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Maintenance of Certification Plan Application Form

Please complete all applicable fields.

Proactively submit this form to request approval for activities which may fulfill MOC requirements.

Paramedic Information

First Name(*)

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EHS #(*)

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Primary Phone Number(*)

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Last Name(*)

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Service(*)

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Email Address(*)

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Select which MOC track you are requesting:(*)

Track 1: Paramedics who have a patient contact every 90 days and more than 10 patient contacts per year

Track 2: No patient contact in 90 days or less than 10 patient contacts per year.

Track 3: Administration PCP certification with conditions

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Track 1

No documentation required, no need to submit this form

Track 2

Complete Simulated Patient Encounter Session
Submit Alternate Clinical Experience or CME for approval

Track 3

Individualized process
Requires both Service and CPER approval

TRACK 2: Simulated Patient Encounter Sessions (SPES)

No Patients in 90 Days
[I will complete and submit MedicLearn documentation for 1 SPES per quarter.]
> 10 Patient Contacts
[I will complete and submit MedicLearn documentation for 1 SPES for every 2 patients below the minimum of 10. (For example, for 6 patient contacts in the year, 2 SPES are required).] Invalid Input

TRACK 2: ALTERNATE CLINICAL EXPERIENCE (Approx. amount & context)

Occupation(s)

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Hours worked within MOC Period

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List and Describe Procedural Skills (ie. IV, IM, SQ, airway management)

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List and Describe Medications

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Other Relevant Experience

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TRACK 2: ASSESSMENTS

N/A

Critically Ill Patient

Chronically Ill Patient

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Describe your assessment of the critically ill patient:

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Describe your assessment of the chronically ill patient

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TRACK 2: OTHER EDUCATION/OTHER CME

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TRACK 3: Administrative Certification

For PCPs who want to retain their certification while working in a non-patient facing role.

I will complete the required yearly CMEs and Symposium required for this certification. I understand that my Service chief and CPER must approve this certification. Invalid Input

By checking this box, I hereby attest that the information provided is correct to the best of my knowledge. I understand that falsification of information is against the Paramedic Conduct Standard as written within the BLS PCS – General Standards of Care. All statements must be true

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