Agency HEI Training Program Course Request
Please use this form if you are an agency seeking an EMR, EMT, or AEMT course.  Course request must be submitted 45 days prior to the start of the course to ensure a CAN number approval from the Oklahoma State Department of Health. 
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Email *
Agency requesting course *
Course Requested *
Preffered Length of Course
(6 weeks, 12 weeks, 16 weeks, etc) *
Where will skills be hosted? *
Will the agency be providing an instructor for skills?  *
Required
List instructor information if providing own;
(Full name, license level, OK State license #)
How many students are anticipated in the course? *
Agency POC  & contact information to confirm course details: *
A copy of your responses will be emailed to the address you provided.
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