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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 OSDHApplication 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

EMRA Applications

Pre-hospital EMRA 
Pre-hospital EMRA's will operate as part of an Emergency Medical System, responding to requests for service within a response area,supporting and being supported by a licensed ambulance service

Event Stand-by EMRA 
Event Stand-by EMRA's will operate or contract for on-site medical care at locations that are open to the public or that will respond to the public.These types of EMRA's are certified to standby at a location or site and provide medical care to the public.

 


Inspection Forms

                                                                            

EMRA
EMRA Equipment/Records Review
EMS Ground Agency

EMS Ground Agency Records Review

EMS Ground Ambulance Inspection Form

EMS Air Agency

EMS Air Agency Records Review

EMS Air Ambulance Inspection Form

Specialty Care Agency

Speciality Care Agency Records Review

Specialty Care Ground Ambulance Inspection Form

Specialty Care Air Ambulance Inspection Form

Stretcher Aid Van
Stretcher Aid Van Ambulance/Records Review

                                                                    

Education / Training

CAN - Course Authorization 2011 EMT National Registry Practical
Distance Learning Site Data 2012 EMR National Registry Practical
Course Modification Form ALS Practical Test/Retest Application Form
Course Roster (Initial - Final - Amended) Practical Site Summary
State EMR Training and Testing Verification  
Verification of Training to test at an Alternate Site CURRICULUM:
        Go to Education tab on EMS Main page for breakdown


All Other Forms:

Death Benefit Beneficiary Form
Exposure Control Plan - Communicable Disease (sample)
Extrication Agreement (see Mutual Aid Agreement)
Approved Procedures List (Protocols)
Individual Protocols - Application
Individual Protocols - Roster
Individual Protocols - Quality Control Checklist
Medical Director Checklist
Medical Director Agreement - (sample)
Mutual Aid Agreement (sample)
Quality Assurance Guideline (sample)
Quality Assurance Procedure (sample)
Referral Form - QI Intake Form
RTAB - Authorized Rep Form
Run Log - (sample)
Run Report - EMS Patient Care Report (sample)
Run Report - EMR (sample)
T3 Algorithm
TReC - Trauma Referral Center Flier

 

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