CPER - PCP AIV Equivalency Form

Primary Care Paramedic:
Autonomous Intravenous Certification Equivalency Request Form

Please complete all applicable fields to request approval for activities that may fulfill PCP-AIV Equivalency requirements.

First Name(*)

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Last Name(*)

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Email Address(*)

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Service(*)

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EHS #

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Type of Previous IV Experience

Start Date

End Date

Former ACP or PCP-IV

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Out-of-province Paramedic or EMT

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Student IV certification

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RN or RPN

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Emergency room technician, extern or equivalent

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Other

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Description of Previous Experience

Describe the training that you received prior to clinical practice. Include theory, supervised practice, evaluations, etc.(*)

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Who provided the training described above, and what is their certification?(*)

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Describe the frequency, approximate number and timeliness of your IV starts.(*)

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Does your IV experience include fluid and medication calculations, dilution and patient reassessment? Describe your experience with these skills.(*)

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What education do you feel you need to review prior to becoming IV certified?(*)

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Clinical Supervisor Name:(*)

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Clinical Supervisor Contact Information (email preferred)(*)

Please provide an email or phone number

PCP-AIV Equivalency Attestation(*)

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. Your signature is required

Primary Care Paramedic:
Autonomous Intravenous Certification Equivalency Request Form

Please complete all applicable fields to request approval for activities that may fulfill PCP-AIV Equivalency requirements.

Description of Previous Experience

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Online Forms

Primary Care Paramedic:Autonomous Intravenous Certification Equivalency Request Form

Please complete all applicable fields to request approval for activities that may fulfill PCP-AIV Equivalency requirements.

Description of Previous Experience

Quick Links

Online Forms

Primary Care Paramedic:
Autonomous Intravenous Certification Equivalency Request Form