OKLAHOMA STATE UNIVERSITY
FIRE SERVICE TRAINING

EMS INSTRUCTOR UPDATE FORM

PLEASE PRINT ALL INFORMATION LEGIBLY

Date:                                                              Birth Date:        

Name:       		     
                          Last                                                          		First

Social Security #                                             Home Phone:         

Home Address:                                            City:                               Zip:      

Fire Dept:                                                   FD Phone #:      

Address:                                                           City:                             Zip:     
E-Mail Address:                                                  Fax:      

EMS INSTRUCTOR INFRORMATION FOR INDIVIDUAL FILE

OSU-FST Field Instructor:  Yes:   No: 

Fire Dept Instructor:  Level I     Level II 

State EMT License #:                                      Expires:       

CPR Instructor Card Type:                            Expires:      

Letter of Request form Fire Chief:                       Date:         

EMS Experience:                    # Years       Type:         

Instructor #:        

Medical Director of your EMS/First Responder Agency:          

Is the ambulance service provided by your department ?  Yes             No 

If no, list the name of the transport agency:        	

EMS Site Coordinator: