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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
EMRAgency Application (Emergency Medical Responder)


Inspection Forms-the inspection forms are currently being redesigned to follow the 2016 Rules and Regs. The below samples are not current.

Ground Ambulance Vehicle Inspection EMS - Records Review
Air Ambulance Vehicle Inspection EMRAgency  - Records Review
Stretcher Aid Van Vehicle Inspection SAV - Records Review
Specialty Care Vehicle Inspection uses the same form as Ground Ambulance Specialty Care uses the same form as EMS however they must supply a list of the equipment they are using in the specialty care capacity

 

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)
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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