Applications and Forms
EMS Certification/Licensure Forms
Initial Applications
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EMS personnel: ECA, EMT, Advanced EMT, EMT-P or LP |
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Texas Fingerprint Service Code Form |
To request the fingerprint service code, email EMS Certification |
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Inactive certification/licensure |
To request a form, email EMS Certification |
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Out-of-state reciprocity |
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Supplemental Forms
| Form Type | Form Link | |
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ECA High School/GED Exemption- for candidates who meet volunteer criteria |
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Name change |
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Address Changes |
Log into your online account, look for manage your license and choose address update. |
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Rule Exemption- Request exemption from EMS rules |
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Volunteer Sign-off form |
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Wallet card replacement |
To request form email EMS Certification. |
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EMS Criminal History Pre-Screening |
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Reciprocity AEMT Skills Out of State Verification Form |
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Out of State Verification Form A |
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EMS Recertification/Relicensure Forms
Renewal Applications
| Form Type | Form Link | |
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EMS personnel: ECA, EMT-basic, Advanced EMT, EMT-P or LP |
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Volunteer-to-Paid Status Change- No longer exclusively a volunteer, you must pay cert fee |
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Supplemental Forms and Documents
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Downgrade Statement form- Apply for lower level of certification |
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Skills Verification Form for Late Renewal |
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EMS Complaints/Criminal History Forms
View more information on complaints and criminal history.
| Form Type | Form Link |
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Complaint Form |
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Texas Service Code Fingerprint Form |
To request the fingerprint service code, email EMS Certification |
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Criminal History Documentation Guide |
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Community Supervision Form |
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Criminal History Form |
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Work History Form |
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Criminal History Report Form
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DPS- Procedure to Access Criminal History Record Information (CHRI) |
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EMS Criminal History Pre-Screening
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EMS Coordinator/Instructor/Education Program Forms
Initial and Renewal Applications
| Form Type | Form Link | Process |
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Initial coordinator, instructor, and information operator instructor |
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Renewal coordinator, instructor, and information operator instructor |
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Educator Fee Exemption |
Education Program Forms
Forms are located on the EMS Education Program page.
EMS Provider Guidelines
Find the nearest regional office.
| Form Type | Form Link |
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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. |
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Surety Bond Form for EMS |
First Responder Organizations
| Form Type | Form Link |
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Notification / Change |
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FRO Administrator Information |
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FRO Medical Director Information |
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FRO Personnel |
Helpful EMS Materials
Brochures and Documents
| Document Name | Link | Link |
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CCMP (Recertification Option 5) presentation in PowerPoint |
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START Triage Student Manual |
Websites and Links
Child Abuse Prevention and Safety Resources
Looking for Out-of-Hospital DNR forms?
New Reporting Requirements for Bloodborne Pathogens
Bloodborne Pathogen Rules/Forms for Reporting
Reginal Advisory Council Development
RAC Contract Resources and Templates
| Form Type | Form Link |
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RAC Annual Report Form |
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B-13 template |
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Board Responsibilities Attestation Form |
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EMS Provider Expenditure Report |
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EMS Distribution Report |
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Quarterly Support Documentation |
Email reports to: CMUReg.svcs@dshs.texas.gov.
Stroke Facility Designation
Stroke Facility Designation Application
| Form Type | Form Link | |
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Application All Levels |
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Comprehensive (Level I) and Primary (Level II) Resource Documents
| Document Name | Document Link | |
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Application Submission Instructions |
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Helpful Information |
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Frequently Asked Questions |
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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) |
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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 |
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Support (Level III) Resource Documents
| Document Name | Document Link | |
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Stroke Facility Designation Process Level-III |
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Stroke Designation Survey Process |
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Guidance on Essential Criteria for Level III Stroke Facility Designation |
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Trauma Facility Designation
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ALL TRAUMA LEVELS |
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Complete Trauma Facility Designation Application |
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RESOURCE DOCUMENTS |
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Application Submission Instructions |
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Helpful Information |
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Frequently Asked Questions |
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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 |
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Process for Level III Trauma Facility Designation Application |
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Guidance on Essential Criteria for Level III Trauma Facility Designation |
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Criteria Checklist for Level III Trauma Facility Designation |
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Audit Filters for Level III Trauma Facility Designation |
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Standards of Care for Level III Trauma Facility Designation |
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ADDITIONAL RESOURCE DOCUMENTS |
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Requirements for Trauma Facility Designation Surveyors |
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Trauma Designation Survey Process |
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Initial/Re-designation Level III Agenda Format |
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Policy – Late Applications |
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BASIC (LEVEL IV) TRAUMA FACILITY DESIGNATION |
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Process for Level IV Trauma Facility Designation Application |
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Guidance on Essential Criteria for Level IV Trauma Facility Designation |
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Criteria Checklist for Level IV Trauma Facility Designation |
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Audit Filters for Level IV Trauma Facility Designation |
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Standards of Care for Level IV Trauma Facility Designation |
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ADDITIONAL RESOURCE DOCUMENTS |
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Requirements for Trauma Facility Designation Surveyors |
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Trauma Designation Survey Process |
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Initial/Re-designation Level IV Agenda Format |
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Policy – Late Applications |
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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.
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.pdf (personal document file) which is viewable with the Adobe Acrobat Reader
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.dbf (database) which will import into most database programs
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.txt (delimited text) which will import into most spread sheet programs
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.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.