Get Doh 3848 2015-2024

Name of Agent Print Signature of Agent Date Name of CEO Print Signature of CEO Send completed report to New York State Department of Health 875 Central Avenue Albany NY 12206 DOH-3848 7/15 Telephone 518-402-0996. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Emergency Medical Services and Trauma Systems Bureau of Narcotic Enforcement Controlled Substances Semi-Annual Report For Emergency Medical Services Agencies This report must be submitted pursuant to PHL Article 33 within 30 days of June 30th and December 31st each year. Retain a copy of this semi-annual report for your records for a minimum of 5 years. Reporting Period January 1 - June 30 This form is for reporting Controlled substances OTHER THAN and July 1 - December 31 Agency Name NYS Agency Code NYS CS License No* Business Phone Address City State County Name of Controlled Substance Zip Dosage Form mg/unit Total Quantity Received from DEA Registrant and Wasted attach DOH-2094 Records stocks and sub stocks Physical Inventory Count stocks and sub stocks Total Number of EMS Responders Authorized to administer EMT-P EMT-CC I certify that on I conducted an actual physical inventory of the controlled substances listed above. Losses have been reported on a Loss of Controlled Substances Report DOH-2094 and have been submitted to BNE and a copy of the form has been enclosed* Overages are explained on a separate attached report. I affirm that this is a true and accurate record of the controlled substance utilization by the above named agency. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Emergency Medical Services and Trauma Systems Bureau of Narcotic Enforcement Controlled Substances Semi-Annual Report For Emergency Medical Services Agencies This report must be submitted pursuant to PHL Article 33 within 30 days of June 30th and December 31st each year. Retain a copy of this semi-annual report for your records for a minimum of 5 years. Reporting Period January 1 - June 30 This form is for reporting Controlled substances OTHER THAN and July 1 - December 31 Agency Name NYS Agency Code NYS CS License No* Business Phone Address City State County Name of Controlled Substance Zip Dosage Form mg/unit Total Quantity Received from DEA Registrant and Wasted attach DOH-2094 Records stocks and sub stocks Physical Inventory Count stocks and sub stocks Total Number of EMS Responders Authorized to administer EMT-P EMT-CC I certify that on I conducted an actual physical inventory of the controlled substances listed above. Retain a copy of this semi-annual report for your records for a minimum of 5 years. Reporting Period January 1 - June 30 This form is for reporting Controlled substances OTHER THAN and July 1 - December 31 Agency Name NYS Agency Code NYS CS License No* Business Phone Address City State County Name of Controlled Substance Zip Dosage Form mg/unit Total Quantity Received from DEA Registrant and Wasted attach DOH-2094 Records stocks and sub stocks Physical Inventory Count stocks and sub stocks Total Number of EMS Responders Authorized to administer EMT-P EMT-CC I certify that on I conducted an actual physical inventory of the controlled substances listed above. Losses have been reported on a Loss of Controlled Substances Report DOH-2094 and have been submitted to BNE and a copy of the form has been enclosed* Overages are explained on a separate attached report.