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EMA Licensing

Request for Adjudication

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Request for Adjudication

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

NameMissing or incorrect value

Licence numberMissing or incorrect value

AddressMissing or incorrect value

CityMissing or incorrect value

Province Missing or incorrect value

Postal code Missing or incorrect value

Address if outside Canada

Phone numberMissing or incorrect value

Email addressMissing or incorrect value

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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Missing or incorrect valueLimited to 75MB in total size.

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

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The information on this form is collected under the authority of Sections 26(c) and 27(1)(c) of the Freedom of Information and Protection of Privacy Act to help us assess and respond to your enquiry. Questions about the collection of information can be directed to the Manager of Corporate Web, Government Digital Experience Division.

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