Form DOH-4452 "Cic Internship Tracking Form" - New York

What Is Form DOH-4452?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2016;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOH-4452 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-4452 "Cic Internship Tracking Form" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
CIC Internship Tracking Form
Bureau of Emergency Medical Services and Trauma Systems
Topic
Date
Hours
Supervising CIC
Completed
Completed
(Signature and CIC Number)
Lectures
Workforce Safety and Wellness
(Minimum of 30
Documentation
minutes per topic)
Medical/Legal and Ethics
Principles of Pharmacology
If CIC candidate is
certified as an ALS
Emergency Medications
provider, he/she
Airway Management
must complete at
least 7 of these topics
Respiration
at their highest level
Scene Size-Up
of certification.
Primary Assessment
History Taking
Monitoring Devices
Neurology
Infectious Diseases
Endocrine Disorders
Psychiatric
Cardiovascular
Toxicology
Respiratory
Shock and Resuscitation
Trauma Overview
Chest Trauma
Orthopedic Trauma
Soft Tissue Trauma
Obstetrics
Geriatrics
Multiple Casualty Incidents
Total Hours (26 Minimum)
Miscellaneous
Develop, implement and oversee
full class lab session
Prepare and process all mandatory
State and Course paperwork
Prepare, conduct, grade, and
r
v e
e i
w
r w
t t i
n e
e
a v
u l
i t a
n o
tool of at least 10 questions
P
e r
a p
e r
a
d n
d a
m
n i
s i
e t
a r
student remediation plan
Review student observation/
c
n i l
c i
/ l a
e fi
d l
o r
a t
o i t
s n
r o f
accuracy completeness
W
o
k r
w
h t i
P
E S
C
o o
i d r
a n
r o t
to set up a Final PSE
P
e r
a p
e r
n fi
l a
o C
r u
e s
a
d n
Student folders/records
P
e r
a p
e r
n a
s d
b u
i m
e t
d n
f o
course paperwork
CIC Candidate’s Name (print)
EMT#
Supervising CIC’s Name (print)
CIC#
Supervising CIC’s Signature
Date
DOH-4452 ( (12/16)
NEW YORK STATE DEPARTMENT OF HEALTH
CIC Internship Tracking Form
Bureau of Emergency Medical Services and Trauma Systems
Topic
Date
Hours
Supervising CIC
Completed
Completed
(Signature and CIC Number)
Lectures
Workforce Safety and Wellness
(Minimum of 30
Documentation
minutes per topic)
Medical/Legal and Ethics
Principles of Pharmacology
If CIC candidate is
certified as an ALS
Emergency Medications
provider, he/she
Airway Management
must complete at
least 7 of these topics
Respiration
at their highest level
Scene Size-Up
of certification.
Primary Assessment
History Taking
Monitoring Devices
Neurology
Infectious Diseases
Endocrine Disorders
Psychiatric
Cardiovascular
Toxicology
Respiratory
Shock and Resuscitation
Trauma Overview
Chest Trauma
Orthopedic Trauma
Soft Tissue Trauma
Obstetrics
Geriatrics
Multiple Casualty Incidents
Total Hours (26 Minimum)
Miscellaneous
Develop, implement and oversee
full class lab session
Prepare and process all mandatory
State and Course paperwork
Prepare, conduct, grade, and
r
v e
e i
w
r w
t t i
n e
e
a v
u l
i t a
n o
tool of at least 10 questions
P
e r
a p
e r
a
d n
d a
m
n i
s i
e t
a r
student remediation plan
Review student observation/
c
n i l
c i
/ l a
e fi
d l
o r
a t
o i t
s n
r o f
accuracy completeness
W
o
k r
w
h t i
P
E S
C
o o
i d r
a n
r o t
to set up a Final PSE
P
e r
a p
e r
n fi
l a
o C
r u
e s
a
d n
Student folders/records
P
e r
a p
e r
n a
s d
b u
i m
e t
d n
f o
course paperwork
CIC Candidate’s Name (print)
EMT#
Supervising CIC’s Name (print)
CIC#
Supervising CIC’s Signature
Date
DOH-4452 ( (12/16)