DOH 5065 EMT Recertification Recert

User Manual: 5065

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NEW YORK STATE DEPARTMENT OF HEALTH

EMT RECERTIFICATION FORM

Bureau of Emergency Medical Services

Continuing Education Recertification Program

Print Neatly in UPPER CASE Letters - Please Complete ALL Information – Incomplete forms will be denied and returned

EMT Number

Social Security Number

-

-

Last Name
MI

First Name

Address

City

State

Zip Code

Enter Agency Code of Your Participating Agency

I affirm that in accordance with the requirements of 10NYCRR Part 800.8(e), I have not been convicted of or am not currently charged with 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 10NYCRR Part 800.

___________________________________________________________

___________________________________

Applicant's Signature

Date

EMT Refresher Training - 26 Hours
Required
Hours

DIVISION
Preparatory

1

Airway

2

Patient Assessment

3

Pharmacology/Med Admin/Emergency Meds

1

Immunology/Toxicology

1

Endocrine/Neurology

1

Abdominal/Geni-Renal/GI/Hematology

3

Respiratory

1

Psychiatric

1

Cardiology

1

Shock and Resuscitation

1

Trauma

4

Geriatrics

2

OB/Neonate/Pediatrics

2

Special Needs Patients

1

EMS Operations

1
TOTALS

DOH-5065 (06/12)

Hours
Earned

CIC Signature

CIC
Number

26
1 of 2

CPR Certification

*A Copy of Current Card (front and back) MUST Accompany This Application*

Additional 46 Hours of Continuing Education
Date

Topic

Hours

Date

Topic

TOTAL HOURS

Hours

TOTAL HOURS

Skill Competency Verification
SKILL

QA/QI

Direct
Observation

Patient Assessment (Medical and Trauma)
Airway / Ventilation (Simple Adjuncts, Supplemental Oxygen Delivery, Bag Valve-Mask one and
two rescuer)
Hemorrhage Control and Splinting (long bone injury, joint injury, and traction splinting)
Spinal Immobilization (Seated and Supine)
Cardiac Arrest / Automatic External Defibrillator (AED)
As the Physician Medical Director or Training Officer for the Participant's Continuing Education Program I hereby affix my signature attesting to
proficiency in all skills outlined above.

_____________________________________

Printed Name of Medical Director / Training Officer

_____________________________________________
Signature of Medical Director / Training Officer

_____________________
Date

I hereby affirm that all statements on this recertification form are true and correct, including all copies of cards, certificates and other required verification.
It is understood that false statements or documents submitted with the intent to falsely recertify may be grounds for revocation of certification and
applicable civil and criminal penalties. It is also understood that the Bureau of Emergency Medical Services or its designee may conduct an audit of the
activities listed herein at any time. This form must be mailed and postmarked no less than 45 days prior to your current expiration date!

________________________________________

________________________________________

____________________

_____________________

Signature of Participant

Date

DOH-5065 (06/12)

Signature of Sponsoring Agency Contact / Coordinator

Date

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