Forms

Certification

EMS Certification Application
EMT Certification Checklist(PDF, 45KB)
EMT Skills Competency Verification Form and Instructions(PDF, 51KB)
Live Scan Form(PDF, 402KB)

Skills Verification Performance Checklists

• Patient Assessment / Management - Trauma(PDF, 270KB)
• Patient Assessment / Management - Medical(PDF, 281KB)
• BVM Ventilation of an Apneic Adult Patient(PDF, 221KB)
• Oxygen Administration by Non-Rebreather Mask(PDF, 194KB)
• Spinal Immobilization Patient (Seated Patient)(PDF, 260KB)
• Spinal Immobilization Patient (Supine Patient)(PDF, 261KB)
• Bleeding Control / Shock Management(PDF, 262KB)
• Cardiac Arrest Management / AED(PDF, 361KB)
• Joint Immobilization(PDF, 273KB)
• Long Bone Immobilization(PDF, 276KB)
• Naloxone Intranasal (IN)(PDF, 39KB)
• Childbirth(PDF, 36KB)
• Epinephrine Auto-Injectors(PDF, 38KB)
• Penetrating Chest Injury(PDF, 32KB)

 Disaster

Medical Transportation Information Log(PDF, 9KB)

Quality Assurance

Quality Improvement Report(PDF, 86KB)

Quality Improvement Tracking Report(PDF, 180KB)

Training

CE Provider Disclosure Form(PDF, 46KB)
Continuing Education Roster(PDF, 89KB)
Field Internship - Major Evaluation Form(PDF, 254KB)
Field Internship - Daily Performance Evaluation Form(PDF, 290KB)

Automatic External Defibrillators

Notification of New Public Access Defibrillator Site(PDF, 79KB)

Notification of Defibrillator Use(PDF, 39KB)

Reporting Forms

CCEMSA Naloxone Reporting Form for First Responders(PDF, 334KB)