Forms & Applications

Initial Instructor Certification

EMS Instructor Initial Application EMS 0086 PDF Word
Assistant EMS Instructor Initial Application EMS 5902 PDF Word
EMS Continuing Education Instructor Initial Application EMS 0089 PDF Word
Physician EMS Instructor Initial Application EMS 0052 PDF Word
Physician Continuing Education Instructor Initial Application EMS 0052 PDF Word
Fire, Assistant Fire and/or Fire Safety Inspector Instructor Initial Application EMS 0107 PDF

 

Reinstatement Applications

EMS Application - Reinstatement EMS 0088 PDF Word
EMS Instructor Reinstatement Application EMS 5922 PDF Word
Assistant EMS Instructor Reinstatement Application EMS 5923 PDF Word
EMS Continuing Education Instructor Reinstatement Application EMS 5924 PDF Word
Firefighter and Fire Safety Inspector Reinstatement Application EMS 0116 PDF
Fire and/or Fire Safety Inspector Instructor Reinstatement Application EMS 0109 PDF

 

Reciprocity Applications

EMS Reciprocity Packet EMS 5911 PDF Word
EMS Instructor Reciprocity Application EMS 1647 PDF Word
Firefighter Reciprocity Packet EMS 5917 PDF
Fire Instructor Reciprocity Packet EMS 5918 PDF

Application Fee: $75.00 application fee required with EMS provider reciprocity applications (check/money order payable to “Ohio Treasurer of State”). There are no reciprocity application fees for firefighter or fire instructor.

Fire Safety Inspector: Per the Ohio Administrative Code, the Fire Safety Inspector certification is not eligible for certification via reciprocity.

 

Request for Extension

Request for Extension of EMS Certificates EMS 0084 PDF Word

Fire Service Certification Extensions

Per the Ohio Administrative Code, firefighter and fire safety inspector certification renewal extensions are not permitted.

 

Request for Exemption

Exemption Request For Continuing Education For EMS Certificates EMS 5933 PDF Word
Exemption Request for Continuing Education for Fire Certificates EMS 1103 PDF Word

 

Grant Applications & Forms

Priority 1 Training & Equipment Grant

Priority 1 applicants shall apply online. Instructions to create an account may be found in our user guide. For assistance logging on to the grants application website, please email our help desk, or call 614-752-6487.

APPLY

 

Financial Hardship Application EMS 0003 PDF Word
Training and Equipment Approved Reimbursement List EMS 0076 PDF Word

Priority 2-5 Research Grants

Research RFP Opportunities
Research Grant Application
Research Grant Application Priority 2-5                   EMS 2083 PDF Word

Sample Only Forms

The forms below are samples of the EMS and Trauma System grant applications. The 2017-2018 EMS grant applications will be available February 1 - April 1, 2017. Email the Grants Section if you have any questions about the grant application forms.


Sample Training and Equipment Grant Application Priority 1 EMS 1803 PDF
Sample Research Grant Application Priority 2-5 EMS 2083 PDF

 

Medical Transportation Checklists & Forms

Ambulance

License Application Checklist EMS 4028 PDF Word
Application for Ambulance or Mobile Intensive Care License EMS 4001 PDF Word
Headquarters Facility Inspection Emergency Medical Service EMS 4014 PDF Word
Ambulance Inspection EMS 4016 PDF Word
Satellite Facility Inspection Emergency Medical Service EMS 4015 PDF Word
Additional Ambulance / MOICU / Non-Transport Vehicle EMS 4006 PDF Word
Deletion of Ambulance EMS 4012 PDF Word
Non-transport Vehicle Inspection EMS 4026 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulance / MoICU / Non-Transport Vehicle EMS 4009 PDF Word
Change in Level of Service Medical Transportation Organization EMS 4011 PDF Word

Ambulette

License Application Checklist EMS 4028 PDF Word
Application for Ambulette License EMS 4002 PDF Word
Headquarters Facility Inspection Non-Emergency Medical Service EMS 4017 PDF Word
Ambulette Inspection EMS 4019 PDF Word
Satellite Facility Inspection Non-Emergency Medical Service EMS 4018 PDF Word
Additional Ambulette EMS 4007 PDF Word
Deletion of Ambulette EMS 4012 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulette Application EMS 4010 PDF Word

MoICU

License Application Checklist EMS 4028 PDF Word
Application for Ambulance or Mobile Intensive Care License EMS 4001 PDF Word
Headquarters Facility Inspection Mobile Intensive Care Service EMS 4020 PDF Word
MoICU Inspection EMS 4022 PDF Word
Satellite Facility Inspection Mobile Intensive Care Service EMS 4021 PDF Word
Additional MoICU / Non Transport Vehicle EMS 4006 PDF Word
Deletion of MoICU EMS 4012 PDF Word
Non-Transport Vehicle Inspection EMS 4026 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word
Temporary Ambulance / MOICU / Non-Transport Vehicle EMS 4009 PDF Word
Change in Level of Service Medical Transportation Organization EMS 4011 PDF Word

