Forms and Publications

Edcuation

Quick Links

Directors Report
News/Updates
Protocols
Photo Gallery
Revive2Survive
CE Sponsorship
Shop OCMCA
Member Login

Forms and Publications for EMS
Life Support Agency & Vehicle Licensure Forms
Ambulance Operation Licensing
Application to Operate Basic, Limited, & Advanced Services	BHS/EMS-352 (Revision: 3/2006)
Life Support Agency License Application	BHS/EMS-180 (Revision: 10/2005)
Life Support Vehicle Application	BHS/EMS-181 (Revision: 10/2005)
Certificate of Insurance for Life Support Agencies	BHS/EMS-0092 (Revision: 10/2005)
Emergency Medical Services Personnel List	BHS/EMS-327 (Revision: 10/2005)
Ambulance Safety Inspection - Certificate of Compliance	BHS/EMS-316 (Revision: 8/2005)
Ambulance Safety Inspection	BHS/EMS-318 (Revision: 8/2005)
Vehicle Operation Course Criteria	BHS/EMS-2007
Manufacturers Certificate of Compliance	BHS/EMS-314 (Revision: 10/2005)
Minimum Required Equipment/Supplies & Agency Criteria
MFR Agency Vehicle Requirements	MFR Equipment List (Revision: 2005)
BLS/LALS/ALS Agency Vehicle Requirements	BLS/LALS/ALS Equipment List (Revision: 2005)
Required Agency Criteria	Agency Criteria (Revision: 1/2006)
Miscellaneous Publications
MEDCOM Requirements	MEDCOM (Revision: 9/2006)
Medical Control Authority Directory	MCA Directory (Revision: 1/2008)
Personnel Licensure
Licensing
Licensing Application Packet - All Levels EXCEPT INSTRUCTOR COORDINATOR	DCH-EMS-250 (Revision: 4/2007)
Relicensure Application Packet (License expired within last 3 years) - All Levels EXCEPT INSTRUCTOR COORDINATOR	DCH-EMS-400 (Revision: 4/2007)
Criminal Conviction History Form (Complete and submit with licensure application if applicable)	DCH-EMS-002 (Revision: 7/2004)
Instructor Coordinator Exam Reservation Form	IC Exam Reservation Form (Revision: 10/2007)
Instructor Coordinator Exam Schedule 2007-2008	IC Exam Schedule 2007-2008
Instructor Coordinator Application Packet	DCH-EMS-500a (Revision: 4/2007)
Instructor Coordinator Relicensure Application Packet (License expired within last 3 years)	DCH-EMS-501a (Revision: 4/2007)
Fee Exemption Request Form for Volunteers	DCH-EMS-003 (Revision: 12/2006)
Education
Application for Initial Approval (used for initial EMS Education, Instructor-Coordinator Education, and Continuing Education Programs)	BHPPA-EMS 136 (Revised: 10/2007)
Re-Approval Program Application	BHPPA-EMS 136b (Revised: 7/2005)
Interim Course Application	BHPPA-EMS 136a (Revised: 10/2007)
Satellite Location Application	BHPPA-EMS 136s (NEW: 2/2006)
Notification of Change in Program	BHPPA-EMS 136r (NEW: 10/2007)
MFR & EMT Practical Examination Assurance Statement	Assurance Statement (NEW: 9/2007)
EMS Education Program Sponsor Explanation and Criteria (used for initial EMS Education, Instructor-Coordinator Education, and Continuing Education Programs)	Program Sponsor Explanation and Criteria (Revised: 10/2007)
Education Objectives
Medical First Responder	MFR Objectives
Basic Emergency Medical Technician	BASIC EMT Objectives
Emergency Medical Technician - Specialist	EMT-S Objectives
Paramedic	Paramedic Objectives
Instructor-Coordinator	IC Objectives
General Forms
Course Schedule (Fill-in Format)	Course Schedule (Revised: 9/2007) (Microsoft Word)
Course Completion Roster	BHPPA-EMS 122 (Revised: 10/2006) (Microsoft Word)
EMT Practical Exam Re-Verification Form (Courses completed prior to 9/1/07)	EMT Practical Exam Re-Verification Form (NEW: 9/2007) (Microsoft Excel)
Subject Matter Expert/Qualified Instructor Policy	SME & Qualified Instructor Policy (Revised: 6/2005)
Program Approval Packet Samples	Program Approval Packet Samples (Revised: 2000)
National Registry Practical Skill Sheets	MFR Skills (ZIP/PDF File Format)
National Registry Practical Skill Sheets	EMT Skills (ZIP/PDF File Format)
Course Audit Sheets	MFR
	MFR Refresher
	EMT Matriculation
	EMT
	EMT Refresher
	EMT-Specialist
	EMT-Specialist Refresher
	Paramedic
	Paramedic Refresher
	Instructor-Coordinator
	RN to EMT
	RN to Paramedic
Continuing Education
For EMS Personnel & Instructor-Coordinators
Personnel CE Record Form	Personnel CE Record Form (Revision: 10/2007)
Instructor-Coordinator CE Record Form	IC CE Record Form (Revision: 12/2006)
Sample Attendance Roster for CE Credits	CE Attendance Roster (Revision 2/2006) (Microsoft Word)
Sample Proof of Attendance (CHIT)	CHIT Sheet (Revision: 3/2006)
Pre-Approved Standardized CE Credits	Standardized CE Credits (Revision: 2/2008)
For EMS Program Sponsors & Instructor-Coordinators
CE Approval Guidelines	CE Approval Guidelines (Revision: 10/2007)
Application for CE Topic	BHPPA-EMS-202 (Revision: 10/2007)
Application for CE topic(s) not included in initial CE approval	BHPPA-EMS-202c (Revision: 2/2006)
General Forms
CE Program Schedule (Fill-in Format)	CE Program Schedule (NEW: 9/2007) (Microsoft Word)
Complaints, Allegations, & Enforcement
Allegation/Complaint Form	BHS-EMS-200 (Revision 1/2006)