FSTEMS Part-time Staff Evaluation Form

Before submitting your request please update your profile information at www.respondnh.org or if you do not have a profile please create one before submitting your request.

Personal Demographics

Name*

First Middle Last

EMS License # or NELP #*

Please enter you EMS License # or NELP number which can be found on your main profile page on RespondNH.org.

Address*

Street Address City State ZIP Code

Date of Birth*

Last 4 Digits of SS#*

Email*

Phone

Equivalency / Reciprocity

I would like to apply for:*

Equivalency (Pro Board, IFSAC, or DoD certification)

Reciprocity (Not nationally accredited)

This means that you have a certification which is already recognized and accredited by the PROBOARD, IFSAC, or the Department of Defense (DOD). The NH Fire Academy will grant direct equivalency for these certifications. You WILL NOT receive a certificate from the Division. You will have your training certificate recorded on the Fire Academy student transcript database. There is NO FEE for equivalency.

This means that you have training and/or certification from an agency or academy that is NOT PROBOARD, NOT IFSAC, NOT Department of Defense (DOD) accredited and you would like to have an analysis done of your training to see if it meets or exceeds the current NFPA and State of NH Training standards to be eligible to challenge both the written and practical exam process to obtain a NH certification and PROBOARD accreditation.

Select up to three Certifications for Equivalency

Equivalency Certification 1*

Equivalency Certification 2

Equivalency Certification 3

Supporting Documentation Upload

You MUST provide an electronic upload of your supporting certifications clearly showing the PROBOARD, or IFSAC, or Department of Defense (DOD) seal of accreditation on the certificate. If your certificate does NOT contain one of the above seals, we MUST be able to verify your accreditation through the corresponding agency's website. Any certificate which can not be verified WILL NOT be granted equivalency.

Upload your documents here*

Max. file size: 256 MB.

File

Max. file size: 256 MB.

File

Max. file size: 256 MB.

Select the Certification you wish to obtain Reciprocity for:

Reciprocity Certification 1*

Total

FIREFIGHTER 1 VERIFICATION OF PREVIOUS EDUCATION

In order for the Division to consider your application for Reciprocity for Firefighter 1 you MUST complete the below curriculum analysis. For each part of the NFPA 1001 standard that is listed, you MUST show where your education and training meets or exceeds it. If you are unable to fill in any of the spaces, your application will be denied. ALL FIELDS must be completed in order for your application to be considered. You MUST also provide electronic documentation of the training. For example any college transcripts, certificates of completion, course outlines, etc must be saved electronically and uploaded to support the analysis that you entered.

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

Building Contruction I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Professional Rescuer CPR I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

First aid certification I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire attack and foam I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

FIre behavior I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire cause determination I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Detection, protection, suppression systems I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire service communications I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire suppression (building fires) I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire suppression (dumpster and auto fires) I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Firefighter rehabilitation I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Firefighter safety I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Firefighter survival I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Firefighter tools and equipment I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Forceable entry I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Ladders I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Portable fire extinguishers I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

PPE and SCBA I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Response and size up I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Ropes and knots I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Salvage and overhaul I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Search and rescue I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

History of the fire service I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Ventilation I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Water supply I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

UPLOAD YOUR SUPPORTING DOCUMENTATION

You must upload electronic documents for all of the education that you entered into the matrix above. For example, if you typed in "ladders class" in one of the spaces provided, you must show us documentation that the class existed and that you took and passed the class. Typically a course syllabus from your program of instruction with dates and numbers of hours can be used to help verify your previous education. Also, any completed skill sheets can help with the verification process. A COPY OF AN OUTLINE FROM A CATALOG IS NOT ABLE TO BE USED FOR VERIFICATION.

File*

Max. file size: 256 MB.

File

Max. file size: 256 MB.

File

Max. file size: 256 MB.

Hazmat Awareness / Operations

I certify that I have a current certification in Hazmat awareness and operations level training which is nationally accredited by either PROBOARD, IFSAC, or Department of Defense DOD. I am uploading a copy of my certification as proof. I understand that if I DO NOT have a valid certification, my application for reciprocity will not and can not be processed until such time as I obtain a nationally accredited program.

I HAVE A CURRENT HAZMAT CERTIFICATION as outlined above

Select one

YES

NO

Upload your nationally accredited certification*

Max. file size: 256 MB.

WE CAN NOT PROCESS YOUR REQUEST FOR FIREFIGHTER ONE RECIPROCITY AT THIS TIME. YOU MUST OBTAIN A CURRENT NATIONALLY ACCREDITED HAZMAT AWARENESS AND OPERATIONS LEVEL CERTIFICATE.

FIREFIGHTER 2 VERIFICATION OF PREVIOUS EDUCATION

In order for the Division to consider your application for Reciprocity for Firefighter 1 you MUST complete the below curriculum analysis. For each part of the NFPA 1001 standard that is listed, you MUST show where your education and training meets or exceeds it. If you are unable to fill in any of the spaces, your application will be denied. ALL FIELDS must be completed in order for your application to be considered. You MUST also provide electronic documentation of the training. For example any college transcripts, certificates of completion, course outlines, etc must be saved electronically and uploaded to support the analysis that you entered.

