EMS Documents and Forms
These documents are provided online by Vermont EMS Office for your convenience. Please note the following important information about these documents:
- We require original signatures on all forms submitted to the EMS Office. Please print your form and fill it out on paper.
- Altering these documents in any way is prohibited. Modified documents will not be honored by the EMS Office.
- The EMS Office makes occasional changes to these documents. Please refer to this site for the most recent version of these documents. Outdated versions of these documents may not be accepted by the EMS Office.
- If you have questions, or would like to request a paper copy of a document, please contact the VT EMS Office at 800-244-0911 (in VT) or 802-863-7310. You may also email your request to vtems@state.vt.us.
Several new forms have been added in compliance with the requirements of Act 142, and the subsequent Vermont EMS Rules revision. The Certification section of this website has been updated as well.
If you have any questions, please contact us.
Emergency Medical Services
Vermont Department of
Health
108 Cherry Street
Burlington, VT 05401
EMAIL: Vermont
EMS
TEL: 802-863-7310 or 800-244-0911 (in Vermont
only)
FAX: 802-863-7577
Document and Form Categories
- Students and Recertifiying EMS Providers
- Course and Exam Coordinators
- Applications for Certification Reciprocity
- Ambulance/Service Managers & Administrators
- Instructors and Training Officers
- National Standard Curricula
EMS Students and Recertifying EMS Providers
| Document Name | Description | Updated |
|---|---|---|
| EMT Exam Application | Use this form if you need to take an EMT-B, EMT-I or FR/ECA exam. Note: Do not use this form for recertifi-cation. Instead, seek out the appropriate recertification form below based on your current level of certification. |
2/24/09 |
| EMT-Basic Recertification Application | A new recertification application that combines the necessary information and signatures with the former continuing education sheet. Note: Use this form if your current Vermont certification level is EMT-Basic. If you are certified above or below the EMT-Basic level in Vermont, please seek out the appropriate recertification form based on your current level of certification. |
10/4/11 |
| FR/ECA Exam Application | Use this form if you need to take a First Responder/ECA or FR to EMT-B Module exam. This is the same form that is used for EMT-B or EMT-I exams. (updated) Note: Do not use this form for recertification. Instead, seek out the appropriate recertification form below based on your current level of certification. |
2/24/09 |
| FR/ECA Recertification Application | A new recertification application that combines the necessary information and signatures with the former continuing education sheet. Note: Use this form if your current Vermont certification level is FR/ECA. If you are certified above the FR/ECA level in Vermont, please seek out the appropriate recertification form based on your current level of certification. |
10/4/11 |
| Paramedic Application | Use this form to gain or recertify your Vermont Paramedic certification with using National Registry. Note: This form has been changed to comply with the March 1, 2011 rules. |
10/4/11 |
| EMT-I Recertification Application | A new recertification application that combines the necessary information and signatures with the former continuing education sheet. The form is compre-hensive and includes EMT-Basic recerti-fication information as well. Note: Use this form if your current Vermont certification level is EMT-I-90 or EMT-I-03. If you are certified above or below the Intermediate level in Vermont, please seek out the appropriate recertification form based on your current level of certification. |
10/4/11 |
| RN and PA Certification and Exam Procedures | 9/22/11 | |
| Updating Information on Personnel Record | Use this form to add information to an EMS provider's personnel record at Vermont EMS. Items such as next of kin, contact information and occupation may be updated using this form. | 8/8/07 |
EMS Course and Exam Coordinators
| Document Name | Description | Updated |
|---|---|---|
| EMT Course Approval App. | Use this form if you are an Instructor/Coordinator and would like to coordinate an EMT course | 8/8/06 |
| Exam Request and Instructions | Use this form if you need to coordinate an EMS certification exam | 1/20/11 |
| Exam Security Agreement | This form should accompany requests for any exams proctored by district proctors. | 5/25/07 |
| Use this form if you are an Instructor/Coordinator and would like to coordinate a First Responder Emergency Care Attendant course | 8/8/06 | |
| Instructor/Coordinator Application | This application can be used to apply for or renew an EMT's Instructor/Coordinator status. | 5/25/07 |
| Module Course Approval Application | Use this form to request approval of a FRECA-to-EMT-Basic module course(s). | 6/18/09 |
Applications for Certification Reciprocity
| Document Name | Description | Updated |
|---|---|---|
