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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
Initial Application
Select if this is your initial notification and wish to start your internship.
End of Internship Submission
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
Certified Lab Instructor
Certified Instructor Coordinator
Fast Track
- Select -
Yes
No
Are you obtaining your CIC through CLI advanced standing (fast track) method?
EMT Number
Contact Information
Name (Last, First Middle Initial)
Email
Phone
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
County
- Select -
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond
Rockland
St. Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming
Yates
Social Security Number
Date of Birth
Section B. Agency Information
Name of EMS Agency
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.
Agency Code
Start Date
Date you started with the agency.
End Date
Date you stopped riding with the agency. If you are still riding, leave it blank.
Letter From Agency Leadership
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".
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Certified Lab Instructor
Submit to the Bureau of EMS Central Office the following documents:
Course Number(s)
Identify the course numbers your internship was associated with.
CLI Internship Completion Form (DOH-3378)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
CLI Internship Tracking Form (DOH-4451)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Favorable Lab Instruction Audit Report (DOH-2423)
Upload
Completed by the supervising CIC.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
2nd Favorable Lab Instruction Audit Report (DOH-2423)
Upload
Completed by a CLI.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Letter of recommendation
Upload
To be filled out by the Regional EMS Council Training and Education Committee, if one exists.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
NAEMSE or CLI Course Completion Certificate
If you did not take a NAEMSE course, fill in the CLI Course number below.
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Certified Instructor Coordinator
Submit to the Bureau EMS Central Office the following documents:
CIC Internship Completion Form (DOH-3377)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
CIC Internship Tracking Form (DOH-4452)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Didactic Presentation Audit Report (DOH-2424)
Upload
A favorable report completed by the supervising CIC.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Didactic Presentation Audit Report (DOH-2424)
Upload
A favorable report completed by a NYS Regional Faculty member or a NYS BEMS Representative.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Fast Track Document Submission
FT Course Number(s)
Identify the course numbers your internship was associated with.
FT CLI Internship Completion Form (DOH-3378)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT CLI Internship Tracking Form (DOH-4451)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT Favorable Lab Instruction Audit Report (DOH-2423)
Upload
Completed by the supervising CIC.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT 2nd Favorable Lab Instruction Audit Report (DOH-2423)
Upload
Completed by a CLI.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT Letter of recommendation
Upload
To be filled out by the Regional EMS Council Training and Education Committee, if one exists.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT NAEMSE or CLI Course Completion Certificate
If you did not take a NAEMSE course, fill in the CLI Course number below.
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT CIC Internship Completion Form (DOH-3377)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT CIC Internship Tracking Form (DOH-4452)
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT Didactic Presentation Audit Report (DOH-2424)
Upload
A favorable report completed by the supervising CIC.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
FT Didactic Presentation Audit Report (DOH-2424)
Upload
A favorable report completed by a NYS Regional Faculty member or a NYS BEMS Representative.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Initial Documents
NAEMSE Certificate
Upload
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Letter of recommendation
Upload
A letter from your sponsoring course sponsor that is accepting you for your internship.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
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.
Applicant's Signature
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Date
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