exist. In contrast to commonwealth countries such as Canada, the United Kingdom, Australia and New Zealand, generally the minimum education is a two- to three-year degree at an accredited college or university for the entry-level paramedic, with four-year or even graduate degrees becoming the preferred credential in such jurisdictions. Many paramedic programs in the United States are through adult career and technical schools that provide a certificate of completion upon completion of the program. All programs must meet the current national standard curriculum. The institutions offering such training vary greatly across the country in terms of programs and requirements, and each must be examined by the prospective student in terms of both content and requirements where they hope to practice. Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams which consist of a psychomotor skills practical examination and a Computer Based Testing (CBT). In addition, most locales require that paramedics attend ongoing refresher courses and continuing medical education to maintain their license or certification. In addition to state and national registry certifications, most paramedics are required to be certified in pediatric advanced life support, pediatric prehospital care or pediatric emergencies for the prehospital provider, prehospital trauma life support; international trauma life support, and advanced cardiac life support. These additional requirements have education and certification from organizations such as the American Heart Association. Credentialling and oversight In the U.S., the community college training model remains the most common, although some university-based paramedic education models exist. These variations in both educational approaches and standards has led to tremendous differences from one location to another. There may be situations in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians (NREMT) attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if an EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States. This confusion was further complicated by the introduction of complex systems of gradation