EMSTAR: Forms

DOH Form No.		Description
	DOH-2260	Application for Instructor Certification (2 pages) (PDF)
	DOH 4135	Notice of Intent to Provide PAD (PDF)
	DOH 3474	Do Not Resuscitate (PDF)
		Notice of Intent to Possess and Use Atropine Auto-Injector PDF file OR Fillable PDF File (fill out online, print and sign)
	Other DOH forms are available at Bureau of EMS Forms
Regional Forms
		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)
		Fibrinolytic Risk Assessment (PDF)
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)