ARSD 44:05:06:02. Contents of standard form

The standard form for an EMS cardiopulmonary resuscitation directive shall include the following information concerning the person who is the subject of the EMS cardiopulmonary resuscitation directive: (1) The person's name, date of birth, and gender; (2) The person's eye and hair color; (3) The person's race or ethnic background; (4) If applicable, the name of the hospice program in which the person is enrolled; (5) The name, address, telephone number, and signature of the person's attending physician, physician assistant, or nurse practitioner; (6) The person's signature or mark, or, if applicable, the signature of a person authorized to execute an EMS cardiopulmonary resuscitation directive; (7) The date on which the EMS cardiopulmonary resuscitation directive was signed; and (8) A statement directing emergency medical service personnel to withhold cardiopulmonary resuscitation attempts.