KITSAP ONBOARDING FORM

KITSAP ONBOARDING FORMTamarah Hoffman2023-03-17T15:00:21-07:00

All incoming Kitsap providers should provide the following form and supporting documents to the KCEMS office. Please contact [email protected] or at 360.447.2068 to ensure the form has arrived.

Once the form has been received by the KCEMS office, the provider will receive notice of their core training enrollments.

First name *

Email address *

Last name *

Phone number *

Already have a Target Account

Yes, Please toggle my accounts.

No.

Other Target Account Agency

Level of Certification

Paramedic

EMT

WA Credential

Yes, I have it. (Include Number)

No, Applying for initial certification.

Primary District

Bainbridge Island

Bremerton Fire

Central Kitsap

North Kitsap

Olympic Ambulance- Bremerton

Olympic Ambulance- Clallam, Pierce or Thurston

Poulsbo Fire

South Kitsap

NON PRIMARY

WA Credential Number

If you have a WA credential number put it here.

WA credential expiration date

Before your DOH application is signed off, you must pass the protocol test.

Protocol test

I understand I cannot provide independent patient care, until I have passed my protocol test, received my DOH credential and appear on my agency roster.

I understand passing score for the protocol test is 80%.

If I fail the test, per policy I must wait 7-21 days to retake the test again.

I understand this test is a proctored closed book exam, which I need to contact my medical officer to administer.

Protocol Test Date *

What date do you want to take the protocol test?

All providers practicing in Kitsap County must complete their level of core training. When onboarding, please attach to this form, any of the following documentation.

Travis Law

I completed a Travis Law Course

Please sign me up for the course

Date of Travis Law

Travis Law Verification

Choose File

ACLS

My ACLS card is current

I am getting my ACLS card

Date of ACLS Expiration

ACLS card

Choose File