Application for Instructor Certification

Instructions

This application must be completed, signed and the required documents submitted prior to certification. Please print or type all information in the spaces provided. Failure to complete and sign this application and/or submit the required documentation will result in a delay in certification.

Read each section carefully. 

EMS Policy Statement 22-02, EMS Instructor Requirements & Certification Process, should be reveiwed if you have any questions. 
Selection One
Select if this is your initial notification and wish to start your internship.
Select this option if you have completed your internship and need to turn in all your documentation.

Section A. Applicant Information

I am applying for
Are you obtaining your CIC through CLI advanced standing (fast track) method?
Contact Information

Section B. Agency Information

Name of the EMS Agency you are actively providing on going, direct, hands-on, pre-hosptial patient care with for at least one of the last three years. 
Date you started with the agency. 
Date you stopped riding with the agency. If you are still riding, leave it blank. 
Attached a signed letter, on agency letterhead, from your Chief Operations Officer or equivalent Supervisor, attesting to the dates you have been active in the last three years providing "on-going, direct, hands-on, pre-hospital patient care". 
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Certified Lab Instructor

Submit to the Bureau of EMS Central Office the following documents:
Identify the course numbers your internship was associated with. 
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Completed by the supervising CIC.
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Completed by a CLI.
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To be filled out by the Regional EMS Council Training and Education Committee, if one exists. 
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If you did not take a NAEMSE course, fill in the CLI Course number below.
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Certified Instructor Coordinator

Submit to the Bureau EMS Central Office the following documents:
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A favorable report completed by the supervising CIC.
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A favorable report completed by a NYS Regional Faculty member or a NYS BEMS Representative.
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Initial Documents

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A letter from your sponsoring course sponsor that is accepting you for your internship. 
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Section C. Personal Affirmation

I affirm that in accordance with the requirements of 10 NYCRR 800, I have NOT been convicted of any misdemeanors or felonies. I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.

Do not sign if you have any convictions.

I hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant. I further understand that offering or providing false information on this document may constitute a crime under the penal law and may subject any certification to revocation or other Department action.

Sign above