Sample Contract Agreement 
between 
(program sponsor) 
and 
(instructor name) 
This agreement is hereby entered into this _____ day of ____________, 19__, between  ________(sponsor)________ of _____(location)__________hereafter called the "Sponsor", and  _______(Course Coordinator)_____ hereafter called the "I/C". 
This agreement serves for the provision of an __(Level of Program) program to be held at the Location of Program.  The starting date of the course is ___________, and the ending date is ___________. 
The said parties, for the consideration hereinafter mentioned, hereby agree to the following: 
1. The I/C is being engaged by the Sponsor to act as its "Primary Instructor/Coordinator or Course  Coordinator" whose major duties and responsibilities are outlined and described by the Sponsor in the  description attached as Section 2. The Sponsor’s Responsibilities are outlines in Section 1. 
2. It is recognized that the I/C is an independent agent and not an employee of the Sponsor. 
3. It is recognized that this is not an exclusive agreement for services between the Sponsor and the I/C, and  that either party may enter into such additional agreements for similar services as is required. 
4. This agreement may be canceled by either party with or without cause by providing ninety (90) days  written notice from one party to the other. 
5. This agreement may not be assigned by either party to any third party. 
6. Any subcontracting of work to be performed under this agreement shall be subject to the advanced  written approval of the Sponsor. 
7. The (program sponsor)_______ agrees to indemnify and hold the _(I/C)____ harmless from and against all  claims, damages, losses and expenses (including, but not limited to, attorney fees) arising out of the  performance of this agreement. 
8. Materials produced to meet the conditions of this agreement and/or for use in programs offered under  this agreement, are the property of the Sponsor. 
9. Programs offered under this agreement must be financially self supporting unless otherwise stipulated  by the Sponsor. The course budget must be approved by the Sponsor along with prior approval for all  expenditures. 
10. The agreement shall be governed by and interpreted under the laws of the State of Michigan. 11. This agreement may be amended in writing by mutual agreement between the parties.
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Section 1: Responsibilities of the Program Sponsor 
The Program Sponsor, (Name of Sponsor) will: 
1. Be ultimately responsible for the training program. 
2. Name ____(sponsor's contact person)_____ as its primary representative for the administration of this  agreement. 
3. Pay the Course Instructor-Coordinator, (Name of IC)_________, a total of _____________. This will be paid  in four (4) equal payments of _________ on a quarterly basis throughout the duration of the course.  Payment of the final _________ will be made following completion of all course activities and  submission of paperwork to (Program Sponsor) . 
4. Provide liability insurance coverage for the I/C for this training program. 
5. Be the financial agency for the course, paying all instructors, I/Cs, etc., as well as provide for all pre approved expenditures involved in conducting this training program. 
6. Submit Application for Course Approval to the Michigan Department of Consumer & Industry Services,  EMS Division for approval.  
7. Order the textbooks for this training program and ensure that they are available to the I/C prior to the  start of the program. 
8. Maintain clinical contracts with all clinical agencies. 
9. Provide the I/C with duplication of course materials according to established procedures. 10. Assist the I/C with equipment needs according to established procedures.  
Section 2: Responsibilities of the Course Coordinator (Instructor-Coordinator). 
The Course Coordinator will: 
1. Agree to provide the Sponsor with coordination and instruction of programs as outlined in the dates of  this agreement. 
2. Be present at all classes for this program, or ensure that a qualified I/C is present. The Sponsor will be  notified in advance of this taking place. Payment may be reduced if absence is excessive. 3. Meet the goals and objectives as agreed upon by the Sponsor, and will be consistent with training  guidelines established by the Michigan Department of Consumer and Industry Services (MDCIS). 4. Adhere to all additional MDCIS requirements for an approved program. 
5. Ensure that all students are provided with the MDCIS course objectives at the first class session. 6. Ensure that all students are provided with a course syllabus at the first class session that specifically  addresses what the student must do in order to successfully complete the program. The syllabus will  also specify when and where all classes will be taught, when the instructor is available for counseling,  and how to reach him or her. 
7. As required by the Sponsor, collect all fees from the students and submit to the Sponsor. 8. Arrange for all instructors for the program assuring that all of the instructors possess the knowledge and  skills appropriate to their area of instruction. 
9. Ensure that instructors receive a copy of the MDCIS objectives concerning their topic prior to the  scheduled time for their class. 
10. Ensure that instructors receive a copy of the course text(s), along with a note outlining the pages  addressed, that the students are using prior to the class they are teaching. 
11. Be prepared to instruct any class, in case an instructor is unable to attend. 
12. Prepare all handouts for the program. 
13. Arrange for all audiovisual equipment or any other equipment needed for each class.  14. Ensure that the test instruments and procedures are evaluated throughout the course and make  recommendations for revision when necessary. 
15. As required by the Sponsor, monitor and maintain the clinical schedule and notify the clinical agency of  the schedule in advance of the student's arrival. 
16. Keep the Sponsor informed as to the status of the course.
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17. Administer the course final written and practical examinations. 
18. Inform the Sponsor of any student who fails the course and provide written documentation why the  student failed. 
19. Coordinate with the SWMS EMS Regional Coordinator for the provision of Licensing Examinations. 20. Maintain records in accordance with state and federal requirements. Additionally, educational records  compiled as a result of this agreement will be maintained no less than four (4) years from the date of the  program. Specific records regarding the administration of this agreement may be requested from time to-time by the Sponsor. These records or copies thereof will be made available to the Sponsor on a  timely basis. 
21. Agree not to compete with the activities of the Sponsor by sponsoring or serving as an agent of a  sponsor offering similar programs to those offered by the Sponsor within a reasonable time and distance  of a program offered under this agreement. 
22. Agree that any education program offered under the terms of this agreement and/or offered using the  Sponsor's name shall have the prior approval of the Sponsor. All marketing of said programs shall have  the approval of the Sponsor. 
This contractual agreement is entered into by: 
________________________________ _____________________________ 
________________________________ ______________________________ 
________________________________ ______________________________ 
________________________________ _______________________________ 
Sponsor's Representative Course Coordinator (Instructor/Coordinator) Sponsor's Name Address 
Address Date 
Date	

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SAMPLE 
Name of Sponsor 
Location of Sponsor 
POSITION DESCRIPTION 
Position Title: Program Course Coordinator (IC) Date: 
Prepared by: Revised: 
Approved by: 
______________________________________________________________________________ ENTRY REQUIREMENTS: 
1. High School Graduate 
2. EMS Provider Licensure (MDCIS) at least the EMT level 
3. Licensed EMS Instructor-Coordinator (MDCIS) 
4. BLS Instructor 
5. EMT-S/Paramedic Licensure preferred 
6. Three (3) years field experience preferred 
7. Previous course coordination experience preferred 
8. Previous instructional experience preferred 
9. Previous general administrative experience preferred 
10. Academic credentialing preferred 
______________________________________________________________________________ ORGANIZATION: 
This position exists within the Program Sponsor with primary reporting responsibilities to  _____________________________. 
This position has contact with the Program Sponsor , area Medical Directors, interfacing departments, and area  emergency medical service personnel. 
______________________________________________________________________________ HUMAN RELATIONS SKILLS: 
Must have ability to plan, coordinate and teach training programs within the scope of the contracted courses. 
Must have the ability to maintain effective interpersonal communications with EMS staff, volunteers, governmental  agencies, medical staff, and other health care/emergency service providers. 
Must have high level of confidentiality and sensitivity. 
Collaborates with other health care professionals in the care of patients. 
Respects the needs and rights of co-workers, students, patients, and the public. 
Assists in promoting and maintaining positive relationships within the EMS field. 
______________________________________________________________________________ PROBLEM SOLVING AND INITIATIVE: 
Ability to instruct well to all types of students and to deal with problems that can be presented in the training setting. Ability to work with minimal supervision/direction to accomplish desired objectives.
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Ability to gather information or research problems/concerns and present facts for action by others within reporting  responsibility. 
Individual must have the ability to exercise good judgment in decisions and be able to work with minimal  supervision/direction to accomplish desired objectives. 
Must exhibit high degree of self motivation. 
______________________________________________________________________________ WORKING CONDITIONS: 
Work can be demanding. Position requires a flexible working schedule with evenings and occasional weekend  responsibilities. Travel by personal auto to and from the courses will be required. 
______________________________________________________________________________ SPECIFIC DUTIES/RESPONSIBILITIES: 
This list of specific duties encompasses the major range of duties/responsibilities to be performed. It should be noted and  understood that this is not intended to be a complete listing and that such duties/responsibilities are subject to change and/or  adjustment. It is further understood that this listing will include all other duties as assigned. 
1. Be present at all classes for the education program, or ensure that a qualified Instructor-Coordinator is present. Notify  the program sponsor in advance of absences. 
2. Adhere to all Michigan Department of Consumer and Industry Services requirements for an approved program. 3. Arrange for all instructors for the program. 
4. Make sure that all instructors possess the knowledge and skills appropriate to their area of Position Description - Course Instructor Coordinator instruction. 
5. Ensure that instructors receive a copy of the MDCIS objectives and the course text with appropriate page numbers  concerning their topic prior to the scheduled time for their class. 
6. Be prepared to instruct any class, in case an instructor is unable to attend. 
7. Ensure that all students are provided with the Michigan Department of Consumer & Industry Services course  objectives at the first class session. 
8. Ensure that all students are provided with a course syllabus at the first class session. 
9. Collect all fees from the students and submit to the program sponsor. 
10. Maintain all course records (attendance, test results, clinical experience, etc.) for the program. 11. Submit all instructor expense forms to the program sponsor for payment. 
12. Keep records of all student payments and instructor expenses. 
13. Prepare all handouts for the program. 
14. Arrange for all equipment, including audiovisual, needed for each class. 
15. Conduct reviews of the test instruments and procedures used and make recommendations for revision when necessary. 16. Obtain all course completion materials from the program sponsor. 
17. Keep track of the clinical scheduled and notify the clinical agency of the schedule in advance of the student’s arrival. 18. Keep the program sponsor informed as to the status of the course. 
19. Administer the course final and written practical exams. 
20. Inform the program sponsor of any student who fails the course and provide written documentation of why the student  failed. 
21. Set up, with the MDCIS Regional Coordinator, the Licensing Examination.	

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SAMPLE CONTRACTUAL AGREEMENT 
between 
(program sponsor) 
and 
(Medical Director) 
This agreement is hereby entered into this _____ day of ____________, 19__, between ________(sponsor)________ of _____(location)__________hereafter called the "Sponsor", and  _______(medical Director)_____ hereafter called the "Medical Director". This agreement serves for the provision  of Medical Direction for a __(Level of Program) program to be held at the Location of Program. The starting date  of the course is ___________, and the ending date is ___________. 
The said parties, for the consideration hereinafter mentioned, hereby agree to the following: 
1. The physician named above is being engaged by the Sponsor to act as its Medical Director whose major duties and responsibilities are outlined and described by the Sponsor in the description attached as  Section 2. The Sponsor’s Responsibilities are outlined in Section 1. 
2. It is recognized that the Medical Director is an independent agent and not an employee of the Sponsor. 3. It is recognized that this is not an exclusive agreement for services between the Sponsor and the Medical  Director, and that either party may enter into such additional agreements for similar services as is required. 4. This agreement may be canceled by either party with or without cause by providing ninety (90) days written  notice from one party to the other. 
5. This agreement may not be assigned by either party to any third party. 
6. Any subcontracting of work to be performed under this agreement shall be subject to the advanced written  approval of the Sponsor. 
7. The (program sponsor)_______ agrees to indemnify and hold the _(Medical Director)____ harmless from and against  all claims, damages, losses and expenses (including, but not limited to, attorney fees) arising out of the performance of this agreement. 
8. The agreement shall be governed by and interpreted under the laws of the State of Michigan. 9. This agreement may be amended in writing by mutual agreement between the parties. 
Section 1: Responsibilities of the Program Sponsor 
The Program Sponsor, (Name of Sponsor) will: 
1. Be ultimately responsible for the training program. 
2. Name ____(sponsor's contact person)_____ as its primary representative for the administration of this agreement. 
3. Pay the course Medical Director, (Name of Medical Director), a total of _____________. This will be paid in four  (4) equal payments of _________ on a quarterly basis throughout the duration of the course. Payment of the  final_________ will be made following completion of the course. 
4. Provide liability insurance coverage for the Medical Director for this training program. 5. Prior to application for Approval to Conduct a Training Program, review the curriculum and course schedule with the Medical Director. 
6. Review with the Medical Director the responsibilities listed in Section 2. 
7. Agree upon scheduled time for the Medical Director to participate in course activities. Section 2: Responsibilities of the Medical Director.
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The Medical Director will: 
1. Agree to provide the Sponsor with medical direction of programs as outlined in the dates of this agreement. 2. Review the training curriculum, as provided by the Program Sponsor, for medical correctness. 3. Approve of all instructors that will be utilized during the program, assuring that all of the instructors  possess the knowledge and skills appropriate to their area of instruction. 
4. Review the test instruments and evaluation procedures that are used throughout the course and make  recommendations for revision when necessary. 
5. Attend, or possibly provide some of the course lecture sessions.  
6. Attend and participate in the course practical skill sessions serving as an instructor for those sessions. 7. Participate in the course final practical examinations. 
8. Discuss with the Sponsor and Course Coordinator (Primary I/C) the competency of individual students.  9. Assure the competency of students who meet the requirements to pass from the course and who apply for state examination and licensure. 
This contractual agreement is entered into by: 
________________________________ _______________________________ 
Sponsor's Representative Medical Director Printed Name and Signature Sponsor's Name Address 
Address Date 
Date	

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SAMPLE Instructor Contractual Agreement 
between 
Name of Sponsor 
(Hereinafter referred to as the Sponsor) 
and 
Name of Instructor 
(Hereinafter referred to as the Instructor) 
I. PURPOSE		
	To provide instruction in the Basic EMT program at (Location) , from (Beginning date) to (Ending date) .	
II. AGREEMENT AMOUNT		
	The Sponsor, subject to the terms of this agreement, shall provide payment of $ per hour, up to a maximum of hours, for a total not to exceed $ .	

