Bureau of Emergency Medical Services and Trauma Systems Staff

Reportable Incident Report 

EMS Complaint Form 

ePCR Issues Reporting Form

NEMSIS v.3 Data Dictionary Information

Policy Statement 12-02 Prehospital Care Reports

Policy Statement 12-03 Electronic PCR Data Submission

Policy Statement 21-04 Submission of Patient Care Reports as of July 1st, 2021 

DOH-5136 Application and Approval for EMS Agency to Use e-PCR 

Course Paperwork Forms: 

DOH-65 Application for Emergency Medical Services Certification

DOH-79 Students Ineligible To Take The State Certifying Examination

DOH-3312 Verification of Membership in A NYS EMS Agency 

DOH-3379 Medical Director's Certification of AEMT Course Completion

DOH-2733 Final Practical Skills Examination Summary Sheet

Click Here To Access Course Paperwork Submission Portal

Instructor Forms:

DOH-3378 CLI Internship Completion Report

DOH-4451 CLI Internship Tracking Form 

DOH-2423 Lab Instructor Audit Report

DOH-4452 CIC Internship Tracking Form 

DOH-3377 CIC Internship Completion Report 

DOH-2424 Didactic Presentation Audit Report 

Additional Submission Portals:

Claim for Payment Submission Portal

Application for Instructor Certification

Application for Instructor Recertification 

Pilot Educational Program Comment & Question Form

EMS Agency Renewal:

DOH Forms Needed for an EMS Agency Renewal:

DOH-206 Application for EMS Operating Certificate 

DOH-1881 Affirmation of Compliance 

DOH-2936 Certified EMS Agency Information Update Form

DOH-4362 Medical Director Affirmation Form

DOH-5131 Funding Document For EMS Agencies

DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care

DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency

DOH-5127 BLSFR Agency Information Application/Update Form

DOH-4135 Notice of Intent to Provide Public Access Defibrillation (PAD)

DOH-2828 EMS Agency Personnel Roster

Completed EMS Agency Renewal Forms must be submitted electronically through the EMS Agency Renewal Portal. Click Here

DOH Forms For Controlled Substance Submissions:

DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency 

DOH-4362 Medical Director Affirmation Form 

DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care

DOH-3848 Semi-Annual Controlled Substance Inventory Form for EMS Agencies

Loss of Controlled Substances Report

Completed forms must be submitted through the Controlled Substance Submission Portal.

Controlled Substance Submissions: Click Here

Additional EMS Agency Operations Submission Portals:

New York State Basic Life Support Vehicle Registration Submission Portal 

DOH-1881 Affirmation of Compliance Submission Portal

Additional EMS Agency Operations Forms:

DOH-3777 Application for New EMS Service, Expansion of Territory or Transfer of Ownership 

DOH-3778 Affirmation of Fitness and Competency 

DOH-3780 Inspection Report for Emergency Ambulance Service Vehicles 

DOH-2596 Inspection Report for Certified Ambulance Vehicles

Prehospital Pediatric Emergency Care Coordinator Form: Click Here

EMS Provider Reporting Long Wait Times at Hospital

EMS Agency Leader and EMS Provider to Sign Up for Bureau Briefings

EMS Agency Leader and EMS Provider Briefing Question Submissions

Claim For Payment Submission Portal: Click Here

Agency Claim for Payment Voucher - AC3253-S 

Course Sponsor Claim for Payment Voucher - AC3253-S 

Proctor Claim for Payment for Non-State Employees - AC3253-S

Mental Health Resources: Click Here

Behavioral Health and Substance Use Disorder Considerations for Emergency Medical Services Class Registration

Regulation: Title: Part 18 - Public Functions With Attendance Of Over 5,000 People | New York Codes, Rules and Regulations (ny.gov)

New York State Mass Gathering Planning Guide: nys-mass-gathering-planning-guide-final-6-12-2018.pdf

DOH-44 Application for a Permit for a Public Gathering: Click Here

File Attachment Upload (for emergency operations, event action, crowd management, evacuation plans and other sensitive documents): Click Here

Post Event Forms: 

DOH-2332 Part 18 Public Function Event Report: Click Here

DOH-2342 Part 18 Public Function Medical Incident Log: Click Here

For events taking place in New York City, Long Island, the Hudson Valley, Capital Region or North Country contact Stephen.Brucato@health.ny.gov; and for events taking place in the Mohawk Valley, Central NY, Southern Tier, Finger Lakes or Western NY contact Melissa.Lockwood@health.ny.gov; with any questions.

ESD Map: Regions | Empire State Development (ny.gov)

DOH-4135 Notice of Intent to Provide Public Access Defibrillation (PAD)

Schedule for Meeting Dates and Events: Click Here

NYS EMS Memorial Page: Click Here

Vital Signs EMS Agency Innovation Awards 2022

Vital Signs Conference Website

Vital Signs Academy