Verification Of Continuing Medical Education Form - Alaska State Medical Board
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1ALASKA STATE MEDICAL BOARD
Department Of Community and Economic Development
Division of Occupational Licensing
(333 Willoughby Street - Ninth Floor)
Post Office Box 110806
Juneau AK 99811-0806
(907) 465-2541
E-mail: license@dced.state.ak.us
MOBILE INTENSIVE CARE PARAMEDIC
VERIFICATION
OF
CONTINUING MEDICAL EDUCATION
INSTRUCTIONS:
Complete this form and have it signed by the host hospital’s emergency room physician or
nurse with whom you worked. The time being claimed in the emergency room must be utilized in a manner
that enhances the paramedic’s knowledge base and must be specifically related to the scope of practice for
paramedics as defined by regulation 12 AAC 40.370. The paramedic may claim no more than 20 hours worked
in the emergency room in this manner. Retain this document for your continuing medical education records in
the event you are audited. Please print legibly.
The following time spent in the emergency room post delivery of patients in conjunction with a mission of an
ambulance/fire fighter medical unit may be recognized by the state of Alaska as continuing medical education.
This time may be counted toward satisfying the State Medical Board’s requirements for CME for paramedics.
_______________________________________
_______________
____________________________________
Printed Paramedic Name (Last, First, MI)
AK License No.
Paramedic Signature
Time Claimed (In 15 min. Increments):
Hours:_________
Mins.:__________
Date of Education Being Claimed:
_____________________________________
DESCRIPTION OF
_______________________________________________________________________________
SPECIFIC ACTIVITY,
TOPIC, OR
_______________________________________________________________________________
PRODECURE
COVERED
_______________________________________________________________________________
I hereby certify that I worked directly with the paramedic named above in an on-the-job educational capacity on
the topics shown. I affirm to the State Medical Board that I consider this time to be individual continuing medical
education that is directly related to the duties of a mobile intensive care paramedic.
____________________________________
___________________________________
______________
Printed Name of Certifying ER MD/DO or Nurse
Signature of Certifying ER MD/DO or Nurse
Date
Alaska License No._______________________
Hospital/Institution______________________________________________________________
08-4424 (10/2000)
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