EMS Forms

Contact Us

Contact Us Form	Staff Listing
Bureau of EMS Contact Us Form	Bureau of Emergency Medical Services and Trauma Systems Staff

Complaints & Investigations

Complaints & Investigations Forms
Reportable Incident Report	EMS Complaint Form Submission

Data & Informatics

ePCR Issues Form	DOH Forms	Elite Viewer	Resources
ePCR Issues Reporting Form	DOH-5136 Application and Approval for EMS Agency to Use e-PCR	Elite Viewer Access Request Form	NYS ImageTrend Site NEMSIS Website NEMSIS v.3 Data Dictionary Information NYS 3.5.0 Data Dictionary NYS Facilities List NYS 3.5.0 Validation Rules

Education-Certification

CME Recertification

CME Portal Link	Forms Needed For Submission	CME Registration
CME Submission Portal	DOH-5065 EMT Recertification Form DOH-5066 AEMT Critical Care Recertification Form DOH-5067 AEMT Recertification Form DOH-4231 Paramedic Recertification Form DOH-5295 CFR Recertification Form	DOH-4227 Agency Registration Form

Education-Certification Submission Portals

DOH-4281 Certification Extension for Military Personnel	DOH-4245 Registration For Emergency Medical Technicians' Exam, Test Scheduling Request	DOH-4453 Name or Address Change and Duplicate Card Requests
ADA Request	NYS Student \| National Registry Exam Submission	Out of State Reciprocity
Verification of NYS Certification

Education- Training & Instructors

Course Paperwork Submission

Course Paperwork Portal	Course Paperwork Forms
EMS Course Paperwork Submission Portal	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

Instructor Forms

Instructor Management Portal	Instructor Forms
Instructor Management Portal	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 Simulation Debriefing Tool

Course Sponsor Forms

Course Sponsor Administration Portal	Course Sponsor Forms
Course Sponsor Administration Portal	Course Sponsor Recommendation Letter \| Instructor Internship Sponsor Personnel Change Form

Additional Submission Forms

Pilot Educational Program Comment & Question Form	Community Internship Education Pilot Program	Exam Incident Report Form

EMS Agency Operations

EMS Agency Renewal

Renewal Portal	Renewal Forms
EMS Agency Renewal Portal	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

Controlled Substance Submissions

Controlled Substance Portal	Controlled Substance Forms
Controlled Substance Portal	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

Additional EMS Agency Operation Forms & Portals

Additional Portals	Additional Forms
New York State Basic Life Support Vehicle Registration Submission Portal DOH-1881 Affirmation of Compliance Submission Portal	DOH-3777 Application for New EMS Service, Expansion of Territory or Transfer of Ownership DOH-3778 Affirmation of Fitness and Competency DOH-3779 Inspection Report for ALS First Response Vehicles New York State Department of Health DOH-5800 Rotary Wing Air Medical Service Equipment Waiver Request, Approval and Inspection Under the Provisions of Part 800.27 DOH-3780 Inspection Report for Emergency Ambulance Service Vehicles DOH-2596 Inspection Report for Certified Ambulance Vehicles

EMS For Children

PECC Program	Always Ready For Children	Additional Portals
PECC Program	Always Ready For Children Commitment Letter Submission	Mental Health Poster Request Form Pediatric Products Request Form

EMS Provider Feedback & Surveys

Provider Feedback	Surveys
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	EMT-CC Sunset Public Comment

Finance & Administration

Finance Portals	Finance Forms
Claim For Payment Submission Portal	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

Part 18- Public Gathering & Public Function

Part 18 Submission Portal	Part 18 Forms	Part 18 Resources
Part 18 Submission Portal	DOH-44 Application for a Permit for a Public Gathering DOH-2332 Part 18 Public Function Event Report DOH-2342 Part 18 Public Function Medical Incident Log	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 For any inquiries, please e-mail the Public Health and Event Safety Unit at: EMS.Part18.Permits@health.ny.gov

Vital Signs

Awards Portals	Resources
NYS EMS Innovation Awards 2025 NYS EMS Annual Awards 2025	Vital Signs Conference Website Vital Signs Academy

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