NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services and Trauma Systems
Topic
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.
CIC Internship Tracking Form
Date
Completed
Hours
Completed
Supervising CIC
(Signature and CIC Number)
Workforce Safety and Wellness
Documentation
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)
Miscellaneous
Develop, implement and oversee
full class lab session
Prepare and process all mandatory
State and Course paperwork
Prepare, conduct, grade, and
review written evaluation
tool of at least 10 questions
Prepare and administer a
student remediation plan
Review student observation/
clinical/field rotations for
accuracy completeness
Work with PSE Coordinator
to set up a Final PSE
Prepare final Course and
Student folders/records
Prepare and submit end of
course paperwork
DOH-4452 ( (12/16)
CIC Candidate’s Name (print)
EMT#
Supervising CIC’s Name (print)
CIC#
Supervising CIC’s Signature
Date