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 953k
|
|
| EMS-21 |
Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) |
pdf 1076k
|
|
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 894k
|
|
