Request for Adjudication

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EMAs in shortfall for continuing competence requirements should complete this form to request adjudication. Please make sure that you submit your supporting documentation along with the form.

Licensee Information

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Summary of Adjudication Request

Outline the details of the course content and what skills and/or knowledge were obtained from the continuing education activity submitted for adjudication below.

  • Include the course provider, name of activity, date, duration, location, and certificate of completion.
  • If submitting a conference, include a copy of the agenda with the breakdown of sessions and their content, and your verification of attendance.
  • For patient contacts, please provide the date, location, your role, patient chief complaint or type of contact, and the skills performed for the patient for each contact submitted.
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Attach Your Supporting Documentation

Attach all your supporting documentation
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Personal information on this form is collected by the EMA Licensing Board under the authority of the Freedom of Information and Protection of Privacy Act Section 26(c) Emergency Health Services Act (section 6) and the Emergency Medical Assistant Regulation (sections 2, 3, 4, 9.2, 10 and 26). This information will be used to issue an EMA licence and maintain a permanent register of licensed EMA's. If you have any questions about the collection of this information contact our office at PO Box 9625 Stn Prov Govt, Victoria B.C., V8W 9P1, phone 250 952-1211. This information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only in accordance with that Act.
HLTH 3735 REV. 2023/12/11
84025188609b8bf2c8760f8ee6b733ded097c05a
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