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

Courage to be safe program I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Firefighter safety skills I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire cause determination I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Fire supression I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Flashover I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Foam and flmmable liquids I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Pre-incident planning, fire prevention, and public education I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Rescue skills air monitoring I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Rescue skills ICS I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Rescue skills lifting and jacking I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Rescue skills ropes and rigging I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

Vehicle rescue and extrication I met with the below class*

Where I took this class*

Number of hours of instruction in this class*

UPLOAD YOUR SUPPORTING DOCUMENTATION

You must upload electronic documents for all of the education that you entered into the matrix above. For example, if you typed in "ladders class" in one of the spaces provided, you must show us documentation that the class existed and that you took and passed the class. Typically a course syllabus from your program of instruction with dates and numbers of hours can be used to help verify your previous education. Also, any completed skill sheets can help with the verification process. A COPY OF AN OUTLINE FROM A CATALOG IS NOT ABLE TO BE USED FOR VERIFICATION.

File*

Max. file size: 256 MB.

INSTRUCTOR 1 VERIFICATION OF PREVIOUS EDUCATION

In order for the Division to consider your application for Reciprocity for Instructor 1 you MUST complete the below curriculum analysis. For each part of the NFPA 1041 standard that is listed, you MUST show where your education and training meets or exceeds it. If you are unable to fill in any of the spaces, your application will be denied. ALL FIELDS must be completed in order for your application to be considered. You MUST also provide electronic documentation of the training. For example any college transcripts, certificates of completion, course outlines, etc must be saved electronically and uploaded to support the analysis that you entered.

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

Challenges of emergency service instruction I met with the below class*

Covers obligations of the instructor, role model issues, effective characteristics, teaching traits

Where I took this class*

Number of hours of instruction in this class*

Safety and the instructor's role I met with the below class*

Instructor’s role, accident prevention and management, safety guidelines and regulations, safe use of props and facilities, live burn concerns

Where I took this class*

Number of hours of instruction in this class*

Legal and ethical considerations I met with the below class*

Law and the instructor, law applications, ethical conduct, environmental concerns, copy right laws

Where I took this class*

Number of hours of instruction in this class*

Effective interpersonal communications I met with the below class*

Interpersonal communication basics, purpose of communications, verbal component, non-verbal component, listening skills

Where I took this class*

Number of hours of instruction in this class*

Instructional facilities and props I met with the below class*

Instructional facilities, training props, acquired structures

Where I took this class*

Number of hours of instruction in this class*

Report writing and record keeping I met with the below class*

Report writing, general record-system components, budgets, inventory, training, maintenance, personnel records

Where I took this class*

Number of hours of instruction in this class*

Principles of learning I met with the below class*

Development of learning principles, terminology, domains of learning, laws of learning, motivation, theories of learning and remembering, factors affecting learning, approaches to teaching

Where I took this class*

Number of hours of instruction in this class*

Student attributes and behaviors I met with the below class*

Development of learning principles, terminology, domains of learning, methods of learning, factors affecting learning, approaches to teaching

Where I took this class*

Number of hours of instruction in this class*

Preparation for insctructors I met with the below class*

Lesson plans, instructor preparation, course continuity and consistency, physical settings

Where I took this class*

Number of hours of instruction in this class*

Instructional delivery I met with the below class*

Methods, presentation techniques, methods for active learning

Where I took this class*

Number of hours of instruction in this class*

Audiovisual technology I met with the below class*

AV benefits, training aid selection, use and development, transitions, training aid types, clean-care-and maintenance

Where I took this class*

Number of hours of instruction in this class*

Structured exercises and practical training evolutions I met with the below class*

Psychomotor skills demonstrations, practical training evolutions

Where I took this class*

Number of hours of instruction in this class*

Student progress, evaluation, and testing I met with the below class*

Formal evaluations through testing, feedback

Where I took this class*

Number of hours of instruction in this class*

UPLOAD YOUR SUPPORTING DOCUMENTATION

You must upload electronic documents for all of the education that you entered into the matrix above. For example, if you typed in "testing class 101" in one of the spaces provided, you must show us documentation that the class existed and that you took and passed the class. Typically a course syllabus from your program of instruction with dates and numbers of hours can be used to help verify your previous education. A COPY OF AN OUTLINE FROM A CATALOG IS NOT ABLE TO BE USED FOR VERIFICATION.

File*

Max. file size: 256 MB.

INSTRUCTOR 2 VERIFICATION OF PREVIOUS EDUCATION

In order for the Division to consider your application for Reciprocity for Instructor 2 you MUST complete the below curriculum analysis. For each part of the NFPA 1041 standard that is listed, you MUST show where your education and training meets or exceeds it. If you are unable to fill in any of the spaces, your application will be denied. ALL FIELDS must be completed in order for your application to be considered. You MUST also provide electronic documentation of the training. For example any college transcripts, certificates of completion, course outlines, etc must be saved electronically and uploaded to support the analysis that you entered.

