Forms - Oklahoma State Department of Health

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Forms

EMS Personnel Forms

Initial Application Forms		Renewal Forms
State License Application and Instructions		EMS Personnel Renewal
EMR - Emergency Medical Responder Application and Instructions		EMR - Emergency Medical Responder Renewal
EMS Instructor Application		EMS Instructor Renewal
*Practical / Psychomotor Exams* Psychomotor Skill Exam - Registration process (Career-Tech) ALS Practical Test/Retest OSDH Application Form		Duplicate License Application
		Affidavit of Lawful Presence

Agency License / Registration

EMS - Ground Ambulance Service Application
EMS - Air Ambulance Service Application
EMS - Stretcher Aid Van Service Application
EMS - Specialty Care Service Application
EMRAgency Application (Emergency Medical Responder)

Inspection Forms

Ground Ambulance Vehicle Inspection		Pre-Inspection Checklist
Air Ambulance Vehicle Inspection		EMS (Office) Inspection - Records Review
Stretcher Aid Van Vehicle Inspection		EMRAgency (Office) Inspection
Specialty Care Vehicle Inspection (same as Ground Ambulance Vehicle Inspection with a checklist for specialty equipment specific to the unit involved)		SAV (Office) Inspection
		EMRAgency Checklist for Inspection

Education / Training

CAN - Course Authorization		2011 EMT National Registry Practical
Course Modification Form		2012 EMR National Registry Practical
Course Roster (Initial - Final - Amended)		ALS Practical Test/Retest Application Form
State EMR Training and Testing Verification		Practical Site Summary
Verification of Training to Test at an Alternate Site
Transition Courses:		Curriculum:
First Responder to Emergency Medical Responder		Go to Education tab on EMS Main page for breakdown
Basic to EMT
I-85 to AEMT		FAQ's
EMT-P to Paramedic

All Other Forms:

Annual Survey (sample)
Course Initial Roster (sample)
Course Final Roster (sample)
Course Practical Skills Exam Roster (sample)
Crew Roster (sample)
Crew Schedule(sample)
Death Benefit Beneficiary Form
Exposure Control Plan - Communicable Disease (sample)
Extrication Agreement (see Mutual Aid Agreement)
Individual Protocols - Application
Individual Protocols - List of Crew
Individual Protocols - Quality Control Checklist
KKK Ambulance Specifications
Medical Director Agreement - (sample)
Mutual Aid Agreement (sample)
Oklahoma Tax Commission Compliance
Patient Care Report (sample)
Quality Assurance Guideline (sample)
Quality Assurance Procedure (sample)
Referral Form - QI Intake Form
RTAB - Authorized Rep Form
Rules and Statutes Book 2009
Run Log - (sample)
Run Report - EMS Patient Care Report (sample)
Run Report - EMR (sample)
Special Event Memo From OSDH EMS Director
T3 Algorithm
TReC - Trauma Referral Center Flier