REPORT AND RECOMMENDATIONS: CRITICAL CARE TECHNICAL ADVISORY GROUP (TAG) NEW YORK STATE EMERGENCY MEDICAL SERVICES COUNCIL MAY 2017 ALBANY, NY

REPORT AND RECOMMENDATIONS: CRITICAL CARE TECHNICAL ADVISORY GROUP (TAG) OF THE NEW YORK STATE EMERGENCY MEDICAL SERVICES COUNCIL MAY 2017 ALBANY, NY Approved as amended by vote of the SEMSCO May 10, 2017 (17 in favor, 3 opposed, no abstentions) EDUCATION FUNDING TECHNICAL ADVISORY GROUP OF THE FINANCE COMMITTEE OF THE 1

INTRODUCTION: The Education Funding Technical Advisory Group (TAG) was established by Steven Kroll, Chair of the New York State Emergency Medical Services Council at the Council s September 2016 meeting. The TAG was established to examine ongoing concerns about the future viability of the EMT-Critical Care (CC) level of certification in New York State. Eighteen members were named to the TAG including Patty Bashaw, Frank Chester, James Deavers, Robert Delagi, Daniel Dennis, Gary Ferrucci, Mickey Forness, Debra Fults, Travis Howe, Donald Hudson, Howard Huth, David Kugler, John Malinchock, Lewis Marshall, Mike McEvoy, John McGuire and Kevin O Hara. Andrew Johnson, represented the Bureau of Emergency Medical Services. On September 7, 2016, the TAG met electronically to review an extensive report of current and historical training trends across New York State at the Paramedic, CC and AEMT levels. Members of the TAG requested additional data to clarify specific questions and asked the Bureau to solicit feedback from REMACs and Regional Councils on their perspectives regarding the future of the CC in their respective locales. The Bureau reported it had sent this solicitation in 2015. The TAG received one direct response from the North Country Regional EMS Program Agency who surveyed their currently practicing CCs. No other REMSCOs, REMACs or Program Agencies provided direct input. The TAG subsequently met multiple times both electronically and in person. CHARGE: Owing to shortages of paramedic training in many rural, primarily volunteer based areas of New York State, a Cardiac Technician, level of care was created by the SEMAC in 1978. A redeveloped curriculum in 1992 renamed the level Critical Care Technician which was ultimately memorialized in NYS Codes, Rules and Regulations as Emergency Medical Technician Critical Care (14 NYCRR 800.6). The purpose of the CC level of care was to assure the availability of ALS level care throughout New York State. The TAG was charged with examining the past and present operation of the CC program in NY with the goal of making recommendations on the CC future. There were no preconceived or specified outcomes delineated. The TAG was instructed that, any and all options were on the table. REVIEW: The TAG initially reviewed CC use in each region, the current CC curriculum, administrative burden and costs of sustaining CC education curriculum and exam development and maintenance, original course participation, refresher course attendance, use of CME refreshers and the comparative scope of practice and availability of AEMT educational programs. Additional data were requested and reviewed as the TAG deliberations proceeded. In our final analysis, three clearly identifiable categories were determined to encompass the voluminous data available to the TAG: 1. Significant declines in CC course enrollments. 2. Substantial evolution in CC curriculum. 3. Comparative scopes of advanced EMT practice. DECLINING CC COURSE ENROLLMENTS: Total numbers of EMTs, AEMTs and Paramedics certified each year have steadily increased whereas the total number of CCs has continually declined since 1997. The total number of original CC courses has also declined whereas there has been an increase in the total number of eligible CC Course Sponsors since 1997 while Paramedic level sponsors have remained the same. Little disparity seems to exist between students enrolled and students who become CC certified, suggesting that changes in testing or course administration are unlikely to account for declining course enrollments or completion. CC refresher program enrollment and completion have also steadily declined. The following charts illustrate the changes over time, including a breakdown of trends by Region. 2

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Total certified providers by level in NYS 2016 The TAG also examined course funding over time for patterns that may have influenced willingness of sponsors to run CC classes or student enrollment. While CFR, EMT and the previous EMT-Intermediate levels saw reduced funding, the CC and Paramedic original and refresher training courses had substantial increases in NYS reimbursement levels. A review of SEMSCO Finance Committee recommendations showed that the increases to CC funding were intended to increase participation in the CC and Paramedic programs because of the observed declines in course offerings and enrollment. 11

The TAG also examined the average ages of various levels of providers, looking for any potential influence on CC course participation. CCs tend to be older than Paramedics and CC age is increasing suggesting that people are not entering the CC level of certification: What seemed most closely connected to declining CC enrollments was the actual numbers of CC level agencies. Currently, of the total 58,703 certified EMS providers in NYS, only 1,631 are CCs. These providers are concentrated in four areas as shown on the chart below. A complete breakdown of CC providers appears in Appendix I, broken down by combination, paid and volunteer agencies. 12

EVOLUTION OF CC CURRICULUM: The current National EMS Educational Standards, approved by SEMSCO in March 2011, recognize EMR (called CFR in NYS), EMT, AEMT and Paramedic levels. There is no current national equivalent of the NYS CC level and while SEMSCO and SEMAC voted to maintain the CC level in 2011, SEMAC directed the Bureau to review the CC level of care in order to determine whether it should remain in NYS. The lack of a national CC equivalent currently poses issues with the transportability of CC certification: 1. NYS CC providers are unable to obtain reciprocity in other states. At times, a CC may be able to obtain reciprocity at the AEMT level. In many cases, CCs applying for reciprocity are able only to obtain EMT level recognition in other states. 2. In mutual aid responses, both within and outside of New York State, CCs are unable to practice at their NYS recognized level of care. Within NY, CCs are not recognized or authorized to practice by the NYC region. Nationally, educational initiatives at all levels have increasingly sought to standardize curriculum. While some elements of education such as the Common Core used in elementary and high school education are controversial, the concept of standardized curriculum is considered a best practice and is supported by New York s Governor. The lack of any national CC equivalent means that NYS DOH owns the entire responsibility for both the CC curriculum, Final Practical Skills Exam (PSE) and the CC written certification exam. The administrative burden and expense of writing, revising and maintaining an entire curriculum led NYS to transition EMT-Intermediates to the national AEMT level several years ago. The CC level was, at that time, kept intact. Presently, the CC curriculum is in need of extensive updating and the written examination bank requires considerable revision. With lack of any national equivalent, the costs ($880,941 for curriculum updates, $134,843 for exam updates) and administrative burden of both tasks is unaffordable. Even without necessary revisions, the current CC written certification exams add significantly to the total cost of NYS written testing as, lacking any national equivalent, they are required to be included as a separate item in testing RFPs and contracts. Additionally, the CC PSE is extremely burdensome, outdated and does not meet National Standards for the skills tested. Under the current National EMS Educational Standards and Scope of Practice Model, the AEMT level of care is intended to assure the availability of ALS service in rural and underserved areas. The AEMT level of care was not available in 1978 when the CC was created in New York State to address the very same concern of assuring ALS availability. 13

