FLORIDA DEPARTMENT OF HEALTH
BUREAU OF EMERGENCY MEDICAL OVERSIGHT
REQUEST FOR APPROVAL OF AN EMERGENCY ALLERGY TREATMENT TRAINING PROGRAM

ENTITY OR INDIVIDUAL REQUESTING APPROVAL
 
 Name of individual or entity: 											
 Address: 														
 City-State-ZIP: 													
 Phone: 														
 Email address: 													
 Website address (if applicable): 						   					
  I understand that all I attest to in this application is subject to audit by the department.  Yes 	No 
 Oath: Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in          
  it are true.
 Applicant Signature: _________________________   Date:  ______________________________

      

	

 	

Application requirements (See page 2 for instructions):

A.	COURSE OUTLINE (Attach)
B.	AGENDA (Attach)
C.  INSTRUCTOR QUALIFICATIONS (Attach)
D.  FORM FOR STUDENT EVALUATION OF COURSE / INSTRUCTORS (Attach)
E.  VOIDED CERTIFICATE (Attach)
F.  STUDENT QUALIFICATIONS (Attach)

SUBMIT COMPLETED APPLICATION WITH ALL REQUIRED ATTACHMENTS TO:

BUREAU OF EMERGENCY MEDICAL OVERSIGHT (BEMO)
EMS TRAINING AND EDUCATION UNIT		
4052 BALD CYPRES WAY, BIN A-22 		
TALLAHASSEE, FLORIDA 32399-1722 		
Phone: (850) 558-9536			
FAX: 	  (850) 245-4378

REVIEW STANDARDS
 
A.  Course Outline/Subject Matter: 
1.  Attach a description of expected learner outcomes in terms that can be evaluated and are attainable and relevant to emergency allergy treatment.

2.  Attach documentation to confirm the curriculum contains at a minimum the recognition of symptoms of systemic reactions to food, insect stings and other allergens and the proper use of an epinephrine auto-injector when a physician is not immediately available. 

B.	Agenda:
1.	Attach an agenda that confirms sufficient time is allowed for each activity to ensure a reasonable opportunity for each student to meet the objectives.  

C.	Instructor Qualifications:
1.	Attach a curriculum vita (CV) or resume for each instructor who confirms they hold current credentials as either a physician, registered nurse, emergency medical technician or paramedic.

D.  Evaluation Methods: 
1.  Attach documentation that demonstrates the course participants are given an opportunity to evaluate learning experiences, instructional methods, and resources used. 

E.  Course Completion Certificate:
1.	Attach a voided sample certificate of completion issued to each person who completes the course.

F.  Student/Candidate Qualifications:
1.  Attach documentation that confirms training will only be given to persons who are 18 years of age or older who have or reasonably expect to have, as a result of occupational or volunteer status, responsibility for or contact with at least one other person who may have severe allergic reactions.  

DH Form 9003-EPCS-07/2017