Doh 4231 Form PDF Details

The New York State Department of Health (DOH) DOH-4231 form is a crucial document for EMT-Paramedics seeking recertification under the Bureau of Emergency Medical Services and Trauma Systems Continuing Education Recertification Program. This comprehensive form requires paramedics to provide detailed personal and professional information, including their EMT number, agency code, and social security number, along with their contact details. Applicants must affirm their commitment to follow all the requirements of the Continuing Education (CME) Program, maintaining their certification throughout. It emphasizes the importance of truthful and complete submissions, as any falsification may lead to severe repercussions, including revocation of certification and potential legal penalties. The form outlines the structured recertification path, detailing specific educational components such as refresher training hours in various critical care areas, mandatory topics, and additional continuing education hours required for recertification. It also integrates a section for the Physician Medical Director to attest to the applicant's proficiency, alongside a declaration by the sponsoring agency confirming the applicant's active participation in the CME-Based Recertification Program. Completing the DOH-4231 form accurately and submitting it within the prescribed timeline is essential for EMT-Paramedics in New York State aiming to maintain their certification and continue providing vital emergency medical services.

QuestionAnswer
Form NameDoh 4231 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesamap recerification form, new york state c4 forms, nys doh recertification, new york state cna recertification form

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH

 

 

EMT-Paramedic Recertification

Bureau of Emergency Medical Services and Trauma Systems

 

 

 

Continuing Education Recertification Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

EMT Number

 

Agency Code

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

XXX

 

 

XX

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have read and agree to follow all requirements for participating in the NYS Continuing Education

 

 

Participant Initials

Recertification Program as found in the current CME Program Manual. Participation is contingent on

 

 

 

 

 

 

maintaining current certification as an EMT, AEMT, CC or Paramedic. I understand that as a participant in this

 

 

 

 

 

 

program I may be required to complete surveys or questionnaires regarding my participation. The Bureau of

 

 

 

 

 

 

Emergency Medical Services or its designee may randomly audit this program and view records pertaining to my participation in continuing education activities. This audit may include written testing and practical skills evaluation. The Bureau or its agent may contact the REMAC, Medical Director(s), receiving hospital personnel, officers of my EMS agency, and others to discuss my participation.

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. This form must be mailed and postmarked no less than 45 days prior to your current expiration date!

Applicant’s Printed Name

Signature

Date

I affirm that in accordance with the requirements of 10NYCRR Part 800, I have not been convicted of, or currently charged with any misdemeanors or felonies. I understand if I have charges or a conviction it will be reviewed. I also understand such charges or conviction may not be an automatic bar to recertification. Do not sign if you have been convicted of any misdemeanor or felony charges that have not previously been cleared by BEMS to be certified.

Applicant's Signature

Date

 

 

As the Physician Medical Director for the Participant's Continuing Education Program I hereby affix my signature attesting to proficiency in all skills outlined in this form.

Medical Director’s Printed Name

Signature

NYS MD License Number

Date

This applicant is in continuous practice as an EMS provider with this EMS agency as defined in 10NYCRR Part 800.3(w) and is actively participating in our agency’s CME-Based Recertification Program. The agency and applicant understand they must abide by the requirements of the program as detailed in the CME-Based Recertification Program Administration Manual.

Sponsoring Agency Contact / Coordinator’ Printed Name

Signature

Date

Official Use

DOH-4231 (1/20) page 1 of 3

Last Name

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

EMT-Paramedic Refresher Training – 35 Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Topic Area

Required

 

Hours

 

 

 

 

Source/

 

Hours

 

Earned

 

Date

Course

Method

 

 

 

 

 

 

 

 

 

Preparatory

2.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Airway

3.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacology, Med. Admin.,

3.0

 

 

 

 

 

 

 

Emergency Meds.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immunology

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toxicology

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Endocrine

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurology

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdominal, Geni-Renal,

1.0

 

 

 

 

 

 

 

GI, Hematology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory

3.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychiatric

2.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiology

3.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shock & Resuscitation

4.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma

3.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Geriatrics

2.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OB, Neonate, Pediatrics

2.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Needs Pt.

