MDCH - Forms and Publications for EMS

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Forms and Publications for EMS

All forms and publications are in PDF format unless otherwise noted. To preview and download the PDF forms, you will need Adobe Acrobat Reader. If you do not have this program, it can be downloaded from their website at:

http://www.adobe.com/products/acrobat/readermain.html

Life Support Agency & Vehicle Licensure Forms
Personnel Licensure Forms
Initial Education
Continuing Education
Complaints, Allegations, & Enforcement
Medical Control Authorities

Life Support Agency & Vehicle Licensure Forms

FORM or PUBLICATION DESCRIPTION	ADOBE PDF FORMAT
Ambulance Operation Licensing
Application to Operate Basic, Limited, & Advanced Services	BHS/EMS-352 (Revision: 3/2006)
Life Support Agency License Application	BHS/EMS-180 (Revision: 7/2009)
Life Support Vehicle Application	BHS/EMS-181 (Revision: 7/2009)
Certificate of Insurance for Life Support Agencies	BHS/EMS-0092 (Revision: 10/2005)
Emergency Medical Services Personnel List	BHS/EMS-327 (Revision: 10/2005)
Ambulance Safety Inspection - Certificate of Compliance	BHS/EMS-318 (Revision: 8/2005)
Ambulance Safety Inspection	BHS/EMS-316 (Revision: 8/2005)
Vehicle Operation Course Criteria	BHS/EMS-2007
Manufacturers Certificate of Compliance	BHS/EMS-314 (Revision: 10/2005)
Minimum Required Equipment/Supplies & Agency Criteria
MFR Agency Vehicle Requirements	MFR Equipment List (Revision: 2005)
BLS/LALS/ALS Agency Vehicle Requirements	BLS/LALS/ALS Equipment List (Revision: 2005)
Required Agency Criteria	Agency Criteria (Revision: 1/2006)
Miscellaneous Publications
MEDCOM Requirements	MEDCOM (Revision: 9/2006)
Medical Control Directory	MCA Directory (Revision: 4/2009)

Personnel Licensure

FORM or PUBLICATION DESCRIPTION	ADOBE PDF FORMAT
*Licensing*
Licensing Application Packet - Medical First Responder, Basic EMT, EMT-Specialist, & Paramedic	DCH-EMS-250 (Revision: 4/2007)
Relicensure Application Packet (License expired within last 3 years) - Medical First Responder, Basic EMT, EMT-Specialist, & Paramedic	DCH-EMS-400 (Revision: 4/2007)
Criminal Conviction History Form (Complete and submit with licensure application if applicable)	DCH-EMS-002 (Revision: 7/2004)
Instructor Coordinator Exam Reservation Form	IC Exam Reservation Form (Revision: 10/2007)
Instructor Coordinator Exam Schedule 2007-2008	IC Exam Schedule 2007-2008
Instructor Coordinator Application Packet	DCH-EMS-500a (Revision: 4/2007)
Instructor Coordinator Relicensure Application Packet (License expired within last 3 years)	DCH-EMS-501a (Revision: 4/2007)
Fee Exemption Request Form for Volunteers	Not available online. Call (517) 241-0179 to have a form mailed to you.
Data Change/Duplicate License Request (You must provide a copy of legal documentation in order to change your name)	DCH-EMS-003 (Revision: 12/2006)
Duplicate Renewal Application (This application is automatically generated and sent to the current licensee's 60-90 days prior to their license expiration date. In addition, you have a 60-day grace period allowing you to renew your license. If you renew during this grace period, you must use this application and pay the additional late fee.)	Not available online. Call (517) 241-0179 for a duplicate application.
Verification of Out of State Licensure	See Licensing Application Packet
IC Verification of 3 Years Experience	See Instructor Coordinator Licensing Application Packet

