Step 1 of 6 16% Requesting Instructor* You must be a licensed EMS Instructor Coordinator or State or Staff fire instructor.Instructor Email address* Type of Course being requested*FireEMS - Licensed Instructor CoordinatorEMS - Division SponsoredName of Agency requesting the training:* Please select the type of EMS course you are requesting:*EMR Initial (EMR)EMR Scope of Practice Moduels (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:*Please select a course:Airport FirefighterARFF live fire recertificationBasic 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 IIPlease enter the name of the course:* Simulation Hours Is this the first time course has been offered?NoYes Curriculum InformationIs this program ProBoard certified?* Yes No 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 No List the modules below*Please click the plus symbol on the right hand side to add additional modules.Module NameModule Hours Are there any prerequisties for this course?*Please only list REQUIRED prerequisites. Yes No Please provide a short course description or link to a course description*Please list the required prerequisite training courses* Location informationWhere 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 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 Maximum number of student* Are you planning to teleconference this training:* Yes No Which locations are you planning to teleconference to?* Bethlehem Gorham 45th Parallel EMS Other Other Teleconferencing Site* Teleconference site address* Street Address 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 Program start date* YYYY dash MM dash DD Program end date* YYYY dash MM dash DD Course Schedule informationCourse 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 Date of Testing YYYY dash MM dash DD Time of Testing : Hours Minutes HiddenAdditional Firefighter I program informationHiddenDate of the CPR Class YYYY dash MM dash DD HiddenDate of the first aid class* YYYY dash MM dash DD HiddenDate in which Hazmat Awareness online completion is due* YYYY dash MM dash DD HiddenHazmat Awareness Test Date* YYYY dash MM dash DD HiddenHazmat Operations start date* MM slash DD slash YYYY HiddenHazmat Operation final day of practical* YYYY dash MM dash DD HiddenHazmat Operations Test Date* YYYY dash MM dash DD EMS Course InformationCourse Medical Director* Would you like to include the Scope of Practice modules with this request?* Yes No Would you like this advertised on the Course Catalog?* Yes No Please provide all contact information to be displayed on the Course Catalog.*Please attach a copy of your course syllabus*Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.You may upload a second file if needed.Max. file size: 256 MB.HiddenPlease 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. HiddenDoes 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*Accepted file types: pdf, xls, xlsx, doc, docx, jpg, gif, Max. file size: 256 MB.HiddenDoes the Division have a copy of your clinical agrreement on file? Yes No 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 informationCourse 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 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 No 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 InformationHiddenUpload any additional documents Drop files here or Select files Accepted file types: doc, docx, pdf, xls, xlsx, Max. file size: 256 MB. Upload any additional documentsMax. file size: 256 MB.