Basic Provider Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-10 |
EMT Verification Report |
|
|
| EMS-38 |
Staff Roster |
|
|
Sample Inspection Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-16 |
Survey Report for Mobility Assistance Vehicles (Sample) |
|
|
| EMS-19 |
Survey Report for Ambulance (Basic Life Support) (Sample) |
|
|
| EMS-20 |
Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample) |
|
|
| EMS-21 |
Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) |
|
|
Quarterly Reports
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-24 |
Quarterly Report of Mobile Intensive Care Program |
|
|
| EMS-25 |
Quarterly Report of Specialty Care Transport Units |
|
Instructions (pdf 22k)
Instructions (doc 44k)
|
| EMS-26 |
Quarterly Report for Basic Life Support Ambulances Providing Emergency Response |
|
|
| EMS-27 |
Quarterly Report for Air Medical Units |
|
|
Basic Course Reimbursement
Information and Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-43 |
EMT Course Schedule |
|
|
| EMS-61 |
Emergency Medical Technician Training Fund Final Reimbursement Report |
|
|
| EMS-62 |
Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education |
|
|
| EMS-65 |
EMT Training Fund Payment Voucher |
|
|
Continuing Education Reimbursement
Information and Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-61 |
Emergency Medical Technician Training Fund Final Reimbursement Report |
|
|
| EMS-62 |
Emergency Medical Technician (EMT) Training Fund Certificate of Eligibility for EMT Education |
|
|
| EMS-65 |
EMT Training Fund Payment Voucher |
|
|
| W-9 |
Vendor Questionnaire |
|
Instructions (pdf 13k)
Instructions (doc 22k)
|
Applications/Forms
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| EMS-28 |
Emergency Medical Technician
Continuing Education Documentation
(With NJ/PA Logos) |
|
|
| EMS-28A |
Emergency Medical Technician
Continuing Education Documentation
(without Logos) |
|
|
| EMS-44 |
Application for Accreditation - Emergency Medical Technician Education Program |
|
|
| EMS-56 |
Application for Certification as an Emergency Medical Technician-Basic Instructor |
|
|
| EMS-57 |
Basic Life Support (BLS) Application for Provider Recertification |
|
|
| EMS-60 |
Advanced Life Support Application for Provider Recertification |
|
|
| EMS-63 |
Form A / EMS First Responder
NJ Protocol for Scene Investigations of Infant and Child Deaths |
|
|
| EMS-64 |
EMT & Paramedic Clinician Reciprocity Application Verification of EMT & Paramedic Education and Licensure |
|
|