Education

FORM or PUBLICATION DESCRIPTION	ADOBE PDF or MICROSOFT WORD FORMAT
*For EMS Education Program Sponsors*
Application for Initial Approval (used for initial EMS Education, Instructor-Coordinator Education, and Continuing Education Programs)	BHPPA-EMS 136 (Revised: 4/2009)
Re-Approval Program Application	BHPPA-EMS 136b (Revised: 7/2005)
Interim Course Application	BHPPA-EMS 136a (Revised: 10/2007)
Satellite Location Application	BHPPA-EMS 136s (NEW: 2/2006)
Notification of Change in Program	BHPPA-EMS 136r (NEW: 10/2007)
MFR & EMT Practical Examination Assurance Statement	Assurance Statement (NEW: 9/2007)
EMS Education Program Sponsor Explanation and Criteria (used for initial EMS Education, Instructor-Coordinator Education, and Continuing Education Programs)	Program Sponsor Explanation and Criteria (Revised: 4/2009)
*Education Objectives*
Medical First Responder	MFR Objectives
Basic Emergency Medical Technician	BASIC EMT Objectives
Emergency Medical Technician - Specialist	EMT-S Objectives
Paramedic	Paramedic Objectives
Instructor-Coordinator	IC Objectives (Revised: 4/2009)
*General Forms*
Course Schedule (Fill-in Format)	Course Schedule (Revised: 9/2007) (Microsoft Word)
Course Completion Roster	BHPPA-EMS 122 (Revised: 10/2006) (Microsoft Word)
EMT Practical Exam Re-Verification Form (Courses completed prior to 9/1/07)	EMT Practical Exam Re-Verification Form (NEW: 9/2007) (Microsoft Excel)
Subject Matter Expert/Qualified Instructor Policy	SME & Qualified Instructor Policy (Revised: 6/2005)
Program Approval Packet Samples	Program Approval Packet Samples (Revised: 2000)
National Registry Practical Skill Sheets	MFR Skills (ZIP/PDF File Format) EMT Skills (ZIP/PDF File Format)
Course Audit Sheets	MFR MFR Refresher EMT Matriculation EMT EMT Refresher EMT-Specialist EMT-Specialist Refresher Paramedic Paramedic Refresher Instructor-Coordinator RN to EMT RN to Paramedic

Continuing Education

FORM or PUBLICATION DESCRIPTION	ADOBE PDF or MICROSOFT WORD FORMAT
*For EMS Personnel & Instructor-Coordinators*
Personnel CE Record Form	Personnel CE Record Form (Revision: 10/2007)
Instructor-Coordinator CE Record Form	IC CE Record Form (Revision: 12/2006)
Sample Attendance Roster for CE Credits	CE Attendance Roster (Revision 2/2006) (Microsoft Word)
Sample Proof of Attendance (CHIT)	CHIT Sheet (Revision: 3/2006)
Pre-Approved Standardized CE Credits	Standardized CE Credits (Revision: 2/2008)
*For EMS Program Sponsors & Instructor-Coordinators*
CE Approval Guidelines	CE Approval Guidelines (Revision: 10/2007)
Application for CE Topic	BHPPA-EMS-202 (Revision: 10/2007)
Application for CE topic(s) not included in initial CE approval	BHPPA-EMS-202c (Revision: 2/2006)
*General Forms*
CE Program Schedule (Fill-in Format)	CE Program Schedule (NEW: 9/2007) (Microsoft Word)

Complaints, Allegations, & Enforcement

FORM or PUBLICATION DESCRIPTION	ADOBE PDF FORMAT
Allegation/Complaint Form	BHS-EMS-200 (Revision: 1/2006)

Medical Control Authorities

FORM or PUBLICATION DESCRIPTION	FILE FORMAT
Data Use and Non-Disclosure Agreement (MI-EMSIS)	Data Use and Non-Disclosure Agreement (Revision: 10/2009) (Microsoft Word)
User Agreement (MI-EMSIS)	User Agreement (Revision: 10/2009) (Microsoft Word)
Request to Deviate from Michigan Protocols	DCH-1464 (Revision 6/2009) (Microsoft Word)

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•	Frequently Asked Questions (FAQs)
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•	Public Health Code (Article 17, Part 209)