Front Matter 0-010 - Signature Page

Polk, Hickory, Cedar, & St Clair EMS Protocols

This document is only valid for two years after the corresponding signatures dates below. Official copies of signatures are on file with Theron Becker at Citizens Memorial Hospital.

Medical Direction Signatures:

Agencies Medical Director Name Medical Director Signature Date Notes
Bolivar City Fire Department
Cedar County First Responders
Cedar County Sheriff's Department - Dispatch
Central Hickory Fire Rescue
Citizens Memorial Hospital - EMS
Collins Fire Protection District
Halfway Fire and Rescue
Humansville Fire Department
Iconium Fire Protection District
Lowry City Volunteer Fire Department
Polk County Central Dispatch
Sac Osage Fire Protection District
Andy Nicholes, DO 2021-12-16 14:40
Signature expires in 23 months
Ellett Memorial Hospital - EMS Paul Kramer, MD 2018-10-15 0:0
Signature is EXPIRED
Pleasant Hope Fire Protection District Kevin Presley, DO 2018-10-15 0:0
Signature is EXPIRED

Agency Head Signatures:

Agency Agency Head Name Agency Head Title Agency Head Signature Date Notes
Bolivar City Fire Department James Ludden Chief 2018-10-15 0:0
Signature is EXPIRED
Cedar County First Responders LaDell Heryford Vice President 2020-7-31 0:0
Signature expires in 6 months
Cedar County Sheriff's Department - Dispatch Dakota Newman Communications Supervisor 2020-8-12 0:0
Signature expires in 7 months
Central Hickory Fire Rescue Jordon Graham Chief 2021-3-3 0:0
Signature expires in 13 months
Citizens Memorial Hospital - EMS Theron Becker PHS Clinical Chief 2021-6-16 9:11
Signature expires in 17 months
Collins Fire Protection District Abel Smith Chief 2018-10-15 0:0
Signature is EXPIRED
Ellett Memorial Hospital - EMS Robert Coskey Director 2018-10-15 0:0
Signature is EXPIRED
Halfway Fire and Rescue Eric Schmidt EMS Captain 2020-9-21 0:0
Signature expires in 8 months
Humansville Fire Department Emma McAntire EMS Captain 2020-9-22 0:0
Signature expires in 8 months
Iconium Fire Protection District Shannon Tucker Chairman of Board of Directors 2020-12-17 0:0
Signature expires in 11 months
Lowry City Volunteer Fire Deparmtent Justin Norris Chief 2021-3-15 10:52
Signature expires in 14 months
Pleasant Hope Fire Protection District Greg Wood Chief 2018-10-15 0:0
Signature is EXPIRED
Polk County Central Dispatch Sarah Newell Director 2020-7-30 0:0
Signature expires in 6 months
Sac Osage Fire Protection District Cheyenne Smart Medical Officer 2019-8-1 0:0
Signature is EXPIRED

Refer to Front Matter 0-010-01 - Hard-Copy Signature Form.


Change Log:

DateLink to
Description of change
08/29/13pdfVersion 2 approved by Roger Merk, MD.
12/16/13pdfVersion 3 approved by Roger Merk, MD.
12/20/13Version 3 re-approved by Roger Merk, MD (includes CVA and STEMI changes).
04/14/15pdf4/1/15 version approved and signed by Dr. Merk and Neal Taylor.
05/31/15Added comments about medications and equipment currently available on ambulances can be found in Section 7-001 - Medications Currently on Response Vehicles and Section 8-001 - Equipment Currently on Response Vehicles. Also added space to fill in who the hard copy is issued to.
11/18/15pdfVersion 5 dated December 1st, 2015 approved and signed my Dr. Merk, Dr. Kramer, Neal Taylor, and Cathy Menninga. Created two cover pages (one for CMH and one for EMH) for signatures.
01/27/16pdfAdded MPDS medical direction details for sections requiring specific instructions in card set.
02/03/16Combined all signature pages into one page for ease of maintaining.
02/06/16Added community responder AED content.
07/05/17pdfChanged medical director and agency heads names to reflect current staff.
08/24/17Added link to download most recent version. Changed William Proctor to Kirk Jones. Moved list of licenses to Section 0-020. Removed paragraph indicating protocols may not reflect what is actually on ambulances.
08/25/17Added Humansville Fire Rescue under Dr. Carter. Added Dr. Presley and Pleasant Hope Fire Ptoection District.
10/17/17Obtained signatures from Megan Carter and Neal Taylor.
10/18/17Obtained signatures from Whitney Gibson and John Hopkins.
10/20/17Obtained signature from Dr. Presley.
10/25/17Obtained signature from Kirk Jones.
11/29/17pdfObtained signatures from Megan Carter and Neal Taylor.
08/24/18pdfAdded two-year expiration to the title page. Added Collins Fire, Iconium Fire, Lowry City Fire, Sac Osage Fire,Wheatland Fire. Changed signatory names as needed for new personnel. Changed definition of pediatric from 18 yr to 16 yr old.
10/01/18Obtained signature from Neal TaylorJordon Graham.
10/10/18Obtained signature from Abel Smith.
10/16/18Changed Melissa Fletcher to Robert Coskey for Ellett.
10/17/18Added signatures from Kirk Jones, Kevin Presley,James Ludden.
10/18/18Removed Iconium Fire from list of associated fire departments.
10/31/18Added signatures from Megan Carter, LaDell Heryford, Travis Foley, Robert Coskey, Justin Norris,Paul Kramer.
11/01/18Changed John Hopkins to Emma Igo. Added signatures from Emma IgoGreg Wood.
11/05/18Added signature from Sarah Newell.
07/31/19Changed medical director to Gustavo Nix.
08/01/19Changed medical director to Tony Cauchi.
08/14/19pdfChanged Travis Foley to Cheyenne Stone for signature for Sac Osage Fire.
11/27/19pdfAdded Halfway FireRescue as signing agency.
12/03/19Dr. Cauchi signature added.
04/21/20Dr. Nicholes reviewed all protocolssigned approval. He also reviewed hard-copy medicationequipment protocols that were yet to be added to the online formatapproved those as well with the understanding they will be added to the website laterstill bear his approval.
09/27/20Added Halfway FireRescue as a signing agency.
10/01/20pdfAdded info from recently signed signature pages from Cedar County Dispatch, Halfway Fire,Humansville Fire.
11/13/20Added links to be able to view only those changes that have happened since each approval signature.
12/18/20pdfAdded Iconium Fire Protection District as protocol signatory agencies.
01/02/21pdfAdded code that displays expiration status for signatures.
03/15/21pdfReceived signature from Justin Norris, Fire Chief for Lowry Volunteer Fire Department.
03/22/21pdfAdded signature page from Central Hickory Fire. Been sitting on my desk for a couple week, but just now got to it.
09/02/21pdfRemoved Morrisville Fire Rescue as a CMH protocol agency.
12/16/21pdfUpdated signature page on file from Dr. Nicholes.

Return to Protocols Table of Contents.

Search protocols:

CMH PHS Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."
Creative Commons License Polk, Hickory, Cedar, & St Clair County EMS Protocols by Theron Becker is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.