Forms and Downloads
Recertification for Providers
CME Recertification Submission Portal
CME Recertification Submission Portal ***
*** Please read carefully when choosing "entity submitting"
-Individual means you are the applicant and you are NOT sponsored by an agency. This means there is no agency code or Coordinator signature on your application. Individual submissions are NOT eligible for EMS education reimbursement funds.
-EMS Agency means you are the agency's CME Coordinator OR you are an individual submitting your own application and the recertification is sponsored by an agency.
-Course Sponsor means you are a representative of a BEMS recognized Course Sponsorship and you are submitting on behalf of a student who is a member of an agency the Course Sponsor represents.
CME Recertification Submission Checklist
CME Recertification Submission Instruction Manual
CME Recertification Forms
CFR - Recertification Form DOH-5295
EMT - Recertification Form DOH-5065
AEMT - Recertification Form DOH-5067
EMT - Critical Care CME Recertification Form DOH-5066
Paramedic - CME Recertification Form DOH-4231
Administrative Manual
CME Recertification Program Administrative Manual
MIST Form
Download the pdf
REMO Restocking Final 2018
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PAD Provider Packet
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NYS Epinephrine Auto-Injector Notice of Intent
Download the pdf
CPAP QI Form
This form is to be completed by the EMT/AEMT who has applied CPAP to a patient using the REMO CPAP protocol. This form should be returned, along with a copy of the completed PCR. These should be returned with the yellow copies of the PCR's by the 15th of the next month.
Download the pdf
CME Attendance
To be used for all attendees at a recognized CME
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CME Certificate
This certificate should be issued by a CIC at an approved CME. By using the “Sign” function of Adobe Reader a CIC can add text to the appropriate fields.
Download the pdf
BLS Glucometry
James Holland
Health Program Administrator, Clinical Laboratory Evaluation Program
Wadsworth Center, New York State Department of Health
Phone: (518) 402-4141| James.Holland@health.ny.gov
Fax: (518) 449-6902
http://www.wadsworth.org/regulatory/clep/limited-service-lab-certs
REMO Credentialing Process
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PAD Usage QI Report
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REMO Collaborative Agreement
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REMO RMA Form
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PAD Quarterly Report
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Roles and Responsibilities for PAD Providers
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Epi-QI Form
This form is to be completed and sent to REMO within 2 business days of the use of an Epinephrine auto-injector.
Download the pdf
NYS Public Health Law Section 3000a-b
http://www.health.ny.gov/nysdoh/ems/art30.htm#BM3000b
The information contained on this website is not the official version of the New York State Public Health Law. No representation is made as to its accuracy. To ensure accuracy and for evidentiary purposes, reference should be made to the official version available on the New York State Legislature Web site. Click on the link for "Laws of New York" and then the link for "PBH Public Health".
The information contains legal definitions used in collaborative agreements.
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NYS Policy Statement 09-03 Re: PAD
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NYS PAD Notice of Intent
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BLS Naloxone QI Form
This form is to be completed by the EMT/AEMT who has administered Naloxone to a patient using the BLS Naloxone protocol. This form should be returned, along with a copy of the completed PCR, to the appropriate Program Agency within 24 hours of administration in order to restock the BLS Naloxone Kit.
Download the pdf
BLS Albuterol QI Form
This form is to be completed by the EMT/AEMT-I who has administered Albuterol to a patient using the REMO Albuterol protocol. This form should be returned, along with a copy of the completed PCR. These should be returned with the yellow copies of the PCRs by the 15th of the next month
Download the pdf
PAD Checklist
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Report of Meaningful Positive Result
This form is to be used for all REMO providers whose skills and efforts at an EMS event are deserving of recognition.
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REMO ePCR Policy Agreement
As the electronic age advances REMO will continue to advance as well. In order to assist the regional agencies in meeting the demands of collecting electronic patient care data, the following policy has been
developed. In order to participate in an electronic PCR program agencies must complete this form.
Download the pdf
CME Participant Survey
CICs can use this form as a program evaluation tool.
Download the pdf
Report a Struck By Incident
The Emergency Responder Safety Institute (ERSI), a committee of the Cumberland Valley Volunteer Firemen’s Association (CVVFA), has worked for years to improve the safety of those who respond to incidents on America’s roadways. Continuing to be proactive in this effort, CVVFA/ERSI has again worked to develop a better document and analyze how and where our country’s first responders are being struck, injured, and killed. This will be accomplished through this enhanced platform and capability to solicit and collect struck-by incident information from voluntary reporters and significantly upgrade its data collection functionality and depth.