COMPARATVE SCOPES OF ADVANCED EMT LEVEL PRACTICE: The TAG was interested in scopes of practice for the AEMT, CC and Paramedic and where scopes currently overlap. To examine current practice, 10,581 medication administrations by CCs and Paramedics were collected from the Image Trend State PCR data bridge spanning a one-year period in the Mountain Lakes EMS Region. In 7,534 instances, Paramedic administered medications were actually within the AEMT scope of practice. In 67 instances, CC administered meds were at the AEMT level and in only 17 instances did CCs administer medications at the Paramedic level. These data suggest that the majority of ALS medications administered by CCs and Paramedics are actually within the current AEMT scope of practice. This finding reinforces the suitability of the AEMT level of care as a mechanism to assure delivery of ALS in rural and underserved areas. A chart comparing scopes of practice between the National and NY AEMT and Paramedic levels is included here for reference. Note that this is not an all encompassing listing: Skill Comparison AEMT and Paramedic NYS vs National Standards The left column lists the National Standard skills. The column directly to the right is the NYS skills that are included in the NYS Standards. Areas that are highlighted in Red are those areas that were added to the NYS Standards and may not be included within the National Standards. Areas highlighted in Blue are areas where NYS is above the National Standards. Skills denoted with an A are skills are already being taught in certain areas of NYS, but are not required statewide. Of note, with the increased number of skills added to the EMT level, less ALS provider skills are needed. NYS Above NYS New NYS w/additional Training Skill - Airway/Ventilation/ AEMT NYS Paramedic NYS Oxygenation AEMT Paramedic Airway - esophageal X X X X Airway supraglottic X X X X Airway nasal X X X X Airway oral X X X X Bag-valve-mask (BVM) X X X X BiPAP/CPAP X X Chest decompression - needle X X Chest tube placement assist X A only Chest tube monitoring and X A management Cricothyrotomy needle X X 14

Cricothyrotomy percutaneous X Demand valve manually X X X X triggered ventilation End tidal CO 2 X X X monitoring/capnography Gastric decompression NG X X Tube Gastric decompression OG X X Tube Head tilt - chin lift X X X X Intubation nasotracheal X X X Intubation - orotracheal X X X Jaw-thrust X X X X Jaw-thrust - Modified (trauma) X X X X Mouth-to-barrier X X X X Mouth-to-mask X X X X Mouth-to-mouth X X X X Mouth-to-nose X X X X Mouth-to-stoma X X X X Obstruction direct X X laryngoscopy Obstruction Manual X X X X Oxygen therapy Humidifiers X X X X Oxygen therapy Nasal X X X X cannula Oxygen therapy X X X X Nonrebreather mask Oxygen therapy partial X X rebreather mask Oxygen therapy simple face X X mask Oxygen therapy Venturi X X mask PEEP therapeutic X X Pulse oximetry X X X X Suctioning Upper airway X X X X Suctioning tracheobronchial AI X X X Skill - Airway/Ventilation/ Oxygenation Ventilator Automated transport (ATV) Skill- Cardiovascular/Circulation Cardiac monitoring multi-lead (interpretive) Cardiac monitoring single lead (interpretive) Cardiopulmonary resuscitation (CPR) AEMT NYS Paramedic NYS AEMT Paramedic X X X X AEMT NYS AEMT Paramedic X X NYS Paramedic X X X X X X 15

Cardioversion electrical X X Carotid massage X X Defibrillation automated / X X X X semi-automated Hemorrhage control direct X X X X pressure Hemorrhage control X X X X tourniquet Internal; cardiac pacing X A monitoring only MAST/PASG X X X X Mechanical CPR device X X Transcutaneous pacing - X manual Skill-Immobilization AEMT NYS AEMT Paramedic NYS Paramedic Spinal immobilization cervical X X X X collar Spinal immobilization long X X X X board Spinal immobilization manual X X X X Spinal immobilization seated X X X X patient (KED, etc) Spinal immobilization rapid X X X X manual extrication Extremity stabilization - manual X X X X Extremity splinting X X X X Splint traction X X X X Mechanical patient restraint X X X X Emergency moves for endangered patients Skill-Medication Administration - Routes Assisting a patient with his/her own prescribed medications (aerosolized/nebulized) Aerosolized/nebulized (beta agonist) X X X X AEMT Int. X NYS AEMT State SOP X Paramedic NYS Paramedic X Buccal X X Endotracheal tube X X Skill-Medication Administration - Routes AEMT NYS AEMT Paramedic NYS Paramedic Inhaled self-administered X X (nitrous oxide) Intramuscular (epinephrine or X X X glucagon) Intranasal (naloxone) X X Intravenous push (naloxone, dextrose 50%) Intravenous push (epinephrine) L X X Intravenous piggyback X X Nasogastric X X Oral (glucose) X X X X 16

Oral (aspirin) X X X X Rectal X X Subcutaneous (epinephrine) L X X Sublingual (nitroglycerin) L X X Auto-injector (self or peer care) X X X X Auto-injector (patient s own X X X X prescribed meds) Skill - IV Initiation/Maintenance Fluids AEMT NYS AEMT Paramedic NYS Paramedic Access indwelling catheters X and implanted central IV ports Central line monitoring X A Intraosseous initiation X X X X Intravenous access X X X X Intravenous initiation - X X X X peripheral Intravenous maintenance of X X X X non-medicated IV fluids Intravenous maintenance of X X medicated IV fluids Skill - Miscellaneous AEMT NYS AEMT Paramedic NYS Paramedic Assisted delivery (childbirth) X X X X Assisted complicated delivery X X X X (childbirth) Blood glucose monitoring X X X X Blood pressure automated X X X X Blood pressure manual X X X X Eye irrigation X X X X Eye irrigation Morgan lens X X Thrombolytic therapy initiation Thrombolytic therapy monitoring Urinary catheterization Venous blood sampling X X Blood chemistry analysis A A 17

CONCLUSIONS: CC provider numbers have been steadily declining since 1997 and appear headed towards extinction. The number of CC original and refresher courses offered has also declined while the number of course sponsors have remained stable. The decline in course offerings is likely related to declining enrollments. Simultaneously, the CC program is in need of extensive curriculum updating and the CC practical skills exam and written test bank requires considerable redevelopment. Unlike all other levels of NYS EMS certification, CC has no national equivalent from which curriculum and test items can be drawn. The resulting administrative burden and cost to NYS to keep the CC program current is unaffordable using the monies currently allocated to EMS training and education. Lack of any national equivalent to NYS CC affects providers seeking reciprocity and limits portability of the CC in disaster both within and outside of NYS. The CC program was created to assure delivery of ALS to rural and underserved areas. The current National EMS Educational Standards suggest that the AEMT level of care exists to fulfil that same purpose. An analysis of scope of practice of the AEMT suggests this skill set may be a suitable replacement for CC level care in some locales. Such a decision lies at the EMS agency level, based on the needs and desires of their community. Use of AEMTs is supported by an analysis of data from one rural region of NYS over a one-year period where the majority of ALS medications administered by CCs and Paramedics were available at the AEMT level of practice. It is important to note that the conclusions of the TAG are not unanimous. Some members of the TAG favor keeping the CC level of care intact. The majority of TAG members agree with the conclusions and recommendations described herein. Effects associated with sun setting the CC level of care are unknown. It is the belief of the TAG that some CC level agencies and CC providers would elect to transition to AEMT level while others would be interested and willing to complete a bridge course to Paramedic level if such a program was affordable, accessible and not overly onerous. A survey conducted by the North Country EMS Regional Council supports both of these contentions as illustrated by the following responses: 18

