Section 1-780 - Class Grade Entry Form

CMH EMS Education Manual

To be completed by Instructor To be completed by Office Staff
Class name:
Completion date: Healthstreams updated
Completion time: Kronos updated
Lead instructor: Name: Hours: NAEMT updated and certs issued
Instructor #2: Name: Hours: OzarksEMS certs issued
Instructor #3: Name: Hours: NREMT updated
Instructor #4: Name: Hours: OzarksEMS credentials updated
Lead instructor signature: Platinum updated
When completed, send this form to theron.becker@citizensmemorial.com.

Please complete the following form with students listed "last name, first name" in alphabetical order.

Student name (License) Academy Contact hours Chapter score Comments
1 (Medic)
2 (Medic)
3 (DO)
4 (Medic)
5 (Medic)
6 (CP)
7 (EMT)
8 (CP)
9 (Medic)
10 (Medic)
11 (CP)
12 (Medic)
13 (Medic)
14 (Medic)
15 (Medic)
16 (Medic)
17 (EMT)
18
19
20
21
22
23
24
25
26
27

Change Log:

DateLink to
previous
version		Description of change
11/27/19pdfMoved the EMT chapter entry form to this section to be used in all Academies.
08/21/20pdfMoved this section to the online format.
07/28/21pdfAdded checklist for office staff when entering data.

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Based on a work at http://ozarksems.com/edman-4-240.php.

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