.DOH Review: _____

Meets NYS-EMS guidelines for re-registration _____

Application did not meet the following criteria: DOH-4231 (7/03)1 of 2NEW YORK STATE DEPARTMENT OF HEALTHBureau of Emergency Medical FORMContinuing Education Recertification ProgramEMT NumberSocial Security Number--Last NameFirst NameMIZip Code-I affirm that in accordance with the requirements of 10NYCRR Part 800.8(e), I have not been convicted of or am not currently charged with anymisdemeanors or felonies.I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic barto certification.The Department of Health will determine if the conviction is applicable under the provisions of 10NYCRR Part SignatureDateEnter Agency Code of Your Participating AgencyAs the participant's CPR Instructor I hereby verify that the participant has satisfactorily completed and shows competence in:Adult, Child and Infant 1& 2 rescuer CPR an Obstructed Airway Name of InstructorSignature of InstructorDate* A COPY OF THE CARD ISSUED MUST ACCOMPANY THIS APPLICATION IF THE INSTRUCTOR DOES NOT SIGN*CPR CertificationACLS DateExpiration Date*A Copy of Current Card (front and back) MUST Accompany This Application*Print Neatly in UPPER CASE Letters - Please Complete ALL Information – Incomplete forms will be denied and returnedDOH-4231 (7/03)2 of 2TopicHoursAirway Management & Ventilation6Medical (see sub categories)
Pulmonary and & & Conditions/Infectious & Communicable and Obstetrics3Special Considerations (see sub categories)
Neonatology and Pediatrics3
Abuse and Assault1
Patients w/Special Challenges and Acute Interventions for Chronic Care Patients2Geriatrics – 3 hours minimumWMD/Terrorism – 3 hours minimumSkillPatient Assessment (Medical and Trauma)Airway/Ventilation (Simple Adjuncts, Advanced Adjuncts, Supplemental Oxygen Delivery,
Bag Valve-Mask – one and two rescuer)Cardiac Arrest Management (Therapeutic Modalities, Megacode, Monitor/Defibrillator Knowledge)Hemorrhage Control & Splinting (long bone injury, joint injury, and traction splinting)IV Therapy / Medication AdministrationSpinal Immobilization (Seated and Supine)As the Physician Medical Director for the Participant's Continuing Education Program I hereby affix my signature attesting to proficiency in all skills outlinedabove.Printed Name of Medical DirectorSignature of Medical DirectorDateI hereby affirm that all statements on this recertification form are true and correct, including all copies of cards, certificates and other required verification.Itis understood that false statements or documents submitted with the intent to falsely recertify may be grounds for revocation of certification and applicablecivil and criminal penalties.It is also understood that the Bureau of Emergency Medical Services or its designee may conduct an audit of the activities listedherein at any time.

This form must be mailed and postmarked no less than 45 days prior to your current expiration of ParticipantSignature of Sponsoring Agency Contact / Refresher Training - 48HoursSkill Competency VerificationAdditional 24 Hours of Continuing Education – Must include mandatory training in Geriatrics and WMD as noted!.