COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
STATE 911 DEPARTMENT
151 Campanelli Drive, Suite A
Middleborough, MA 02346
Phone (508) 828-2911
www.mass.gov/e911
CERTIFIED EMD RESOURCE ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
THIS FORM IS DUE ON OR BEFORE JULY 31, 2019
If the Certified EMD Resource serves as the Certified EMD Resource for more than one PSAP/RECC,
the Certified EMD Resource shall complete a separate form for each PSAP/RECC.
N
ame of Certified EMD Resource
Address
City/Town/Zip
Telephone Number
Fax Number
Website
N
ame /Title of Authorized Signatory
Address (if different from above)
Telephone Number
Fax Number
Email Address
*FORM MUST BE TYPED*
I, , hereby certify on behalf of
(“Certified EMD Resource”) as follows:
1. I am authorized by the Certified EMD Resource to complete this Certification of Compliance.
2. The Certified EMD Resource was at all times and remains now in compliance with the requirements of 560 CMR 5.00
applicable to t
he Certified EMD Resource.
3. Each person who acts as an emergency medical dispatcher for the Certified EMD Resource has maintained
certification in em
ergency medical dispatch through an emergency medical dispatch certification organization
approved by t
he State 911 Department.
4. Each person who acts as an emergency medical dispatcher for the Certified EMD Resource has completed 16
hours of c
ontinuing education annually.
5. New employees have completed all minimum requirements including an approved 40 hour basic telecommunicator
course.
6. Attached to this Certification of Compliance is documentation that each person that acts as an emergency medical dispatcher
for t
he Certified EMD Resource has maintained certification in emergency medical dispatch through an emergency medical
dispatch certification o
rganization approved by the State 911 Department and has maintained CPR certification. (See page 3
for s
preadsheet)
