OHA EMS Program

EMR Course Application

All applications/notifications to conduct Emergency Medical Responder (EMR) courses must be submitted at least 30 business days prior to the course start date. If you have questions or require technical assistance to complete this form, please contact the EMS Education Program at ems.education@odhsoha.oregon.gov.

Course Director Information

This will be the primary instructor who is also responsible for course administration.

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Phone

Briefly describe the course director's prehospital care experience (minimum of three years required).

CPR Certification*

I verify that the course director holds a current Basic Life Support (BLS) provider card or proof of course completion that meets or exceeds the American Heart Association (AHA) Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) guidelines.

Please select the educational experience(s) being used to meet the requirements as outlined in Oregon Administrative Rule 333-264-0100.

Please explain what other instructor training course or educational experience is being used to fulfill the Oregon Administrative Rule requirements.

Course Information

The hosting organization is the entity responsible for the course participants, who are typically associated as students, volunteers, trainees, or employees.


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Write the agency or institution name in full. Do not use acronyms.

Is the course director being contracted to teach the course on behalf of the hosting organization?

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Write the name of the course director's primary agency/institution affiliation in full. Do not use acronyms.

If the hosting organization would like to have a contact person other than the course director included on communications, input an email address below.

The medical director must be associated with the hosting organization or the course director's agency and registered in eLicense for verification by OHA EMS Program staff.

Will the course have hybrid, distance-learning, and/or asynchronous components?

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Including hybrid learning components, if applicable.

Will additional instructors be involved in teaching this course?

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Please attach:

(1) the course schedule;

(2) the course director's BLS provider card or proof of course completion; and

(3) proof of completion of the educational experience requirements.


Failure to provide all required documents will result in delays in processing the course application and may result in denial of the application.

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Would you like your organization name and course director contact information posted to the OHA-EMS webpage for EMR courses?

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If there is a website for your agency/institution that you would like to have posted, please paste the URL in the box below.

I verify that all information submitted is complete and accurate to the best of my knowledge. I fully understand that failure to comply with the requirements in Oregon Administrative Rules 333-264, furnishing any false information, or not following the approved curriculum shall constitute cause for the immediate suspension of the course and/or possible denial of future courses. The organization running the course will notify the OHA EMS Program immediately if the course director or course location is changed.


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