2.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMS Operations

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALS

35.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIC Signature

CIC Print Name

CIC Number

DOH-4231 (1/20) page 2 of 3

Last Name

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

Mandatory Topics 5 hours

 

 

 

 

 

 

 

 

Topic Area

 

Required

Hours

 

 

 

 

Source/

 

 

Hours

Earned

 

Date

Course

Method

Mental Health of EMT

 

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Lifting and Moving

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Safe Transport of Ped. Patients

1.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Vehicle

 

2.0

 

 

 

 

 

 

 

Driver Training

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALS

5.0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional 20 Hours of Continuing Education

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Topic Area

 

Required

Hours

 

 

 

 

Source/

 

 

Hours

Earned

 

Date

Course

Method

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

Total Hours

 

 

 

 

 

 

 

 

 

 

 

 

CPR, ACLS and PALS

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

 

 

 

 

 

 

 

Skill Competency

Verification PSE Skill Sheets must be used.

 

 

 

 

 

 

 

 

 

 

 

 

Skill

 

 

 

 

 

 

 

 

Training Officer’s Signature

Patient Assessment (Medical and Trauma)

 

 

 

 

 

 

 

 

 

 

 

Airway/Ventilation (Simple Adjuncts, Supplemental Oxygen Delivery, BVM – one and two rescuer)

 

 

 

 

 

 

 

 

 

 

Cardiac Arrest Management

 

 

 

 

 

 

 

 

 

 

 

 

 

Hemorrhage Control and Splinting (long bone injury, joint injury, and traction splinting)

 

 

 

 

 

 

 

 

 

 

IV Therapy/IO Therapy/Medication

 

 

 

 

 

 

 

 

DOH-4231 (1/20) page 3 of 3

How to Edit Doh 4231 Form Online for Free

Should you wish to fill out new york state c4 forms, you won't need to download and install any applications - simply try using our PDF tool. In order to make our editor better and more convenient to work with, we continuously implement new features, considering feedback coming from our users. Starting is effortless! Everything you should do is stick to the following basic steps down below:

Step 1: Open the PDF doc inside our tool by pressing the "Get Form Button" in the top section of this webpage.

Step 2: This editor enables you to change your PDF in a variety of ways. Modify it with your own text, adjust what's already in the document, and put in a signature - all readily available!

This PDF form will require particular details to be typed in, therefore ensure that you take whatever time to fill in exactly what is expected:

1. Before anything else, once completing the new york state c4 forms, start out with the area that contains the following blanks:

Filling out segment 1 of emt recertification any

2. The next step is to fill out these particular fields: I hereby affirm that all, Applicants Printed Name, Signature, Date, I affirm that in accordance with, Applicants Signature, Date, As the Physician Medical Director, Medical Directors Printed Name, Signature, NYS MD License Number, Date, and This applicant is in continuous.

Step # 2 of filling in emt recertification any

3. Completing Last Name, First Name, EMTParamedic Refresher Training, Topic Area, Preparatory, Airway, Pharmacology Med Admin Emergency, Immunology, Toxicology, Endocrine, Neurology, Abdominal GeniRenal GI Hematology, Required, Hours, and Hours Earned is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

emt recertification any completion process outlined (portion 3)

4. It's time to start working on this next part! In this case you'll have these Respiratory, Psychiatric, Cardiology, Shock Resuscitation, Trauma, Geriatrics, OB Neonate Pediatrics, Special Needs Pt, and EMS Operations fields to complete.

OB Neonate Pediatrics, EMS Operations, and Trauma in emt recertification any

5. The last step to submit this PDF form is integral. You'll want to fill out the required fields, for instance EMS Operations, TOTALS, CIC Signature, CIC Print Name, CIC Number, and DOH page of, prior to finalizing. Neglecting to accomplish that can give you an unfinished and possibly nonvalid document!

EMS Operations, CIC Print Name, and CIC Number of emt recertification any

Regarding EMS Operations and CIC Print Name, be sure you don't make any errors here. Both of these are the most important ones in the file.

Step 3: Make certain your details are right and press "Done" to progress further. After creating a7-day free trial account here, it will be possible to download new york state c4 forms or send it via email right off. The PDF form will also be accessible from your personal account page with all your edits. Here at FormsPal, we endeavor to ensure that your details are maintained private.

Doh 4231 Form isn’t the one you’re looking for?

Related Documents