DOH Forms
Additional Health Department Forms

Forms for Office of Emergency Medical Services


Basic Provider Forms
Form # Title PDF/WORD Instruction/ Comments
EMS-8 Vehicle Accident Report pdf 15k
doc 49k
 
EMS-10 EMT Verification Report pdf 12k
doc 40k
 
EMS-12 Incident Report pdf 13k
doc 39k
 
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 39k
doc 147k
 
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-Basic Course Application and Schedule pdf 21k
doc 133k
 
EMS-52 Basic Course Voucher pdf 27k
doc 2797k
 
EMS-53 Initial EMT Education Reimbursement Report pdf 8k
doc 29k
 
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 Accreditation - Emergency Medical Technician Education Program pdf 68k
doc 99k
 
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
 
Go to Office of Emergency Medical Services     Additional Health Department Forms