OFFICIAL OEMS ATTENDANCE ROSTER			                                   ______________
	DATE   ___________________					                          OEMS APPROVAL NUMBER
	TIME(S)   ___________                                			                                   ________________________
	TITLE    ______________________	                                                                        ¦ *HOURS APPROVED    ¦	SPONSOR   ________________________	 	                                                ¦ _2___ BASIC                  ¦   
	INSTRUCTOR  __________________________________                                    ¦ _2___ INTERMEDIATE¦												            ¦ _2___ PARAMEDIC___¦

COURSE SPONSOR OR LEAD INSTRUCTOR
1)	Provide copy of official OEMS Approval Notice to EMT’s when course is held.
2)	Provide complete and accurate information in the spaces above.
3)	Report in writing any changes to length, content, times, dates, etc to OEMS.
4)	Notify attendees of actual number hours program is approved for versus total length of program.
5)	Sign this roster in space(s) provided attesting to conduct of this course in accordance with application and outline submitted to and approved by OEMS.
6)	Forward original attendance roster(s) directly to MDPH/OEMS no later than five (5) working days after completion of program.
*EMT’S ATTENDING PROGRAM
1)	Check and record all information listed at top of this roster for your records.  Review for accuracy and report any discrepancies to OEMS.
2)	Legibly PRINT and SIGN your name after your six digit MA EMT number attesting that you attended course as described above.*
3)	Review official OEMS approval notice to check that program is approved and the actual number of credit hours awarded.
4)	Any program lacking an official OEMS Approval number may never receive credit.  Attendance is at your own risk!
FAILURE TO SIGN THE ATTENDANCE ROSTER MEANS THAT NO CREDIT CAN BE AWARDED.

Note: Under the pains and penalties of perjury, I attest that this is a true and accurate record of the conduct and actual attendance for this training course. Signature of Course Sponsor or Instructor _____________________________________

 MA EMT NUMBER		PRINT NAME				SIGNATURE  (*see EMT’s #2 above)
1.			

			

			

			

			

			

			

			
			
OFFICIAL OEMS ATTENDANCE ROSTER
                                                                                                         _____________
OEMS APPROVAL NUMBER
(SEE INSTRUCTIONS ON OTHER SIDE)

MA EMT NUMBER			PRINT NAME				SIGNATURE

			

			

			

			

			

			

			

			

			

			

			

			
			
Rev. 8/2009

                              MASTER ATTENDANCE LIST FOR EMT-BASIC REFRESHER	___________
OEMS APPROVAL NUMBER

DIRECTIONS:
1.	Fill out the top section of this form and the OEMS Attendance rosters for each session completely and accurately and make enough copies to accommodate expected number of attendees and number of sessions scheduled.
2.	Ensure that each EMT fills in the printed name, MA EMT number and signs each roster for every session.
3.	Print legibly or type the MA EMT number and name of each EMT on this form.  Enter dates of each session in the slots provided and enter attendance for each session with an (X) or (√) mark.  Session(s) not attended should be marked with a (-) or (o).  Enter written and practical exam grades in slots provided and enter actual number of hours attended in last box.
4.	Draw a single line through the MA EMT number and name of any EMT(s) that either did not attend every session, and/or failed the written and/or practical examinations.
5.	Sign the Master List and Attendance Rosters attesting to the fact that the course was held as submitted to and approved by OEMS.  Send the original rosters directly to OEMS within five (5) working days from the end of the course.  It is recommended that you use a traceable or verifiable method to send the Master List and rosters.  You should make and keep copies of the Master List and rosters for your records.

FAILURE TO SIGN THE ATTENDANCE ROSTER(S) MEANS THAT NO CREDIT CAN BE AWARDED.

EMT-BASIC REFRESHER COURSE		COURSE SPONSOR: Village Ambulance Service
Under the pains and penalties of perjury, I attest that this is a true and accurate record of the conduct of and actual attendance for this training course:						 __________________________________________________________
							Signature of Lead Instructor or Course Coordinator

NOTE:  Successful completion requires attending all mandatory topics and sessions, and passing written and practical
	exams in the minimum 24 hours.
									DATES OF SESSIONS

EMT NUMBER	

NAME (print or type)								

	PRACTICAL
GRADE	WRITTEN
GRADE	

TOTAL
HOURS	
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Rev. 8/2009
MASTER ATTENDANCE LIST FOR EMT-PARAMEDIC REFRESHER		________________________
OEMS APPROVAL NUMBER

DIRECTIONS:
1.	Fill out the top section of this form and the OEMS Attendance rosters for each session completely and accurately and make enough copies to accommodate expected number of attendees and number of sessions scheduled.
2.	Ensure that each EMT fills in the printed name, MA EMT number and signs each roster for every session.
3.	Print legibly or type the MA EMT number and name of each EMT on this form.  Enter dates of each session in the slots provided and enter attendance for each session with an (X) or (√) mark.  Session(s) not attended should be marked with a (-) or (o).  Enter written and practical exam grades in slots provided and enter actual number of hours attended in last box.
4.	Draw a single line through the MA EMT number and name of any EMT(s) that either did not attend every session, and/or failed the written and/or practical examinations.
5.	Sign the Master List and Attendance Rosters attesting to the fact that the course was held as submitted to and approved by OEMS.  Send the original rosters directly to OEMS within five (5) working days from the end of the course.  It is recommended that you use a traceable or verifiable method to send the Master List and rosters.  You should make and keep copies of the Master List and rosters for your records.

