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 (RN)
2 (None)
3 (None)
4 (EMR)
5 (None)
6 (DO)
7 (EMT)
8 (None)
9 (EMT)Onboarding
10 (EMR)
11 (EMT)
12 (DO)
13 (None)
14 (Medic)
15 (None)
16 (Medic)
17 (CNA)
18 (Medic)
19 (None)
20 (None)
21 (None)
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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