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Additionally, given the current funding dollars spent at the CC level, considerably more AEMTs could be trained each year were providers and agencies to elect to transition to AEMT level. The following numbers illustrate such a reallocation: Original Courses 2016 2015 2014 2013 2012 AEMT Training $ 22,600.00 $ 47,700.00 $ 38,160.00 $ 16,960.00 AEMT PSE $ 3,675.00 $ 8,400.00 $ 7,125.00 $ 2,850.00 CC Original $ 159,600.00 $ 156,000.00 $ 139,200.00 $ 205,200.00 $ 166,800.00 CC PSE $ 14,100.00 $ 14,900.00 $ 12,000.00 $ 17,100.00 $ 19,900.00 Total Training Dollars $ 201,991.00 $ 229,015.00 $ 198,499.00 $ 244,123.00 $ 186,700.00 AEMT Students 43 90 72 32 0 CC Students 133 130 116 171 139 Total AEMT + CC 176 220 188 203 139 Potential if all were AEMT 344 385 335 420 315 Since January of 2017, sixteen ALS agencies have ceased operations and many more are struggling financially. Many NYS CC and Paramedic agencies operate currently with 1 to 5 providers on their membership roster. The AEMT level of care may be more affordable and appropriate for many of these agencies. The reduced costs and less time commitment might allow for more AEMTs than current declining numbers of CCs. RECOMMENDATIONS: [Note: recommendations amended by SEMSCO see p. 31] The TAG proposes SEMAC and SEMSCO approve four actions to gradually sunset the CC level of certification in NYS. These actions would allow continued CC certification renewals, affording REMSCOs and REMACs a prolonged period in which to sustain or reconfigure their systems, based on Regional needs. They would also address the immediate inability of NYS to shoulder the administrative burden and financial costs of revising and maintaining the CC curriculum, Practical Skills Exam and Written CC Certification Exam. The proposed actions are: 1. DOH no longer approve original CC courses starting after September 1, 2017. 2. DOH no longer approve CC refresher or CC rapid refresher courses starting 18 months from item #1 above. 3. Continue the CC CME refresher program. 4. DOH create an automatic advanced standing CC to Paramedic bridge program open to any currently on-line NYS CC. Such a bridge program should include on-line didactic content with availability of skills and testing a local course sponsors. 30

By vote of the New York State Emergency Medical Services Council on May 10, 2017, the preceding recommendations were reordered, amended and approved to read in final form as follows: SEMSCO approves four actions to gradually sunset the CC level of certification in NYS. These actions would allow continued CC certification renewals, affording REMSCOs and REMACs a prolonged period in which to sustain or reconfigure their systems, based on Regional needs. They would also address the immediate inability of NYS to shoulder the administrative burden and financial costs of revising and maintaining the CC curriculum, Practical Skills Exam and Written CC Certification Exam. The proposed actions are: 1. Continue the CC CME refresher program. 2. DOH no longer approve original CC courses starting after January 1, 2018. 3. DOH no longer approve CC refresher or CC rapid refresher courses starting 18 months from item #2 above. 4. DOH create an automatic advanced standing CC to Paramedic bridge program open to any currently on-line NYS CC with 3 years of continuous practice 1. Such a bridge program should include on-line didactic content with availability of skills and testing a local course sponsors. DOH will operate this bridge program for a minimum of 10 years from January 1, 2018. [Items highlighted in yellow were added by SEMSCO] 1 the term continuous practice is substituted here for SEMSCO s active practice. The motion makers and SEMSCO voting body indicated their desire to utilize language in the dissemination of this action consistent with 10 NYCRR 800.3(w) to avoid any misinterpretation of intent. (see: www.health.ny.gov/professionals/ems/public_health_law/part_800.pdf) 31

Appendix I Breakdown of advanced level providers by Agency: Combination agencies Paid agencies Volunteer agencies 32

Combo Agencies Monday, November 07, 2016 1:48:40 PM 4 = EMT 7 = CC 8 = Paramedic 9 = AEMT agency_name city EMTs AEMTs CCs Paramedics Altamont Rescue Squad, Inc. Altamont 22 0 0 2 Colonie Emergency Medical Services, Town of Latham 42 0 0 52 Smithfield Eaton Volunteer Ambulance Corp, Inc. Morrisville 8 0 3 1 Level of Care: 07 Broome Volunteer Emergency Squad, Inc. Binghamton 18 0 9 9 Cortlandt Regional Paramedics Cortlandt Manor 0 6 0 29 Union Volunteer Emergency Squad, Inc. Endwell 32 0 8 25 Vestal Volunteer Emergency Squad Inc. Vestal 30 0 6 25 Broome Volunteer Emergency Squad, Inc. Binghamton 10 0 9 9 Union Volunteer Emergency Squad, Inc. Endwell 32 1 8 25 Soldiers & Sailors Mem Hosp of Yates Co. Penn Yan 5 0 2 8 Irondequoit Ambulance, Inc. Rochester 16 0 0 19 Vestal Volunteer Emergency Squad, Inc. Vestal 30 0 6 25 Gates Volunteer Ambulance Service, Inc. Rochester 78 0 0 31 Hampton Bays Volunteer Ambulance Corp, Inc. Hampton Bays 35 0 4 22 Page 1 of 21

Tully Ambulance, Town of Tully 16 0 1 14 Cato, Ira, Meridian, Victory Ambulance Corps, Inc. Cato 13 0 3 2 Southern Cayuga Instant Aid, Inc. Poplar Ridge 6 0 1 5 Four Town First Aid Squad, Inc. Moravia 5 0 4 8 Warrensburg Emergency Medical Services, Inc. Warrensburg 19 0 5 9 Scotia Fire Department, Village of Scotia 5 0 0 11 Marathon Area Volunteer Ambulance Corps, Inc. Marathon 7 0 2 9 Johnsburg Emergency Squad, Inc. Johnsburg 7 0 1 8 Riverhead Volunteer Ambulance Corps, Inc. Riverhead 45 0 11 10 Fair Haven Ambulance, Village of Fair Haven 0 0 3 4 Pompey Hill Volunteer Fire Dept, Inc. Pompey 6 0 0 3 Chautauqua Fire District #1 Chautauqua 6 0 3 6 Fredonia Fire Department, Village of Fredonia 13 0 3 7 Genesee Valley EMS, Inc. Caledonia 8 0 0 8 Maine Emergency Squad, Inc. Maine 14 0 5 4 Page 2 of 21

Berkshire Emergency Squad, Inc. Newark Valley 5 1 0 1 Champlain EMS, Inc. Champlain 10 0 20 1 Level of Care: 07 Thousand Islands Emergency Rescue Service, Inc. Clayton 14 0 3 17 Phelps Ambulance, Inc. Phelps 14 0 1 1 Berkshire Emergency Squad, Inc. Newark Valley 5 0 0 1 Madison Ambulance, Village of Madison 5 0 2 9 Greene Emergency Squad, Inc. Greene 11 0 5 7 Brewerton Volunteer Fire Department Ambulance, Inc. Brewerton 12 0 2 17 Sherburne Fire Department Emergency Squad Sherburne 7 0 9 8 Town of Watertown Ambulance Service, Inc. Watertown 19 1 4 11 Ski Windham Operating Corporation Windham 0 0 0 8 Delmar Volunteer Ambulance Service, Inc. Delmar 44 2 0 3 Level of Care: 09 Walworth Ambulance, Inc. Walworth 24 0 1 5 Norwich Fire Department, City of Norwich 0 0 13 6 Canandaigua Emergency Squad, Inc. Canandaigua 24 1 4 9 Page 3 of 21

