SD County Paramedic Accreditation Workshop Application San Diego County Paramedic Accreditation Application Application to attend Paramedic Accreditation workshop First Name*Last Name*Middle InitialPhone Number*Mailing Address*E-mail address*Workshop date preferred*Name and location of original training agency*Date of original accreditation*County/State of current accreditation*State Registry Number (If applicable)Are you attending this workshop for a Field Internship in San Diego County? Yes No Please Indicate which of the following that you have NOT been tested on* Interosseous Infusion External Jugular IV Access AV Fistula/Shunt, Indwelling IV Catheter Access ET intubation, Bougie and King Airway Insertion with LEADSD NG Tube and Gastric Suction Length Based Resuscitation Tape and Pediatric Drug Sheets CPAP Hemostatic Gauze and Tourniquet application Push-dose Epinephrine prep and administration SD County Standard Radio Report practice At least one box must be checked.Do you hereby affirm that the information submitted on above form is true and correct? (Signature will be requested at time of course to affirm)* Yes No Submit copies of the front and back sides the following to the EME Office:State Medic LicenseACLS CardPicture IDCourse Completion Record*This course includes all San Diego County protocol updates. ** You will be required to provide your Social Security Number at the time of the course. Δ