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Adirondack - Appalachian Regional Emergency Medical Services Council


Forms and Applications

Here are some items in PDF (or Word) format which you might find helpful to download

For a copy of the AAREMS BLS Glucometer Program application and information, click below:

AAREMS EMT Glucometer Program

For a copy of the Application for a Regional TEK number, click below.

AAREMS TEK Number Application. pdf

For a copy of the Regional "ALS Procedure and CME Record" Folder (the "TEK Booklet"), click below:

AAREMS TEK Booklet.pdf

For a copy of the Regional protocol for EMT-B Nebulized Albuterol, including a copy of the agency application, click below:

Albuterol (BLS)

For a copy of a sample agency incident report form that may be modified for your agency, click below:

Agency Incident Report

For a copy of the DOH mandatory Reportable Incident Form (DOH 4461), follow this link:

http://www.health.ny.gov/forms/doh-4461.pdf

For a copy of the BLS First Responder Update forms for DOH, click below:

BLS FR Update Forms

For a copy of the Regional CME Approval form, click below:

CME Approval Form. pdf

For a copy of the form to report suspected child abuse or maltreatment, click below (Word document):

Report of Suspected Child Abuse or Maltreatment

For a copy of the Epi-Pen program Notice of Intent form, click below:

EpiPen Application. pdf

For a copy of a sample EpiPen Collaborative Agreement, click below:

EpiPen Sample Collaborative Agreement. pdf

For a copy of the current (May 2006) PAD (Public Access Defibrillation) Notice of Intent, click below:

PAD

For a copy of a sample collaborative agreement for a PAD application, click below:

PAD Sample Collaborative Agreement. pdf

To report the use of a PAD, click below:

PAD Use Report

For a Copy of the Roles and Responsibilities of the Service Medical Director, click below. Agencies should use this form when acquiring or changing a Medical Director.

Medical Director Role and Responsibility.doc

For a copy of the form for an agency to request approval of change from one ALS level to another, click below:

Request for REMAC Approval of ALS Level Change

For a copy of the form for an agency to request ALS status, click below:

Request for an Agency to Provide ALS Service

For a copy of the suggested AAREMS form for Refusal of Care, Treatment, and/or Transportation, click below:

Refusal of Medical Care, Treatment, and/or Transportation, pdf

Refusal of Medical Care,Ttreatment and/or Transportation (Word Format) in English and Spanish

This page will be regularly updated. For further information, contact the Regional Office at 518-548-3535, or send us an e-mail by clicking here.