| FR/ECA Reciprocity | Use this form if would like to use your National Registry card to gain Vermont ECA certification | 3/19/03 |
| EMT-B Reciprocity | We have recently changed this form to combine it with the "VT Recert with NR Card Application," thereby streamlining the process and eliminating confusion about which form to use. Use this form if would like to use your National Registry card. | 10/4/11 |
| EMT-I Reciprocity | Use this form if would like to use your certification from another state to gain Vermont EMT-I certification | 9/22/08 |
| EMT-I90 vs EMT-I03 Reciprocity Fact Sheet | Vermont EMT-Intermediate certification information for reciprocity applicants |
9/22/08 |
| Paramedic Application | Use this form to gain or recertify your Vermont Paramedic certification with using National Registry. Note: This form has been changed to comply with the March 1, 2011 rules. |
10/4/11 |
EMS Service Managers/Administrators
| Document Name | Description | Updated |
|---|---|---|
| Ambulance Equipment List | This form is used in conjunction with the Ambulance Inspection Form | 9/15/06 |
| Ambulance Inspection | This is the form VT EMS uses when performing ambulance inspections | 9/15/06 |
| General Waiver of Rules | Use this form if would like to request a waiver of the EMS rules for non-research related purposes | 12/4/03 |
| License Status Change Form | Use this form if you would like to change the level of care your service can provide (for example, moving from the EMT-I level to the Paramedic level) | 5/25/07 |
| Mental Health Ambulance Transport Intake Form | This form is being used by EMS District #12 personnel for a Mental Health Ambulance Transport Pilot Project | 11/28/06 |
| Pandemic Flu Response Working Draft | Preparation and response strategies for EMS organizations and hospital partners. | 1/30/07 |
| Protocols | The purpose of these protocols is to provide a common framework in VT for the provision of preshospital emergency medical treatment. New Stroke Symptoms/Neurological Emergencies Protocol and Vermont EMS Stroke Alert form added. |
Revised 1/20/07
3/2011 |
| Public Access Defibrillator (PAD) Registration | Use this form to register a Public Access Defibrillator. This form was changed to reflect changes in the law in 2009. | 7/19/11 |
| Public Access Defibrillation Legislation | 18 V.S.A. § 907, last modified May 1, 2009 | 7/19/11 |
| Public Notice and Instructions for Submission | These instructions outline the submission process for a Public Notice and provide a sample notice. This form may be downloaded and modified in Microsoft Word. | 4/28/08 |
| Research Waiver of Rules | Use this form if would like to request a waiver of the EMS rules for research related purposes | 2/12/09 |
| Rules | This is the most recent copy of the Vermont EMS Rules, effective March 1, 2011 | 3/1/11 |
| Ryan White CARE Act Provision | Guidelines for exposure to infectious diseases | 5/08 |
| Sample Operational Letter of Agreement | Agreement between transporter and first responder encompassing dispatching and patient care. | 11/28/06 |
| Statute | Current copy of Title 24 V.S.A. Sections 2561-2688 Chapter 071 - This is the statute that pertains to emergency medical services in Vermont | 3/1/03 |
| Use this form if you need to put an ambulance into service until such time as an official inspection can occur | Revised 1/14/08 |
|
| Vermont map | This map shows District and Town divisions | 9/15/06 |
| Vest Inserts | Familiarize yourself with the first two documents below, as they explain the possible uses for the vest inserts as well as outlining the official NIMS job and position titles. We've created both Adobe pdf and Microsoft Word documents of the job and position cards in order for agencies to modify them as necessary. The Adobe pdf version will retain the margin settings when printed on any printer, making it easy for cards to be cut out and inserted. Opening a Word document will conform that document to individual printer settings and may skew margins and alignments.
|
7/19/11 |
EMS Instructors and Training Officers
| Document Name | Description | Updated |
|---|---|---|
| Documentation Presentation | These files contain a PowerPoint presentation and five Word files to assist you in teaching documentation. |
11/8/06 |
| Exam Security Agreement | This form should accompany requests for any exams proctored by district proctors. | 5/25/07 |
| Instructor/Coordinator Application | This application can be used to apply for or renew an EMT's Instructor/Coordinator status. | 5/25/07 |
| This PowerPoint presentation provides information beyond what is provided by the National Registry as to how this is being implemented in Vermont. | 11/8/06 | |
| Quality Improvement Plan for EMS Instructor/Coordinators | This file is available in PowerPoint and PDF format: |
11/28/06 |
EMS National Standard Curricula
- National Standard First Responder Curriculum (pdf)
- National Standard EMT Curriculum (pdf)
- National Standard Refresher Curriculum (pdf)
- National Standard EMT-I curriculum
- National Standard Paramedic Curriculum
National EMS Education Standards and Instructional Guidelines