EMSTAR: Forms

Form No.	Description
DOH-2260	Application for Instructor Certification (2 pages) (PDF)
DOH 4135	Notice of Intent to Provide PAD (PDF)
DOH 4453	Lost your EMT card? Duplicate Card Request
	Reciprocity: go to http://www.nyhealth.gov/nysdoh/ems/emsforms.htm and scroll down; there are three forms.
DOH 4188	Notice of Intent to Possess and Use Epinephrine Auto-Injector [PDF file] and Sample Collaborative Agreement
DOH 3474	Do Not Resuscitate (PDF) or MOLST
LDSS-2221A	Report of Suspected Child Abuse or Maltreatment - PDF or MS Word
Other DOH forms are available at Bureau of EMS Forms
Regional Forms
	Patient Refusal Form (pdf)
	CISM Debriefing Report: PDF (fill out online, print & mail OR Word Document
	Application to borrow Videotapes
499	Hospital Diversion Status Report (PDF)
501 rev	On-Line Medical Control (PDF)
	Service Medical Director Agreement (PDF)
	Sample Collaborative Agreement for PAD (2 pages) (PDF)
	PAD Quality Assurance Report (PDF)
906	ALS Renewal Form (PDF)
907	AED Renewal Form (PDF)
	EMS Course Evaluation (PDF) (revised 9/09)
	Fibrinolytic Risk Assessment (PDF)
	Photo ID Request (be sure you have complied with STREMS Council Policy #22)
Quality Improvement Forms
	Ambulance Re-Routing Report PDF format
	Quality Improvement PCR Audit (PDF)
506	Case Review Evaluation (PDF)
507	Area QI Report to regional QI(2 pages) (PDF)
507a	Same as above, but this version may be completed on line (with free Adobe Reader 8), then printed out and mailed or faxed
508	Agency Report to Area QI (2 pages) (PDF)
	EMS/EMD QI Disposition Sheet (PDF)
	PCR Audit Tool (2 pages) (PDF)
EMD QI 100	EMD Quality Improvement Audit Tool (PDF)