Orchard Park Fire District EMS, Inc. Orchard Park 12 2 2 15 New York State Office of Fire Prevention and Control Albany 22 0 0 11 Dannemora Fire Department Dannemora 12 0 15 4 Level of Care: 07 Lyon Mountain Volunteer Fire Company, Inc. Lyon Mountain 13 0 14 1 Morrisonville Schuyler Falls Vol. Ambulanc Service, Inc. Morrisonville 29 0 29 2 Wading River Fire District Wading River 14 0 3 15 Wilmington Ambulance Service, Town of Wilmington 12 0 5 5 Saranac Lake Volunteer Rescue Squad, Inc. Saranac Lake 14 0 11 7 Indian River Ambulance Service, inc. Philadelphia 22 1 3 9 Bolton Emergency Medical Services, Inc. Bolton Landing 8 0 3 5 Centereach Fire District Centereach 59 0 4 28 Brockport Volunteer Ambulance Corps Brockport 26 3 0 12 Old Erie Emergency Services, Inc. Jordan 18 2 8 Malone E.M.S., Inc. Malone 9 1 5 4 Chatham Rescue Squad, Inc. Chatham 11 0 0 13 Page 4 of 21

Clausson Raught Community Rescue Squad, Inc. Copake 22 1 1 14 Greenport Rescue Squad, Inc. Hudson 19 2 0 25 Valatie Volunteer Rescue Squad, Inc. Valatie 22 1 0 20 Onondaga County Sheriff's Office Camillus 1 14 Florence Ambulance Service, Town of Camden 7 4 2 Union Hill Volunteer Ambulance Corps, Inc. Union Hill 33 0 Raquette Lake Volunteer Ambulance Squad, Inc. Raquette Lake 7 1 1 Holtsville Fire District Holtsville 27 1 17 Arlington Fire District Poughkeepsie 84 0 0 22 Beacon Volunteer Ambulance Corps, Inc. Beacon 35 0 0 12 La Grange Fire District EMS Poughkeepsie 24 0 0 15 Pleasant Valley Fire Department Rescue Squad Pleasant Valley 30 0 0 0 Fairview Fire District Poughkeepsie 28 0 0 2 Gowanda Ambulance Service Corp. Gowanda 7 4 0 9 Lancaster Volunteer Ambulance Corps, Inc. Lancaster 24 3 0 19 Page 5 of 21

Elizabethtown Lewis Emergency Squad, Inc. Elizabethtown 10 1 4 2 Newcomb Volunteer Fire Department, Inc. Town of Newcomb 1 0 5 2 Ausable Forks Volunteer Ambulance Service Corporation Ausable Forks 20 0 11 2 Lake Placid Volunteer Ambulance Service, Inc. Lake Placid 11 0 5 6 Tupper Lake Volunteer Ambulance & Emergency Squad Tupper Lake 5 0 6 3 North Country Life Flight, Inc. Saranac Lake 0 0 2 6 Northampton Ambulance Service, Town of Northville 6 0 5 3 Level of Care: 07 Leroy Ambulance Service, Inc. LeRoy 10 3 0 10 Durham Ambulance Inc. Oak Hill 18 4 0 0 Level of Care: 09 Indian Lake Volunteer Ambulance Corps, Inc. Indian Lake 8 0 3 4 Inlet Volunteer Emergency Services, Inc. Inlet 11 0 2 6 West Winfield Fire Department West Winfield 13 0 2 5 Mohawk Valley Ambulance Corps, Inc. Mohawk 12 0 3 13 Carthage Area Rescue Squad, Inc. Carthage 11 0 3 4 Page 6 of 21

Evans Mills Volunteer Ambulance Squad, Inc. Evans Mills 17 0 3 3 Henderson Fire Department, Inc. Henderson 2 0 0 1 South Jefferson Rescue Squad, Inc. Adams 13 0 7 2 Lewis County Search and Rescue, Inc. Lowville 24 1 9 12 Greater Lenox Ambulance Service, Inc. Canastota 20 0 0 15 Southern Madison County Volunteer Ambulance Corps, Inc. Hamilton 17 0 0 9 Smith Ambulance Service Inc. DeRuyter 2 0 2 2 Cazenovia Area Volunteer Ambulance Corps, Inc. Cazenovia 14 0 1 10 West Webster Fire District West Webster 37 0 0 4 Greece Volunteer Ambulance Service Rochester 29 0 0 40 Henrietta Volunteer Ambulance Service, Inc. Rochester 25 0 0 26 Honeoye Falls Ambulance, Village of Honeoye Falls 17 0 0 10 Penfield Vol. Emergency Ambulance Service, Inc. Penfield 70 0 1 2 Perinton Volunteer Ambulance Corps, Inc. Fairport 69 0 0 10 Gates Volunteer Ambulance Service, Inc. Rochester 78 0 0 31 Page 7 of 21

Irondequoit Ambulance, Inc. Rochester 16 0 0 19 Brighton Volunteer Ambulance, Inc. Rochester 35 0 0 15 Greater Amsterdam Volunteer Ambulance Corps, Inc. Amsterdam 33 0 3 40 St. Johnsville Volunteer Ambulance Corps, Inc. St. Johnsville 18 0 3 18 Mineola Volunteer Ambulance Corps, Inc. Mineola 40 0 6 3 Long Beach Fire Department, City of Long Beach 6 0 25 5 Bellmore Fire Department Bellmore 32 0 4 5 East Meadow Fire District East Meadow 30 0 10 10 Vigilant Engine and Hook and Ladder Co., Inc. Great Neck 36 0 4 5 Glenwood H&L E&H Company, Inc. Glenwood Landing 20 0 9 9 Glen Cove Volunteer EMS Corps, City of Glen Cove 36 0 9 8 Lawrence Cedarhurst Fire Department, Inc. Lawrence 17 0 5 8 Oceanside Fire Department Oceanside 20 0 6 22 Friendship Engine and Hose Company, Inc. Merrick 19 0 8 1 Plainview Fire Department Plainview 19 0 11 13 Page 8 of 21

Syosset Fire District Syosset 25 0 4 17 New Hyde Park Fire Department New Hyde Park 25 0 4 16 Port Washington Fire Department Port Washington 39 0 12 5 North Bellmore Fire Department North Bellmore 25 0 8 11 Central Oneida County Volunteer Ambulance Corps, Inc Clark Mills 45 1 8 29 Prospect Volunteer Ambulance Inc. Remsen 5 0 7 7 Waterville Area Volunteer Ambulance Corps, Inc. Waterville 8 0 2 2 Fayetteville, Village of Fayetteville 20 0 0 15 Lafayette Fire Department, Inc. Lafayette 13 0 2 5 Greater Baldwinsville Ambulance Corps, Inc. Baldwinsville 23 1 2 21 Manlius Ambulance / EMS Service, Village of Manlius 11 0 2 17 Marcellus Ambulance Voluntary Emergency Svcs, Inc. Marcellus 17 0 0 11 Minoa Ambulance, Village of Minoa 36 1 1 26 Northern Onondaga Volunteer Ambulance, Inc. Liverpool 30 1 2 31 North Area Volunteer Ambulance Corps, Inc. North Syracuse 23 3 2 27 Page 9 of 21

