This application form is for EMS providers to apply to be a lab instructor for Jefferson County EMS. Once application requirements are complete, eligible applicants will be notified of their application status by email. To be considered as a lab instructor, you must be an EMT or higher for a minimum of one year at the level you wish to assist labs and be an active provider. JCEMS will request a review from the Fort Drum Regional Health Planning Organization (FDRHPO) EMS Program Agency to ensure that the proposed preceptors are in good standing within the Region, have no open Regional or State Continuous Quality Improvement (CQI) investigations, and have not been found culpable in any Regional or State CQI investigations within the past 12 months.

*Approval as a lab instructor does not equal approval as a field preceptor.

*First Name

*Last Name

*Phone

*Email

*Retype Email

*Address

*City

*State

*Postal Code

EMS Provider Information

*Current Level of Care

*NYS EMT Number

*NYS EMT Expiration Date

*Instructor Certification

Instructor Certification Number

Instructor Certification Expiration Date

*Instructor Certification Level

*EMT Certificate

Please upload a clear image of your NYS EMS certification card

CLI/CIC Certificate (if applicable)

Please upload a clear image of your NYS EMS CLI/CIC certificate

First Responder Agency Affiliation

*Primary Agency Name

*Agency Type

EMS

Fire

Fire/EMS

First Responder

*Your Affiliation

Certification of Information

I acknowledge that the information set forth on this application and attachments are true and accurate to the best of my knowledge. I give Jefferson County EMS and designated members of the instructional staff permission to contact references at EMS agencies or employers listed. I understand that any information given in references will remain confidential between the County and references. I hereby hold harmless any and all liability from the County of Jefferson, and references resulting from providing information regarding my character and abilities.

*Acknowledgment

I agree

*Signature (type your name)

Confirm

Cancel

Contact Info

Jefferson County New York
175 Arsenal Street
Watertown, NY 13601

EMS Lab Instructor Application

Contact Info

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