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.