 
III. RESPONSIBILITIES - INSTRUCTOR 
	A. The Instructor shall serve as faculty for the Basic EMT program, providing didactic and practical instruction, as assigned by the course coordinator. 
B. The Instructor shall be on time and prepared for all assignments. 
C. The Instructor shall abide by all policies of the Sponsor pertaining to faculty (attached).	
IV. RESPONSIBILITIES - CONTRACTOR		
	A. The Contractor shall provide assignments and preparation material to the Instructor on a timely basis. 
B. The Contractor shall provide payment in accordance with this agreement, based on completion of assignment(s) as certified by the course coordinator.	
V. ASSURANCES		
	A. In compliance with Title VI of the Civil Rights Act of 1964 and the Regulations of the U.S. Department of Health and Human Services issued thereunder, and Section 504 of the Rehabilitation Act of 1973, and the Rules of the Michigan Civil Rights Commission; the Instructor assures that, in carrying out this program no person shall be excluded from participation, denied any benefits, or subjected to discrimination on the basis of race, creed, age, color, national origin or ancestry, religion, sex, or marital status (except where a bonafide occupational qualification exists). This policy of nondiscrimination shall also apply to otherwise qualified handicapped individuals. 
B. It is the policy of the Sponsor to provide an environment that is free of discriminatory harassment. Discriminatory harassment is prohibited. Discriminatory harassment constitutes any behavior or pattern of behavior, malicious or benign, intended or unintended, physical or verbal, that: creates an intimidating, hostile, or offensive work/educational environment; creates an unreasonable 
interference with an individual’s work/education performance; or otherwise adversely affects employment/education opportunities.	

 

 
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VI. INDEPENDENT CONTRACTOR STATEMENT		
	Under the provisions of Section 3401 of the Internal Revenue Code of 1986, an employer must withhold income tax from all remuneration actually or constructively paid to an employee. The employment relationship herein offered is for professional educational services. Under the terms of this agreement, the Instructor is exempt from the IRS statute referred to above, because the Instructor is an “independent 
contractor” offering educational services and is required to pay all applicable payroll taxes and required FICA contributions personally.	
VII.AGREEMENT PERIOD		
	This agreement is in full force and effect from through , 19 . This agreement may be terminated by either party by giving thirty (30) days written notice to the other party stating the reasons for termination and effective date or upon the failure of either party to carry out the terms of the agreement by giving ten (10) days written notice stating cause and effective date.	
		
	Any changes to this agreement will be valid only if made in writing and accepted by all parties of this agreement.	
VIII.SIGNATURES 
For the Instructor: 
Signature Date  
For the Sponsor: 
Signature Date  
Title 		

 

9 
SAMPLE 
Position Description 
EMS Instructor 
The EMS Instructor-Coordinator is responsible for teaching within the EMS Program those courses assigned by the EMS  Director. The Instructor-Coordinator is also responsible for operational aspects of Quality Assurance and EMS Instructor  Professional Development and Education. 
Qualifications 
Required		
	1. Associates Degree in EMS	
2. State of Michigan EMS Instructor Coordinator License 
3. State of Michigan Paramedic License 
4. AHA CPR Instructor 
5. 3 years experience teaching EMS courses 
Preferred 
1. Bachelor’s Degree in EMS 
2. BLS Instructor 
3. ACLS Instructor 
4. AHA Instructor Trainer 
5. 2 years experience teaching Advanced level EMS courses 
Functions 
1. Teach EMS Courses (½ load) 
2. EMS Instructor Professional Development 
3. Coordinate Special Programs 
4. Quality Assurance/Quality Improvement 
Specific EMS Instructor Tasks 
1. Teaching (1/2 load) 
a. Fall Semester EMT ____ 5 credits b. Fall Semester EMT ___ 5 credits c. Spring Semester EMT ___ 5 credits ½ program d. Spring Semester EMT ____ 5 credits e. Spring Semester EMT _____ 1 credit 
f. Miscellaneous Continuing Education (BTLS, ACLS, AED, EMD, EMS, CE) 
g. Cover various EMS Instructor sick days, vacations, special events, etcetera. 
h. Assist with testing of students in various lab sections. 
2.Instructor Orientation 
a. Provide all new instructors with orientation to EMS area and ___ facilities 
b. Orient all new instructors to EMS and ___ policies relating to their position 		
	c. Work with new provider level instructors as they begin classes. This includes spending time working with the instructor’s lesson plans, time spent with the instructor in the classroom and time spent developing the  instructor’s tools such as syllabi and classroom activities.	
3. Instructor Education & Evaluation		
	a. Investigation of complaints, as assigned by the EMS Director related to EMS and/or CPR classes. This can  include phone reports, mailing and evaluating student surveys, meeting with students and/or meeting with  contract contracts.  
b. Reporting results of complaint investigations to the EMS Director and developing a plan of remediation for  the instructor or taking other disciplinary action. 
c. Remediation of instructors secondary to a complaint or instructor mistake.	

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	d. Quality Assurance and evaluation visits to ____ sponsored classes. Reporting on the instructor’s strengths  and weaknesses using SWOTS (see Professional Development). 
e. QA/QI using random mailing of student survey form. 
f. Compile results received from student surveys and work with instructors improve performance.	
4. Instructor Professional Development		
	a. Continuing education for instructors and instructor coordinators. 
b. Review of site visit information and development of instructor skills in weak area. This may include  remediation, continuing education, recommendation of outside continuing education (PALS, I.C. Conference  session, etcetera). 
c. Instruction in all CPR Instructor classes and many CPR-1 re-certification courses (with other I.T.’s). d. Dissemination of State of Michigan Updates and other educational materials to the proper instructors  (between 50-60 different items per year). 
e. Review of all new State or governing body requirements with proper instructors to ensure compliance.	
5. Student Advising/Scheduling		
	a. Program and career advising of all EMT, Specialist, Paramedic, and Associate Degree students once per  semester (approximately 50-60 hours per semester) 
b. Respond to all inquiries about our professional education program from prospective students. c. Interview all prospective paramedic students during the Spring and Fall Semester.  d. Assist with creating schedules which students can function with and work with students on scheduling  problems. 
e. Coordinate and schedule all clinical hours for __________. 
f. Troubleshooting with students and instructors when conflicts arise. 
g. Speak with walk in students and others with interest in our program.	
6. Accreditation		
	a. In the future, we will be required to have accreditation through Joint Review Commission however current  restructuring at the State level has postponed this task for one year. 
b. Coordinate State EMS licensure Exams at the Basic EMT, Specialist and Paramedic levels. This entails  coordinating dates and times with the EMS Regional Coordinator and scheduling State certified evaluators for  testing stations.	
7. Clinical Coordination		
	a. Develop clinical objectives for all levels of providers per the requirements of the State EMS Division. b. Development of the annual Critical Care Paramedic Clinical Guide. 
c. Weekly evaluation and coordinating visits to clinical sites with students. 
d. Monthly to weekly contact with all EMS clinical sites and coordinators. This includes 10 clinical sites in five  counties. 
e. Review all clinical paperwork and student skills for complete and proper information. f. Determine if students have completed clinical skills requirements according to State EMS Division and EMS  Department Policy. 
g. Compile results of student clinical evaluation surveys and disseminate results to our clinical partners.	
8. Other		
	a. Develop Paramedic Program Annual Student Handbook. 
b. Continual development of the Critical Care Paramedic, Emergency Medical Services Instructor Coordinator  and EMS Management program objectives. 
c. Coordinate all operational aspects of the BTLS program. This includes preparing student and faculty  precourse materials, mailing precourse materials, arrangements for on-campus facilities, arrangements for  equipment, obtaining and coordinating volunteer victims, arrangements for visiting instructor lodging,  arrangements for meals and snacks, coordinating and necessary retesting and submitting final grades.	

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CV TEMPLATE 
NAME 
ADDRESS 
CITY, STATE, ZIP 
PHONE 
  
PERSONAL INFORMATION			
	Home Address		
			
	Date/Place of Birth		
			
	Citizenship		
			
	Spouse (if applicable)		
			
	Children (if applicable)		
 EMPLOYMENT			
	Job Title Year(s) 
Organization Name City, State		
			
	Job Title Year(s) 
Organization Name City, State		
 EDUCATION			
	Name of Degree Year(s) 
Institution Name City, State		
Major: Describe major field of study here 
Minor: Describe minor field(s) of study here			
	Name of Degree Year(s) 
Institution Name City, State		
Major: Describe major field of study here 
Minor: Describe minor field(s) of study here 
  
CERTIFICATIONS, LICENSURES, PROFESSIONAL AFFILIATIONS			
		?? Bullets may be used here to list the above	

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	SAMPLE 
Practical Skill Rotation Lesson Plan 
Date: Time: 
Location: 
Primary Instructor: Assistant Instructors:													
														
	Skills: (Musculoskeletal Injuries) Splinting Practice													
		(Introduction of skills already completed)												
														
	Plan: Rotate through stations practicing splinting of long bone injuries, 													
		extremity joint injuries, bony thorax injuries, femur and hip injuries.												
	Ratio: One instructor for every three to five students (class of 15-25 students)													
	Time 			long bone  
splints		joint splinting 		thorax injuries 		femur fractures 		hip fractures		
														
	6:10 			Group A 		Group B 		Group C 		Group D 		Group E		
	6:50 			Group B 		Group C 		Group D 		Group E 		Group A		
	7:30 			Group C 		Group D 		Group E 		Group A 		Group B		
	8:10 			Break										
	8:30 			Group D 		Group E 		Group A 		Group B 		Group C		
	9:10 			Group E 		Group A 		Group B 		Group C 		Group D		
														
	Alternate plan for smaller group 
Ratio: One instructor for every 3-5 students (class of 9-15 students)													
	Time 			long bone  
splints		joint splinting 		thorax injuries						
														
	6:10 			Group A 		Group B 		Group C						
	6:40 			Group B 		Group C 		Group A						
	7:10 			Group C 		Group A 		Group B						
	7:40 			Break										
				Femur fractures 		Hip Fractures 		Combinations						
	8:00 			Group A 		Group B 		Group C						
	8:40 			Group B 		Group C 		Group A						
	9:20 			Group C 		Group A 		Group B						

