Doh-4010 Application For Aemt Rapid Recertification Page 2
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1
2Service Medical Director’s Affirmation
NEW YORK STATE DEPARTMENT OF HEALTH
for AEMT Rapid Recertification
s
Bureau of Emergency Medical Service
THIS SIDE OF FORM SHOULD ONLY BE USED FOR AEMT RAPID RECERTIFICATION
I, ________________________________________________, serving in the capacity of Service Medical
Name of Service Medical Director
Director for _____________________________________________________________ due affirm that
Name of ALS Service
_______________________________________ is deemed competent and qualified for admission to the
Name of AEMT Recertification Applicant
State practical skills examination and subsequent State written certification examination in accordance
with the State EMS Code (10 NYCRR 800) and the policies and procedures of the Bureau of Emergency
Medical Services. I affirm that the applicant meets at minimum all the following criteria:
* Actively practicing as a New York State certified AEMT within a regionally
approved ALS system.
* Clinically competent and qualified to practice as an AEMT.
* Remains proficient in all of the cognitive and performance objectives
of the New York State approved AEMT curriculum.
* In the judgement of the Service Medical Director the candidate is of sound
character and judgement.
* Successfully completed the national cognitive and skills objectives in
Basic Cardiac Life Support (BCLS), Cardiopulmonary Resuscitation (CPR)
and Emergency Cardiac Care as outlined in the Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiac Care:
Recommendations of the [most current] National Conference.
* Other requirements as set forth by the Service Medical Director.
The determination of whether a candidate meets the above criteria is made solely by the Service
Medical Director and should be based on, but not limited to, direct clinical observation, evaluation of
performance through quality improvement/quality assurance activities, in-service training and continuing
medical education (CME).
Medical Director's Signature
As the Service Medical Director for this applicant, I do hereby affirm that the applicant named above meets
the criteria to participate in the AEMT Rapid Recertification examinations. In my judgement, the applicant is
clinically competent and qualified to continue practicing as an AEMT. I understand this committment is
made under the sole authority of my license to practice medicine in the State of New York.
Medical Director's Name (Printed) ________________________________________________________
Medical Director's Signature ____________________________________________________________
License Number:
Date:
Month
Day
Year
This is a two-sided form; it will not be processed unless both sides are
completed, signed and submitted.
DOH-4010 (10/04) page 2 of 2
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