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SPRING 2015 EMT INITIAL TRAINING COURSE
REGISTRATION PACKET
Course Dates: January 13, 2015 – April 14, 2015 *Students are expected to attend all dates.*
Course Times: Tuesdays & Thursdays 6:30-10:30 p.m. and Saturdays 8:30 a.m.-4:30 p.m.
Course Location: Robert Wood Johnson University Hospital, Somerset Campus
Steeplechase Cancer Center, 3rd Floor Conference Room
30 Rehill Avenue, Somerville, New Jersey 08876
Materials Fee: $200 due with registration. Checks made payable to RWJUH. Materials fee
covers the cost of a textbook, workbook, 2 uniform shirts, blood pressure cuff,
stethoscope, and ID.
Course Fee: In addition to the registration fee, students must submit one of the following forms
of payment at the first class session in order to stay in the course:
(1) Valid Training Fund Form for volunteers from qualified agencies; OR
(2) $750 check or money order.
Fees are non-refundable once course begins.
To Register for this Course:
Please complete the following registration packet if you are interested in taking this course.
Only complete applications will be accepted. A spot will not be reserved for you until this
packet is completed in full.
Please bring completed packet with your registration fee to the RWJUH Mobile Health Services
Office on the Somerset Campus and submit to Kevin Kurzweil, Education Supervisor or mail it to
RWJUH Mobile Health Services, Attn: Kevin Kurzweil, 110 Rehill Ave., Somerville, NJ 08876.
COMPLETED REGISTRATION PACKETS ARE DUE NO LATER THAN JANUARY 1, 2015
UNLESS APPROVED BY THE COURSE COORDINATOR.
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Meet Our Staff
MARCELO ADINOLFI has 21 years of EMT and 5 years of Paramedic experience that accompanies 20
years of volunteering with Westfield Rescue Squad. During the day, he works in commercial real estate
sales, owns a court reporting agency called “Simply Steno,” and is an independent distributor for
Advocare, a company specializing in health & wellness of EMS professionals. In his evenings, Marcello
works full time as a paramedic for RWJUH-Rahway.
HEATHER APSLEY welcomes you to one of the greatest families you will ever join. She has been an EMT
for 8 years starting her journey with Branchburg Rescue Squad following many family members and
continued it at Somerset, now RWJ at Somerset. The skills she gained in EMS inspired her to pursue a
career in nursing. She has been working as a RN for a little over a year while staying involved in EMS.
Heather is excited to share the beginning of your journey through this next great chapter of your life.
DIANE HOFFMAN has volunteered with the Branchburg Rescue Squad for 20 years. In addition to
volunteering, Diane has worked doing paid EMS at Somerset Medical Center for 6 years. She is also an
American Heart Association BLS Skills Instructor and an educator for the Mobile Health Services
Education Division at RWJ. Diane loves teaching about the relationship of respect between caregiver
and patient which has affectionately earned her the nickname “Mamma D” in the EMS community.
KATHLEEN HONEYWELL welcomes you to the beginning of a career you’ll love and will pay you not
only in your pocket, but also in your heart. EMS was a late in life career change for her after seeing
how much one of her sons was enjoying volunteering. She has since been in EMS for 13 years, a
paramedic for 7 years, and an EMT Instructor for 4 years. Her Mom always said, “Find a job you love,
and you will never ‘work’ a day in your life” and she finds that has been true!
CHRIS IRELAND has volunteered in Bridgewater for 20 years, has served many squad leadership
positions including Chief, and in 2014 was publicly elected to serve the township as a fire
commissioner. He has worked for RWJUH as an Educator for 8 years and is one of our AHA Training
Center Faculty. During the day, Chris works as a music educator in the Bridgewater-Raritan Schools
having a B.M. in Music Education from Ithaca College and M.Ed in Educational Leadership from TCNJ.
WARREN KOLENDRISKI has been an EMT for 10 years with 9 years of volunteering with the Port
Reading First Aid Squad where he held the position of Chief from 2010-2013. He holds an EMT-I and
NREMT certification, is an AHA Faculty member, and an instructor for the American Safety and Health
Institute (ASHI), the National Safety Council (NSC) , and CEVO/DDC. Warren has a BS in Business
Administration/Management and a MBA, both from Monmouth University.
