Get Doh Form 3778

Filling out the Doh Form 3778 is an essential step for individuals seeking to affirm their fitness and competency in accordance with New York State public health laws. This guide provides clear, step-by-step instructions to help users effectively navigate and complete the form online.

Follow the steps to complete the Doh Form 3778 online

1. Click the ‘Get Form’ button to obtain the Doh Form 3778 and open it in your preferred editor.
2. Fill in the 'name of EMS service' section with the official name of your emergency medical service.
3. Enter the 'NYS EMS agency code' which is a unique identifier assigned to your service.
4. Provide the 'full name' of the corporate entity requiring the fitness and competency review as a new owner/operator.
5. Input the 'full name' of the individual completing the form, including their title.
6. Include the 'address' of the individual or corporate entity requiring the review.
7. Enter your 'social security number' which will remain confidential and is not subject to disclosure.
8. Fill in your 'date of birth' accurately.
9. Indicate with 'YES' or 'NO' whether you have held specified roles with emergency medical services or similar facilities in the past 10 years.
10. If 'YES' is checked, provide detailed information such as the name of the agency or facility, address, certifying authority, and positions held on an attached page.
11. Attach your current resume or curriculum vitae along with copies of any relevant licenses and certifications, and a listing of addresses if applicable.
12. Proceed to the certification sections, sign and date the affirmations of competency and fitness.
13. Obtain a notary public’s affirmation and acknowledgment, including their signature and stamp.
14. Review your completed form for accuracy, then save your changes, download, print, or share the form as necessary.

Complete your Doh Form 3778 online today to ensure compliance with New York State requirements.