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Foundations of Medical Oversight Course (FOMOC)
Application
Section 1: Course Personnel
Requirements: Must be an active member of NAEMSP and have significant relevant experience in EMS medical oversight. Course directors must also have participated in teaching a Foundations of Medical Oversight Course with satisfactory reviews.
Name
First
Last
Current Title
Email
Prior FOMO Course(s) taught - list date(s) and location(s)
Have you served as a course director for a prior FOMO Course? If yes, list date(s)/location(s)
Qualifications to serve in this role: Please include relevant reaching experiences, NAEMSP leadership positions, EMS board certification status, experience as an EMS medical director
Course Faculty:
Course faculty may help by teaching a portion of the course. In the qualifications section under each instructor, please highlight what unique traits and experiences deem them qualified to instruct on the topic(s) being covered. We recommend a minimum ratio of one course faculty for every 10 participants in order to facilitate small group discussion. We also recommend involving state EMS officials as faculty for the Legislation and Regulation module.
Instructor 1 - Name
Current Title
Qualifications to serve in this role: Please include relevant reaching experiences, NAEMSP leadership positions, EMS board certification status, experience as an EMS medical director or expertise in topic to be taught
Any competing or relevant financial disclosures?
Yes
No
If yes, please specify
Upload CV
*
Instructor 2 - Name
Current Title
Qualifications to serve in this role: Please include relevant reaching experiences, NAEMSP leadership positions, EMS board certification status, experience as an EMS medical director or expertise in topic to be taught
Any competing or relevant financial disclosures?
Yes
No
If yes, please specify
Upload CV
Instructor 3 - Name
Current Title
Qualifications to serve in this role: Please include relevant reaching experiences, NAEMSP leadership positions, EMS board certification status, experience as an EMS medical director or expertise in topic to be taught
Any competing or relevant financial disclosures?
Yes
No
If yes, please specify
Upload CV
Instructor 4 - Name
Current Title
Qualifications to serve in this role: Please include relevant reaching experiences, NAEMSP leadership positions, EMS board certification status, experience as an EMS medical director or expertise in topic to be taught
Any competing or relevant financial disclosures?
Yes
No
If yes, please specify
Upload CV
Section 2: Course Information
Proposed Date of Course
MM
/
DD
/
YYYY
Proposed Location (City, State)
Is this an NAEMSP State Chapter sponsored course?
Yes
No
Instructor Line up: Please fill in name of faculty next to the appropriate module
Faculty/Facilitator(s)
Introduction
System Design and Response
Legislation and Regulation
Credentialing and Continued Training of EMS Providers
Clinical Care
Quality Improvement
Section 3: Attestation
I will represent NAEMSP professionally
*
Yes
I will not distribute the teaching material and exercises outside this course
*
Yes
I will use the standardized NAEMSP designed course evaluations
*
Yes
Signature
Clear
Date
MM
/
DD
/
YYYY
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