EmailMe Form - Foundations of Medical Oversight Course (FOMOC)

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

Are you requesting to participate as faculty or are you asking NAEMSP to teach a course in your state? Note: If we teach a course for your state, we will also need instructors from the state to help teach, especially related to state laws and guidelines.

Faculty Application

Teach a Course in My State

Both

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

Electronic Signature

By checking this box I am adding my electronic signature to this form.

Section 2: Course Information

Proposed Date of Course

MM / DD / YYYY

This course will be...

In-person

Virtual

Proposed Location (City, State)

Is this an NAEMSP State Chapter sponsored course?

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

Date

MM / DD / YYYY

File Upload

Checkbox

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Second option

Third option

Multiple Choice

First option

Second option

Third option