Fresh Course Request Form Step 1 of 4 25% Course InformationType of Course Being Requested:(Required)Please select a course typeFireEMS - Licensed Instructor CoordinatorEMS - Division SponsoredPlease select the type of EMS course you are requesting:(Required)Please select an EMS course typeEMR Initial (EMR)EMR Scope of Practice Modules (RSOP)EMT Initial (EMT)EMT Scope of Practice Modules (ESOP)EMS I/C Programs (INSTED)AEMT Initial (AEMT)AEMT Scope of Practice Modules (ASOP)Paramedic Initial (P)Paramedic Scope of Practice Modules (PSOP)Continuing Education, Seminars and Training (CON)PEETE (PEETE)Challenge for Medical Professionals (CMP)Please select the type of Fire/EMS course you are requesting:(Required)Please select a courseAirport FirefighterARFF Live Fire Training - SAFT and Fuel SpillARFF Live Fire Training - SAFT ONLYBasic Pumps OperationsCancer AwarenessCourage to be SafeDriver Operator - All VehicleDriver Operator - Aerial ApparatusDriver Operator - Pump ApparatusEMS New Instructor OrientationEMS Continuing EducationEMS - PHTLSEMS Simulation ProgramEmergency Preparedness and ODPFire and Emergency Services Instructor IFire and Emergency Services Instructor II & IIIFire Inspector IFire Inspector IIFire Officer IFire Officer IIFirefighter IFirefighter I - Modules (specify below)Firefighter IIFirefighter II - Modules (specify below)Firefighter I & IIFirefighter III - Confined Space TechnicianFirefighter III - Ice Rescue TechnicianFirefighter III - Rope Rescue TechnicianFirefighter III - Trench Rescue TechnicianHazardous Materials AwarenessHazardous Materials OperationsHazardous Materials DecontaminationHazardous Materials TechnicianIAFF Fireground SurvivalICS 100 Intro to ICSICS 200 Basic ICSICS 300 Intermediate ICSICS 400 Advanced ICSInstructor DevelopmentInstructor Mentor TtT ProgramNational Fire AcademyODPOtherRope Rescue OperationsRadiological Equipment Training (RET)SeminarSwiftwater Rescue AwarenessSwiftwater Rescue Level ISwiftwater Rescue Level IISwiftwater Rescue Boat OperationsTraining for Rapid Intervention TeamsTrain the TrainerWildland Firefighter IWildland Firefighter IIIs this the first time course has been offered?(Required)NoYesPlease enter the name of the course (or module):(Required)The title of the event. Do not include any other information such as CREF or location. The course title should reflect the official name of the course, certification, etc. Please use language that is for all audiences at any level of experience (e.g.: "Emergency Medical Technician" is appropriate while "EMT Initial" is not). Sponsoring Agency(Required)Is this event sponsored by the NH Fire Academy & EMS or by a third party agency? NH Fire Academy & EMS Third party Number of Student Hours:(Required)Are there any prerequisites for this course?(Required) Yes No Please list the required prerequisite training courses(Required)Curriculum InformationIs this program ProBoard certified?(Required) Yes No NFPA Standard # NFPA Edition # Please provide a course description(Required)A description of the event should be provided. Generally 1-3 paragraphs would be most appropriate. Descriptions should be written in plain English and should not assume that the readers are familiar with the program.Course WebsiteOptional link to a course description page Would you like to Include Scope of Practice Modules with this request?(Required) Yes No Course Medical Director(Required) Is this program broken down into modules?(Required)YesNoList the modules below(Required)Please click the plus symbol on the right hand side to add additional modules. Module NameModule Hours Add Remove Course Location InformationVirtual Event?(Required) In Person Only Virtual (Online) Event Only Hybrid (Both in person and online) Virtual Event URLYouTube Live, Facebook Live, Zoom Name of Agency Requesting the Training:(Required) Where will the course be held?(Required) Field NH Fire Academy & EMS - Concord NH Fire Academy & EMS- Bethlehem NHFA-EMS Gorham Office Course location name(Required) Course Location Physical Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Course Location PhoneCourse Location Website Additional Location InformationAre you planning to teleconference this training? If so, where? Are there any additional details about the location?Requesting InstructorYou must be a licensed EMS Instructor/Coordinator or State or Staff fire instructor. Dates & TimesProgram Start Date(Required) YYYY dash MM dash DD Program End Date(Required) YYYY dash MM dash DD Testing Date (If Applicable) YYYY dash MM dash DD Time of TestingPlease provide time in a 24-hour clock format (e.g.: 16:00 instead of 4:00p.m.) Hours : Minutes When would you like the registration window to open?(Required)The sponsoring agency has the ability to submit applications prior the application opening. Once the application window opens, applications will be processed on a first-come first-serve basis. YYYY dash MM dash DD Registration Open TimeThe time when registration will open. 24-hour clock. Hours : Minutes When would you like the registration window to close?(Required)Default application window will close 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. YYYY dash MM dash DD Registration Close TimeThe time when registration will close. 24-hour clock. HH : MM Registration link(Required)URL for this course's registration page. Providing a URL is mandatory for third party events as this is the link people are directed to when they click register. Course Schedule InormationSchedule DescriptionIf applicable, provide a general description for the course schedule for a listing (e.g.: Tuesdays and Thursdays 08:00-16:00; Saturdays, 09:00-13:00) Course Days of the Week(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Weekday Start Time(Required)Please provide time in a 24-hour clock format (e.g.: 16:00 instead of 4:00p.m.) Hours : Minutes Weekday End Time(Required)Please provide time in a 24-hour clock format (e.g.: 16:00 instead of 4:00p.m.) Hours : Minutes Weekend Start Time(Required)Please provide time in a 24-hour clock format (e.g.: 16:00 instead of 4:00p.m.) Hours : Minutes Weekend End Time(Required)Please provide time in a 24-hour clock format (e.g.: 16:00 instead of 4:00p.m.) Hours : Minutes Additional Firefighter I Program InformationDate of The First Aid Class(Required) YYYY dash MM dash DD Date When HazMat Awareness Online is Due(Required) YYYY dash MM dash DD HazMat Awareness Test Date(Required) YYYY dash MM dash DD HazMat Operations Start Date(Required) YYYY dash MM dash DD HazMat Operations Final Day of Practical(Required) YYYY dash MM dash DD HazMat Operations Test Date(Required) YYYY dash MM dash DD Final Course DetailsWould you Like This Course Advertised in The Course Catalog?(Required) Yes No Organizer Name(Required)Course contact information which will be listed publicly with the course First Last Organizer Email(Required)Course contact information which will be listed publicly with the course Organizer PhoneOptional course contact information which will be listed publicly with the courseOrganizer WebsiteOptional course contact information which will be listed publicly with the course HiddenPlease Provide Contact Information to be displayed in the Course Catalog(Required)Please attach a copy of your course syllabus Drop files here or Select files Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB. Does the Division have a copy of your course and student guidelines on file? Yes No Please attach a copy of your course and student guidelines(Required)Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.Does the Division have a copy of your clinical agreement on file? Yes No Please attach a copy of your Clinical / Field Internship Affiliation Form?(Required)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.Course Funding(Required)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 Please attached the quote for the contracted training program.(Required)Max. file size: 256 MB.Additional InformationUpload any additional documents Drop files here or Select files Accepted file types: doc, docx, pdf, xls, xlsx, Max. file size: 256 MB.