Equipment List 
Long Boards Traction SplintsBlankets, Pillows 
Rigid Splints Soft Supplies (dressings, bandaging, ace, triangles)
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SAMPLE 
EQUIPMENT VERIFICATION LETTER 
Acme EMS Academy 
2000 Nowhere Ave. 
Acme, MI 
Rae Ramsdell 
Michigan Department of Consumer 
 & Industry Services 
Bureau of Health Services 
611 W. Ottawa, P.O. Box 30670 
Lansing, MI 48909 
Dear Ms. Ramsdell; 
This letter is to serve as verification that the ACME EMS Academy owns all of the required training equipment  as listed in the Education Program Approval Process packet. 
We have enough equipment for a class size of 15. If a class enrolls more than 15 students, a skill rotation lesson  plan will be developed and available for your review. 
The ability to borrow and share equipment with other EMS training programs in our area is another option and  those agreements will be developed as needed and available for your review. 
Thank you for your consideration of this statement. 
Sincerely, 
Joe Acme, EMT-P, IC 
Acme EMS Academy	

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SAMPLE 
DECLARATION OF FINANCIAL SUPPORT 
Date 
To Whom It May Concern: 
As the program sponsor of EMS education programs we recognize the need to ensure financial support.  Through various funding mechanisms, (name of sponsor) assures that we are able to and will maintain the  financial support necessary for completion of the course(s) listed below. 
Course Name Start Date End Date 
MFR 00/00/00 00/00/00 
EMT-Basic 00/00/00 00/00/00 
EMT-S 00/00/00 00/00/00 
EMT-P 00/00/00 00/00/00 
In the event of default on the part of the Instructor/Coordinator, clinical facilities, or other integral components  of the course(s), (name of sponsor) assures that the course(s) will continue and be completed in a timely manner  in accordance with MDCIS requirements. 
If you have any questions or concerns, please contact me at (900) 555-5555 
Sincerely 
____________________ 
Signature 
Name 
Chief Financial Officer 
Education Program Sponsor		

15
		SAMPLE 
Letter on Learning Resource Availability 
Acme EMS Academy 
2000 Nowhere Ave. 
Acme, MI	
Rae Ramsdell 
Michigan Department of Consumer 
 & Industry Services 
Bureau of Health Services 
611 W. Ottawa, P.O. Box 30670 
Lansing, MI 48909			
			
	Please let it be known, that the Acme EMS Academy will provide learning resources to all of its  students and the faculty. The Academy understands the criteria as outlined in the EMS Education  Program Approval packet and welcomes the opportunity for you or the Regional Coordinator to review.		
			
We have a small library containing various EMS texts and other books that provide reference for  anatomy and physiology, medical-legal, EMS Operations, Medical Control, Infection Control and many 			
	others.		
			
	Our students receive assignments that send them to the local community college library for reference  use and they are welcome to visit the hospital library.		
			
	We have several computer interactive learning programs available to the students by appointment.		
			
	Several of our faculty are in the process of developing study and evaluation tools on our computers for  the students.		
			
	Please do not hesitate to contact me with any questions about our learning resource availability. Again,  we welcome your review.		
			
