EMS Forms and Documents

• Certification / Recertification Forms
• Training and Education Forms
• Provider and Licensure Forms
• Grant Forms
• Other Forms
• Documents

Some of the forms on this page can be completed in Adobe Reader or Microsoft Word.  These forms are available in the "Editable" column to open or download.  Upon completion they may be printed and signed for submission to the department.

Certification / Recertification forms

Note: Certification and recertification forms can be found on the Division of Medical Quality Assurance's website.

Training & Education forms

Form #	Form name	Editable format	Print (non-editable) format
1698C	Application for Review of Continuing Education	.pdf (165kb)	.pdf(100kb)
1698	Application for Approval of an EMS Training Program	.doc (154.50 kb/7 pages)
1938	CPR or ACLS course evaluation		.pdf (59kb)

Provider & Licensure forms

Form #	Form name	Editable format	Print (non-editable) format
	Listing of Florida Licensed Services and Provider Codes		.pdf (36kb)
	Basic Life Support Vehicle Inspection		.pdf (85.88kb)
	Air Ambulance Inspection		.pdf (99.89kb)
631	Ground Ambulance Service Provider License Application	.pdf (916.35 kb/6 pages)	.pdf (42kb/6 pages)
	Advanced Life Support Vehicle Inspection		.pdf (74.14kb)
1264	Personnel Records Inspection		.pdf (10kb)
1265	Supplemental Inspection		.pdf (10kb)
	Equipment Test Results Inspection		.pdf (35.12kb)
1267	Neonatal Interfacility Vehicle Inspection		.pdf (17kb)
1510	Vehicle Permit Application	.pdf (625kb/ 1 page)	.pdf(47.39kb)
1575	Air Ambulance Service License Application	.pdf (432 kb/6 pages)	.pdf (44kb/6 pages)
1576	Air Ambulance Permit Application	.pdf (323kb)	.pdf(15.40kb)
1579	Service Record and Facilities Inspection		.pdf (13kb)
1831	Inspection Corrective Action Statement		.pdf (12kb)

Grant forms

Form #	Form name	Print (non-editable) format
1684	EMS County Grant Application	County Grant Booklet and Application packet.pdf  44.61kb
1684A	EMS Grant Program Expenditure Report	EMS Grant Program Expenditure Report.pdf  19kb
1684C	EMS Grant Program Change Request	EMS Grant Program Change Request.pdf  21kb
1767	EMS Matching Grant Application	Matching Grant Booklet and Application packet.pdf  85.50kb
1767G	Matching Grants Evaluation Worksheet	Mating Grant Evaluation Worksheet.pdf  92kb
1767P	Request for Grant Fund Distribution	Request Grant Fund Distribution.pdf  18kb

Other forms

Note: Do Not Resuscitate Order (DNRO) information and forms are located at the Office of Trauma DNRO page.

Form #	Form name	Print (non-editable) format
	2008 EMS Awards Nomination Packet	.pdf (157.96kb/7 pages)
	Investigative Services Complaint Form	.pdf (1.49mb/4 pages)
	Stroke Alert Checklist	.pdf (40kb)
1256	Certification of Training (Administering Immunizations)	.pdf (14kb)
1304	Quarterly Data Submission	.pdf(103kb)
DHP 150-445	Data Submission Instruction Manual	.pdf(310kb)
1882	Bite/sting	.pdf (40kb)

Documents

To view, print or edit some of the files on this page may require Adobe Acrobat. Use the link below to download a free version of Acrobat Reader.