KEVIN KURZWEIL is our course's lead instructor. Kevin has been an EMT for 13 years and has worked
with the EMS agencies of Clark, Rahway, Care Station, Ontime, and Bradley Gardens. He spent 14
years volunteering with Clark Volunteer EMS where he was Captain for 3 years. Kevin has been a
Paramedic for 9 years working at UMDNJ, RWJUH Rahway, Somerset, RWJUH New Brunswick, and
Medcor. Kevin is currently the Education Supervisor for RWJ's Mobile Health Services.
DIRK McKENNEY is the EMT Course Coordinator for RWJ-Somerset. An EMT since 1989, he became an
EMT Instructor in 2000 and teaches at Sussex Community College, Less Stress Instructional Services,
and RWJ-Somerset. Dirk has volunteered for Hopatcong Ambulance, Hamburg First Aid Squad, and
Hardyston Rescue and has worked for Tri-State Ambulance, Linden EMS and RWJ–Somerset. In
addition to teaching, Dirk is the Information Technology Manager for a medical insurance company and
recently completed a Paramedic program in Wall, NJ.
ANN RYAN has been an EMT for 25 years and currently volunteers with Peapack Gladstone First Aid
Squad. She is also a past Captain of Califon First Aid Squad. Ann has works for RWJUH as one of our
Training Center Faculty. Ann holds a B.A. in English, a M.A. in Special Education, and is certified as a
Teacher of the Handicapped. Ann currently works at North Plainfield High School.
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Course Schedule
Date
1/13/15
1/15/15
1/17/15
1/20/15
1/22/15
1/24/15
1/27/15
1/29/15
1/31/15
2/3/15
2/5/15
2/7/15
2/10/15
2/12/15
2/14/15
2/17/15
2/19/15
2/21/15
2/24/15
2/26/15
2/28/15
3/3/15
3/5/15
3/7/15
3/10/15
3/12/15
3/14/14
3/17/14
3/19/15
3/21/15
3/24/15
3/26/15
3/28/15
3/31/15
4/2/15
4/4/15
4/7/15
4/9/15
4/11/15
4/14/15
Topics to be Covered (order subject to change)
Orientation, books, CPR
Components of EMS, EMT well being, personal protection, diseases of concern, and scene safety
Skills Practice
Lifting & Moving, EMT scope of practice, pt. consent & refusal, & other legal issues
Medical terminology, anatomy & physiology, body systems, and skills practice
Lifting and moving patients practice
Principles of pathophysiology and life span development
Evaluation on the Foundation of EMT Practice
Airway physiology, pathophysiology, using adjuncts, suctioning, special considerations, respirations,
ventilations, O2 therapy, assisting with advanced airways, and practice.
Evaluation: Airway Management
Scene Size-Up & Skills Practice
Assessment of the trauma & medical patient, critical thinking & decision making, communication &
documentation, and skills practice
Skills Practice
Evaluation: Patient Assessment
Skills Practice
Medications EMT’s administer, common medications pts. take, and assisting IV therapy
Skills practice and cardiac anatomy & physiology, acute coronary syndrome, causes of cardiac conditions,
and cardiac arrest
Skills Practice
Diabetic emergencies and other causes of altered mental status
Allergic reactions, self administered epinephrine, poisoning & overdoses, & skills practice
Abdominal conditions, behavioral & psychiatric conditions, hematologic & renal emergencies, and skills
practice
Evaluation: Medical Emergencies
Bleeding, shock, and skills practice
Soft tissue trauma, closed & open wounds, burns, electrical injuries, dressings & bandages
Musculoskeletal system, care of injuries, and skills practice
Trauma to the head, neck, and spine, treatment, and skills practice
Skills practice and lecture catch up as needed
Identifying & treating the multisystem trauma and cold, heat, water, bites, & sting emergencies
Skills Practice
Skills Practice & Evaluation: Trauma Emergencies
Obstetric and Gynecologic Emergencies
Pediatric Emergencies
Review of pediatric considerations
Child abuse & neglect, infants & children with special emergencies
Geriatric emergencies and skills practice
Emergencies with patients with special challenges
Evaluation: Special Populations
EMS Ops, hazardous materials, multiple casualty incidents, and vehicle extrication
Response to terrorism and CBRNE incidents
Final Written and Practical Exams
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Application Checklist
Use this checklist to make sure you have completed and attached the following
paperwork to make sure that you have a successful submission. A spot will not be
reserved for you in class until all documents are completed:
Student Information Sheet
$200 Registration Fee, checks made payable to RWJUH
Student Authorization Form
Performance Agreement
Create your LMS ID #: store it in a safe place & put it on your application
Statement of Health
Waiver for Hepatitis B vaccine (only if you are refusing to have it)
Check here to indicate you understand one of the following payments is
due at or before sign-in on the first day of class:
EMT Training Fund Form
$750, check / money order made payable to RWJUH
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Student Information Sheet
Name: _______________________________________
State EMS ID #: _________________
Street Address: ________________________________________________________________
