Initial Course Request Form (CREF)

"*" indicates required fields

Step 1 of 6

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Requesting Instructor*

You must be a licensed EMS Instructor Coordinator or State or Staff fire instructor.

Instructor Email address*

Type of Course being requested*

Name of Agency requesting the training:*

Please select the type of EMS course you are requesting:*

Please select the type of Fire/EMS course you are requesting:*

Please enter the name of the course:*

Simulation Hours

Is this the first time course has been offered?

Curriculum Information

Is this program ProBoard certified?*

Yes

NFPA Standard #*

NFPA Edition*

Please select the type of certification that shall be issued?*

None

Certificate of Attendance

FST Commission Certification

Online Certificate

HSEM Certificate of Attendance

Minimum number of students*

Maximum number of student*

Number of student hours*

Is this program broken down into modules?*

Yes

List the modules below*

Please click the plus symbol on the right hand side to add additional modules.

Module Name

Module Hours

Are there any prerequisties for this course?*

Please only list REQUIRED prerequisites.

Yes

Please provide a short course description or link to a course description*

Please list the required prerequisite training courses*

Location information

Where is the course being held?*

Field

Fire Academy

Bethlehem

Gorham office

Virtual (no location)

Facility Name*

Please specify the physical address of the course*

Street Address Address Line 2 City State ZIP Code

Maximum number of student*

Are you planning to teleconference this training:*

Yes

Which locations are you planning to teleconference to?*

Bethlehem

Gorham

45th Parallel EMS

Other

Other Teleconferencing Site*

Teleconference site address*

Street Address City State ZIP Code

Program start date*

YYYY dash MM dash DD

Program end date*

YYYY dash MM dash DD

Is this course being offered at multiple locations?

First Additional Location Name

First Additional Location Address

Street Address Address Line 2 City State ZIP Code

Second Additional Location Name

Second Additional Location Address

Street Address Address Line 2 City State ZIP Code

Course Schedule Information

Course Schedule*

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Weekday start time*

Hours

Minutes

Weekday end time*

Hours

Minutes

Weekend start time*

Hours

Minutes

Weekend end time*

Hours

Minutes

Testing Schedule Information

If not applicable, enter the program start date and “N/A” for Exam Type

Testing Date 1 (if applicable)*

YYYY dash MM dash DD

Exam Type (Practical/Written)*

Testing Date 2 (if applicable)

YYYY dash MM dash DD

Exam Type (Practical/Written)

Testing Date 3 (if applicable)

YYYY dash MM dash DD

Exam Type (Practical/Written)

Testing Date 4 (if applicable)

YYYY dash MM dash DD

Exam Type (Practical/Written)

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Additional Firefighter I program information

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Hazmat Awareness Test Date*

YYYY dash MM dash DD

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Hazmat Operations Test Date*

YYYY dash MM dash DD

EMS Course Information

Course Medical Director*

Would you like to include the Scope of Practice modules with this request?*

Yes

Would you like this advertised on the Course Catalog?*

Yes

Please provide all contact information to be displayed on the Course Catalog.*

Please attach a copy of your course syllabus or course outline*

Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.

Course outline must contain at minimum the location, dates, times, and topics of each class.

You may upload a second file if needed.

Max. file size: 256 MB.

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Please attach a copy of your course syllabus

Drop files here or

Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.

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Does the Division have a copy of your course and student guidelines on file?

Yes

Please attach a copy of your course and student guidelines*

Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.

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Does the Division have a copy of your clinical agrreement on file?

Yes

Please attach a copy of your Clinical / Field Internship Affiliation Form*

The form can be found at: https://www.nh.gov/safety/divisions/fstems/ems/documents/clinical.pdf

Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.

Additional course information

Is the Division the Sponsoring Agency:*

Yes

Sponsoring the course means we are one of the main organization coordinating the training program. We may partner with another agency but we are sponsoring the training. This might include responsibilities such as managing registration, handling payments, hiring instructors, providing resources, and overall ensuring the smooth execution of the training. It’s a significant commitment that often comes with various logistical and administrative duties to ensure the success of the program.

Partnership with an outside organization

Yes

Is the Division partnering/co-sponsoring this training with an outside organization. Example, the Division is partnering with the IAFF to bring in one of their programs to the State. The Division conducts the logistics and registration for the program.

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Course funding

Funded 35%: This is part of the Division’s budget programs
Non-Funded: Division does not bear the cost of this program
Contracted: The Division works with the Agency on a customized quote for the requested training. The Department agrees to pay for 100% of the course cost.

Funded-Tuition 35%

Non-Funded

Contracted

Grant Funded

Is the Division being contracted to offer this course??*

Yes

If the Division is being contracted to offer this course a quote is required to be attached outlined the cost of the training program.

Please attached the quote for the contracted training program.*

Max. file size: 256 MB.

Do you want this course list on the Course Catalog?*

Yes

When would you like the application window to open?*

YYYY dash MM dash DD

The sponsoring agency has the ability to submit applications prior the application window opening. Once the application window opens, applications will be processed on a first-come first-serve basis.

Additionally, the application window close day will be 10 days prior to the start of the class. In the event at the end of the application window there is still space available, applications will still be accepted. If an outside agency requires an earlier application window close date please include this information in the additional details on the last page.

Additional Information

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Upload any additional documents

Drop files here or

Accepted file types: doc, docx, pdf, xls, xlsx, Max. file size: 256 MB.

Upload any additional documents

Max. file size: 256 MB.

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Curriculum Information

Location information

Course Schedule Information

Testing Schedule Information

Additional Firefighter I program information

EMS Course Information

Additional course information

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