Title: FOR -019 –Form A Training and Education Testimony Overseas Qualified Page: 1 of 4
Owner: PD Approved by: PD Approval Date: Jan 2013
Address: Pre-Hospital Emergency Care Council, Assessment of Qualifications Section
Abbey Moat House, Abbey Street, Naas, Co. Kildare, Ireland.
E: info@phecc.ie
W: www.phecc.ie
Form A Training and Education Testimony
To: Applicant
Complete Part 1 and email the form to your educational institute. They should complete the form and return by email to info@phecc.ie
or by post to PHECC at the above address above (see guidelines for more information).
Part 1
Applicant’s name:
Date of birth:
Day Month Year
Title of course:
Qualification:
Certificate number:
Date of Course: Commence ment
D D M M Y Y Y Y
Cessation:
D D M M Y Y Y Y
To: Course Administrator
The applicant named in Part 1 above is applying for registration in Ireland. In order to proceed we require information about their academic and clinical training. Please complete this form and return directly to us at the address above or by email to info@phecc.ie
. A copy of the syllabus (in English) may also be sent to supplement the information provided on this form. You are requested to insert detailed information regarding the course content that they undertook at your educational institute. Note the table overleaf will expand to accommodate your typed text.
Topic, subject or module title eg
Airway
Management
Descriptive text to outline content of topic, subject or module title including learning outcomes and/or competencies
Examination method
Written exam = W
Practical exam = P
Project portfolio =
PP eg
To establish and maintain an airway, oxygenate and ventilate a patient in accordance with clinical practice guidelines and scope of practice.
Including use of oxygen masks, delivery devices, suctioning, bag-valve mask, oro/nasopharyngeal airways, supraglottic airway, SpO
2
monitoring, oxygen humidification, peak expiratory flow, end tidal CO
2 monitoring, endotracheal intubation, laryngoscopy and forceps use, nasogastric tube.
Include medications – Oxygen, Salbutamol,
Epinephrine, Entonox, Naloxone, Furosemide eg
W & P and Hydrocortisone.
Please start overleaf and note the table will expand to accommodate your typed text.
Hours of classroom instruction including labs, simulation etc. eg
56
Hours of online/ eLearnin g or distance study eg
56
Date Printed:
13/04/2020
Uncontrolled document when printed or copied.

Topic, subject or module title
Descriptive text to outline content of topic, subject or module title including learning outcomes and/or competencies
Examination method
Written exam = W
Practical exam = P
Project portfolio =
PP
Hours of classroom instruction including labs, simulation etc.
Hours of online/ eLearnin g or distance study
Date Printed:
13/04/2020
Uncontrolled document when printed or copied.
Page 2 of 4

Summary of course duration- in hours
Classroom instruction (including labs, simulation etc):
Distance/Online study:
Hours
Hours
Duration of in-hospital placements: Hours
Please list clinical areas below
1.
2.
3.
4.
5.
6.
Duration of clinical practice in emergency medical services (EMS)
Date from: To:
Please list types of EMS (eg emergency ambulance vehicles)
Duration of clinical practice other :
Date from: To:
Please list other clinical areas below
Hours
Hours
Total duration of course:
Hours
I certify that the above represents a true summary of the education and training and subsequent qualification of the applicant
Your name:
Job title / position:
Name of educational institute:
Address of institute:
Email address:
Telephone number: (please include international dialling codes where applicable)
Please stamp with official seal
Signature:
Date:
D D M M Y Y Y Y
Date Printed:
13/04/2020
Uncontrolled document when printed or copied.
Page 3 of 4

Version History
Version Date
1 Jan 2013
Details
New form
Date Printed:
13/04/2020
Uncontrolled document when printed or copied.
Page 4 of 4