CME Approval Request - Birmingham Regional EMS System

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Course Coordinator Information

First name *

Last name *

Email *

Mobile Phone *

Sponsoring Agency

EMS Region *

County *

Agency Affiliation *

Other Agency

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Street

City

State

Zip Code

Phone

Course Information

Course Title *

Course Start Date *

Course End Date *

Course Type *

Course Availability *

Hours Distribution

Classroom Hours

Distributive Hours

Skills Hours

Total CEU Hours *

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Distribution of CEU hours for each level

EMR

EMT

Advanced

Intermediate

Paramedic

Attesting Statements To the best of my ability and knowledge, all the statements contained in this application are true and accurately represent the proposed continuing education activity.

Course Coordinator Signature *

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Supporting Documentation Upload any supporting documentation that you feel may be need for approval consideration.

CME 2: Course Outline

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Visit https://bremss.org/wp-content/uploads/2023/12/CME_2_fillable.pdf to access the CME 2 PDF

CME 3: Instructor Information

Allowed file formats: .jpg, .jpeg, .zip, .rar, .png, .bmp, .pdf, .docx, .doc, .pptx, .ppt, .mp4, mp3, m4a, wav, .ics, .webp, .gif, .xlsx, .xls, .csv Maximum file size: 20Mb

Visit https://bremss.org/wp-content/uploads/2023/12/CME_3_fillable.pdf to access the CME 3 PDF

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