	Sincerely,		
			
	Joe Acme, EMT-P, IC		
Acme EMS Academy Director			

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SAMPLE  
HOSPITAL/EMS AGENCY AGREEMENT 
CLINICAL AGREEMENT 
This agreement made this first day . By and between name of the teaching organization (agency) and name of the hospital . A Michigan nonprofit corporation at Address of hospital (The “hospital”) is  intended to set forth the working relationships between (Agency) And the hospital relating to clinical experience  for emergency medical technicians.  
INTRODUCTION 
Clinical experience is an integral part of an education program for Basic Emergency Medical Technician. 
The hospital possesses certain facilities, equipment, services and personnel (“services”) conducive to the obtaining  of these skills and is willing to grant students access to and use of such services for the purposes of their education. 
NOW, THEREFORE, in consideration of the mutual promises herein contained, the parties agree as follows: 1. Scope of Services 
1.1 (Agency) agrees during the term of this agreement to: 
a. Schedule student and their respective clinical experiences at times agreed upon by  
(agency) and the hospital. A copy of the schedule will be supplied to the hospital in  
advance of each students participation. 
b. Appoint a representative for clinical coordination (“Clinical Coordinator”) who shall be  a licensed Paramedic and who shall coordinate all aspects of this agreement with the  
designated hospital representative. 
c. Orient the hospital representative to the objectives of the program and the teaching  
methods employed. 
d. Review and select qualified students for the participation in the program. 
e. Require evidence of an annual chest x-ray or tuberculosis skin test, rubella vaccination  or evidence of rubella titer 1;8 or above, and Heptavac B vaccination of students in  
direct contact with patients. Faculty and students must comply with attached student  
immunization requirements. 
f. Cause the students participating in the program to abide by applicable rules and  
regulations set by the hospital and to report to the hospital representative in charge  
while on the hospital premises. 
g. Provide professional liability insurance and general liability insurance in the amount of  one million dollars per occurrence with an aggregate of three million dollars. 
h. Students must be trained in OSHA blood borne pathogen before clinical experience. 
1.2 The hospital agrees during the terms of this agreement to: 
a. Permit students access to and use of its services in accordance with the instructional  plan established by (agency) and the hospital. 
b. Appoint a representative (“hospital representative”) who will coordinate the use of  
hospital services by the students. 
c. Provide access to the cafeteria for students who shall pay for their own meals. 
d. Provide emergency medical care consistent with hospital policies to students in the  
program should such care become necessary while students and faculty are on hospital  
premises. The recipients of such care are solely responsible for payment for services  
rendered. 
e. Provide access to and use of various sources of information for educational purposes,  including but not limited to, nursing station references, pertinent procedures and policy  
manuals, standard clinical references such as medical dictionaries and information on 
17 
diagnostic tests, drugs, etc. And use of the library and audio equipment as may be  
available. 
f. Upon request, hospital will furnish a copy of pertinent hospital rules, to clinical  coordinator and regulations. 
2. Policies and Procedures (agency) will comply with the hospital’s policies, rules, regulations and  procedures related to patient safety, including but not limited to appropriate health requirements, infection  control procedures and general safety requirements. 
3. Limitations on Clinical Access. The hospital reserves the right to restrict any and all student activity  when, in the sole direction of the hospital representative, the welfare of any patient so required such  restriction. The hospital, in consultation with the clinical coordinator, further reserves the right to refuse  access to its clinical areas to any student who fails to conform with pertinent hospital rules and  regulations. 
4. Liability Insurance (agency) and the hospital shall procure and maintain such policies of comprehensive  general liability insurance, professional liability and other insurance, as shall be deemed necessary to  insure their officers, students, agents, and employees against any claim or claim for damages of any kind  occasioned directly or indirectly by the terms of this agreement. Upon request, each party agrees to  provide the other with certificates evidencing the foregoing insurance coverage. 
5. Indemnification (agency) shall indemnify and save harmless the hospital from and against liability for  personal injury, death, or property damage caused directly or indirectly by any act or omission by the  hospital or its employees, agents, or representatives pursuant to this Agreement. 
6. Terms of agreement. The terms of this agreement shall be for twelve (12) months commencing as of  , and shall continue until terminated: (I) by notice to the other, in the event that the other party upon sixty  (60) days prior written notice to the other, in the event that the other party fails or refuses to perform any  of its duties and responsibilities under this agreement. 
7. Assignment. Neither this agreement, nor any interest created hereby, may be assigned by either party  without the express written consent of the other party. 
8. Third parties. This agreement shall be enforceable only by the parties hereto and their successors in  interest by virtue of an assignment which is not prohibited under the terms of this agreement and not  other person shall have the right to enforce any of the provisions contained herein. 
9. Amendments. This agreement may be amended at any time by mutual agreement of the parties hereto,  provided that before any amendment shall be operative or valid, it shall be reduced to writing and signed  by both parties. Such amendments or modifications shall be attached hereto and become part of this  agreement. 
10. Complete agreement. This agreement executed by the contracting parties contains the entire  understanding may not be modified except in writing signed by the parties. 
11. Severability. If any provision of this agreement is found to be unenforceable or illegal, the remaining part  of the agreement shall remain in effect and be enforceable. 
By:  
Its:  
By:  
Its: 
18 
SAMPLE Clinical Contract 
Agreement Between 
______________ 
and 
________________ 
This Agreement is entered into between _____________, henceforth know as the agency, and ______________ henceforth known as the clinical facility, on date , know as the effective date. 
The purpose of this Agreement is to set forth the terms and conditions under which the agency and the clinical  facility (collectively, the "Parties") will engage in a program for the clinical education of agency EMS students  enrolled in the agency EMS education programs.  
Responsibilities/Rights of the clinical facility: 
1. To provide clinical experiences for the students of the agency in specific areas identified at the time of  student placement. For the purpose of this Agreement, the placement is defined as clinical facility  location. 
2. To provide the clinical experience and assume the following responsibilities: a. To assist the agency in supervising the students while on site at the clinical facility. (NOTE: Ultimate supervision of the students is the responsibility of the agency). 
b. To cooperate with the agency in the planning of the student's education experience so that the  experience may be appropriate in light of the agency's education plan. 
c. To make available information for educational purposes, such as policies, procedures and  clinical reference material available at the clinical facility. 
d. Be aware that each student is responsible for the costs of any medical care for any illness or  injury that might be sustained while the student is participating in this experience at the clinical  facility. 
3. To terminate a student from continuing his/her clinical experience at the clinical facility at their  discretion at any time. 
Responsibilities/Rights of the agency: 
1. To advise students and instructors, and enforce compliance with, all existing policies, rules and  regulations the clinical facility including, but not limited to the confidentiality of patient and clinical  facility records and information. 
2. To assign students with preparation in the foundation of the Emergency Medical Services Program and  to provide evidence of competency in the skills of this program. 
3. Appoint a representative for clinical coordination ("Clinical Coordinator") who shall coordinate all  aspects of the Agreement with the designated clinical facility representative. 
4. To provide evidence of an annual chest x-ray or negative tuberculosis skin test, and rubella vaccination  or evidence of rubella titer 1:8 or above, from each student and instructor. 
5. To provide the clinical facility documentation that each student and instructor has been offered, and  have either received or declined, hepatitis B vaccine before participating in this Program. 6. To provide pre-clinical instruction to each student in accordance with standards mutually agreeable to  both parties, including all MIOSHA required training, which includes but is not limited to blood borne  pathogens, prior to the educational experience and to present for clinical experience at the clinical  facility only those students who have satisfactorily completed the pre-clinical instructional program. 7. To have full responsibility for the conduct of any student, instructor disciplinary proceedings and  conduct the same in accordance with all applicable statutes, rules, regulations and case law.
19 
8. To maintain general public liability and professional liability coverage for its instructors and students  with minimum limits of liability of One Million Dollars ($1,000,000) per incident and shall furnish the  clinical facility appropriate certificates of insurance evidencing such continuous current coverage before  the beginning of the clinical experience. 
9. To indemnify and hold harmless the clinical facility, its employees, and agents, from all claims, liability  or damages, including reasonable attorney's fees, which the clinical facility or its employees or agents  may incur as a result of claims or costs of judgments against any of them arising out of acts or omissions  of the agency's instructors, staff or students while in the performance of their responsibilities under their  Agreement. 
10. To indemnify and hold harmless the clinical facility, its employees and agents from all claims, liability  or damages, including reasonable attorney's fees, which the clinical facility or its employees or agents  may incur as a result of claims or costs of judgments against any of them regarding injuries to the  agency's students arising out of their participation in the classes described under this Agreement. 
11. The agency shall maintain all educational records and reports relating to the educational experience  completed by individual students at the clinical facility, and the clinical facility shall have no  responsibility regarding the same. The clinical facility shall refer all requests for information of such  records to the agency. The agency agrees to comply with all applicable statutes and regulatory  requirements respecting the maintenance of and release of information from such records. 
12. The agency shall certify that each student has provided it with evidence that the student has passed a  physical examination prior to beginning education experience and shall certify that such evidence  indicated at the time of the physical examination the student was free from contagious diseases as could  be ascertained by such examination. 
13. The agency shall have full responsibility for the conduct of any disciplinary proceedings concerning any  student, however, the clinical facility, at its sole discretion, may deny the educational experience to any  individual. 
14. The agency agrees, and shall obtain from each student and furnish to the clinical facility a written  agreement of each student acknowledging, as a condition of being able to participate in the educational  experience, that the Student: 
a. shall comply with all the clinical facility rules, regulations, policies and procedures; b. shall comply with all directives of the clinical facility regarding conduct; 
c. shall refrain from touching in any way any patient except at the patient's consent and with  the clinical facility personnel's authorization; 
d. shall not be considered an employee of the clinical facility for the purpose of this agreement; e. shall not disclose information without written authorization by the clinical facility regarding  any patient's care, including the identity of the patient or the services performed for that patient;  and 
f. shall upon request leave an area of the clinical facility. 
Major Responsibilities of the agency students, under the direction of the agency: 
1. To adhere to existing policies and procedures of the clinical facility. 
2. To report for clinical experiences as assigned or call to report absences. 3. To respect the patients right to confidentiality. 
4. The agency will notify students of 1-3 above.
20 
GENERAL PROVISIONS: 
The parties mutually acknowledge and agree as follows: 
A. Students of the agency shall not be deemed to be employees of the clinical facility for purposes of  compensation, fringe benefits, workers' compensation, unemployment compensation, minimum wage  laws, income tax withholding, social security, or any other purpose, because of their participation in the  EMS program. Each student shall be placed with the clinical facility to receive clinical experience as a  part of his/her academic curriculum. The duties performed by a student shall not be performed as an  employee, but in fulfillment of the student's academic requirements. At no time shall students replace or  substitute for any employee of the clinical facility. The provisions of this section shall not be deemed to  prohibit the employment of any such student by the clinical facility under a separate employment  agreement. The agency shall notify each student of the requirements of this paragraph. 
B. In the performance of their respective duties and obligations under this Agreement, each party shall be  an independent contractor and neither shall be the employee or servant of the other, and each party shall  be responsible for their own conduct. 
C. Each party shall be responsible for compliance with all laws, including anti-discrimination laws, which  may be applicable to their respective activities under the EMS program. 
D. No provision of the Agreement shall prevent any patient from requesting not to be a teaching patient or  prevent any member of the clinical facility professional staff from designating any patient as a non teaching patient. 
E. Neither this Agreement nor any part of it shall be assigned by either Party without prior written consent  of the other Party. 
F. This Agreement constitutes the entire agreement between the parties, and all prior discussion,  agreements and understandings, whether verbal or in writing, are merged in to this agreement. There  may be no amendment of the Agreement, unless the same is in writing and signed to the party to be  charged. 
G. This Agreement shall be effective as the Effective Date and shall continue thereafter until terminated by  either party upon 30 days advance written notice of termination, with or without cause. 
H. Students will be placed at the clinical facility without cost to the clinical facility. This Agreement shall  be in effect for one year as of _________________, and may be renewed annually. 
The Clinical Facility The Agency 
_____________________________ Date__________ __________________________ Date___________ Signature Signature
21 
SAMPLE EDUCATIONAL AFFILIATION AGREEMENT 
This Education Affiliation Agreement (“Agreement”) is entered into this _______day of______, 19___, by and between * and______________________________________________________________ located at  ___________________________________, hereinafter called _______________________________________. 
The parties wish and intend by this Agreement to set forth the terms and conditions of engaging in a program for  the clinical education at * of students enrolled in __________________________ School for training. 
TERMS 
I. EDUCATIONAL PROGRAM __________________________________ shall, in consultation with  representatives of * , plan and administer the educational program for its students at __________________________ , and  shall assume the following responsibilities: 
A. Overall Educational Plan: ____________________________ shall provide * with its overall plan for use of  clinical facilities at least three months prior to the commencement of the academic year. The plan shall include details of  ____________________________’s educational program at * including the objectives, and approximate number of  students for each term, dates, times, and levels of each student’s academic preparation. __________________________  shall modify its educational program as necessary to accommodate the requirements of  
__________________________________. 
B. Student Names: __________________________________, will provide names of students as soon as possible  after registration for each semester, but in no event later than one week before the beginning of the clinical experience  program at *. 
C. Preclinical Training: _________________________________ agrees to provide adequate preclinical instruction  to each student, in accordance with standards mutually agreeable to * and ______________________________, and to  present for clinical experience at * only those students who have satisfactorily completed the preclinical instructional  program. 
D. Compliance with * Policies: _____________________________________  
shall instruct all of its students assigned to * with regard to and shall monitor compliance with all rules, regulations and  policies and procedures of *, including but not limited to those relating to the confidentiality of patient and *, records and  information, and to the responsibility and authority of the medical, nursing, and administrative staff of * over patient care  and * administration and the* Student Policy, a copy of which is attached as Exhibit A. 
______________________________ shall instruct all of its students that * identification badges must be worn at all time  students are participating in * educational activities. 
E. Educational Records: __________________________________ shall maintain all educational records and  reports relating to the educational program completed by individual students at *, and * shall have no responsibility  respecting the same. * shall refer all requests for information respecting such records to ___________________________  and ____________________________ agrees to comply with all applicable statutes, rules and regulations respecting the  maintenance of and release of information from such records. 
F. Student Health Status: Subject to the requirements of the Americans with Disabilities Act,  __________________________________ shall certify that each student has provided it with evidence that the student has  passed a physical examination of a scope within time periods satisfactory to * and shall certify that such evidence indicated  that at the time of the physical examination, the student was free from contagious diseases as could be ascertained by such  examination. __________________________________ shall furnish * with written evidence that each student presenting  for participation in the clinical experience had undergone HBV vaccination, or that such student has been informed of and  advised to be so vaccinated, but has refused.
22 
G. Student Discipline: ____________________________________ shall have full responsibility for the conduct of  any student disciplinary proceedings and shall conduct the same in accordance with all applicable statutes, rules,  regulations and case law. 
H. Declined Students: No provision of this Agreement shall prevent * from refusing to accept any student who has previously been discharged for cause as an employee of *, who has been removed from or relieved of responsibilities for  cause by *, or who would not be eligible to be employed by *. *shall in writing of its refusal to accept student for clinical  experience at *. * may submit a written request to _______________________________ for the withdrawal of any student  from the program after the commencement of the student’s clinical experience at *. * may submit a written request to  ________________________________ for the withdrawal of any student from the program after the commencement of the  students clinical experience at * for a reasonable cause related to the need for maintaining an acceptable standard of patient  care, and ____________________ shall immediately comply with such request. The written request from * shall set forth  the basis for removal. 
II. PATIENT CARE PROGRAM, * shall plan and administer all aspects of patient care at * and shall assume the  following responsibilities: 
A. Supervision of Patient Care: * shall provide qualified supervision of all patient care activities. * supervisory  personnel may, in an emergency, or in certain cases based upon applicable standards of patient care, temporarily relieve a  student from a specific assignment or require that such student leave a vehicle, accident scene or * Division pending a final  determination of the future status of the student by the parties. 
B: Staff Time: * shall provide staff time for the following purposes: 
(I) Orientation of ____________________________ faculty to * physical plant and it’s operational policies, procedures, rules, and regulations; 
(ii) Planning, in conjunction with _________________________ faculty, students’ clinical field work experiences at *; and 
(iii) Conferences and consultations with students concerning the students’ carrying out of their clinical field work experiences at *. 
C. Implementing the Student Experience: * shall cooperate with ________________________ in the planning  and conduct of the students’ clinical experience, to the end that the students’ clinical experience may be appropriate in light  of ______________________________ educational objectives. 
D. Non-teaching Patients: No provision of the Agreement shall prevent any patient from requesting not to be a  teaching patient or prevent any member of * clinical staff from designating any patient as a non-teaching patient. 
E. * Amenities: * shall make available the use of its cafeteria, conference rooms, dressing rooms and library as  available and as required by the educational program and without charge except for food consumed by the students. 
F. Student Health Care: Students may use the emergency and outpatient services of ________________________  for medical care of themselves while they are participating in the educational program at the cost customarily charged to the  general public for such services. 
III. GENERAL PROVISION, The parties mutually acknowledge and agree as follows: 
A. Indemnification: 
1. ___________________________________ agrees to indemnify, defend and hold *, its directors, officers and  employees harmless from and against any claims, liabilities, losses, costs or expenses of any kind or nature arising out of  the actions or omissions of ____________________________, its faculty or its students in connection with the clinical  experience provided for in the Agreement. 
2. * agrees to indemnify, defend and hold _____________________________________ its directors/trustees,  officers and employees harmless from and against any claims, liabilities, losses, costs or expenses of any kind of nature  arising out of the actions or omissions of *, its directors, officers, or employees.
23 
3. If a court or administrative tribunal of competent jurisdiction determines that ___________________ is  constitutionally or statutorily prohibited from complying with its obligations under subparagraph (2) of this paragraph,  then: 
(I) both subparagraphs (1) and (2) shall be invalid and unenforceable against either  
_____________________________ or *. 
(ii) the invalidity an unenforceability of subparagraph (1 and (2) shall not invalidate or  
Render unenforceable the remainder of the Agreement; and 
(iii) the obligations of the parties respecting apportionment of liability shall be governed by common law and statutory theories and principles of indemnity, contribution and equitable 
restitution. 
It is expressly agreed that neither ________________________________ nor * shall assert in any proceeding that  ____________________________ shall constitutionally or statutorily prohibited from complying with the indemnification  or defense obligations stated in subparagraph (1) of this paragraph. 
B. Insurance 
1. ________________________________ Coverage: Throughout the term of this Agreement,  _____________________________ shall maintain in full force and effect comprehensive general liability and professional  liability insurance covering ______________________________ its employees and faculty wherever  __________________________________ liability may exists. This comprehensive general liability insurance and  professional liability insurance shall provide for liability limits of $__________________ per occurrence/claim,  $______________ annual aggregate, respectively, for each type of coverage. If the coverage is on a claims-made basis,  _____________________or the student, as applicable, shall provide for commercially reasonable tail coverage. All  insurance shall be placed with an insurer admitted to do business in Michigan that is acceptable to *.  ______________________ shall furnish * with written evidence of all insurances provided for in this Agreement no later  than one week prior to the commencement of the clinical experience each academic year. __________________ shall give  * at least (10) days’ advance written notice of any threatened or actual cancellation, termination or modification of the  insurance provided for herein. 
2. Student Coverage: _____________________________ (or its _______________________ Program) shall  require each assigned to * to keep and maintain in full force and effect a professional liability and personal liability  insurance policy. ________________________________ (or its_______________________ Program) shall ascertain that  each student assigned to * has complied with this requirement, and shall furnish evidence of such compliance to * upon  request. 
C. Legal Compliance: Each party shall be separately responsible for compliance with all laws, including anti discrimination laws, which may be applicable to their respective activities under this program. 
D. No Employment Relationship: Students of ________________________________ shall not be deemed to be  employees of * for purposes of compensation, fringe be3nefits, workers compensation, unemployment compensation,  minimum wage laws, income tax withholding, social security or any other purpose, because of their participation in the  educational program. Each student is placed with * to receive clinical experience as a part of his or her academic  curriculum; those duties performed by a student are not performed as an employee, but in fulfillment of these academic  requirements and are performed under supervision. 
At no time shall students replace or substitute for any employee of *. This provision shall not be deemed to prohibit the  employment of any such student by * under a separate employment agreement. ______________________ shall notify  each student of the content of this paragraph. 
E. No Monetary Consideration: There shall be no monetary consideration paid by either party to the other, it being  acknowledged that the program provided hereunder is mutually beneficial. The parties shall cooperate in administering this  program in a manner which will tend to maximize the mutual benefits provided to ____________________ and *.
24 
F. No Third-Party Benefits:This Agreement is intended solely for the mutual benefit of the parties hereto, and there  is no intention, express or otherwise, to create any rights or interest for any party or person other that * and  _______________________; without limiting the generality of the foregoing, no rights are intended to be created for any  patient, student, parent or guardian of any student, employer or prospective employer of any student. 
G. Independent Contractor In he performance of their respective duties and obligations under this Agreement, each  party is an independent contractor, and neither is the agent, employee or servant of the other, and each is responsible only  for its own conduct. 
H. Entire Agreement This Agreement constitutes the entire agreement between the parties, and all prior discussion,  agreements and understandings, whether verbal or in writing, are hereby merged into this Agreement. 
I. Amendments to Agreement No amendment or modification to this Agreement, including any amendment or  modification to this paragraph, shall be effective unless the same is in writing and signed by the party to be charged. 
J. Term of Agreement This agreement shall become effective as of _______________________ and shall continue  thereafter until terminated by either party upon forty-five (45) days’ written notice of termination with or without cause. 
K. Notice Any notice under this Agreement shall be directed to: 
* 
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first above  written 
---------------------------------------- _________________________________  Witness Signature & title 
* Insert name applicable facility/service
25 
SAMPLE 
Clinical Attendance Verification and Assignment 
Student Name ________________________________ 
Clinical Facility/EMS Agency __________________________ 
Date _________________ Time In ____________________ Time Out_______________ Clinical Facility Staff Signature ______________________________________ 
Clinical Objective: 
(The EMS instructor or student inserts an objective here related to the expected outcome of the student having completed  the clinical assignment.) 
Student Assignment: 
Please describe the activities of this clinical assignment. Please detail how these activities helped you to meet the above  objective(s).
26 
SAMPLE 
EMS STUDENT CLINICAL ATTENDANCE 
AND VERIFICATION LOG 
Clinical Facility/EMS Agency  
Address  
Please have student sign out when clinical assignment is complete. 
Staff member should witness and sign. 
Any comment regarding student attendance is appreciated.
Date 	Student Name 	Time In 	Time Out 	Staff Signature 	Comments	