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

Lesson plan development I met with the below class*

Lesson plan and its components, learning objectives, development, lesson plan types, creation, modification and adaptation

Where I took this class*

Number of hours of instruction in this class*

Instructor and course evaluations I met with the below class*

Instructor evaluations, evaluating other instructors, types of evaluations, course and lesson evaluations, summative evaluations, analyzing results

Where I took this class*

Number of hours of instruction in this class*

Student testing instrucments I met with the below class*

Test planning steps, constructing exams, test instruments, written test types, oral exams, performance exams, test data collection, test item and result analyses

Where I took this class*

Number of hours of instruction in this class*

Course and evolution management I met with the below class*

Transition usage, class discussion usage, Training evolution management, ICS, evolution planning, multi-agency evolutions, implementation, supervision

Where I took this class*

Number of hours of instruction in this class*

Administrative duties I met with the below class*

Research data, collection, information sources, analysis process, needs analysis, task analysis, risk analysis, budget process, creating budgets, grants, revision of budgets, 10 minute in class presentation of budget, purchasing development of request for proposal, funding sources, bid specifications

Where I took this class*

Number of hours of instruction in this class*

Supervision and management I met with the below class*

Methods and styles of supervision and management, creating effective team, creating job interest within the team, maintaining positive examples/attitudes, leadership elements, methods and styles of management/supervision, resource scheduling, creating schedules

Where I took this class*

Number of hours of instruction in this class*

UPLOAD YOUR SUPPORTING DOCUMENTATION

You must upload electronic documents for all of the education that you entered into the matrix above. For example, if you typed in "testing class 101" in one of the spaces provided, you must show us documentation that the class existed and that you took and passed the class. Typically a course syllabus from your program of instruction with dates and numbers of hours can be used to help verify your previous education. A COPY OF AN OUTLINE FROM A CATALOG IS NOT ABLE TO BE USED FOR VERIFICATION.

File*

Max. file size: 256 MB.

INSTRUCTOR 3 VERIFICATION OF PREVIOUS EDUCATION

In order for the Division to consider your application for Reciprocity for Instructor 3 you MUST complete the below curriculum analysis. For each part of the NFPA 1041 standard that is listed, you MUST show where your education and training meets or exceeds it. If you are unable to fill in any of the spaces, your application will be denied. ALL FIELDS must be completed in order for your application to be considered. You MUST also provide electronic documentation of the training. For example any college transcripts, certificates of completion, course outlines, etc must be saved electronically and uploaded to support the analysis that you entered.

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

Administration, records, policies, and personnel I met with the below class*

Records management, system types, development of training policies, revision process, human resource management, personal evaluations, feedback and legal considerations

Where I took this class*

Number of hours of instruction in this class*

Analysis and evaluation I met with the below class*

Analysis process, programs, policy, need, task, risk, application, evaluation process, course and instructional design

Where I took this class*

Number of hours of instruction in this class*

Program and curriculum development I met with the below class*

Sample planning model, training programs and curriculum design, job performance requirements, hierarchy of work, implementing the program or course, course revision

Where I took this class*

Number of hours of instruction in this class*

UPLOAD YOUR SUPPORTING DOCUMENTATION

You must upload electronic documents for all of the education that you entered into the matrix above. For example, if you typed in "testing class 101" in one of the spaces provided, you must show us documentation that the class existed and that you took and passed the class. Typically a course syllabus from your program of instruction with dates and numbers of hours can be used to help verify your previous education. A COPY OF AN OUTLINE FROM A CATALOG IS NOT ABLE TO BE USED FOR VERIFICATION.

File*

Max. file size: 256 MB.

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Equivalency / Reciprocity

Select up to three Certifications for Equivalency

Supporting Documentation Upload

Select the Certification you wish to obtain Reciprocity for:

FIREFIGHTER 1 VERIFICATION OF PREVIOUS EDUCATION

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

UPLOAD YOUR SUPPORTING DOCUMENTATION

Hazmat Awareness / Operations

FIREFIGHTER 2 VERIFICATION OF PREVIOUS EDUCATION

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

UPLOAD YOUR SUPPORTING DOCUMENTATION

INSTRUCTOR 1 VERIFICATION OF PREVIOUS EDUCATION

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

UPLOAD YOUR SUPPORTING DOCUMENTATION

INSTRUCTOR 2 VERIFICATION OF PREVIOUS EDUCATION

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

UPLOAD YOUR SUPPORTING DOCUMENTATION

INSTRUCTOR 3 VERIFICATION OF PREVIOUS EDUCATION

TYPE IN YOUR EDUCATION IN THE SPACES PROVIDED

UPLOAD YOUR SUPPORTING DOCUMENTATION

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