Skaneateles Ambulance Vol. Emergency Service, Inc. Skaneateles 16 0 0 10 Syracuse University Ambulance Syracuse 34 0 0 1 Level of Care: 09 East Area Volunteer Emergency Service, Inc. East Syracuse 18 1 2 21 Western Area Volunteer Emergency Service Camillus 40 2 4 23 Dewitt Fire District Dewitt 8 0 0 14 Richmond Fire Department #1, Inc. Honeoye 11 1 0 4 Victor Farmington Volunteer Ambulance Corps, Inc. Victor 23 1 2 15 Canandaigua Emergency Squad, Inc. Canandaigua 28 0 2 17 Blooming Grove Volunteer Ambulance Corps, Inc. Washingtonville 25 0 0 20 New Windsor Volunteer Ambulance Corps, Inc. New Windsor 38 0 0 20 Port Jervis Volunteer Ambulance Corps, Inc. Port Jervis 24 0 0 17 Highlands Ambulance Corps, Inc., Town of Highland Falls 12 0 0 0 Wallkill Volunteer Ambulance Corps, Inc., Town of Middletown 14 0 0 12 Kiryas Joel Volunteer EMS, Inc. Monroe 61 0 0 16 Page 10 of 21

Medina Fire Department, Village of Medina 10 0 1 8 Central Orleans Volunteer Ambulance, Inc. Albion 13 5 0 15 North Shore Volunteer Emergency Squad, Inc. Cleveland 12 0 5 8 Donald McFee Memorial Ambulance Service, Inc. Mexico 17 1 5 10 Southern Oswego Volunteer Ambulance Corps Central Square 17 0 5 7 Northern Oswego County Ambulance, Inc. Pulaski 12 0 9 5 Philipstown Volunteer Ambulance Corps, Inc. Cold Spring 22 0 0 1 Rensselaer Volunteer Ambulance Service, Inc. Rensselaer 6 0 0 0 North Greenbush Ambulance Association, Inc. Wynantskill 11 0 1 10 Hoosic Valley Rescue Squad, Inc. Schaghticoke 15 0 0 26 WF Bruen Emergency Squad, Inc. Rensselaer 24 0 1 24 Congers Valley Cottage Vol. Ambulance Corps, Inc. Congers 34 0 0 0 Haverstraw Ambulance Corps, Inc. Haverstraw 20 0 0 0 Nanuet Community Ambulance Corps, Inc. Nanuet 56 0 0 5 New City Vol. Ambulance Corps Rescue Squad Inc. New City 46 0 0 5 Page 11 of 21

Nyack Community Ambulance Corps, Inc. Nyack 29 0 0 8 Pearl River Alumni Ambulance Corp. Pearl River 14 0 0 2 Ramapo Valley Ambulance Corps, Inc Suffern 53 0 0 2 South Orangetown Ambulance Corps, Inc. Tappan 53 0 0 4 Spring Hill Community Ambulance Corps, Inc. Spring Valley 100 0 0 0 William Paul Faist Volunteer Ambulance Corps, Inc. Chestnut Ridge 31 0 0 0 Chevra Hatzoloh of Rockland County, Inc. Monsey 165 0 4 26 Sloatsburg Community Ambulance Corps, Inc. Sloatsburg 11 0 0 0 Gouverneur Volunteer Rescue Squad, Inc. Gouverneur 13 1 5 5 Massena Volunteer Emergency Unit, Inc. Massena 19 0 9 3 Ogdensburg Volunteer Rescue Squad, Inc. Ogdensburg 16 1 17 4 Potsdam Volunteer Rescue Squad, Inc. Potsdam 28 0 8 4 Tri Town Volunteer Rescue Squad, Inc. Brasher Falls 24 0 7 1 Level of Care: 07 Clifton Park Halfmoon Emergency Corps, Inc. Clifton Park 18 0 0 72 Ballston Lake Emergency Squad, Inc. Ballston Lake 23 0 3 12 Page 12 of 21

Community Emergency Corps Ballston Spa 4 0 0 33 Galway Ambulance Corps, Inc Galway 7 0 0 7 Malta Ambulance Corps, Inc. Malta 33 1 1 33 General Schuyler Emergency Squad, Inc. Schuylerville 12 0 0 14 Moreau Emergency Squad, Inc. Moreau 25 0 3 29 Waterford Rescue Squad, Inc. Waterford 7 0 1 10 Wilton Emergency Squad, Inc. Saratoga Springs 23 0 2 19 Niskayuna Fire District #1 Niskayuna 9 0 0 14 Richmondville Volunteer Emergency Squad, Inc. Richmondville 6 0 0 3 Schuyler County Volunteer Ambulance Association Watkins Glen 28 0 3 11 South Seneca Community Vol. Ambulance Corps, Inc. Ovid 17 0 3 4 North Seneca Ambulance, Inc. Waterloo 16 0 2 14 Bath NY, Volunteer Ambulance Corps of Bath 34 0 1 3 Farmingville Fire Department Farmingville 20 0 10 9 Page 13 of 21

Southampton Village Volunteer Emergency Ambulance Service, Inc. Southampton 16 0 8 12 Smithtown Fire Department Smithtown 25 0 12 2 Level of Care: 07 Coram Fire Department Coram 16 0 0 20 Middle Island Fire Department Ambulance Company Middle Island 13 0 14 12 Bay Shore Brightwaters Rescue Ambulance, Inc. Bayshore 81 42 9 33 Exchange Ambulance Corporation of the Islips East Islip 54 0 12 11 Melville Volunteer Fire Department, Inc. Melville 41 0 10 17 Amityville Fire Department, Village of Amityville 19 0 5 5 Rocky Point Fire Department Shoreham 29 0 13 20 Islip Fire Department Islip 20 0 3 6 Terryville Fire Department Port Jefferson Sta. 9 0 6 25 Lindenhurst Fire Department Lindenhurst 21 0 12 4 Northport Fire Department Northport 30 0 3 3 Islip Terrace Fire Department Islip Terrace 15 0 1 0 Page 14 of 21

Center Moriches Fire Department Ambulance Company Center Moriches 10 0 3 18 East Farmingdale Volunteer Fire Company, Inc. East Farmingdale 26 0 10 12 North Amityville Fire Company, Inc. Amityville 12 0 3 0 Level of Care: 07 Centerport Fire Department Centerport 16 0 1 10 West Babylon Fire Department Rescue West Babylon 44 0 7 15 Ambulance Committee of the Moriches, Inc. East Moriches 22 0 10 9 Central Islip Hauppauge Volunteer Ambulance, Inc. Central Islip 53 0 5 15 Holbrook Fire District Holbrook 24 0 2 26 Mastic Beach Ambulance Company, Inc. Mastic Beach 33 0 11 6 Ridge Fire Department Ridge 15 0 3 20 Westhampton War Memorial Ambulance Association, Inc Westhampton Beach 33 0 3 15 Setauket Fire Department, Inc. East Setauket 40 0 10 34 Commack Volunteer Ambulance Corporation, Inc. Commack 81 0 19 23 Gordon Heights Volunteer Fire Department, Inc. Middle Island 0 0 3 3 Page 15 of 21

East Northport Fire Department East Northport 29 0 2 25 Brookhaven Ambulance Company, Inc. Brookhaven 25 9 0 4 Nesconset Fire District Nesconset 35 0 7 13 Brentwood Legion Ambulance Service, Inc. Brentwood 59 0 8 17 Selden Fire Department Ambulance Selden 18 0 4 12 West Islip Fire Department West Islip 31 0 5 7 Port Jefferson Volunteer Ambulance Corps, Inc. Port Jefferson 59 0 0 21 East Brentwood Fire Department Brentwood 18 0 11 1 Dix Hills Fire District Dix Hills 42 0 10 18 Sound Beach Fire Department, Inc. Sound Beach 12 0 11 8 North Lindenhurst Volunteer Fire Department, Inc. North Lindenhurst 22 0 6 8 Lakeland Fire District Ronkonkoma 25 0 2 19 Community Ambulance Company, Inc. Sayville 60 0 14 15 Jeffersonville Volunteer First Aid Corps, Inc. Jeffersonville 18 1 0 8 Mamakating First Aid Squad, Inc. Wurtsboro 18 0 0 0 Page 16 of 21