City: __________________________ State: ______ Zip Code: ______________
Date of Birth: _____/______/___________
Email: __________________________________
Home Phone # (________)______-_________
T-Shirt Size (circle one):
S
M
Cell Phone # (________)______-___________
L
XL
2X
3X
4X
Emergency Contact: ____________________________________________________________
Street Address: ________________________________________________________________
City: __________________________ State: ______ Zip Code: ______________
Phone # (________)______-_________
Alternate Phone # (________)______-___________
Medical Conditions: ____________________________________________________________
Medications: __________________________________________________________________
Allergies: _____________________________________________________________________
Are you on a rescue squad? Y
N
If so, what one? _________________________________
Please tell us if you have any first aid experience (use back of more room is needed):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Student Authorization Form
FOR STUDENTS UNDER AGE 18:
I ____________________________ parent / guardian of _______________________________
give permission for my son / daughter to participate in the Emergency Medical Technician
Program being conducted by Robert Wood Johnson University Hospital at its Somerset Campus.
I have reviewed the course schedule and understand that it contains subject matter that must be
dealt with a mature fashion, requires physical contact between students during practical exercises
and lifting, moving, and bending. I also understand that my son / daughter may be photographed
and/or videotaped while in class. At no time will photographs or video be taken without their
knowledge and consent. These photographs and videos are strictly for use in class and for public
outreach. For questions or concerns, I can contact the Robert Wood Johnson University Hospital
Mobile Health Services Education Division Supervisor at (908) 595-2353.
________________________
Parent’s Name
_________________________ _________________________
Parent’s Signature
Date
FOR STUDENTS OVER AGE 18
I ____________________________ give permission to participate in the Emergency Medical
Technician Program being conducted by Robert Wood Johnson University Hospital at its
Somerset Campus. I have reviewed the course schedule and understand that it contains subject
matter that must be dealt with a mature fashion, requires physical contact between students
during practical exercises and lifting, moving, and bending. I also understand that I may be
photographed and/or videotaped while in class. At no time will photographs or video be taken
without their knowledge and consent. These photographs and videos are strictly for use in class
and for public outreach. For questions or concerns, I can contact the Robert Wood Johnson
University Hospital Mobile Health Services Education Division Supervisor at (908) 595-2353.
_________________________
Student’s Name
________________________
Student’s Signature
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_________________________
Date
PERFORMANCE AGREEMENT
First and foremost, our students should feel calm and confident when they come to this course.
The instructors' primary goal is to assist all of the students in becoming competent and apathetic
individuals and they want to see the students succeed.
If any student has an individualized education plan (IEP) or 504 plan that allows them to have
any accommodations during classroom activities or testing, our staff will gladly acknowledge the
same throughout our course. We understand this information is sensitive and will be kept
confidential within our instructional staff. If a student needs any accommodations, please notify
Mobile Health Services Education Division Supervisor Kevin Kurzweil at
[email protected].
Although seeing each student reach their fullest potential is our objective, there does have to be a
standard of academic excellence. Each student attending this course is expected to maintain a
course average of 80%. If a student drops below this 80%, the lead instructor may opt to offer
extra help, assignments, etc. If, after remediation and assistance deemed appropriate by the lead
instructor the student cannot maintain an average of 80%, they will not be eligible to complete
the course.
In addition to the academic work, students will also have skills tests where they are evaluated
with medical scenarios on their ability to respond to the patient’s condition with the appropriate
affect. If a student does not meet all critical criteria for a skills test, they will be given an
opportunity to practice and review that particular skill. If after a second evaluation the student
still cannot satisfy all critical criteria of that skill, they may become ineligible to complete the
course.
We cannot reiterate enough that we strive to have all students succeed and look forward to a very
productive course. By signing below, the student and parent/guardian where appropriate
acknowledge that they are aware of the performance expectations for this course.
