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 

Education Processing Timeline:

Education Processing Timeline:

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

Course Signature Form

Course Memorandum

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

Course Sponsor Administration Portal

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

Provider Feedback:

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

Surveys:

EMS Salary Survey

New York State Emergency Medical Services Council Diversity, Equity and Inclusion (DEI) Technical Advisory Group Survey

Part S- Feedback Survey

Rural Ambulance Service Task Force Stakeholder Survey

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