Get DOH-4231 2020-2024

NEW YORK STATE DEPARTMENT OF HEALTH EMT-Paramedic RECERTIFICATION FORM Bureau of Emergency Medical Services Continuing Education Recertification Program Print Neatly in UPPER CASE Letters - Please Complete ALL Information Incomplete forms will be denied and returned EMT Number Social Security Number - Last Name MI First Name Address City State Zip Code Enter Agency Code of Your Participating Agency 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 any misdemeanors 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 bar to certification* The Department of Health will determine if the conviction is applicable under the provisions of 10NYCRR Part 800. Applicant s Signature Date CPR Certification A Copy of Current Card front and back MUST Accompany This Application ACLS Certification Skill Competency Verification QA /QI Skill Direct Observation Patient 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 Administration Spinal 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 outlined above. Printed Name of Medical Director DOH-4231 06/12 Signature of Medical Director 1 of 2 Required Hours Topic Preparatory Trauma CIC Initials Airway Management Ventilation Earned Medical see sub categories Pulmonary and Cardiology Neurology/Endocrinology/Allergies Anaphylaxis Gastroentaerology/Renal Urology/Toxicology/Hematology Environmental Conditions/Infectious Communicable Diseases/Behavioral Gynecology and Obstetrics Special Considerations see sub categories Neonatology and Pediatrics Abuse and Assault Patients w/Special Challenges Acute Interventions for Chronic Care Patients Operations TOTALS Additional 24 Hours of Continuing Education Must include mandatory training for the EMT National Standards EMT National Standards Update I hereby affirm that all statements on this recertification form are true and correct including all copies of cards certificates and other required verification* It is understood that false statements or documents submitted with the intent to falsely recertify may be grounds for revocation of certification and applicable civil and criminal penalties. It is also understood that the Bureau of Emergency Medical Services or its designee may conduct an audit of the activities listed herein at any time. This form must be mailed and postmarked no less than 45 days prior to your current expiration date Signature of Participant Signature of Sponsoring Agency Contact / Coordinator 2 of 2.