EVOC Approval Request - Birmingham Regional EMS System

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Today's Date *

Course being requested *

Sponsoring Agency

EMS Region *

County *

Agency Affiliation *

Street *

City *

State *

Zip Code *

Phone *

Course Coordinator Information

First name *

Last name *

Email *

Mobile Phone *

Additional Instructors

Check this box if there are assisting instructors that need to be listed

Course Information

Course Start Date *

Course End Date *

Course Type *

Course Availability *

Course Location: Street Address *

Course Location: City *

Course Location: State *

Course Location: Zip Code *

If Module B is included in this course request, will it be conducted at a different location? *

Hours Distribution

Classroom Hours

Distributive Hours

Driving Course Hours

Total CEU Hours *

Add the entries from the above hours

Supporting Documentation

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

Course Roster Upload

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

Download roster template at http://www.bremss.org/uploadedFiles/EVOC/EVOC_Roster.xlsx

Course Exam Upload

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

All EVOC Module A students are required to complete the 100 question EVOC exam (Full Course and Refresher Course)

Attesting Statements

Each of the following items must be checked prior to a course approval. By checking, you are agreeing to follow all policies and/or procedures established by the ADPH OEMS and/or the BREMSS regional office. Failure to adhere to the policies and procedures outlined in the EVOC course application packet will result in the invalidation of the course and all certifications issued in association with the course, as well as forfeiture of your instructor credentials.

EVOC meets the National Standard Curriculum requirements for Emergency Vehicle Operator Course. The EVOC certificate will have the NHTSA DOT logo. To receive a certificate, the student must have met all requirements outlined in the EVOC Course Application Packet. *

The regional EMS office will issue an EVOC certificate for the participant of an EVOC Full Course (Module A and B) and deliver it to the EVOC program or instructor for distribution. *

Participants must successfully complete approved courses covering NHTSA EVOC Ambulance Modules A and B to receive the EVOC-Ambulance completion certificate for the state of Alabama. The EVOC modules must be completed in order. If a participant takes Module A at one location and wishes to take Module B at another location, the participant must provide a Module A certificate of completion. *

To obtain EVOC Full Course certificates the instructor must complete the course roster, send it to the Region with all completed test results, and apply for a Regional Course number. We must have the course roster and test results before certificates or course numbers will be issued. Certificates will be sent to the course instructor for distribution.

EVOC Mod A Refresher Course approval applications will receive a course approval number once the roster and completed test results are turned into the Regional Office. The EVOC Instructor is responsible for EVOC refresher certificates.

Module A/B and Module B Courses: Participants either pass or fail the driving exercises based on their ability to perform the maneuver as demonstrated. If a participant does not meet the standard for an exercise, the instructor must decide if additional coaching, practice, or both will be necessary for the participant to achieve the standard. The primary standard for successfully completing an exercise is the ability to maneuver through the course without hitting a cone. All exercises must be successfully passed in order to complete Module B. Each exercise may have locally developed scoring based on specific needs or expectations. Time should not be a part of the scoring. *

Course Coordinator Signature *

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.