EMS Course Paperwork | Survey Builder

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Course Information

CIC Information

Name

Email

Phone

Primary CIC Number

Primary CIC EMT Number

Is there a Secondary CIC?

Second CIC information

Name

Email

Phone

Secondary CIC Number

Secondary CIC EMT Number

Course Number

Course Level

Course Type

Do you intend on vouchering?

Tuition Amount Charged

Any Additional Fee(s) Charged? Please List fee(s) and amount(s)

Is this a high school course?

Is this a BOCES course?

Is this a public or private course?

Please Provide Registration Website, If One is Being Used

Are you using one of the education pilot programs for this course?

If Yes, Which one?

End of Course Date

Course Start Date

PSE Exam Date

End of Course Date

Session dates

Day of Week	start time	End Time
Day of Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday	start time	End Time

Additional date time

Cancellation Date

Cancellation Reason

Class Location

Class address

Address

City/Town

State/Province

ZIP/Postal Code

County

Which Region is the Course Being Held in?

Notes

Add any notes that you need to keep track of your course.

Administration signature

Sign above

File Uploads

Pilot Community Internship Students

Community internship students must have a completed DOH-3312 and a letter on official agency letterhead stating that the individual has completed the requirements outlined in 23-08.

There should be one letter for each student. The letters are attached in this field and the DOH-3312 can be attached with the others below

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How many Pilot Community Internship Students are there in this course?”

Course signature page

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Agency Verification Forms

The DOH 3312s, Agency Verification Forms, are not required to be sent in to the Bureau any longer.

You must keep them in the student files for audit purposes.

Signed Student Applications (DOH-65)

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Unsigned Student Application (DOH-65)

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Medical Director Verification (DOH-3379) for ALS courses only

These forms only need to be uploaded for AEMT & Paramedic original courses.

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PSE Summary (DOH-2733)

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Ineligible Students (DOH-79)

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Course Roster- Signed by Administrator or CIC

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Student Enrollment

This replaces the Course Memorandum DOH-263.
The spreadsheet can not be modified or altered in any way.
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Course Syllabus and Schedule

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Modification Plan

Please submit a letter on Course Sponsor letterhead signed by the Sponsor Administrator identifying the requested modification and brief explanation for modification. If a CIC change is being requested, please also include the proposed CIC's name, CIC number, EMT number, and signature in this letter.
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Missed session attestation

Please submit letter with this attesting to the student completing the requirements of the class

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Attach course policies and procedures being used for this course

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Attach Registration Flyer

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