						

						

						

						

						

						

27 
SAMPLE 
STUDENT CLINICAL EVALUATION FORM 
While attending the clinical facility, the following skills will be observed or performed: 
Potential Skills: 	Performed 	Observed	
Adult Assessment			
Pediatric Assessment			
Airway (OPA, NPA, Combitube)			
Vital Signs			
Bandaging			
Splinting			
CPR			
Spinal Immobilization			
Radio Communications			
Documentation			

Comments:  
Date Time In Time Out  
Student Signature  
Staff Signature 
28 
SAMPLE CLINICAL ORIENTATION CHECKLIST 
CLINICAL ORIENTATION CHECKLIST 
SAFETY ORIENTATION 
(To be completed by instructor and kept in student record) 
A. Policies and Procedures Instructor’s Initials 1. Blood borne Pathogen Exposure Control Plan 
a. Overview of policies and procedures  
b. Review control plan  
c. Site specific plan including cleaning schedule  
2. Respiratory Protection Plan and Exposure Control Plan-TB 
a. Baseline education on TB  
b. Site specific plan  
c. Mask fitting  
d. Overview of policies and procedures  
3. Right to Know 
a. MSDS  
b. Hazard communication  
c. Hazmat  
d. Safe medical devices - patient care area  
B. Health and Fitness 
1. Physical - Hep B, TB test, medical evaluation form  
2. Fit for duty  
3. Pre-employment drug and ETOH testing  
C. Safety Review 
1. Safety concerns  
2. PPE and Masks  
3. Student employee injury reporting  
4. Student employee exposure reporting  
5. Signage and where site OSHA information available 
29 
SAMPLE 
Clinical Objectives for Basic EMT Program: 
All EMS students will visit the Hospital Emergency Department for two 8 hour shifts. The following objectives will be met during these visits. 
First 8 hour shift: 
During the clinical visit to the hospital emergency department, the EMT student will: 
1. Observe the communication between the EMS personnel and the ED staff via the radio and upon their  entry with a patient to the emergency department. 
2. Observe the professionalism of the EMS personnel when communicating with the ED staff and the  patient upon entering the ED and the transfer of the patient's care. 
3. Observe and participate in the transfer of the patient from the ambulance stretcher to the ED cot. 
4. Observe the areas utilized by EMS personnel for delivery of patients, cleaning equipment, report  writing, etc. 
5. Observe and discuss with the EMS personnel their documentation of pre-hospital care. 6. Observe and participate in the patient assessment done in the emergency department. 7. Observe and participate in the collection of emergency patient vital signs. 
8. Observe emergency care provided in the emergency department. 
Second 8 hour shift: 
During the clinical visit to the hospital emergency department, the EMT student will: 1. All of the objectives listed above. 
2. Participate in the transfer of patients to other units of the hospital. 
3. Be responsible for frequent vitals signs on one or more patients and the reporting of those to the staff. 
4. Observe and participate in the emergency care provided to patients in the emergency department such as  bandaging, stabilization of limbs during suturing/splinting/casting, cervical spine immobilization, basic  airway management.  
5. Stay in attendance of patient during radiological procedures.
30 
SAMPLE CLINICAL OBJECTIVES 
for 
Emergency Departments, Cardiac Care Unit, etc. 
The Clinical rotation in the ED is designed to provide the Paramedic Student, under the direct supervision of a  qualified preceptor, an opportunity to gain valuable practical and/or observational experience in the following areas: 
1. Performing Physical Assessments. 
a. obtaining, recording, and monitoring vital signs (b/p, pulse, and resp.) 
b. obtaining clinical history 
c. auscultation of lung and heart sounds 
d. neurologic, cardiovascular, and respiratory systems evaluation 
e. other pertinent body system evaluations (such as urinary output, etc.) 
2. Respiratory Therapy and Airway Care 
a. oxygen administration 
b. assisting respirations manually 
c. endotracheal and nasotracheal intubation 
d. endotracheal tube care 
e. suctioning techniques (nasal, oral, and endotracheal) 
f. care of ventilator patients 
g. interpretation of blood analysis 
h. using pulse oximetry and interpreting readings 
3. Use of Cardiac Monitoring and Defibrillator Systems 
a. application of cardiac monitor 
b. changing lead configurations 
c. interpretation and management of cardiac dysrhythmias 
d. performing manual defibrillation 
e. performing synchronized cardioversion 
f. application of transcutaneous cardiac pacemaker 
g. observation of insertion of transvenous cardiac pacemaker 
4. Preparation and Administration of Medications 
a. oral route 
b. intramuscular route 
c. subcutaneous route 
d. intravenous route 
5. Fluid therapy and Hemodynamic Monitoring 
a. starting, maintaining, and discontinuing peripheral IV’s 
b. using mechanical IV pumps 
c. observation of insertion, monitoring, and discontinuance of CVP and Arterial lines 
d. interpretation of CVP and Arterial line measurements 
6. Phlebotomy 
a. drawing blood samples via venous access 
b. observation of drawing blood samples via arterial access 
7. Emergency Resuscitation 
a. charting patient care
31 
b. performing advanced cardiac life support procedures (AHA guidelines) 
c. use of the “crash cart” system 
8. Documentation 
a. charting patient care 
b. measuring and charting intake and output 
c. charting medication administration 
d. charting hemodynamic measurements 
9. Other 
a. practice interpersonal relationship skills with patients, family, and other members of the health care  team. 
b. using universal precautions and various types of isolation techniques 
c. interpretation of x-rays, CT scans, angiography, and other diagnostic tests 
d. assist in hemorrhage control, splinting, bandaging, and suturing of wounds 
e. observe and/or assist in the insertion of chest tubes 
f. observe and/or assist in the insertion of nasogastric tubes
32 
SAMPLE  
HEALTH & SAFETY POLICIES 
Health/Vaccination Requirements 
Prior to beginning the EMS training program, the student must receive and show proof to 
the Academy's Clinical Coordinator: 
Hepatitis B Vaccine series  
Standard Immunizations: 
a. Tetanus and Diphtheria Toxoids 
b. Measles Vaccine* 
c. Mumps Vaccine* 
d. Rubella Vaccine** 
e. Poliovirus Vaccine 
f. Varicella Vaccine** 
*Born since 1956 must have documentation of two doses on or after 1st birthday or proof of seropositivity 
**Must have documentation of vaccination on or after 1st birthday or proof of seropositivity 
TB Testing 
The student will receive TB testing or chest x-ray from an approved Public Health source and provide proof of testing every year  they are enrolled in the EMS program.  
Student Health 
Students are not to attend a clinical site if they are ill and at risk to spreading a contagious illness. If more than one clinical  assignment is missed, a doctor's examination and proof of release will be necessary. If any questions regarding health issues arise,  contact the Academy's Clinical Coordinator. 
Student Infectious Exposure 
As explained in the Clinical Orientation Program, any student who believes they have received an exposure to an infectious agent  should contact their clinical supervisor, their instructor, or the Clinical Coordinator immediately. The documentation of the exposure will be completed on the Exposure Reporting Form. The supervising instructor will assist the student through the process  of reporting and follow-up evaluation as needed. 
Students who are exposed to tuberculosis through patient contact, shall receive a baseline TB test and re-test in 3 months, or as  otherwise recommended by physician. 
Classroom/Clinical Program Safety 
Students must attend the Clinical Orientation Program before participating in any clinical assignment. 
Students shall be supervised in all classroom and clinical areas. The student is responsible to determine when they should not  participate in an activity that they believe to be a risk to their health or safety. 
Students will participate in the classroom acting as patients and rescuers. Students must understand they will be in close contact  with others so cleanliness and good personal hygiene is expected. The instructor reserves the right to dismiss the student from that  class for lack of either.  
Lifting/Carrying: No student shall be moved on a backboard unless three straps are in place. The instructor shall monitor this process and other students must be available to assist as needed. Students will not be carried out of the classroom without specific  permission and supervision from the instructor. 
Universal Precautions will be utilized in all classroom and clinical areas as indicated. Students will not be allowed to start IVs or  administer medications to each other. 
Electrical devices will only be used with the close supervision of the instructor.
33 
SAMPLE INFECTIOUS EXPOSURE POLICY AND REPORT EMS Program Infection Control Policy and Procedure 
Any information obtained or exchanged regarding communicable disease exposures must be handled with strict confidentiality. 
I. This policy and procedure will be utilized for students, faculty, and ancillary personnel in the practical lab classroom and in all clinical observation/participation settings.  
II. Universal Precautions and Body Substance Isolation (BSI) Policy  
A. Purpose: To prevent the transmission of all bloodborne pathogens that are spread by blood, tears, sweat,  saliva, sputum, gastric secretions, urine, feces, CSF, amniotic fluid, semen and breast milk. 
B. Rational: Since medical history and examination cannot reliably identify all patients infected with HIV,  or other bloodborne pathogens, blood and body fluid precautions shall be consistently used for all patients. This approach, previously recommended by the CDC, shall be used in the care of all patients.  This is especially important in the emergency care settings in which the risk of blood or body fluids  exposure is increased and the infection status of the patient is usually unknown. 
1. Universal Precautions/BSI shall be done for every patient if contact with their blood or body  fluid is possible, regardless of whether a diagnosis is known or not. This includes but is not  
limited to starting IVS, intubation, suctioning, caring for trauma patients, or assisting with  
OB/GYN emergencies. 
C. Procedures: 
1. Handwashing shall be done before and after contact with patients regardless of whether or not  gloves were used. Hands contaminated with blood or body fluids shall be washed as soon as  
possible after the incident.  
2. Non-sterile disposable gloves shall be worn if contact with blood or body fluids may occur.  Gloves shall be changed in-between patients and not used repeatedly. 
3. Outerwear (Example: Gown, Tyvek suit, turn-out gear) shall be worn if soiling of clothing with  blood or body fluids may occur. The protection shall be impervious to blood or body fluids  
particularly in the chest and arm areas. 
4. Face Protection (including eye protection) shall be worn if aerosolization of blood or body  fluids may occur (examples of when to wear include: suctioning, insertion of endotracheal  
tubes, patient who is coughing excessively and certain invasive procedures). 
5. Mouth-to-Mouth resuscitation: CDC recommends that EMS personnel refrain from having  direct contact with patients whenever possible, and that adjunctive aids be carried and utilized.  These adjunctive aids include pocket masks, face shields or use of BVM. 
6. Contaminated Articles: Bag all non-disposable articles soiled with blood or body fluids.  Wear gloves when handling soiled articles. Bloody or soiled non-disposable articles shall be  decontaminated prior to being placed back into service. Refer to manufacturer's  
recommendations for proper cleaning and disinfecting. The items that are not disposable shall  be sterilized prior to reusing. For example: laryngoscope blades, OPAs, NPAs, Bag-valve-mask  units, Magill Forceps, etc. Bloody or soiled disposable equipment shall be carefully bagged and  discarded. 
7. Linens soiled with blood or body fluids shall be placed in appropriately marked container.  Gloves shall be worn when handling soiled linens. 
8. Needles and syringes shall be disposed of in a rigid, puncture-resistant container.  
9. Blood spills shall be cleaned up promptly with a solution of 5.25% sodium hypochlorite  (household bleach), diluted 1:10 with water or other FDA approved disinfectant. Wear gloves  when cleaning up such spills. 
10. Routine cleaning of equipment shall be done following manufacturer's guidelines and CDC  recommendations. 
D. Respiratory Isolation  
1. In the event of a suspected or confirmed TB patient, an N95 or HEPA mask must be worn, in  accordance with MIOSHA regulations. 
34 
2. Decontamination of equipment after exposure to a patient with a known or suspect respiratory  route of transmission shall be carried out following manufacturer's recommendations and CDC  guidelines.  
III. EMS Program Responsibilities 
A. The EMS Program will be responsible for assuring that students/personnel are familiar with infection control policy and procedures, epidemiology, modes of transmission and means of 
preventing transmission of communicable disease per CDC guidelines and MIOSHA 
regulations. 
B. The EMS Program will assure that students/personnel are supplied with the appropriate personal protective equipment. 
C. The EMS program will provide documentation that the student/personnel has received adequate  immunizations per CDC Immunization Guidelines for Health Care Workers, or per local Community  Health system policy. 
IV. Student/Personnel Exposure to a Communicable Disease 
A. Definition of an Reportable Exposure 
1. Contaminated Needle or sharp instrument puncture 
2. Blood/body fluid splash into mucous membrane including mouth, nose, and eye 
3. Blood/body fluid splash into non-intact skin area 
B. Student/Personnel Post Exposure Procedure 
1. If skin is punctured with a contaminated needle or sharp instrument or experience a blood/body  fluid splash, wash the substance off immediately.  
2. Fill out an incident report of injury and notify your supervisor in the clinical or classroom  setting. Supervisor shall ensure that the MDCH Request for HIV/HBV Testing Form is  
completed by the exposed student/personnel and forwarded immediately with notification to the  EMS Program Director, or their designee. 
