NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Emergency Medical Services and Trauma Systems CIC Internship Tracking Form

DOH-4452 ( (12/16)

Lectures(Minimum of 30 minutes per topic)

If CIC candidate is certified as an ALS provider, he/she must complete at least 7 of these topics at their highest level of certification.

Topic Date Completed

Hours Completed

Supervising CIC(Signature and CIC Number)

Workforce Safety and WellnessDocumentation

Medical/Legal and Ethics

Principles of Pharmacology

Emergency Medications

Airway Management

Respiration

Scene Size-Up

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)

Develop, implement and oversee full class lab session

Prepare and process all mandatory State and Course paperwork

Prepare, conduct, grade, and noitaulave nettirw weiver

tool of at least 10 questions

a retsinimda dna eraperPstudent remediation plan

Review student observation/ rof snoitator dlefi/lacinilc

accuracy completeness

rotanidrooC ESP htiw kroWto set up a Final PSE

dna esruoC lanfi eraperPStudent folders/records

fo dne timbus dna eraperPcourse paperwork

Miscellaneous

CIC Candidate’s Name (print) EMT#

Supervising CIC’s Name (print) CIC#

Supervising CIC’s Signature Date