In an effort to streamline the process of managing emergency medical services personnel, the New York State Department of Health has implemented the DOH 2828B form. This crucial document serves as an EMS Agency Personnel Roster, meticulously maintained by the Bureau of Emergency Medical Services. It is designed to organize and list all personnel affiliated with an agency, from first responders to emergency medical technicians, ensuring a transparent and efficient system for tracking qualifications and certification expirations. Agencies are required to submit this form with information arranged alphabetically by the personnel's last and first names, alongside other critical details such as date of birth, certification levels, ID numbers, and the validity of their certifications, including CPR, AED/PAD, and First-Aid. The form's structured format, updated last in March 2007, aims to ensure that every emergency medical service provider is credentialed properly, thereby enhancing the quality of emergency healthcare services across the state.
| Question | Answer |
|---|---|
| Form Name | Doh 2828B Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Expires, Responders, 2828b, AED |
New York State Department of Health |
EMS Agency Personnel Roster |
|
Bureau of Emergency Medical Services |
||
|
||
|
|
|
|
|
Agency Name
Agency Code
Date Submitted
Page ______ of ______
List all personnel alphabetically
Last name, First name
Date of Birth |
Certified First Responders |
Emergency Medical Technicians |
Check Other Levels |
|||
|
|
|
|
|
|
|
mm/dd/yy |
ID Number |
Expires |
ID Number |
Expires |
B I CC P |
CPR AED/PAD |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DOH