FAILURE TO SIGN THE ATTENDANCE ROSTER(S) MEANS THAT NO CREDIT CAN BE AWARDED.

EMT-PARAMEDIC REFRESHER COURSE		COURSE SPONSOR: ___________________________________________
Under the pains and penalties of perjury, I attest that this is a true and accurate record of the conduct of and actual attendance for this training course:						 __________________________________________________________
							Signature of Lead Instructor or Course Coordinator

NOTE:  Successful completion requires attending all mandatory topics and sessions, and passing written and practical
		exams in the minimum 48 hours.
									DATES OF SESSIONS

EMT NUMBER	

NAME (print or type)								

	PRACTICAL
GRADE	WRITTEN
GRADE	

TOTAL
HOURS	
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Rev. 8/2009

MASTER ATTENDANCE LIST - EMT-INTERMEDIATE ADD-ON REFRESHER	________________________
OEMS APPROVAL NUMBER

DIRECTIONS:
1.	Fill out the top section of this form and the OEMS Attendance rosters for each session completely and accurately and make enough copies to accommodate expected number of attendees and number of sessions scheduled.
2.	Ensure that each EMT fills in the printed name, MA EMT number and signs each roster for every session.
3.	Print legibly or type the MA EMT number and name of each EMT on this form.  Enter dates of each session in the slots provided and enter attendance for each session with an (X) or (√) mark.  Session(s) not attended should be marked with a (-) or (o).  Enter written and practical exam grades in slots provided and enter actual number of hours attended in last box.
4.	Draw a single line through the MA EMT number and name of any EMT(s) that either did not attend every session, and/or failed the written and/or practical examinations.
5.	Sign the Master List and Attendance Rosters attesting to the fact that the course was held as submitted to and approved by OEMS.  Send the original rosters directly to OEMS within five (5) working days from the end of the course.  It is recommended that you use a traceable or verifiable method to send the Master List and rosters.  You should make and keep copies of the Master List and rosters for your records.

FAILURE TO SIGN THE ATTENDANCE ROSTER(S) MEANS THAT NO CREDIT CAN BE AWARDED.

EMT-I ADD-ON REFRESHER COURSE		COURSE SPONSOR: ___________________________________________
Under the pains and penalties of perjury, I attest that this is a true and accurate record of the conduct of and actual attendance for this training course:					 __________________________________________________________
							Signature of Lead Instructor or Course Coordinator

NOTE:  Successful completion requires attending all mandatory topics and sessions, and passing written and practical
		exams in the minimum 12 hours.
									DATES OF SESSIONS

EMT NUMBER	

NAME (print or type)								

	PRACTICAL
GRADE	WRITTEN
GRADE	

TOTAL
HOURS	
1.													
2.													
3.													
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Rev. 8/2009

MASTER ATTENDANCE LIST FOR MULTI-SESSION PROGRAM		________________________
OEMS APPROVAL NUMBER

DIRECTIONS:
1.	Fill out the top section of this form and the OEMS Attendance rosters for each session completely and accurately and make enough copies to accommodate expected number of attendees and number of sessions scheduled.
2.	Ensure that each EMT fills in the printed name, MA EMT number and signs each roster for every session.
3.	Print legibly or type the MA EMT number and name of each EMT on this form.  Enter dates of each session in the slots provided and enter attendance for each session with an (X) or (√) mark.  Session(s) not attended should be marked with a (-) or (o).  Enter actual number of hours attended in last box.
4.	Draw a single line through the MA EMT number and name of any EMT(s) that either did not attend every session, and/or otherwise failed to successfully complete all program requirements.
5.	Sign the Master List and Attendance Rosters attesting to the fact that the course was held as submitted to and approved by OEMS.  Send the original rosters directly to OEMS within five (5) working days from the end of the course.  It is recommended that you use a traceable or verifiable method to send the Master List and rosters.  You should make and keep copies of the Master List and rosters for your records.

FAILURE TO SIGN THE ATTENDANCE ROSTER(S) MEANS THAT NO CREDIT CAN BE AWARDED.

PROGRAM TITLE:______________________________	COURSE SPONSOR: ___________________________________________
Under the pains and penalties of perjury, I attest that this is a true and accurate record of the conduct of and actual attendance for
 this training course:				__________________________________________________________
							Signature of Lead Instructor or Course Coordinator

NOTE:  Successful completion requires attending all mandatory topics and sessions.  Original attendance rosters must
	accompany this Master List.
									DATES OF SESSIONS

EMT NUMBER	

NAME (print or type)								

	PRACTICAL
GRADE	WRITTEN
GRADE	

TOTAL
HOURS	
1.													
2.													
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Rev. 8/2009