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Student Information FormModular Emergency Response Radiological Transportation Training
Indicate the position code(s) that apply: 1-Fire Department, 2-Law Enforcement, 3-EMS, 4-Emergency Management, 5-Regulatory/Compliance, 6-Other, 7-Local Government, 8-Hospital Staff, 9-Tribal Rep.
This form must be filled out for each student. Please PRINT all information.If the student is requesting CAPCE Continuing Education Hours, all boxes marked with (*) must be filled out.
*Last Name: *First Name:
*Org. Address:
*County:*City:
*State: *Zip: Phone:
*Email Address:
Mail Certificate to Organization
Address: City: State: Zip:
*Indicate the code that best applies as your employment status:
1- Paid Full-Time2- Paid Part-Time3- Volunteer
*Position Code:*Position
Code:*Position Code:
Requesting Medical CEH’s *State of license:
*License or cert. No: *Exp. Date (MM/DD/YY):
National Registry EMTs complete the following:NREMT Number: Re-registration Date:
*Level of License:EMT EMT-2EMT-1 EMT CCEMT-B EMT-PEMT-D EMREMT-Int CFROther AEMT
Check Appropriate Class:Compressed MERRTT
Full MERRTT Train the Trainer
Partial MERRTT
Course Start date:
Course End date:
Test score:
Instructor 1 & Organization
Course location City: State:
By signing this sheet, I hereby certify that the information is true and accurate and the student, if requesting, is entitled to receive the Continuing Education Hours (CEH).
Instructor Signature
*Basic*1 Radiological Basic 5 Initial Response 2 Biological Effects 6 Patient Handling 3 RAM Shipping Packages 10 DOE Shipping and Resource 4 Hazard Recognition 11 Waste Isolation Pilot Plant
*Operational*7 Incident Control 8 Radiological Survey Instruments and Dosimetry Devices9 Decontamination, Disposal and Documentation12 Pre-Hospital Practices 13 Transportation of Safeguard Material 14 Transportation by Rail Practical 1 Instrumentation15 Case Histories Practical 2 Patient Handling16 Public Information Officer Practical 3 Package Integrity Practical 4 Contamination Survey
Practical 5 Picture Card Practical
Note: Modules and Practical’s listed above are equal to 0.5 CEH
CEH’s Awarded per category: Basic Operational
CAPCE Activity Number: 16-CECB-F2-0696
Instructor 2 & Organization
Instructor 3 & Organization
Mail Certificate to Address Below
FEMA SID number:
*Organization Name:
Use QR Code below to retrieve your SID number
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TEPP Course Evaluation
You have participated in a program that has received Commision on Accreditation for Pre-Hosipatal Continuing Education (CAPCE) approval for continuing education credit. If you have any comments regarding the quality of this program and/or your satification with it, please contact CAPCE at: CAPCE, 12300 Ford Road Suite 350, Dallas, TX 75234, (972) 247-4442.