Front Matter 0-010-01 - Signature Page - Hard-Copy Signature Form

CMH EMS & MIH Protocols

Print this page and update the following to renew signatures. Once completed, return the hard-copy signature form to the CMH EMS Clinical Chief to remain on file. Completed form can be faxed (417-328-7209) or emailed (theron.becker@citizensmemorial.com).

By signing below, you certify the content of the version and date above are true, correct, and approved by you. You also attest your intension to implement, educate, and enforce the guidelines and protocols that apply to your agency/agencies.
Agencies you represent:
Your printed name:
Your title:
Approval date:
Your signature:

Citations:

Appendix 9-010 - References
None

Change Log:

Date	Link to previous version	Description of change
07/05/20		Moved this section from 0-010 onto its own page.
06/05/21	pdf	Moved to emsprotocols.online

Return to Protocols Table of Contents.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.