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 Outdated versions of these documents may not be accepted by the EMS Office.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 new legislation and the subsequent Vermont EMS Rules revisions. The Personnel Licensing (formerly called Certification) section of this website is being 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 Relicensing EMS Providers
- Course and Exam Coordinators
- Applications for Reciprocity
- Ambulance/Service Managers & Administrators
- Instructors and Training Officers
- National Standard Curricula
- Transitioning to the new Scope of Practice
EMS Students and Renewing EMS Providers
| Document Name | Description | Updated |
|---|---|---|
| A-EMT License Application | This form is to be used by all persons applying for Advanced-EMT initial licensure. To be eligible for Vermont A-EMT licensure, you must have an affiliation with an EMS agency licensed at or above the Advanced level or be affiliated with a medical facility that requires you to hold this level of EMS license. |
7/31/12 |
| AEMT and EMT-I License Renewal Application | To be used by any Vermont AEMT or EMT-I to renew their license. |
1/9/13 |
| EMT License Exam Application | Use this form if you need to take an EMT or EMR exam. Note: Do not use this form for renewing your license. Instead, seek out the appropriate license renewal form below based on your current level of licensure. |
7/31/12 |
EMT-Basic License Renewal Application
|
A license renewal 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. |
7/31/12 |
| EMR License Exam Application | Use this form if you need to take an EMT or EMR exam. Note: Do not use this form for renewing your license. Instead, seek out the appropriate license renewal form below based on your current level of licensure. |
7/31/12 |
| EMT-I and AEMT License Renewal Application | To be used by any Vermont EMT-I or AEMT to renew their license. |
1/9/13 |
| FR/ECA License Renewal Application | A license renewal application that combines the necessary information and signatures with the former continuing education sheet. Note: Use this form if your current Vermont license level is FR/ECA. If you are licensed above the FR/ECA level in Vermont, please seek out the appropriate license renewal form based on your current level of licensure. |
7/31/12 |
| Instructor/Coordinator Application | This application can be used to apply for a VT EMS Instructor/Coordinator status. | 2/20/13 |
| Psychomotor (Practical) Exam Skill Sheets | ||
| 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 |
| Transition Guidance | Click the link to the left to find guidance on transitioning to the new Scope of Practice. The guidance is based on your current licensure status in Vermont and your certification status with the National Registry | 3/12/13 |
EMS Course and Exam Coordinators
| Document Name | Description | Updated |
|---|---|---|
| EMS Course Approval App. | Use this form if you are an Instructor/Coordinator and would like to coordinate an EMS course | 7/27/12 |
| EMS Transition Course Approval App. | Use this form to apply to teach a transition course to the new scope of practice at any level. | 12/03/12 |
| Exam Request and Instructions | Use this form if you need to coordinate an EMS certification exam | 8/31/12 |
| 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 a VT EMS Instructor/Coordinator status. | 2/20/13 |
| I/C Peer Mentor Comprehensive Evaluation Form | This form is to be used by a supervising I/C to evaluate an I/C Bridge Course candidate's overall performance. | 4/22/13 |
| I/C Peer Mentor Presentation Session Evaluation Form | This form is to be used by a supervising I/C to evaluate an I/C Bridge Course candidate's individual presentation. One presentation per form, please. | 4/22/13 |
| Testing and Licensure Information for Advanced Level Instructors | The following is important information to help your students register for an Advanced Level exam and obtain a state license: | 9/11/12 |
Applications for Reciprocity
| Document Name | Description | Updated |
|---|---|---|
| Reciprocity Application For All Levels Except Paramedic | Use this form if would like to use your National Registry card to gain Vermont licensure at any level other than Paramedic. Note: This form has been changed to comply with the March 1, 2012 rules. |
9/11/12 |
| 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 renew your Vermont Paramedic license with using National Registry. Note: This form has been changed to comply with the March 1, 2012 rules. |
7/31/12 |
EMS Service Managers/Administrators
| Document Name | Description | Updated |
|---|---|---|
| Ambulance Equipment List | Guildelines list the supplies and equipment that should be stocked on an ambulance to provide accepted standards of patient care. | 3/1/11 |
| Ambulance Inspection | This is the form VT EMS uses when performing ambulance inspections | 9/15/06 |
| First Responder Service Equipment List | When filing a First Responder Service License Application, please ensure that at a minimum this equipment list is met | 8/31/12 |
| 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 |
| Quality Improvement Plan for EMS Instructor/Coordinators | This file is available in PowerPoint and PDF format: |
11/28/06 |
| Transition Guidance | Click the link to the left to find guidance on transitioning to the new Scope of Practice. The guidance is based on your current licensure status in Vermont and your certification status with the National Registry | 1/9/13 |
National EMS Education Standards and Instructional Guidelines
New Scope of Practice Transition Guidance
Locate the document that describes your current license level in Vermont as well as your status with the National Registry.
- VT EMS Transition Frequently Asked Questions (FAQs)
- VT FR-ECA without National Registry FR-ECA
- VT FR-ECA with National Registry FR-ECA
- VT EMT-Basic without National Registry EMT-Basic
- VT EMT-Basic with National Registry EMT-Basic
- Vermont EMT-Intermediate (90 or 03) without National Registry at any level
- Vermont EMT-Intermediate (90 or 03) with National Registry EMT-Basic only
- Vermont EMT-Intermediate (90 or 03) with National Registry EMT-I-85
- Vermont EMT-Paramedic with National Registry