_________________________
Student’s Name
________________________
Student’s Signature
_________________________
Date
If the student is under 18 years of age:
_________________________
Parent’s Name
________________________
Parent’s Signature
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_________________________
Date
CREATING YOUR EMS ID #
Go to www.njems.us
Click “Create New EMS Account” on the left, lower corner
Sign off (Click continue) on a Terms of Agreement at bottom of page.
Provide an Email Address
Please provide a personal email address which is accessed only by you. Do not use a
family email address or a joint organization email (eg. [email protected].) If you do not
have an email address, we recommend that you can obtain a free one from any of the
larger email providers such as GMAIL, HOTMAIL or YAHOO.
Create a password
Please create a password containing at least 8 characters, ideally a combination of
alphabetic, numeric and special characters. e.g. A-Z a-z 0123456789 ! @ ^ * ( )
Provide a Social Security number
Submission of the Social Security Number is required by N.J.S.A. 2A:56.44(e). The
number will be used to prevent errors and enforce federal and state laws. Please ensure
that you have entered your Social Security Number correctly. This information will only
be used by NJDHSS OEMS for the purposes of verifying your credential. Intention
misrepresentation of your social security number can be a basis for revoking your
credential.
Age Requirement: You must be 16 years of age or older to create an account.
RECORD YOUR SIX DIGIT ID AND PASSWORD!
Log back into your account.
Click ‘Apply for INITIAL EMT TRAINING’
Review your demographic information and click SUMBIT at the bottom of that page
Answer the legal questions and click submit.
Logoff.
Go back into the portal and search for the RWJ Somerset class starting January 13 th,
2015 and register.
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STATEMENT OF HEALTH
Student’s Name: __________________________________________ DOB: _________________
Note to student: You are required to have a negative tuberculosis test within the last year,
must have received your MMR vaccine, and must have a flu shot for the most recent season to
be eligible for this course. You must also have had or have started the Hepatitis B vaccine
series or complete the Hepatits B Vaccine Waiver on the next page.
To be completed by student’s physician:
1. Do you anticipate this student will be able to perform all physical
tasks associated with this course without health complications?
Students may be asked to lift up to 100 lbs., crawl on the floor,
climb in and out of ambulances, perform CPR, and maneuver
patients up and down stairs.
If you answered no, please elaborate:
_____ Yes _____ No
2. Has this student completed their Hepatitis B series?
_____ Yes _____ No
3. Has this student had a tuberculosis test within the last year? If no,
this student is required to have it prior to the first day of class.
_____ Yes _____ No
4. Has this student ever tested positive or been treated for TB?
If you answered yes, please elaborate:
_____ Yes _____ No
5. Has this student received the flu shot for the most recent season?
_____ Yes _____ No
6. If born after 1956, has this student received their MMR vaccine?
_____ Yes _____ No
7. Are there any health conditions RWJUH should be aware of
regarding this patient?
If you answered yes, please elaborate:
_____ Yes _____ No
Physician’s Name (printed)
Physician’s Signature
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Date
WAIVER FOR HEPATITIS B VACCINE
To be completed only if you have not had the Hepatitis B vaccine and do not wish to have it.
I, ________________________________________, understand that due to my
occupational exposure to blood or other potentially infectious materials I may be at risk
of acquiring hepatitis B virus (HBV) infection. However, I have declined to be vaccinated
for hepatitis B. I understand that by declining this vaccine, I continue to be at risk of
acquiring hepatitis B, a serious disease.
Student’s Name (printed)
Student’s Signature
Date
If the student is under 18 years of age:
_________________________
Parent’s Name
________________________
Parent’s Signature
_________________________
Date
Please note that the Hepatitis B vaccination is recommended for:
All infants, starting with the first dose of hepatitis B vaccine at birth
All children and adolescents younger than 19 years of age who have not been vaccinated
People whose sex partners have hepatitis B
Sexually active persons who are not in a long-term, mutually monogamous relationship
Persons seeking evaluation or treatment for a sexually transmitted disease
Men who have sexual contact with other men
People who share needles, syringes, or other drug-injection equipment
People who have close household contact with someone infected with the hepatitis B virus
Health care and public safety workers at risk for exposure to blood or blood-contaminated body
fluids on the job
People with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis, and
home dialysis patients
Residents and staff of facilities for developmentally disabled persons
Travelers to regions with moderate or high rates of hepatitis B
People with chronic liver disease
People with HIV infection
Anyone who wishes to be protected from hepatitis B virus infection
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Robert Wood Johnson University Hospital, Somerset
January 13, 2015
128661
EMT Initial Training
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