 3. Have you ever been suspended, been required to resign, and/or had your registration cancelled due to professional misconduct or unskilled practice by another regulatory body? *Yes No Name and address of the organization: Reason for discipline: Nature of discipline: 4. Have you been the subject of a finding of unprofessional conduct, professional misconduct, incompetence, or unskilled practice by a professional licensing or registration body other than the Alberta College of Paramedics, or are you currently under investigation for any such allegations? *Yes No 5. Are there any mental or physical conditions that might affect your ability or suitability to function as a temporary EMR? *Yes No 6. Have you read and do you understand the limitations of practice outlined in the College s Temporary Registration Policy (included in this application)? Yes No 7. Have you included a security clearance that includes a Vulnerable Sector Check with this application? Yes Is your security clearance more than 30 days old? Yes No If yes, and you have not been convicted of a criminal offence since the date of your security clearance, please complete, sign and date the following: I, please print clearly, have not been convicted of a criminal offence since mm/dd/yyyy Signed: (date of your security clearance). Date: mm/dd/yyyy If you have been convicted of a criminal offence since the date of your security clearance, please provide full particulars on a separate sheet of paper and attach to this form. Registration fees The registration fees are payable to the Alberta College of Paramedics. Certified cheque, company cheques, money order, Visa or MasterCard are accepted. You may also pay by debit card at the College office. Personal cheques are not accepted. Do not send cash. Registration Jan. 1 - Sept. 30, 2013 = $ ($ Registration Fee + $50 - Administration Fee) Registration expires Dec. 31, Page 4 of 5

5 REGISTRATION FORM Payment information Please indicate: VISA MasterCard Money Order Certified Cheque Cash/Debit (In person at the College office only) Credit card authorization (VISA/MasterCard ONLY) PLEASE PRINT CLEARLY Name of cardholder: Card number: Expiry date: Amount to be billed to card: $ Signature of cardholder: Office Use Only Office Use Only Debit Cash M/O Certified Cheque VISA MC Declaration I declare/hereby certify that the statements made by me on this form are complete and correct to the best of my knowledge and belief. If it is determined that any contents of the application, including character references are false, I recognize that I may be denied registration for a period of time specified by the Registration Committee. I have read, understand and agree to abide by the College s Code of Ethics and by the practice limitations of temporary registration. I acknowledge that my application, including character references, may be audited. I agree to notify the College, in writing, of a change in name, home or address, place of employment or employment status. Applicant s Signature: Date: Page 5 of 5

6 Registration Policy Temporary Registration Policy RFD # Policy Type: Registration Policy Number: REG-02 Approval Date: October 2, 1989 Last Review Date: December 1, 2010 Revision Date(s): January 12, 2011 February 8, 2007 October 18, 2002 June 4, 2002 Scheduled Review Date: January 2012 Purpose The College administers the Health Disciplines Act and the EMT Regulation. The concept of Temporary Registration is outlined in section 4 of the Regulation. Registration 1. The Registrar shall register a person as an Emergency Medical Responder, an Emergency Medical Technician-Ambulance or an Emergency Medical Technologist-Paramedic if, with respect to an area of practice: a. the person has satisfactorily completed a program of study i. that is approved by the Board, or ii. that is substantially equivalent to a program approved under subclause (i), b. the person has satisfactorily completed an examination approved by the Board, c. the person has, i. within the two years immediately preceding the date of application, been employed in a manner that indicates that the person is competent to act as an Emergency Medical Responder, Emergency Medical Technician-Ambulance or Emergency Medical Technologist- Paramedic, as the case may be, ii. within one year immediately preceding the date of application, met the requirements of clause (a), or iii. within one year immediately preceding the date of the application, satisfactorily completed a refresher program approved by the Board, d. the person has completed and submitted to the Registrar the applicable forms prescribed by the Minister, and e. the person has paid the prescribed fees. Alberta College of Paramedics ACP: January 12, 2011 Replaces: February 8, 2007 P:\2. Communications\Website\2011 REDESIGN\DOCS\DOCUMENTS\Policies\TemporaryRegistration.docx