3. The EMS Program Director, or their designee will contact the appropriate hospital designee and  provide additional follow-up as it is necessary to obtain source testing if necessary. 
C. EMS Program Responsibilities upon Notification of a Potential Exposure to Infectious Disease 1. Verify exposure has occurred with involved student/personnel. 
2. Contact appropriate hospital designee to request source testing be done. 
3. Notify the hospital Infection Control Nurse of source testing request and forward the MDCH Request for HIV/HBV form to that office. 
4. Upon obtaining notification of possible exposure to student/personnel, will assist the hospital in notifying the appropriate personal physician of the involved 
student/personnel regarding the need for follow up related to the discovery of a 
communicable disease. 
D. Hospitals' Responsibilities 
1. Each contracted hospital will designate an infection control practitioner(s) to serve as liaison(s) with the staff of the EMS Program for the purpose of communicating  
information about infectious patients or potential exposures. 
2. Hospitals, upon learning that any patient has an infectious or communicable disease, will check the patient chart to determine if any EMS Program students/personnel 
were involved with the patient prior to hospitalization. When determined that a 
student/personnel may have had contact with the patient, the designated individual 
will notify the EMS Program Director for further follow-up and complete the 
required MDCH forms. 
3. Hospitals, when requested to do so, will obtain lab tests and results on source patients when exposure to a student/personnel has occurred.  
a. Hospitals will report the results of testing on the "MDCH Request for HIV/HBV  
Testing Form" and return to the address indicated on the form. 
4. Hospitals will notify students/personnel at the time patient care is to be provided, if  
any infection potential exists with the patient and the precautions necessary.  
F. Follow-up Care/Counseling 
1. Follow-up care and counseling of exposed student/personnel shall be the 
responsibility of the person’s private physician or occupation health physician if contracted, and  shall be carried out without delay upon notification of exposure.
35 
SAMPLE 
PRE-HOSPITAL PROVIDER REQUEST FORM 
FOR HIV/HEPATITIS TESTING OF EMERGENCY PATIENT 
In accordance with Michigan Public Act 419 of 1994 
I. To Be Completed by Exposed Individual (Please Print) 
Name of Exposed Person:____________________________________________ Job Classification:___________________________________________________ Home Address:_____________________________________________________ City/State/ZipCode__________________________________________________ 
Home Phone Number:________________________________________________ Employer/EMS Program:_____________________________________________ 
Employer/EMS Program Contact: 
Name:______________________________________________________ 
Address:____________________________________________________ 
Phone:______________________________________________________ 
Time/Date of Exposure:______________________________________________ Patient ID #:_______________________________________________________ Route of Exposure: 
__ Contaminated Sharp/Needlestick ___Non-Intact Skin (Open Wound) __ Mucous Membrane (Splash) __ Other: _____________________ 
Detailed Description of Exposure: _____________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 
Personal Protective Equipment Used When Exposed: (Check all that apply) 
__Gloves __Gown __Eye Protection __Face Mask __Turnout Gear __None __Other:________________ 
Exposure information provided by: 
__________________________________ ________________________ Signature of Person Providing Information Date
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BASED UPON MY EXPOSURE DESCRIBED ABOVE, I am requesting that this emergency patient be tested for: __ HIV __Hepatitis B __Both 
I would like the test results sent to (please check only one of these options below): 
1. __ Me 
Address:________________________________________________________________ 
2. __My physician 
Address:________________________________________________________________ 
Phone number:____________________________________________________________ 
3. __Other Health Care Professional: (Agency Infection Control Contact) 
Name:__________________________________________________________________ 
Address:________________________________________________________________ 
Phone Number:___________________________________________________________ 
I understand that the NAME of the patient to be tested, and that person’s test results are confidential according to  Section 5131 of the Michigan Public Health Code. I understand that a person who discloses information in violation of  this Section is guilty of a misdemeanor. 
I understand that I am ultimately responsible for the payment of the charges associated with the testing of this patient,  unless an agreement has been worked out between me and my employer, or is otherwise covered by health care or  benefits plan.  
________________________________________ _____________________________ Signature of Exposed Individual Date 
Note to Exposed Individual: Please contact the health care facility if the test results on the emergency patient are not  received within ten (10) days. Results will not be provided over the telephone. 
II. TO BE COMPLETED BY HEALTH FACILITY 
Name of Exposed Individual: ________________________________________________ Evaluation of Exposure: 
__ Exposure Did Occur based upon the information provided.  
 The type of exposure was determined to be: 
__ Percutaneous 
__ Mucous Membrane 
__ Non-intact skin (Open Wound) 
NOTE: The exposed individual should be counseled and tested for HIV/Hepatitis. 
No Exposure Occurred 
Explanation:____________________________________________________ 
______________________________________________________________ 
_______________________________________________________________ 
_____________________________ _______________________________ Signature of Health Care Worker Date 
Making Determination 
_____________________________ 
Title of Health Care Worker
37 
III. To Be Completed by Health Facility 
Source Patient was tested for: __HIV __Hepatitis B 
Test Results: 
HIV: ELISA __Positive __Negative 
Western Blot: __Positive __Negative __Indeterminate Hepatitis B: HBsAg __Positive __Negative 
Source Patient was NOT tested: (Check all reasons below that apply) 
__ Patient expired before test(s) could be performed. 
__ Patient refused testing/to have blood drawn. 
__ Patient was released from health facility before testing could be done. 
__ Patient did not present to this facility for care. 
__________________________________ ____________________________________ Signature of Person Providing Test Results Title of Person Providing Test Results 
Date Lab Results were completed:__________________________________________________ Date Lab Results were mailed:_____________________________________________________ Lab Results were mailed to:_______________________________________________________ 
Notes/Comments:
38 
SAMPLE CLINICAL INSTRUCTOR CONTRACT 
Sub-Contractual Agreement 
between 
Name of Sponsor 
(hereinafter referred to as the Sponsor) 
and 
Name of Clinical Instructor 
(hereinafter referred to as the Clinical Instructor) 
I. PURPOSE 
To provide clinical instruction and supervision in the Basic EMT program at 
 (location) , from (beginning date) to (ending date) . 
II. AGREEMENT AMOUNT 
The Sponsor, subject to the terms of this agreement, shall provide payment of  
$_____ per hour, up to a maximum of _____ hours, for a total not to exceed $_____. 
III. RESPONSIBILITIES - CLINICAL INSTRUCTOR 
A. The Clinical Instructor shall serve as faculty for the Basic EMT program, providing clinical  instruction and supervision as assigned by the course coordinator. 
B. The Clinical Instructor shall be on time and prepared for all assignments. 
C. The Clinical Instructor shall abide by all policies of the Sponsor pertaining to faculty and to  clinical sites. 
D. The Clinical Instructor shall document student attendance at clinical and student completion of  clinical objectives on forms provided by the Sponsor. 
IV. RESPONSIBILITIES - CONTRACTOR 
A. The Contractor shall provide student assignments and clinical objectives to the Clinical  Instructor on a timely basis. 
B. The Contractor shall provide payment in accordance with this agreement,  
based on completion of assignment(s) as certified by the course coordinator. 
V. ASSURANCES 
A. In compliance with Title VI of the Civil Rights Act of 1964 and the Regulations  of the U.S. Department of Health and Human Services issued thereunder, and Section 504 of the  Rehabilitation Act of 1973, and the Rules of the Michigan Civil Rights Commission; the  Instructor assures that, in carrying out this program no person shall be excluded from  participation, denied any benefits, or subjected to discrimination on the basis of race, creed, age,  color, national origin or ancestry, religion, sex, or marital status (except where a bonafide  occupational qualification exists). This policy of nondiscrimination shall also apply to  otherwise qualified handicapped individuals.
39 
B. It is the policy of the Sponsor to provide an environment that is free of discriminatory  harassment. Discriminatory harassment is prohibited. Discriminatory harassment constitutes  any behavior or pattern of behavior, malicious or benign, intended or unintended, physical or  verbal, that: creates an intimidating, hostile, or offensive work/educational environment; creates  an unreasonable interference with an individual's work/education performance; or otherwise  adversely affects employment/education opportunities. 
VI. INDEPENDENT CONTRACTOR STATEMENT 
Under the provisions of Section 3401 of the Internal Revenue Code of 1986, an employer must withhold  income tax from all remuneration actually or constructively paid to an employee. The employment  relationship herein offered is for professional educational services. Under the terms of this agreement,  the Clinical Instructor is exempt from the IRS statute referred to above, because the Clinical Instructor  is an "independent contractor" offering educational services and is required to pay all applicable payroll  taxes and required FICA contributions personally. 
VII. AGREEMENT PERIOD 
This agreement is in full force and effect from __________ through __________, 19__. This agreement  may be terminated by either party by giving thirty (30) days written notice to the other party stating the  reasons for termination and effective date or upon the failure of either party to carry out the terms of the  agreement by giving ten (10) days written notice stating cause and effective date. 
Any changes to this agreement will be valid only if made in writing and accepted by all parties to this  agreement. 
VIII. SIGNATURES 
For the Clinical Instructor: Signature _______________________Date ____________ For the Sponsor: Signature _______________________Date ____________ 
 Title ___________________________
40 
SAMPLE BASIC EMT COURSE SYLLABUS 
1. Attendance Policy: Four (4) absences are allowed. On the fifth absence you are dropped from the class. No  exceptions, no excuses, no refunds. 
2. Grades: You must receive a grade of eighty percent (80%) or higher to pass this class. a. The final grade is determined as follows: 
1. 10% from Case Study scores. 
2. 20% from Quiz scores 
3. 30% from the three (3) Exams 
4. 40% from the Final Written Exam 
b. You must pass the final written and practical exam to pass the class. Individuals failing either the written  or practical exam may re-test one time at the discretion of the instructor, based on overall course  performance. 
c. Case studies not turned in on time will receive a zero (0). 
d. You must be present in class to take a quiz. Quizzes not taken on time will receive a zero (0).  e. If, due to extenuating circumstances, you are not able to be in class on an exam night, you must notify the  instructor ahead of time and make other arrangements. If you do not notify the instructor and are absent,  your grade for that exam will be a zero (0). 
3. Clinical Time: Your clinical time will start approximately halfway through the class, at which time it will be explained in detail. In order for your to participate in clinical time 
(which is a required part of the course) you must have the following: 
a. Proof of negative TB skin test or negative chest x-ray within one (1) year of the last day of class. b. Proof of Hepatitis B vaccination, or signed declination form. 
c. Proof of professional liability insurance. 
Prior to beginning clinical time and after all of the above requirements are met, each student will receive an  identification tag which will be worn during all clinical experiences. Clinical experience must be completed and  appropriate documentation given to the instructor prior to the final exam. 
4. Refunds: 
a. One-hundred percent (100%) if canceled by the instructor. 
b. One-hundred percent (100%) if the student drops out of the course before the second meeting (defined as  notifying the Programs Coordinator or the course instructor prior to the beginning of the second class).  Books may be returned if not written in, otherwise there will be a charge for the cost of those that can’t be  returned. 
c. All refund requests must be delivered in writing within forty-eight (48) hours of cancellation to the  GTAMCA office or the course instructor. 
d. No refunds after the beginning of the second class meeting. 
5. Testing: Tests will be multiple choice, true and false, matching, short answer and essay. There will also be  realistic scenario and skill-based practical testing. Note taking is strongly encouraged. 
6. Homework: Completion of the workbook is mandatory. Case studies and other projects will be assigned  periodically. 
7. Required Texts: Brady Emergency Care, Sixth Edition 
Brady Emergency Care, Sixth Edition, Workbook 
8. Dress Code: Students are required to use proper hygiene and to come to class clean each time. Specific dress  requirements exist in the various clinical areas and are addressed specifically in the clinical notebook.
41 