R & R Volunteer Ambulance Corp Roscoe 6 0 0 2 Tusten Volunteer Ambulance Service, Inc. Narrowsburg 5 0 0 0 Candor Emergency Squad Candor 15 0 4 1 Owego Fire Department Emergency Squad Owego 22 0 11 6 Owego Fire District, Town of Endicott 12 0 4 11 Spencer Emergency First Aid Squad, Inc. Spencer 8 1 1 0 Level of Care: 07 Trumansburg EMS, Village of Trumansburg 12 0 0 13 Groton Fire Department Groton 9 0 1 8 Dryden Ambulance, Inc. Dryden 19 0 2 16 Diaz Memorial Ambulance Service, Inc. Saugerties 8 0 0 17 Ellenville First Aid and Rescue Squad, Inc. Ellenville 15 0 0 14 New Paltz Rescue Squad, Inc. New Paltz 34 0 0 17 Woodstock Fire Co. #5 Emergency Rescue Squad, Inc. Woodstock 16 0 1 14 Bay Ridge Rescue Squad, Inc. Queensbury 26 0 4 10 North Warren Emergency Squad, Inc. Chestertown 19 1 4 5 Page 17 of 21

Lake George Post 374 American Legion Emergency Squad, Inc. Lake George 14 0 10 7 West Glens Falls Emergency Squad, Inc. Queensbury 28 0 6 9 Argyle Emergency Squad, Inc. Argyle 7 3 5 2 Cambridge Valley Rescue Squad, Inc. Cambridge 21 6 5 5 Easton Greenwich Rescue Squad, Inc. Greenwich 17 0 3 2 Fort Edward Rescue Squad, Inc. Fort Edward 23 0 8 5 Granville Rescue Squad, Inc. Granville 22 6 6 1 Salem Rescue Squad, Inc. Salem 6 0 5 0 Level of Care: 07 Skenesborough Emergency Squad, Inc. Whitehall 8 0 5 2 Macedon EMS Department, Village of Macedon 5 0 0 1 Ontario Volunteer Emergency Squad Ontario 12 0 1 2 Newark Arcadia Volunteer Ambulance, Inc. Newark 16 0 0 15 Croton on Hudson Emergency Medical Services, Village of Croton on Hudson 22 0 0 1 Dobbs Ferry Volunteer Ambulance Corps, Inc. Dobbs Ferry 34 0 0 0 Eastchester Volunteer Ambulance Corps, Inc. Eastchester 69 0 1 22 Page 18 of 21

Sleepy Hollow Volunteer Ambulance Corps Sleepy Hollow 22 0 0 1 Ossining Volunteer Ambulance Corps, Inc. Ossining 55 0 0 33 Port Chester Rye Rye Brook Volunteer Ambulance Corps, Inc. Port Chester 18 0 0 22 Scarsdale Volunteer Ambulance Corps Scarsdale 48 0 0 18 Tarrytown Volunteer Ambulance Corps, Inc. Tarrytown 23 0 0 0 Harrison Volunteer Ambulance Corps, Inc. Harrison 28 1 0 20 Penn Yan Area Volunteer Ambulance Corps Penn Yan 24 0 3 3 Brutus Ambulance,Town of Weedsport 18 2 8 Barnard Fire District Rochester 19 1 0 12 Coxsackie Ambulance Service, Town of Coxsackie 14 2 1 1 Macedon Ambulance Service, Town of Macedon 11 0 2 11 New Berlin Ambulance Service, Village of New Berlin 4 0 9 7 Columbia County EMS Hudson 121 5 1 111 Corinth Ambulance Service, Town of Corinth 3 0 0 20 Day EMS, Town of Hadley 0 20 Page 19 of 21

Broome County Emergency Medical Services Binghamton 1 1 5 Bethlehem Ambulance, Town of Bethlehem 35 8 4 Level of Care: 09 Cobleskill, Town of Putnam County Bureau of Emergency Services Cobleskill Carmel Chevra Hatzalah, Inc. Brooklyn 912 0 0 166 ALS Services, Inc. Brooklyn 0 0 0 167 Brooklyn College Emergency Medical Squad Brooklyn 9 0 0 4 Patchogue Fire Department Ambulance Co., Inc. Patchogue 45 0 8 3 East Quogue Fire Department East Quogue 15 0 2 11 Ronkonkoma Fire Department Ronkonkoma 17 0 13 7 Kings Park Fire Department Kings Park 26 0 11 5 Mastic Volunteer Ambulance Company, Inc. Mastic 36 0 0 15 St. James Fire District St. James 18 0 11 5 Stony Brook Fire Department, Inc. Stony Brook 32 0 1 3 Wyandanch Wheatly Heights Ambulance Corps Wyandanch 33 0 13 4 Page 20 of 21

North Babylon Volunteer Fire Company, Inc. North Babylon 26 0 6 15 Copiague Fire District Copiague 15 0 9 13 Deer Park Volunteer Fire Department, Inc. Deer Park 27 0 12 8 Southampton Volunteer Ambulance, Inc. Southampton 10 0 5 10 Manorville Community Ambulance, Inc. Manorville 22 0 8 9 Shirley Community Ambulance Shirley 31 0 10 8 North Patchogue Fire District North Patchogue 23 0 11 8 Medford Volunteer Ambulance, Inc. Medford 37 0 11 17 Flanders Northampton Volunteer Ambulance Co., Inc Flanders 16 0 1 1 Grand Island Fire Company, Inc. Grand Island 33 0 0 12 Jericho Fire Department Jericho 34 0 2 12 Carle Place Hook, Ladder & Hose Co. No. 1 Carle Place 10 0 1 1 Greater Valley EMS, Inc. Sayre 9 0 1 10 Greater Valley Emergency Medical Services, Inc. Sayre 13 0 1 11 308 Page 21 of 21

Paid Agencies Monday, November 07, 2016 1:45:17 PM 4 = EMT 7 = CC 8 = Paramedic 9 = AEMT agency_name city EMTs AEMTs CCs Paramedics Capital District Ambulance Service, Inc. Physician's Ambulance Service, Inc. New York Presbyterian / Queens Albany Albany Flushing NYU Hospitals Center Brooklyn 126 75 Lamoille Ambulance Service, Inc. Johnson 5 0 4 1 Level of Care: 07 Western Turnpike Rescue Squad, Inc. Albany 40 0 0 2 Albany Schenectady Greene Co. Ag. Societies, Inc. Altamont 20 0 0 0 Albany Department of Fire & Emergency Services, City of Albany 155 0 0 90 Port Authority of New York and New Jersey Police Jamacia 18 0 0 0 TransCare New York, Inc. Brooklyn 495 0 0 273 Fire Department of New York (aka: FDNY) Brooklyn 0 0 0 0 New York State Police Aviation Unit Latham 0 0 0 0 Albany County Sheriff's Department Advanced Life Support Clarksville 30 0 0 42 Page 1 of 16

