Additional Health Department Forms

Forms for Office of Emergency Medical Services

Basic Provider Forms
Form # Form Name/Title Linked File Instruction/ Comments
EMS-10 EMT Verification Report
pdf (12k)
doc (40k)
 
EMS-38 Staff Roster
pdf (23k)
doc (144k)
 
Sample Inspection Forms
Form # Form Name/Title Linked File 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 (953k)
 
EMS-21 Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample)
pdf (1076k)
 
Quarterly Reports
Form # Form Name/Title Linked File Instruction/ Comments
EMS-24 Quarterly Report of Mobile Intensive Care Program
pdf (56k)
doc (249k)
Instructions (pdf 61k)
Instructions (doc 93k)
 
EMS-25 Quarterly Report of Specialty Care Transport Units
pdf (33k)
doc (81k)
Instructions (pdf 22k) Instructions (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 # Form Name/Title Linked File 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 # Form Name/Title Linked File 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) 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)
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 (894k)
 
Go to Office of Emergency Medical Services     Additional Health Department Forms