NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Course No. Course
Location
Final Practical Skills Examination Summary Sheet
Certified
Instructor/
Coordinator
Practical Exam
Coordinator
CIC Signature
PEC Signature
Practical Exam Date
mm
dd
yy
Station
Evaluator
Student’s Name
P = Pass F = Fail
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DOH­2733 (3/11) Page 1 of 2
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Final
Result
P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F Pass Fail
Station
Evaluator
Student’s Name
P = Pass F = Fail
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DOH­2733 (3/11) Page 2 of 2
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Final
Result
P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F P F Pass Fail