Additional Health Department Forms

Forms for Office of Emergency Medical Services

Basic Provider Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-10 EMT Verification Report pdf 12k
doc 40k
 
EMS-38 Staff Roster pdf 23k
doc 144k
 
Sample Inspection Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-16 Survey Report for Mobility Assistance Vehicles (Sample) pdf 779k
 
 
EMS-19 Survey Report for Ambulance (Basic Life Support) (Sample) pdf 968k
 
 
EMS-20 Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample) pdf 1045k
 
 
EMS-21 Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) pdf 48k
doc 183k
 
Quarterly Reports
Form # Title PDF/WORD Instruction/ Comments
EMS-24 Quarterly Report of Mobile Intensive Care Program pdf 56k
doc 249k
Instructions
pdf 61k
doc 93k  
EMS-25 Quarterly Report of Specialty Care Transport Units pdf 33k
doc 81k
Instructions
pdf 22k
doc 44k  
EMS-26 Quarterly Report for Basic Life Support Ambulances Providing Emergency Response pdf 30k
doc 92k
 
EMS-27 Quarterly Report for Air Medical Units pdf 39k
doc 116k
 
Basic Course Reimbursement
Information and Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-43 EMT Course Schedule pdf 1318k
 
 
EMS-61 Emergency Medical Technician Training Fund Final Reimbursement Report pdf 756k
 
 
EMS-62 Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education pdf 762k
 
 
EMS-65 EMT Training Fund Payment Voucher pdf 87k
 
 
Continuing Education Reimbursement
Information and Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-61 Emergency Medical Technician Training Fund Final Reimbursement Report pdf 756k
 
 
EMS-62 Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education pdf 762k
 
 
EMS-65 EMT Training Fund Payment Voucher pdf 87k
 
 
W-9 Vendor Questionnaire pdf 37k
doc 70k
Instructions
pdf 13k
doc 22k  
Applications/Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-28 Emergency Medical Technician
Continuing Education Documentation
(With NJ/PA Logos)
pdf 21k
doc 60k
 
EMS-28A Emergency Medical Technician
Continuing Education Documentation
(without Logos)
pdf 8k
doc 33k
 
EMS-44 Application for Accreditation - Emergency Medical Technician Education Program pdf 68k
doc 99k
 
EMS-56 Application for Certification as an Emergency Medical Technician-Basic Instructor pdf 13k
doc 45k
 
EMS-57 Basic Life Support (BLS) Application for Provider Recertification pdf 20k
doc 80k
 
EMS-60 Advanced Life Support Application for Provider Recertification pdf 18k
doc 55k
 
EMS-63 Form A / EMS First Responder
NJ Protocol for Scene Investigations of Infant and Child Deaths
pdf 23k
doc 109k
 
EMS-64 EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure pdf 923k
 
 
Go to Office of Emergency Medical Services     Additional Health Department Forms