Fillable FY2019 Psap Recc Certification Of Compliance Form (Commonwealth of Massachusetts)

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FY2019 Psap Recc Certification Of Compliance Form (Commonwealth of Massachusetts)

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The FY2019 Psap Recc Certification Of Compliance Form (Commonwealth of Massachusetts) form is 5 pages long and contains:

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  • 5 check-boxes
  • 268 other fields

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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
PSAP/RECC ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
Name of PSAP/RECC
Address
City/Town/Zip
Telephone Number
Fax Number
Website
Name /Title of Authorized Signatory
Address (if different from above)
Telephone Number
Fax Number
Email Address
I, , hereby certify on behalf of the above Public Safety
Answering Point or Regional Emergency Communication Center (“Certifying Entity”) as follows:
1. I am authorized to complete this Certification of Compliance.
2. Each person who acts as an enhanced 911 telecommunicator for the Certifying Entity is certified as an
enhanced 911 telecommunicator in accordance with the provisions of 560 CMR 5.00.
3. The following is a complete list of each person who acts as an enhanced 911 telecommunicator for the
Certifying Entity, and each such person is certified as an enhanced 911 telecommunicator in accordance
with the provisions of 560 CMR 5.00 and the continuing education training and hours for each person.
(See page 4 for spreadsheet)
THIS FORM IS DUE ON OR BEFORE JULY 31, 2019
*FORM MUST BE TYPED*
PSAP/RECC ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
Page 2
4. Primary PSAPs, Regional PSAPs, RECCs only:
The Certifying Entity provides EMD as required by the provisions of 560 CMR 5.00 as follows:
(check one)
through certified emergency medical dispatchers (provided by the PSAP)
Or
through the following certified EMD resource (provided by Fire Department, Private Ambulance
Company or other Certified Entity): .
Insert Name of Certified EMD Resource*(if applicable)
5. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), list for each enhanced 911 telecommunicator the expiration date for EMD certification and CPR
certification.
(See page 5 for spreadsheet)
6. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), please identify the EMD protocol being used. (check one)
APCO
PowerPhone
Priority Dispatch
7. Please provide the name and contact information for the Medical Director that approves your EMD
protocols?_________________________________________________________________________
8. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), who performs quality assurance for the Certifying Entity (i.e., who is your Quality Assurance
Administrator)?
9. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), how many medical calls have you received as of the date of this Annual Certification of
Compliance filing with the State 911 Department?
10. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), what percentage of medicals calls were reviewed for quality assurance?
11. If the Certifying Entity provides EMD through certified emergency medical dispatchers (provided by the
PSAP), describe briefly the method of documentation being used for quality assurance. (Attach separate page
if more space is necessary)
12. The Certifying Entity has notified the local emergency medical services provider of the EMDPRS that is
used for the Certifying Entity and the local emergency medical services provider has acknowledged
receipt of such notification.
PSAP/RECC ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
Page 3
I understand that records disclosed to the State 911 Department may be or may become a public record and may
not be protected from disclosure by law.
I hereby declare, under the pains and penalties of perjury, that the above statements are true and correct to the
best of my knowledge and belief.
Printed Name and Title
Signature Date
*Please note, if your PSAP or RECC is providing EMD through a Certified EMD Resource, that the Certified
EMD Resource is also required to complete and submit to the State 911 Department a Certified EMD Resource
Annual Certification of Compliance Form. Please coordinate with your Certified EMD Resource to ensure
Annual Certification of Compliance Form is filed in compliance with regulations.
Mail Completed Application to:
STATE 911 DEPARTMENT
151 Campanelli Drive, Suite A
Middleborough, MA 02346
ATTN: MONNA WALLACE
For assistance, please contact Monna Wallace at 508-821-7220 or by email at monna.wallace@state.ma.us
click to sign
signature
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PSAP/RECC ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
Page 4
Continuing Education Hours for Enhanced 911 Telecommunicators
Please be advised that, in order to maintain certification, each certified enhanced 911 telecommunicator
shall successfully complete sixteen (16) hours of Department-approved continuing education annually. If
a person fails to comply with this requirement, in whole or in part, in a given annual period, the person
may be required to complete additional hours of continuing education in a subsequent annual period,
and the State 911 Department reserves the right to withhold grant funding for such additional hours of
continuing education.
To see a completed sample of this page please visit www.mass.gov/e911
Please list certified enhanced 9-1-1 telecommunicators alphabetically by last name, first name
Last Name, First Name of Enhanced
911 Telecommunicator
Name of Continuing Education Course
Name of Vendor who provided
Training or In-house Instructor
Date of Course
PSAP/RECC ANNUAL CERTIFICATION OF COMPLIANCE FORM
FOR FISCAL YEAR 2019
Page 5
CPR Certification Expiration Date and EMD Certification Expiration Date
To be completed by PSAP/RECC providing EMD through certified emergency medical dispatchers (provided
by the PSAP) ONLY.
To see a completed sample of this page please visit www.mass.gov/e911
Please list certified enhanced 9-1-1 telecommunicators alphabetically by last name, first name
Last Name, First Name of Enhanced 911
Telecommunicator
CPR Certification
Expiration Date
(month/day/year)
EMD Certification
Expiration Date
(month/day/year)
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FY2019 Psap Recc Certification Of Compliance Form (Commonwealth of Massachusetts)

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Completed 20 July 2020

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