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IDPH Forms

New EMT Reciprocity Application
IDPH Ambulance Inspection Form - Effective 9/1/2012
IDPH Training Application
Training Application
State of Illinois DNR
Manual for the Illinois EMS Prehospital Care Report Form
EMT Relicensure Recommendations
Non-Transport Inspection Form


IDPH Forms (updated December 2012)

• Ambulance Staffing Waiver Request Application
• Authorization for Release of Information
• Examination Application
• Extension Request Application
• Fee Schedule
• Inactive Request
• Independent Renewal
• License Reinstatement Application
• Military Licensure Request
• Non-Transport Provider Application
• Reactivation Request
• Reasonable Accommodation Request
• Reciprocity Application
• Renewal Notice
• Request to Modify/Amend Approved System Plan
• Special Events Request Application
• Volunteer License Fee Waiver Application

System Forms

System Entry Packet Form (New fillable form)
Patient Navigator Referral Form
Remediation Plan
Instructor's Record (timesheet for Registry Instructors)
School Bus Release Form
System Wide Crisis Form
Agency CE Certificate for 2013
Generic CE Roster
EMS System Compliments or Recognition Form
Experience Shift Summary
Continuing Education RecordField
F.A.S.T. Stroke Screening Form
Ambulance Availability Form
MCAEMS ALS Agency Inspection Checklist
MCAEMS ILS Agency Inspection Checklist
MCAEMS BLS Agency Inspection Checklist
MCAEMS First Responder Agency Inspection Checklist
ALS Medication Replacement Form
ILS Medication Replacement Form
BLS Medication Replacement Form
Background Check Form
Refusal Form
EMS Run Card
EMS Run Card
Preceptor Paramedic Student Final Eval Form
Registration form for all EMS classes

Renewal Forms

IDPH Extension Application
IDPH Inactive-Reactivation Form
IDPH Renewal Notice

More information on renewals can be found here. Also, please check out this brochure from IDPH.

Quality Related Forms

Incident Report Form
IOR Form
Service Excellence Form