Applications and Forms

Applications and Forms

EMS Certification/Licensure Forms

Initial Applications

Form Type Form Link

EMS personnel: ECA, EMT, Advanced EMT, EMT-P or LP 

Apply Online

Texas Fingerprint Service Code Form

To request the fingerprint service code, email EMS Certification

Inactive certification/licensure

To request a form, email EMS Certification

Out-of-state reciprocity 

Apply Online

Supplemental Forms

Form Type Form Link

ECA High School/GED Exemption- for candidates who meet volunteer criteria    

PDF

Name change

PDF

Address Changes

Log into your online account, look for manage your license and choose address update.  

Rule Exemption- Request exemption from EMS rules    

PDF

Volunteer Sign-off form

PDF

Wallet card replacement

To request form email EMS Certification.

EMS Criminal History Pre-Screening

PDF

Reciprocity AEMT Skills Out of State Verification Form

PDF

Out of State Verification Form A

PDF


 

EMS Recertification/Relicensure Forms

 Renewal Applications

Form Type Form Link

EMS personnel: ECA, EMT-basic, Advanced EMT, EMT-P or LP

Renew Online

Volunteer-to-Paid Status Change- No longer exclusively a volunteer, you must pay cert fee

PD

Supplemental Forms and Documents

Form Type Form Link

Downgrade Statement form- Apply for lower level of certification

PDF

Skills Verification Form for Late Renewal

PDF


 

EMS Complaints/Criminal History Forms

View more information on complaints and criminal history.

Form Type Form Link

Complaint Form

PDF

Texas Service Code Fingerprint Form

To request the fingerprint service code, email EMS Certification

Criminal History Documentation Guide

PDF

Community Supervision Form

PDF

Criminal History Form

PDF

Work History Form

PDF

Criminal History Report Form

  • This form is intended for EMS certificants/licensees to self-report an arrest, indictment, charge, conviction, deferred adjudication community supervision, and/or deferred disposition                 

PDF

DPS- Procedure to Access Criminal History Record Information (CHRI) 

PDF

EMS Criminal History Pre-Screening

  • This form is intended for evaluating criminal history prior to taking an EMS course to determine eligibility for EMS certification

PDF


 

EMS Coordinator/Instructor/Education Program Forms

 Initial and Renewal Applications

Form Type Form Link Process

Initial coordinator, instructor, and information operator instructor

Apply online

Process

Renewal coordinator, instructor, and information operator instructor

Apply online

Process

Educator Fee Exemption

PDF

 

Education Program Forms

Forms are located on the EMS Education Program page.


 

EMS Provider Guidelines

 Find the nearest regional office

Form Type Form Link

The Clinical Laboratory Improvement Act (CLIA) of 1988 established licensing requirements for facilities (including EMS firms) performing lab tests. Even simple tests such as blood glucose testing and monitoring fall under the CLIA requirements. Fortunately, those simple tests that are commonly performed on EMS units qualify for a CLIA Certificate of Waiver. Effective September 1, 2004, EMS Providers will be responsible for securing and maintaining a current CLIA Certificate of Waiver. This applies to any firm using glucometers or other devices to test blood or other patient fluids.

Information

Surety Bond Form for EMS

PDF


 

First Responder Organizations

 View FRO applications.

Form Type Form Link

Notification / Change

PDF  

FRO Administrator Information         

PDF

FRO Medical Director Information

PDF

FRO Personnel

PDF


 

Helpful EMS Materials

Reginal Advisory Council Development

RAC Contract Resources and Templates  

Form Type Form Link

RAC Annual Report Form

Word

B-13 template

Word

Board Responsibilities Attestation Form

Word

EMS Provider Expenditure Report

Excel

EMS Distribution Report

Excel

Quarterly Support Documentation

Excel

Email reports to: CMUReg.svcs@dshs.texas.gov.