Air Service

License Application Checklist EMS 4028 PDF Word
Application for Air Medical License EMS 4003 PDF Word
Headquarters Facility Inspection Air Medical Service EMS 4023 PDF Word
Aircraft Inspection EMS 4025 PDF Word
Satellite Facility Inspection Air Medical Service EMS 4024 PDF Word
Additional Aircraft EMS 4008 PDF Word
Deletion of Aircraft EMS 4013 PDF Word
Headquarters Change of Address EMS 4004 PDF Word
Application for New Satellite EMS 4005 PDF Word

Sample Only Forms

Periodic Mechanical Safety Report EMS 4039 PDF
Renewal Application for Ambulance or Mobile Intensive Care EMS 4040 PDF
Renewal Application for Ambulette License EMS 4041 PDF
Renewal Application for Air Medical License EMS 4042 PDF
Violation Notification EMS 4029 PDF

Miscellaneous 

Complaint Form for EMS, Fire or Medical Transportation EMS 0050 PDF Word

 

Fire Charter Program Administration

Fire Charter Program Director Guidebook EMS 0028 PDF
Fire Charter Application EMS 0029 PDF Word
Change of Fire Program Notification EMS 0083 PDF Word
Request for Fire Training Offsite Location EMS 1270 PDF Word
Written Testing Agreement Chartered Fire Training Programs EMS 1105 PDF Word
Request for Change to Practical Skill Sheet EMS 1264 PDF Word
ADA Policy   PDF

 

Fire Charter Course Materials

Firefighter
   
Recommended Hour Guide for Fire Training Courses EMS 0118 PDF
Volunteer Firefighter Course Objectives Check-Off Packet EMS 0114 PDF Word
Firefighter I and Firefighter II Course Objectives Check-Off Packet EMS 0121 Word
Courage to be Safe: Sixteen Life Safety Initiatives Course    
Fire Safety Inspector
   
Fire Safety Inspector Course Objectives (2011 Ohio Fire Code Compliant) EMS 0126 PDF Word
Fire Safety Inspector Skill Sheets EMS 0120 PDF Word
Fire Safety Inspector Teaching Slides   PDF Slides
Emergency Vehicle Operations
   
Ohio Fire Academy Competency Evaluation Driver/Operator – Fire Apparatus   PDF
Fire Instructor
   
Ohio Fire and EMS Instructor Curriculum EMS 0122 PDF
Fire Service Training Module EMS 1109 PDF
Live Fire Instructor
   
LiveFire Training Awareness Course EMS 1110 PDF
Live Fire Training Operations Course EMS 1107 PDF
Live Fire Training - Operations Level Practical Skills Evaluation Packet EMS 0127 PDF Word
Live Fire Training Operations Level Positional JPR Check-Off Sheets EMS 1112 PDF Word

 

Fire Charter Examinations

Course and Examination Administration Manual EMS 1271 PDF
Written Testing Agreement Chartered Fire Training Programs EMS 1105 PDF Word
ADA Policy   PDF
Practical Skills
   
Practical Skills Evaluator Training Course Manual EMS 1260 PDF
Firefighter Practical Skills Evaluator Training   PDF Slides
Practical Skills Evaluation Forms    
Practical Skills Evaluator Training Program Frequently Asked Questions EMS 1108 PDF
   

 

EMS Training Program Administration

Certificate of Accreditation Application EMS 1652 PDF Word
Written Testing Agreement EMS Accredited Institutions EMS 1106 PDF Word

 

EMS Training Program Curriculum & Education Standards

Ohio Approved EMS Curriculum Standards – EMS Instructor Guidance   PDF
National EMS Education Standards   PDF

 

EMS Training Program Instructor Information

EMS Instructor

EMS Assistant Instructor

EMS Physician Instructor

Ohio Fire and EMS Instructor Curriculum EMS 0122 PDF
Ohio EMS Instructor Curriculum Mentorship Program for Assistant EMS Instructors EMS 0128 PDF
EMS Instructor Orientation   PDF

 

More Forms

Request for Replacement Card EMS 0079 PDF Word
Change of Address EMS 0080 PDF Word
Declaration of Criminal History EMS Certificates EMS 0095 PDF Word
Declaration of Criminal History Fire Certificates EMS 0101 PDF Word
Complaint Form for EMS, Fire, or Medical Transportation EMS 0050 PDF Word
Application Fee / Disciplinary Payment Remittance EMS 1101 PDF Word
Regional Physician Advisory Board Membership Application EMS 0096 PDF Word
EMS / FIRE Agency Information EMS 0018 PDF Word

 

Have Questions?

Email us at Ask EMS

Or call (614) 466-9447 or (800) 233-0785