Guilderland Emergency Medical Service Guilderland 0 0 0 20 Watervliet Arsenal Fire Department Watervliet 18 0 0 0 Medical Transport Service of Allegany County, Inc. Scio 10 1 9 4 Plum Island Ambulance Greenport 7 0 2 5 Troy Bureau of Fire, City of Troy 23 0 0 87 Ossining Volunteer Ambulance Corps, Incorporated Ossining 0 0 0 29 Northern Dutchess Paramedics, Inc. Rhinebeck 57 0 0 48 Windham Ambulance Service, Town of Hensonville 7 5 0 14 Superior Ambulance Service, Inc. Binghamton 35 0 12 26 Binghamton Bureau of Fire, City of Binghamton 79 0 0 42 Eastern Wayne Emergency Medical Services Savannah 12 1 Corning Ambulance Service Inc. Corning 32 0 0 28 Genesee Valley EMS, Inc. Caledonia 0 0 0 8 Monroe Medi Trans, Inc. Rochester 102 0 0 74 Salamanca Ambulance Service, City of Salamanca 8 1 3 3 Page 2 of 16

Mount Sinai Hospital New York Olean Fire Department, City of Olean 9 4 16 11 Cairo Ambulance Service, Town of Cairo 3 0 0 5 Level of Care: 09 Montrose VA Fire Department Montrose 23 0 0 1 Ravena Rescue Squad, Inc. Ravena 16 2 0 3 Level of Care: 09 TransCare Westchester, Inc. Brooklyn 42 0 0 42 Wyoming County Emergency Services Warsaw 8 2 0 12 Phillgrey, Inc. Massena 7 0 4 1 New York Presbyterian EMS New York 185 0 0 254 TC Ambulance Group, Inc. Brooklyn 197 0 0 153 TC Ambulance North, Inc. Brooklyn 257 0 0 83 TC Ambulance Corp. Brooklyn 197 0 0 153 Rockland Mobile Care, Inc. Chestnut Ridge 59 0 0 37 Amsterdam Fire Department, City of Amsterdam 8 0 0 25 Starnet Emergency Services, Inc. Armonk 63 0 0 41 Page 3 of 16

Greene County Emergency Medical Services, Inc. Cairo 0 0 0 28 TCBA Ambulance, Inc. Brooklyn 197 0 0 153 Sullivan Paramedicine, Inc. Hurleyville 22 0 1 26 Jamestown Fire Department, City of Jamestown 45 0 1 3 Dunkirk Fire Department, City of Dunkirk 24 0 0 0 Chautauqua County Ambulance Service Jamestown 46 1 10 44 Catskill Ambulance Service, Town of Catskill 15 4 0 10 W.C.A. Services Corporation Jamestown 48 0 5 53 Dover Ambulance Service, Town of Dover Plains 86 0 0 0 TC Hudson Valley Ambulance Corp. Poughkeepsie 6 0 0 0 First Response Ambulance, Inc. Inwood 110 0 0 30 Emergacare NY, LLC Yonkers 2 0 0 1 North Tonawanda Fire Department, City of North Tonawanda 11 0 19 8 Primary Care Ambulance Corp. Staten Island 48 0 0 29 Wyckoff Heights Medical Center Ambulance Service Brooklyn 47 0 0 25 Page 4 of 16

New York City Police Department Emergency Service Unit Brooklyn 0 0 0 11 Hunter EMS, Inc Bay Shore 129 0 0 25 MediSys Ambulance Service, Inc. Jamaica 15 0 0 2 Erway Ambulance Service, Inc. Elmira Heights 16 0 1 27 Livingston County EMS Mount Morris 29 0 0 28 Wayne County Lyons 0 0 0 17 Fletcher Allen Coordinated Transport, LLC Burlington 1 0 0 3 Northern Ambulance Corps, LLC Malone 11 0 7 0 Level of Care: 07 Rotterdam Emergency Medical Services, Inc. Schenectady 19 0 0 25 Center for Emergency Medicine of Western PA West Mifflin 0 0 0 5 Seniorcare Emergency Medical Services, Inc. Bronx 603 0 0 109 Crest Transportation Services, Inc. Brooklyn 116 0 0 18 Air Methods Corp, subsidiary Rocky Mountain Holdings LLC Selkirk 0 0 0 49 Priority One Ambulance, Inc. Staten Island 129 0 0 18 Richmond Medical Center Staten Island 82 0 0 51 Page 5 of 16

Momentive Performance Materials USA, Inc. Waterford 54 6 0 1 Emergency Ambulance Service, Inc Bohemia 250 0 6 43 SABIC Innovative Plastics, US, LLC Selkirk 28 0 0 1 World Racing Group, Inc Ambulance Service Weedsport 4 0 1 2 Montefiore Medical Center E.M.S. Bronx 14 0 0 2 Ace Ambulance Service, LLC Inwood 34 0 0 1 Mercy Flight, Inc. Buffalo 15 7 0 31 Emergency Medical Transport of CVPH, Inc. Plattsburgh 15 0 21 0 Plattsburgh Fire Department, City of Plattsburgh 12 0 21 2 Varin's Ambulance Service Inc. Plattsburgh 6 0 0 0 TLC Medical Transportation Services, Inc. Syracuse 54 0 11 52 Rockwell Falls Ambulance Service, Inc. Lake Luzerne 5 0 3 8 Bath Veterans Administration Fire Department Bath 7 1 0 7 Elizabethtown Community Hospital Transport Elizabethtown 5 2 7 4 Columbus Ambulance Service, Town of Sherburne 4 0 9 7 Page 6 of 16

West Point Fire Department Ambulance West Point 40 1 Richmond County Ambulance Service, Inc. Staten Island 223 54 Lebanon Valley Auto Racing Corporation West Lebanon 8 1 0 0 Cattaraugus County Sheriff's Office SRT Little Valley 1 0 1 Level of Care: 09 Hackensack University Medical Center Hackensack 6 Osceola Ambulance Service, Town of Camden 7 4 2 TLC Emergency Medical Services, Inc. Syracuse 54 0 11 52 Utica Ambulance Service, Inc. Utica 18 11 26 Empire State Ambulance Corp. Suffern 125 97 Med Trans Corporation Trans Am Ambulance Services, Inc. Manhasset Olean Comprehensive Ambulance Service Bi County LLC Bohemia 15 6 Comprehensive Ambulance Service Suffolk, LLC Bohemia 15 1 5 Comprehensive Ambulance Service Long Island, LLC Bohemia 15 6 Community Care EMS, LLC Brooklyn 2 Page 7 of 16

Darien Lake Holdings LLC Level of Care: 09 Margaretville Memorial Hospital Ambulance Squad Darien Center Margaretville 8 0 0 11 Avarint, Inc. Springville 1 1 Level of Care: 09 St. Luke's Roosevelt Hospital Center New York 58 0 70 MedicEast Corp Bronx NYU Lutheran Medical Center Brooklyn 86 52 NYPD Aviation Unit Brooklyn 15 10 LaSalle Ambulance, Inc. Buffalo 219 38 6 144 Town's Ambulance Service, Inc. Buffalo 218 73 6 136 Beacon Transportation, Inc. Rochester 100 8 88 National Ambulance & Oxygen Service, Inc. Rochester 165 108 National Ambulance & Oxygen Service, Inc. Rochester 165 108 Corning Ambulance Service, Inc. Corning 32 2 24 Corning Ambulance Service, Inc. Corning 32 0 2 24 Eastern Paramedics, Inc. Syracuse 105 4 10 118 Page 8 of 16

