Applications and Forms

EMS CERTIFICATION/LICENSURE FORMS

Initial applications

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

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

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

PDF

Supplemental Forms and Documents

Downgrade Statement form- Apply for lower level of certification

PDF

Skills Verification Form for Late Renewal

PDF

 


 

EMS COMPLAINTS/CRIMINAL HISTORY FORMS

Click for more information on complaints and criminal history

Complaint Form

PDF  

Texas Service Code Fingerprint Form

PDF   

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

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 can now be found on the EMS Education Program page.

 

 


 

EMS PROVIDER GUIDELINES

Find the nearest regional office 

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

Click here for FRO applications 

Notification / Change

PDF Form     

FRO Administrator Information         

PDF Form

FRO Medical Director Information

PDF Form

FRO Personnel

PDF Form

 


 

REGIONAL ADVISORY COUNCIL DEVELOPMENT

RAC Contract Resources and Templates 

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  

Complete Application for Level I Designation    

PDF

Level I Self-Survey Report

PDF

Sample Attestation

PDF

LEVEL II-IV FORMS

 

Complete Application for Level II-IV Designation 

PDF

 


 

NEONATAL FACILITY DESIGNATION

LEVEL I FORMS

Complete Application for Level I Designation    

PDF

Level I Self-Survey Report

PDF

Sample Attestation 

PDF

LEVEL II-IV FORMS

Complete Application for Level II-IV Designation  

PDF

 


 

STROKE FACILITY DESIGNATION

STROKE FACILITY DESIGNATION APPLICATION

All Levels                                                                 

PDF 

COMPREHENSIVE (LEVEL I) AND PRIMARY (LEVEL II) RESOURCE DOCUMENTS

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

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


 

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.
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