Pam’s Add A Learner Page Add BHP Learner BHP New Learner 2017 Education, Training and Employment Documentation This form must be completed by a Certified BHP Trainer or an agency's assigned representative. Fields marked with an asterisk (*) are required. All such fields must be completed in order to submit the form.Employee Name* First Last Last 4 SSN*Please enter only the last four digits of the employee's social security number.Employee Email* Enter Email Confirm Email Employee Phone*Please include the best number at which the employee can be reached, for example to be notified of changes to trainings during non-work hours. A personal cell phone number is preferable, whereas an office phone number is not recommended.Date of Birth* Date Format: MM slash DD slash YYYY Agency*Date of Hire as BHP* Date Format: MM slash DD slash YYYY Agency LocationEnter a location if multiple locations exist for your agency.Registration for: (choose 1)*Module 1 online ONLYBHP (35 hour) Blended Learning Curriculum, Modules 1 - 12 online with Live DayModules 2 - 12 online with Live Day (Employee has Provisional BHP Certificate)Effective Date of Provisional BHP Certificate: Date Format: MM slash DD slash YYYY Additional Requirements for full BHP Certification:If the requirement is met, click Yes and enter the applicable date; if not or if the information is not available at this time, click NoAdult & Child CPR with AED Certified*NoYesCPR Expiration Date Date Format: MM slash DD slash YYYY Adult & Child First Aid Certified:*NoYesFirst Aid Expiration Date Date Format: MM slash DD slash YYYY OSHA compliant Blood Borne Pathogen Training:NoYesDate of completion: Date Format: MM slash DD slash YYYY Program and Education DetailsMaineCare Program:*MC Section 28 RCS or RCS SpecializedMC Section 28 School-BasedMC Section 65 DTMC Section 65 HCTEducation Level*High School Diploma or GED60 higher education credit hours90 college credits/CEUsSchool Name*Graduation Year*only year is necessaryDegree Awarded*Please enter "diploma" or "GED" for high school level employees.Major*Please enter "N/A" for high school level employees.AuthorizationAuthorization*By checking this box, I signify that all of the information provided above is correct, has been authenticated by my Human Resources Department, and is on file at my Agency Authorized Agency Contact Name* First Last Contact Email Address* Enter Email Confirm Email A copy of the form data will be emailed to this address for confirmation of entry.Title/Position*Phone numberIncluding your phone number is not required, but it provides us with another way to contact you in the event of issues with your employees.