9. Appeals: If you feel that you have been treated unfairly in this course you should first discuss the issue with the  course instructor-coordinator. If you are still unsatisfied, you may contact the Programs Coordinator, sponsor  Manager, sponsor Board of Directors, and the EMS Division of the Michigan Department of Consumer and  Industry Services (in that order) until resolution is reached.  
10. Guidance Procedure: The course instructor-coordinator will be reasonably available to assist those students  needing extra help. The instructor will be available one-half hour before and after class to meet with you or you  may contact him or her at _____________to set up an appointment. 
11. Class Cancellation: If, due to weather or other unavoidable circumstances, class must be canceled, it will be  broadcast on local area radio stations. Attempts will be made, if at all possible, to reach students by telephone as  well. 
12. Health/Safety Policy: Due to the nature of EMS and close contact with fellow students, faculty, and patients,  students are required to take necessary precautions to ensure that the safety and health of all are protected. All  students are required to practice universal precautions at all times in the classroom and clinical setting. In  addition, proof of negative TB skin testing and Hepatitis Vaccination (or signed declination form) are required.  Students who are ill should not attend class or visit a clinical site if there is any danger of transmission of the  illness to others. 
13. Fairness in Advertising/Access to Information Policy: It is the policy of this program sponsor to ensure that all  student candidates and students are made aware of how to access information. Information regarding program  requirements, tuition and fees, program policies and procedures, and supportive services will be made available to  all student candidates and students. In addition, the current curriculum, a statement of course objectives, copies of  course outlines, class and clinical schedules, and lesson plans will be on file in the offices of the program sponsor  and available to candidates and enrolled students when requested. 
14. Disclosure Policy: Information on whether a student successfully completed a course will be made available to  MDCIS, EMS Division. The program will not release any other information without signed consent of student.  EMS program faculty are allowed to share information regarding student’s successes. 
15. Miscellaneous: 
a. Coffee - the class can chip in for coffee, etc. 
b. Pagers will be turned off during classroom hours. 
c. If you leave class to respond to an emergency call, you will be considered absent for that night.
42 
SAMPLE COURSE ANNOUNCEMENT 
BASIC EMERGENCY MEDICAL TECHNICIAN TRAINING 
WHAT:This Michigan Department of Consumer & Industry Services-approved course, taught by professionals in the  emergency care field, will provide fundamental working knowledge for the Basic EMT. Topics covered  include: Medico-legal aspects, basic anatomy, patient assessment, basic life support, pre-hospital care of  medical emergencies and trauma, extrication, and more. A minimum of 40 hours of clinical observation  time is required in addition to the scheduled class time. During clinical experiences students may be  exposed to hazardous materials, communicable diseases, lifting and moving, etc. An 8-hour required  extrication session is held on a Saturday. Professional liability insurance is required prior to entering  clinical areas. Persons successfully completing this course will be eligible for the State licensing exams. 
PREREQUISITES: 
1. 18 years of age (or be 18 prior to licensing exam) 
2. Current CPR certification desirable 
3. First Aid or Medical First Responder training desirable 
4. Negative TB skin test or chest x-ray with one (1) year of ending date of class 
5. Proof of Hepatitis B vaccination or signed declination form 
COST: Tuition $365.00 
Fees 85.00 
Books 65.00 
TOTAL $515.00 
INSTRUCTOR: Name , Title/Licensure  
WHERE: Place and Address  
WHEN: Days/Times  
DATES: Beginning _____________ and ending ________________ 
REGISTRATION: Your application must be received no later than ______________ and adequate enrollment must  be insured in order to conduct the course. Admission is on a first-come, first-served basis. You  may assume you are enrolled in the class unless you are notified to the contrary. Payment is due  no later than the first class session. 
QUESTIONS: Contact Name , Programs Coordinator at Phone Number 
43 
GENERIC COURSE ANNOUNCEMENT 
CENTRAL CITY COMMUNITY COLLEGE 
SCHOOL OF EMS 
Central City Community College will be accepting registrations for its 23rd Emergency Medical Technician-Paramedic program which will be starting on July 1, 1996. CCCC has been providing quality EMS education since 1974. CCCC graduates of the School of EMS score consistently in or above the 90th percentile of students who sit for the state paramedic licensure exam. 
PARAMEDIC SKILLS 
Students enrolled at CCCC School of EMS EMT-P program will learn and become proficient in these areas: 
?? Expanded patient care 
?? Endotracheal intubation and surgical and surgical airway techniques 
?? IV therapy and IV drug administration 
?? Cardiac monitoring and external pacing 
?? Cardiac Defibrillation 
?? Expanded clinical roles for Paramedics 
This program is one year in length starting every July. There will two areas of instruction: didactic and psychomotor (clinical experience). Clinical experiences will begin in the class room and extend to ambulance services, hospitals, and dispatch centers. 
After successful completion of the program, the student will be eligible to sit for the state paramedic examination.  After receiving licensure, one may be employable by ambulance services, hospitals and insurance companies, etc. 
ADMISSION PROCESS 
Candidates to the School of EMS must meet with a counselor and submit an application to CCCC. In order to be accepted, all prerequisites must be successfully completed. These prerequisites include ASSET testing, a medical history and physical examination, and all appropriate immunizations. 
Call 1-800-555-4EMS for more information about this program
44 
GUIDELINES for 
GENERAL NON-DISCRIMINATION POLICY  
 does not discriminate on the basis of race, color, sex, national origin, disability, sexual orientation, religion, or age in its educational programs, activities, admission procedures or employment practices as required by Title VI of the Higher Education Amendments, Title IX of the Civil Rights Act, Section 501 of the Rehabilitation Act and the Americans with Disabilities Act of 1990.
45 
SAMPLE STUDENT APPEAL PROCESS 
Students who feel they have been treated unfairly by a faculty member or College employee have the right of appeal. The purpose of this appeal process is to facilitate equitable solutions to student complaints. 
I. General Provisions 
A. A complaint is a claim by one or more students that they have been treated unfairly by a faculty member  or College employee, or that his/her rights as outlined in the Student Handbook under Policy on Student  Rights and Responsibilities have been violated. 
B. All documents, communications, and records dealing with an appeal shall be filed in a Student Appeal  file maintained by the Vice president for Student and Instructional Support Services. All records of  actions under this procedure shall be held in strict confidence and will be available to the student  initialing the appeal or his/her representative, the person against whom the action is filed or his/her  representative, the faculty mediator, any resource panel, when convened in this matter the Vice President  for Student and Instructional Support Services, and the President of the College. 
C. Hearings and conferences held under this procedure shall be conducted at a time and place which will  afford a fair and reasonable opportunity for all appropriate persons to be present. When such hearings  and conferences are held during College hours, employees who are required to attend shall be excused  from classes, with no penalty during the time their presence is required. 
II. Procedure 
A. In the interest of maintaining harmonious relations, a complaint shall first be discussed by the student, on  his/her behalf, with the person or office representative against whom the complaint is alleged, with the  object of resolving the matter informally. Either party may be accompanied by another person he/she  chooses, when discussing the complaint. The student must inform the person or office representative  what the complaint is about prior to the meeting. The student must initiate this informal discussion  within ten days after the occurrence of the condition about which he/she is dissatisfied. The informal  discussion(s) shall be considered completed ten days after their initiation date. 
B. In the event that the complaint is not resolved thorough the informal discussion, the matter shall be  presented in writing on a form available from the Vice President for Student and Instructional Support  Services Office, by the student to the Vice President for Student and Instructional Support Services or  his/her designee within seven (7) days after completion of the informal discussion(s). Within five (5)  days of the receipt of the written appeal, the Vice President for Student and Instructional Support  Services or his/her designee will meet with the student and other appropriate parties in an attempt to settle  the disagreement. The Vice President for Student and Instructional Support Services or his/her designee  may (a) convene the Student Coalition Committee as a Resource Panel to review the matter under  consideration and provide such counsel as may be helpful in bringing a satisfactory conclusion to the  matter; or (b) designate a faculty mediator. 
C. The faculty mediator shall discuss the matter with the student and other appropriate parties within five (5)  days of his/her appointment. The faculty mediator shall give the student and the Vice President for  Student and Instructional Support Services his/her analysis of the situation and a decision in writing  within fifteen (15) days of appointment.  
D. If the student is dissatisfied with the decision of the Faculty Mediator he/she must within ten (10) days of  receipt of the decision submit to the President of the College a written statement as to why the Faculty  Mediator’s decision was not satisfactory. The President will give all parties to the matter an opportunity  to be heard within ten (10) days of receipt of this document. The President shall render his/her decision  in writing to both parties and the Vice President for Student and Instructional Support Services within  twenty (20) days after initiation of his/her hearing(s), and it shall be final.
46 
GUIDELINES for 
CONFIDENTIALITY OF STUDENT INFORMATION/RECORDS 
I. Family Education Rights and Privacy Act of 1974 (FERPA) 
A. Introduction 
1. Helps protect the privacy of student records 
2. Generally applies to all educational institutions which receive federal funding 
3. Provides for the: 
a. Right to inspect and review education records 
b. Right to seek to amend those records 
c. Right to limit disclosure of information from the records 
4. Written consent is required prior to disclosure of any personally identifiable information. 
B. Who is protected? 
1. Students who are currently enrolled or formerly enrolled regardless of age or status in regard to  parental dependency. 
2. Parents of “dependent” students have access to student records. 
3. Deceased students 
C. What are educational records? 
1. Those records that are directly related to a student and maintained by the institution or by as  party acting for the institution. 
2. “Records” is defined as “any information regarded in any way, including but not limited to,  handwriting, print, film, microfilm.” 
3. Any records which are shared with or accessible to another individual. 
D. Exclusions 
1. Sole possession records or private notes which are not accessible or released to other personnel. 2. Law enforcement, campus security records 
3. Records pertaining to employment by the institution 
4. Records relating to treatment provided by a physician, psychiatrist or other recognized  professional and disclosed only to those involved in the treatment. “Treatment” does not include  remedial activities such as tutoring. 
5. Records which contain information obtained only after the person is no longer a student (i.e.  alumni) 
E. Disclosure 
1. “To permit access to or to release, transfer, or otherwise communicate by any means the contents  of education records or personally identifiable data therein to another person, agency, or  
organization. 
F. Permissible disclosure 
1. Can be made to: 
a. School personnel 
b. Instructors who have legitimate educational interests. 
c. Another school where the student is seeking enrollment 
2. Information in connection with a health or safety emergency if that information is needed to  protect the health or safety of that student or other persons. 
G. Directory information 
1. “Directory information” may be disclosed without violating FERPA 
2. Includes: 
a. Student’s name 
b. Major field of study 
c. Dates of attendance 
d. Degree and awards received
47 
H. Written consent to disclose personally identifiable information 
1. Must include: 
a. Specific records that may be disclosed 
b. Purpose of the disclosure 
c. Party or parties to whom disclosure may be made 
I. Personally identifiable information 
1. Includes: 
a. Student’s name 
b. Name of student’s parents or other family members 
c. Student’s address or family address 
d. Social security or student number 
e. List of personal characteristics 
J. When is consent not required? 
1. School officials 
2. Schools to which the student is seeking enrollment 
3. Federal, state, or local authorities of financial aid or law enforcement 
4. Accrediting organizations 
5. To parents of dependent child 
6. To comply with judicial order or subpoena 
7. Health or safety emergency 
8. Directory information 
9. To the student 
10. Results of disciplinary hearing to an alleged victim of a crime of violence 
II. State Law Protection of Student Records 
A. Michigan Codified Law 600.2165 
1. Prohibits instructors or other professional persons engaged in character building, and who  maintain records of student behavior or who have records in their custody from disclosing in any  civil or criminal proceedings any information obtained from the records or communications. 
B. Maintaining student records 
