DOH 5065 EMT Recertification Recert
User Manual: 5065
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Page Count: 2
DOH-5065 (06/12)
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DIVISION Required
Hours Hours
Earned CIC Signature CIC
Number
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 26
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
EMT RECERTIFICATION FORM
Continuing Education Recertification Program
EMT Number
Social Security Number
- -
Last Name
First Name
MI
Address
City
State
Zip Code
-
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
Enter Agency Code of Your Participating Agency
Print Neatly in UPPER CASE Letters - Please Complete ALL Information
–
Incomplete forms will be denied and returned
DOH-5065 (06/12)
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Date Topic Hours Date Topic Hours
TOTAL HOURS TOTAL HOURS
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 Signature of Sponsoring Agency Contact / Coordinator
____________________ _____________________
Date Date
Additional 46 Hours of Continuing Education
Skill Competency Verification
CPR Certification *A Copy of Current Card (front and back) MUST Accompany This Application*
