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Have you ever had any action taken against your First Responder certification, or has it ever been suspended or revoked for any reason? Have you ever been denied First Responder certification? Yes No If yes, thoroughly explain on the last page of this application.
Please read the following Section of the Health and Safety Code. If any portion applies to you, you may not be eligible for certification. 1798.200 (a) The medical director of the local EMS agency may place on probation any certificate holder or suspend, deny or revoke any First Responder, EMT-I, or EMT-II certificate or suspend or recommend to the authority the revocation of any EMT-P certificate issued under this division, in accordance with guidelines established by the authority, upon the finding by that medical director of an imminent threat to the public health and safety as evidenced by the occurrence of any of the following actions: (1) Fraud in the procurement of any certification under this division. (2) Gross negligence. (3) Repeated negligent acts. (4) Incompetence. (5) The commission of any fraudulent, dishonest, or corrupt act which is substantially related to the qualification, functions, and duties of prehospital personnel. (6) Conviction of any crime which is substantially related to the qualifications, functions, and duties of prehospital personnel. The record of conviction or certified copy of the record shall be conclusive evidence of such conviction. (7) Violating or attempting to violate directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate, any provision of this division or the regulations promulgated by the authority pertaining to prehospital personnel. (8) Violating or attempting to violate any federal or state statue or regulation which regulates narcotics, dangerous drugs, or controlled substances. (9) Addiction to the excessive use of, or the misuse of, alcoholic beverages, narcotics, dangerous drugs, or controlled substances. (10) Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification. (11) Demonstration of irrational behavior or occurrence of a physical disability to the extent that a reasonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired. I have read and understand Section 1798.200 of the Health and Safety code (above). I am not precluded from being certified for any reason defined in Section 1798.200, or I have enclosed a complete explanation of any item that applies to me. I am eighteen (18) years of age or older. I hereby certify that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may causes forfeiture on my part of all rights to First Responder certification in the State of California. I understand all information on this application is subject to verification and I hereby give my express permission for the Alpine, Mother Lose, San Joaquin EMS Agency to contact any employer or agency for information related to my role and function as a First Responder in California.
Remember to enclose your $30.00 application fee, and late fee if applicable, payable to the EMS Agency, copies of picture identification, First Responder and CPR certification cards and to follow all instructions on this form. PLEASE USE A PEN AND NEATLY PRINT THE REQUESTED INFORMATION IN THE PROPER SPACE. THIS FORM WILL NOT BE ACCEPTED WITHOUT YOUR SIGNATURE. COPIES OF ALL CONTINUING EDUCATION CERTIFICATES OR DOCUMENTS MUST BE ATTACHED.
I certify under the penalty of perjury, under the laws of the State of California, that I have successfully completed the courses and activities listed above, and that the corresponding hours are accurate and meet the continuing education recertification requirements of Section 100080, Title 22 of the California Code of Regulations. I understand that falsification of records will result in immediate revocation or denial of my First Responder certification under Health and Safety Code 1798.200. I also understand that the Mountain-Valley EMS Agency may audit the information given above to certify its accuracy for up to four (4) years.
If your First Responder certificate has lapsed, be sure to list additional required C.E. hours on this form. If you need additional space, please use the last page of this application. Please maintain your continuing education records for four (4) years.
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