1. State Department of Education requires maintaining records for a minimum of 5 years. 2. Should include: all evaluations, progress records, terminal examinations, final grades and credits  awarded, counseling recommendations. 
2/95
48 
SAMPLE SEXUAL HARASSMENT POLICY 
 is committed to providing students and faculty with a learning environment which is safe, comfortable, and productive. Sexual harassment in any form will not be tolerated. 
Sexual harassment is any unwanted sexual attention pressed on an unwilling person by students or faculty. Sexual harassment is further defined as follows: 
1. Sexual relations, sexual contact, or the threat of sexual relations or sexual contact, which is not freely or mutually  agreeable to both parties. 
2. The continual or repeated verbal abuse of a sexual nature, including but not limited to sexually explicit statements,  sexual suggestive objects or picture, propositions of a sexual nature, sexually degrading words used to describe the  employee or student. 
3. The threat or insinuation that lack of sexual submission will adversely affect the student’s grades, advancement,  assigned duties, or other conditions that affect the student’s status. 
If you believe that you are a victim of sexual harassment, deal with the problem immediately by contacting the Program Director at . Each student can have the confidence that all allegations of sexual harassment will be investigated impartially and with discretion. 
Anyone who is found, after appropriate investigation, to have engaged in sexual harassment of another will be subject to discipline, up to and including dismissal, depending on the circumstances.
49 
GUIDELINE 
DUTIES TO THE DISABLED STUDENT 
(AMERICANS WITH DISABILITIES ACT OF 1990) 
I. Application of the ADA to the Educational Process 
In 1990, President Bush signed into law the Americans with Disabilities Act of 1990 (ADA) . The ADA provides  broad protection to the disabled in areas of employment, public accommodations provided by private entities and  telecommunications. 
A. Applicability 
Title III of the ADA includes in its definition of public accommodation an “undergraduate” or post graduate private school, or other place of education”. In addition, it includes in the definition exams and  courses. 
B. General prohibitions of discrimination 
As a general rule, individuals cannot be discriminated against on the basis of a disability in the “full and equal  enjoyment of the goods, services, facilities, privileges, advantages or accommodations...” 
II. Duty of Accommodation 
A. Scope 
1. Protection is provided to individuals: 
a. with physical or mental disability 
b. with a history of having such a disability 
c. who are regarded by the public as having a disability 
* A protected disability is a physical or mental impairment that substantially limits a person in some major  life activity (i.e., ability to walk, talk, work, see, hear, study, read, learn) 
“Substantially limited” is based on: 
- nature and severity 
- duration - or expected duration 
- permanent or expected impact 
2. Limits to protection 
a. Temporary disabilities: a disability of limited duration with no long term effect (i.e.,  sprain, infection, pregnancy) 
b. A disability which excludes a candidate from a specialized job or professional requiring  extraordinary skill or talent. The individual can still perform various other positions  
within the scope of training. 
c. Statutory exemptions 
1) current illegal drug use (previous use is protected) 
2) person with disorders caused by alcohol that impacts job performance 
3) pedophiles 
4) compulsive gamblers 
5) homosexuals, bisexuals, transsexuals, transvestites 
6) voyeurs 
7) pyromaniacs 
8) exhibitionists 
9) kleptomaniacs 
III. Activities that Are Prohibited: 
A. Denial of participation 
B. Participation of unequal benefit 
C. Separate benefit
50 
D. Opportunity to participate 
E. Administrative methods 
* It is discriminatory to impose or apply eligibility criteria that tend to screen out disabled individuals  unless the criteria is shown to be necessary or essential function for the provision of the educational  opportunity. 
* It is discriminatory to fail to make reasonable modifications to policies, practices, or procedures, unless you can demonstrate that making such accommodations would fundamentally alter the nature of the  educational opportunity. 
* Not obligated to waive, modify program requirements or lower academic requirements which are  reasonable and nondiscriminatory. 
IV. Special Considerations for Examinations and Courses 
In general, examinations and courses must be offered in a place and manner accessible to persons with disabilities.  The specific requirements include: 
A. Modifications 
1. Must make modifications to a course that ensure that the place and manner in which the course  is given is accessible. 
B. Suggested modifications 
1. Change in length of time permitted to complete the course. 
2. Substitution of specific requirements 
3. Change in the manner in which the course is conducted 
C. Provision of auxiliary aids 
1. Must provide appropriate adjunctive aids and services (specialized voice activated computers,  readers, translators, videotaped lectures, prepared notes, large print materials) 
2. Put the burden of proof back on the student to determine what needs to be provided. 
* Auxiliary aids not required if it would fundamentally alter the measurement of the skills or knowledge the  exam is trying to measure. 
V. Defenses to Accommodation 
A. Necessity 
1. If eligibility criteria is necessary to providing an educational opportunity 
House Committee on Education and Labor states that: “A public accommodation may...impose  rules and criteria that are necessary for the safe operation of its business...Safety criteria,  
however, must be based on actual risks and not on speculation, stereotypes, or generalizations  about disability” 
B. Fundamental alteration 
1. A modification that is so significant that it alters the essential nature of the education 
C. Undue Burden 
1. “Significant difficulty or expense”. Factors to be considered include: 
a. the nature and cost of the action needed 
b. overall financial resources of the institution, the number of students, the effect on  
expenses, resources, and legitimate safety requirements. 
* In establishing any eligibility criteria which would tend to screen out disabled persons, consider whether  those requirements are necessary to providing the education. Are they essential requirements for  completion of the program? 
D. Direct threat defense 
1. “Significant risk to the health and safety of others that cannot be eliminated by a modification of  policy, practice or procedure, or by the provision of auxiliary aids or services”
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2. Need to determine the: 
a. nature, duration, and severity of the risk 
b. probability that the potential injury will actually occur 
c. whether reasonable modifications will decrease the risk 
* When confronted with a disabled student who poses a direct threat to the health and safety of others,  consider the following: 
- is the risk so significant that a modification will not eliminate the risk? 
- that the determination of “risk” is based on an individualized assessment using reasonable  judgment based on objective evidence of medical knowledge. 
VI. Summary 
A. Identify essential functions and standards of course program completion. Make these known prior to the  student’s entry into the program. 
B. Identify what a disabled person can do, not what he cannot do 
C. When making reasonable accommodations, an institution does not have to waive or modify program  requirements or lower academic standards. 
D. Shift the burden of accommodation to the disabled individual. Have him/her identify what special aids  will be needed. 
E. Establish a consistent, objective system for individuals assessment of disabled students who demonstrate  an inability to effectively perform or succeed.
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SAMPLE PROFESSIONAL PROTECTION CHECKLIST Listed below are several items that should be kept on file and/or provided to the student. 
1. Requirements for continuance, good standing and program completion 
2. Each instructor should distribute and explain the course syllabus at the first class meeting. The class syllabus  should include: 
?? attendance requirements 
?? course requirements 
?? specific due dates for assignments/projects 
?? method of determining grade 
?? format for submitting written work 
?? penalties for late work 
?? description of course content and objectives 
3. Clearly documented due process procedure, including an appeal mechanism 
4. “Automatic” dismissal policies for unsatisfactory progress, should be reviewed for appropriateness and uniformity.  Must be published. 
5. Academic, clinical evaluation methods 
6. Required courses, prerequisites 
7. Refund policies 
8. Admission requirements, transfer admissions 
9. Narrative records of incidents that may increase liability: 
disciplinary actions, accidents 
10. Records of student evaluations, grades
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SAMPLE Exercise 
Affective Evaluation Examples 
The following examples deal with a situation of child abuse. The father has broken both of his 4-year-old son’s  upper arms by shaking the child violently. 
Receiving Level Objective: Given a list of possible emotional responses when dealing with child abuse, the  EMT will identify the appropriate response. 
Receiving Level Evaluation: Given the situation above, choose of the following, the correct response: 
a. Explain to the father why he was wrong to do what he did and recommend counseling. b. Be very angry with the father in front of the child so the child will know who was at fault. *c. Obtain information from the father and child in a non-judgmental fashion. 
d. Be very angry with the child as his poor behavior caused the whole incident. 
Responding Level Objective: When dealing with child abuse situations, the EMT will be able to discuss  appropriate emotional responses of the EMT. 
Responding Level Evaluation-Written or Oral: Given the situation above, please describe your feelings  toward the father and how to appropriately respond emotionally to the situation. 
Expected feelings: 
Anger 
Pity 
Points for the following responses: 
Non-judgmental 
Objective 
Maintain composure 
Valuing Level Objective: Given a situation of child abuse, the EMT will initiate a professional emotional  response. 
Valuing Level Evaluation-Scenario/Observational Report: Given the situation above, obtain a medical  history of the child a current history of the incident from the father. 
S NI U Obtains information objectively 
S NI U Maintains Composure 
S NI U Remains non-judgmental 
Comments: 
Organizing Level Objective: Given a situation of child abuse, the EMT will be able to defend his non judgmental, objective response even when questioned by others. 
Organizing Level Evaluation-Scenario/Observational Report: Given the situation above and having  obtained a medical history of the child a current history of the incident from the father in a non-
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judgmental, objective fashion, your senior partner questions your response. Please defend  yourself. 
S NI U Maintains current response as appropriate 
S NI U Maintains composure while dealing with partner 
S NI U Explains accurately reasons for maintaining professionalism while dealing with father Comments: 
Characterizing Level Objective: Given a situation of child abuse, the EMT will be able appropriately  intervene when his partner loses self-control when obtaining a medical history. 
Organizing Level Evaluation-Scenario/Observational Report: Given the situation above your senior partner  begins to accuse the father and become very angry. Please respond. 
S NI U Interrupts partner’s questioning and takes control appropriately S NI U Maintains professionalism while dealing with father 
S NI U Explains to the partner after the scenario reasons for maintaining professionalism while  dealing with father 
Comments:
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SAMPLE EVALUATION FORM 
Please select and circle the response that comes closest to the way you feel about each statement. 1. Strongly Agree 
2. Slightly Agree 
3. Slightly Disagree 
4. Strongly Disagree 
1. The Instructor/Coordinator shared course objectives (what you needed to accomplish to successfully complete the  course) at the beginning of the course. 
1. 2. 3. 4. 
2. The course was well organized and the topics were adequately covered. 
1. 2. 3. 4. 
3. The instructors had a thorough knowledge of the subject taught. 
1. 2. 3. 4. 
4. The instructors used class time well. 
1. 2. 3. 4. 
5. The instructors were well prepared for each class. 
1. 2. 3. 4. 
6. The instructors were supportive of classroom participation and encouraged student interaction. 1. 2. 3. 4. 
7. Work assignments, grading system, and attendance requirements were made clear from the beginning of the course. 1. 2. 3. 4. 
8. Course examinations covered the important aspects of the course. 
1. 2. 3. 4. 
9. The instructor was willing to discuss examination outcomes. 
1. 2. 3. 4. 
10. Examinations were graded and returned to students in a timely manner. 
1. 2. 3. 4. 
11. I gained a good understanding of the concepts and principles relating to the EMS field. 1. 2. 3. 4. 
12. My clinical training was well organized. 
1. 2. 3. 4. 
13. My clinical training was effective in offering “hands-on” experience relative to course clinical objectives. 1. 2. 3. 4. 
14. I believe the course adequately prepared me for state licensing examinations. 
1. 2. 3. 4.
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15. There was adequate time devoted to practical skill training using equipment, mannequins, etc. 1. 2. 3. 4. 
16. There was adequate equipment available during practical skill sessions. 1. 2. 3. 4. 
17. The equipment used was in good repair. 
1. 2. 3. 4. 
18. Visual aids were used appropriately to illustrate the subject matter. 
1. 2. 3. 4. 
19. I would recommend this instructor to a friend wishing to train for the EMS field. 1. 2. 3. 4. 
20. I would recommend this program sponsor to a friend wishing to train for the EMS field. 1. 2. 3. 4. 
Additional comments please:
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