Alamo Ambulance Service, Inc. LaGrangeville 100 0 0 86 LaSalle Ambulance, Inc. Buffalo 219 38 6 144 Mercy Flight, Inc. Buffalo 33 7 1 50 Town's Ambulance Service, Inc Buffalo 218 73 6 136 International Paper Ticonderoga 12 0 0 0 Ambulance Service of Fulton County, Inc. Gloversville 32 0 6 21 Broadalbin Volunteer Ambulance Corps, Inc. Broadalbin 7 0 1 9 Hunter Area Ambulance Service Tannersville 13 0 0 1 Little Falls Ambulance Little Falls 8 0 2 3 Ilion Ambulance Department, Village of Ilion 3 0 5 6 Guilfoyle Ambulance Service, Inc. Watertown 31 0 9 36 Fort Drum Emergency Medical Services Fort Drum 1 0 2 9 Avon Rotary Lions Ambulance Service, Inc. Avon 23 0 0 13 Mount Morris Town Ambulance Mt. Morris 12 0 0 0 Vineall Ambulance, Inc. Oneida 23 0 10 14 Page 9 of 16

Monroe Medi Trans, Inc. Rochester 102 0 0 79 South East Quadrant Mobile Critical Care Unit, Inc. Penfield 19 0 0 31 Nassau County Police Department Mineola 0 0 64 84 North Shore University Hospital Ambulance Service Syosset 235 0 0 165 Nassau University Medical Center East Meadow 8 0 24 18 Twin City Ambulance Corporation Amhurst 108 15 3 82 AmCare Ambulance Service, Inc. Rome 9 2 16 34 Camden Ambulance Service, Town of Camden 7 0 4 2 Edwards Ambulance, Inc. Chadwicks 14 0 9 26 Utica Fire Department, City of Utica 34 0 1 73 Oneida Fire Department, City of Oneida 16 6 3 6 Syracuse Fire Department, City of Syracuse 284 12 1 14 Carrier Dome Health Squad Syracuse 38 0 4 20 Citizens Hose Company Shortsville 6 0 0 1 Finger Lakes Ambulance EMS, Inc. Clifton Springs 44 0 3 31 Page 10 of 16

Finger Lakes Racing Association, Inc. Farmington 6 0 0 0 Mercy Flight Central Canandaigua 8 0 0 16 Mobile Life Support Services, Inc. Newburgh 211 0 1 159 Oswego County Ambulance & Hearse Service, Inc. Fulton 41 1 11 36 Oswego Fire Department, City of Oswego 2 0 29 24 Oneonta Fire Department, City of Oneonta 17 1 12 5 Cooperstown Medical Transport, Inc. Cooperstown 39 0 12 27 Troy Ambulance Service, Inc. Cohoes 45 0 17 17 Rockland Paramedic Services, Inc. Chestnut Ridge 0 0 0 77 R.B. Lawrence Ambulance Morristown 9 0 7 0 Level of Care: 07 Akwesasne Mohawk Ambulance Akwesasne 7 0 3 1 Saratoga Harness Ambulance Saratoga Springs 14 0 0 0 Parkland Ambulance Service, Inc. Schenectady 205 0 1 64 Schenectady Ambulance Service, Inc. Schenectady 205 0 1 64 Schenectady Fire Department Schenectady 4 0 0 110 Page 11 of 16

Knolls Atomic Power Lab Ambulance Schenectady 33 0 0 0 Schoharie County Critical Care Team Cobleskill 0 0 0 4 Corning Ambulance Service, Inc. Corning 32 0 2 24 Hornell Fire Department Ambulance, City of Hornell 5 0 4 13 Monticello Raceway Management, Inc. Monticello 4 0 0 0 Bangs Ambulance, Inc. Ithaca 39 0 6 37 Shandaken Ambulance Service, Town of Shandaken 10 0 0 9 Lyons Ambulance, Town of Lyons 17 0 5 5 Empress Ambulance Service, Inc. Yonkers 159 0 0 63 Greenburgh Police Department, Town of White Plains 17 0 0 25 Perry Emergency Ambulance, Inc. Perry 10 0 0 2 Clinton Ambulance, Town of Churubusco 16 19 1 Level of Care: 07 Suffolk County Yaphank 665 0 1 6 Mamaroneck Ambulance District, Town of Mamaroneck 29 0 0 31 Ashland Ambulance, Town of Ashland 11 0 0 0 Page 12 of 16

Utica Fire Department Ambulance, City of Utica 33 0 1 73 Auburn City Ambulance Auburn 54 0 11 52 New Square Ambulance Service, Village of New Square 52 0 0 4 Watervliet, City of Watervliet 5 0 0 19 White Plains Rescue Medical Team, City of White Plains 12 0 0 4 Albany County Sheriff's Office EMS Unit Clarksville 32 0 0 76 Glens Falls Fire Department Ambulance, City of Glens Falls 15 0 16 5 Green Island, Village of Green Island 15 0 0 19 Niagara County Sheriff's Office Emergency Response Team Lockport 0 0 0 0 Saratoga Springs Fire Department, City of Saratoga Springs 13 0 2 43 Covert Ambulance, Town of Interlaken 18 2 10 Providence Ambulance Service, Town of Middle Grove 17 1 5 Greenfield Ambulance Service,Town of Greenfield Center 26 2 36 Lebanon Ambulance Service, Town of Earlville 4 2 Nelson Ambulance Service, Town of Cazenovia 2 1 Page 13 of 16

Prattsville, Town of Level of Care: 02 Lexington, Town of Prattsville Lexington Pittsfield, Town of Pittsfield 1 4 7 Springville Emergency Medical Services, Village of Springville 33 7 50 Elmira City Police Department SWAT Elmira 0 1 Level of Care: 09 Erie County Emergency Services Division of EMS Niagara, Town of Alden EMS, Town of Webster Emergency Medical Service, Town of Cheektowaga Niagara Falls Alden Webster Citywide Mobile Response Corp. Bronx 142 0 0 28 Maimonides Medical Center Brooklyn 33 0 0 53 Hunter Ambulance, Inc. Inwood 164 0 0 83 Midwood Ambulance & Oxygen Service, Inc. Brooklyn 447 0 0 52 Lenox Hill Hospital New York 53 0 0 60 St. Lukes Roosevelt Hospital Center New York 58 0 0 70 Page 14 of 16

NYC Police Relief Fund EMS Long Island City 10 0 1 2 Lifeline Ambulance Service, Inc. Brooklyn 67 0 1 15 New York Hospital Medical Center of Queens, The Flushing 0 0 0 2 Flushing Hospital Medical Center Flushing 62 0 0 32 Long Island Jewish Medical Center New Hyde Park 235 0 0 165 Jamaica Hospital Ambulance Department, The Jamaica 92 0 0 45 Century Ambulance Service, Inc. Locust Valley 2 0 0 0 New York Racing Association, Inc. Jamaica 17 0 0 16 North Shore Ambulance and Oxygen Service, Inc. Corona 59 0 0 7 Staten Island University Hospital Staten Island 52 0 0 41 Brookhaven National Laboratory Upton 23 0 2 0 Stony Brook, University Hospital, SUNY at Stony Brook 18 0 0 55 Suffolk County Police Department Brentwood 680 0 16 12 Tonawanda Fire Department, City of Tonawanda 3 7 2 13 Tonawanda Emergency Medical Unit, Town of Kenmore 0 0 0 21 Page 15 of 16