Basic Provider Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| EMS-8 |
Vehicle Accident Report |
pdf 15k
doc 49k |
|
| EMS-9 |
Application for Change in Vehicle Status |
pdf 13k
doc 41k |
|
| EMS-10 |
EMT Verification Report |
pdf 12k
doc 40k |
|
| EMS-12 |
Incident Report |
pdf 13k
doc 39k |
|
| EMS-15 |
Application to Upgrade Provider License Classification |
pdf 14k
doc 41k |
|
| EMS-22 |
Application for Licensure-New Vehicle |
pdf 27k
doc 56k |
|
| EMS-37 |
Application for Change of Trade Name, Address, Contact Person or Telephone Number (With No Change of Ownership) |
pdf 13k
doc 44k |
Instructions
pdf 18k
doc 22k
|
| 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 18k
doc 57k |
|
| EMS-19 |
Survey Report for Ambulance (Basic Life Support) (Sample) |
pdf 43k
doc 146k |
|
| EMS-20 |
Survey Report for Ambulance (Advanced Life Support) (Non-Transport) (Sample) |
pdf 50k
doc 153k |
|
| EMS-21 |
Survey Report for Ambulance (Advanced Life Support) (Transport) (Sample) |
pdf 61k
doc 184k |
|
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-Basic Course Application and Schedule |
pdf 21k
doc 133k |
|
| EMS-52 |
Basic Course Voucher |
pdf 27k
doc 2797k |
|
| EMS-53 |
Basic Course Reimbursement Report |
pdf 11k
doc 32k |
|
| EMS-80 |
Certificate of Eligibility for EMT Education |
pdf 18k
doc 31k |
Instructions
|
Continuing Education Reimbursement
Information and Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| EMS-49 |
EMT Training Fund / Continuing Education Course Final Reimbursement Report |
pdf 9k
doc 29k |
|
| EMS-51 |
Continuing Education Voucher |
pdf 27k
doc 2797k |
|
| EMS-81 |
Certificate of Eligibility for Continuing Education Courses |
pdf 8k
doc 29k |
Instructions
|
| W-9 |
Vendor Questionnaire |
pdf 37k
doc 70k |
Instructions
pdf 13k
doc 22k
|
Applications/Forms
|
| Form # |
Title |
PDF/WORD |
Instruction/ Comments |
| EMS-3 |
EMT-Basic Instructor Endorsement - Initial |
pdf 14k
doc 38k |
|
| EMS-4 |
EMT-Basic Instructor Endorsement - Renewal |
pdf 15k
doc 44k |
|
| EMS-28 |
NJ/PA EMT Continuing Education Documentation |
pdf 21k
doc 60k |
|
| EMS-40 |
Emergency Medical Technician - Application for Reciprocity |
pdf 15k
doc 62k |
|
| EMS-44 |
Application for the Accreditation of Emergency Medical Technician Basic Training Site |
pdf 21k
doc 71k |
|
| EMS-50 |
Emergency Medical Technician Training Programs Certificate of Eligibility for the N. J. State Certification Examination |
pdf 10k
doc 31k |
|
| EMS-54 |
Emergency Medical Technician-Paramedic Provider Reciprocity Application |
pdf 14k
doc 38k |
|
| EMS-55 |
Emergency Medical Technician-Paramedic Provider Reciprocity Application Verification of EMT-Paramedic Training and Certification |
pdf 14k
doc 40k |
|
| 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 |
|