 

Maternal Facility Designation

LEVEL I FORMS

Form Type Form Link

Complete Application for Level I Designation    

PDF

Level I Self-Survey Report

PDF

Sample Attestation

PDF

LEVEL II-IV FORMS 

Form Type Form Link

Complete Application for Level II-IV Designation 

PDF


 

Neonatal Facility Designation

 LEVEL I FORMS

Form Type Form Link

Complete Application for Level I Designation    

PDF

Level I Self-Survey Report

PDF

Sample Attestation 

PDF

 LEVEL II-IV FORMS

Form Type Form Link

Complete Application for Level II-IV Designation  

PDF


 

Stroke Facility Designation

 Stroke Facility Designation Application

Form Type Form Link

Application All Levels                                                                 

PDF 

Comprehensive (Level I) and Primary (Level II) Resource Documents 

Document Name Document Link

Application Submission Instructions

PDF  

Helpful Information

PDF  

Frequently Asked Questions

PDF  

Policy and Procedure- Facility with Conditional Certification as Primary Stroke Center and De-Certification with The Joint Commission, Det Norske Veritas (DNV), or Healthcare Facilities Accreditation Program (HFAP)

PDF

Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Stroke Facility Designation

PDF

Support (Level III) Resource Documents 

Document Name Document Link

Stroke Facility Designation Process Level-III

PDF

Stroke Designation Survey Process

PDF

Support (Level III) Stroke Facility Designation Criteria

Guidance on Essential Criteria for Level III Stroke Facility Designation

PDF


 

Trauma Facility Designation

ALL TRAUMA LEVELS

Complete Trauma Facility Designation Application     

PDF  

RESOURCE DOCUMENTS

Application Submission Instructions

PDF          

Helpful Information

PDF  

Frequently Asked Questions

PDF  

Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Trauma Facility Designation 

PDF

 

 

ADVANCED (LEVEL III)     

Process for Level III Trauma Facility Designation Application

Webinar

Guidance on Essential Criteria for Level III Trauma Facility Designation

PDF

Criteria Checklist for Level III Trauma Facility Designation

PDF

Audit Filters for Level III Trauma Facility Designation

PDF

Standards of Care for Level III Trauma Facility Designation 

PDF

ADDITIONAL RESOURCE DOCUMENTS

Requirements for Trauma Facility Designation Surveyors

PDF

Trauma Designation Survey Process

PDF

Initial/Re-designation Level III Agenda Format 

PDF

Policy – Late Applications

PDF

 

 

BASIC (LEVEL IV) TRAUMA FACILITY DESIGNATION

Process for Level IV Trauma Facility Designation Application

Webinar

Guidance on Essential Criteria for Level IV Trauma Facility Designation

PDF

Criteria Checklist for Level IV Trauma Facility Designation

PDF

Audit Filters for Level IV Trauma Facility Designation

PDF

Standards of Care for Level IV Trauma Facility Designation

PDF

ADDITIONAL RESOURCE DOCUMENTS

Requirements for Trauma Facility Designation Surveyors

PDF

Trauma Designation Survey Process

PDF

Initial/Re-designation Level IV Agenda Format

PDF

Policy – Late Applications

PDF

Information on Zip Files

Some files are listed in a self-extracting zip format . These are compressed files that must be unzipped (uncompressed). The unzipped file is the one you will use. Select the file you wish to download by placing your pointer over the file name and double-click with your left mouse button. Save the file to a directory that you select. Open Windows File Manager or Windows Explorer. Go to the directory in which you placed the file. Find the file name that you saved. You must expand the contents of this file. Place your pointer over the file name and double-click with your left mouse button. This will open the file. Press the F5 function key on your keyboard. This will "refresh" your file listing. Your new file will now be listed. Your new file is ready for use!

Once the files have been uncompressed, these document files will be in one of the following formats.

  • .pdf (personal document file) which is viewable with the Adobe Acrobat Reader

  • .dbf (database) which will import into most database programs

  • .txt (delimited text) which will import into most spread sheet programs

  • .wpd (WordPerfect document) which is viewable with Wordperfect 6.1 or later or Word 97 or later


For more information contact your regional office.
Go to the regional map.