7 Temporary Registration Policy 2 Temporary Registration 1. A person is eligible to be temporarily registered as an Emergency Medical Responder, Emergency Medical Technician or an Emergency Medical Technologist-Paramedic if, with respect to the area of practice in which the person is to be registered temporarily, the person has met section 1(a), (c), (d) and (e) as above. 2. The application may be approved by the Registration Committee through the Substantial Equivalency process, or the Mutual Recognition Agreement (MRA), Agreement on Internal Trade (AIT). 3. Practitioners who are practicing under a temporary registration may only provide services under the direct supervision of a registered member who holds registration at the same or higher discipline. The College has defined "direct supervision" of temporary registrants as the supervisor's ability to physically intervene when necessary, with little or no delay, and without disruption of patient care and/or transport (please see Council Policy ROA-01: Definition of Supervision - as revised); 4. Temporary registration is valid for one year after, whichever comes first: a. Graduation from an approved educational program; b. Acceptance by the Registration Committee as possessing substantially equivalent education and competencies for entry to practice; c. Acceptance under the Mutual Recognition Agreement, Agreement on Internal Trade; or d. After completion of the provincial registration examination. 5. Temporary registration may not be renewed, except if an individual registers in one calendar year and their registration extends to the next calendar year. Renewal fees apply between October to December - if the individual registers earlier in the year. 6. If a person's temporary registration is revoked, and they successfully complete an entirely new educational program, they are eligible to be issued a new temporary registration number. 7. Temporary registration is not available to persons who have been unsuccessful at the provincial registration examination. Their temporary registration will be revoked as soon as their unsuccessful examination results are known. Alberta College of Paramedics ACP: January 12, 2011 Replaces: February 8, 2007 P:\2. Communications\Website\2011 REDESIGN\DOCS\DOCUMENTS\Policies\TemporaryRegistration.docx

8 CHARACTER + REPUTATION REFERENCE FORM To be completed by the referee (the person providing the reference) and submitted to the Alberta College of Paramedics with your application. Under legislation, registrants with the Alberta College of Paramedics must be of good character and reputation. The College requires new applicants to provide character references that can attest to your character and reputation. Referees must fall into one of five categories, and CANNOT be related to the applicant in any way. Please complete the following information: Applicant s name: first+last Please indicate which of the following category best suits your current status and relationship to the applicant (no family members accepted): The most recent employer or instructor at a recently-completed education program. A regulated professional (e.g., health professional, lawyer, teacher) who has known the applicant for at least two years. A member of the clergy, who has known the applicant for at least two years. A peace officer who has known the applicant for at least two years. Any other person who has known the applicant for a minimum of five years. NOTE: Only one referee is allowed from this category. Referee name: first+last Referee address: Street City Prov. Postal Code Referee telephone: Referee What is your relationship to the applicant? What is your occupation? How long have you known the applicant? Have you reviewed the College s Mission, Vision and Values located on the College website ( Yes No I understand that the reference I provide may be released to the applicant if the applicant requests a copy. Yes Please provide your comments about the applicant s character and reputation and how you believe they would function in the paramedic profession (attach a separate sheet of paper if required): Referee s signature: Date:

9 CHARACTER + REPUTATION REFERENCE FORM To be completed by the referee (the person providing the reference) and submitted to the Alberta College of Paramedics with your application. Under legislation, registrants with the Alberta College of Paramedics must be of good character and reputation. The College requires new applicants to provide character references that can attest to your character and reputation. Referees must fall into one of five categories, and CANNOT be related to the applicant in any way. Please complete the following information: Applicant s name: first+last Please indicate which of the following category best suits your current status and relationship to the applicant (no family members accepted): The most recent employer or instructor at a recently-completed education program. A regulated professional (e.g., health professional, lawyer, teacher) who has known the applicant for at least two years. A member of the clergy, who has known the applicant for at least two years. A peace officer who has known the applicant for at least two years. Any other person who has known the applicant for a minimum of five years. NOTE: Only one referee is allowed from this category. Referee name: first+last Referee address: Street City Prov. Postal Code Referee telephone: Referee What is your relationship to the applicant? What is your occupation? How long have you known the applicant? Have you reviewed the College s Mission, Vision and Values located on the College website ( Yes No I understand that the reference I provide may be released to the applicant if the applicant requests a copy. Yes Please provide your comments about the applicant s character and reputation and how you believe they would function in the paramedic profession (attach a separate sheet of paper if required): Referee s signature: Date: