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:

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

EMS Students and Renewing EMS Providers

Document Name Description Updated

A-EMT License Application (paper form)

 

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.

5/14/14

A-EMT --or --EMT-I License Renewal Application (paper form)

 

To be used by any Vermont AEMT or EMT-Intermediate to renew their license.

 

5/14/14

EMT --or-- EMT-Basic License Renewal Application (paper form)

 

 

Used by an EMT-Basic or EMT to renew their EMS license.

Note: If you are certified above or below the EMT-Basic/EMT level in Vermont, please seek out the appropriate recertification form based on your current level of certification.

5/14/14

EMR -- or-- EMT License Exam Application (paper form)

 

 

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.

5/14/14

EMR --or-- FRECA License Renewal Application (paper form)

 

 

To be used by any Vermont EMR or FRECA seeking to renew their license.

Note: If you are licensed above the FR/ECA/EMR level in Vermont, please seek out the appropriate license renewal form based on your current level of licensure.

5/14/14
General Waiver of Rules Use this form if would like to request a waiver of the EMS rules. 11/12/13
Instructor/Coordinator Application This application can be used to apply for a VT EMS Instructor/Coordinator status. 2/20/13

Paramedic Initial License or License Renewal Application (paper form)

 

This application is used only to initially license or renew a Paramedic (or EMT-Paramedic) license in Vermont. National Registry at the appropriate level and affiliation with a Paramedic level service is required. 5/14/14
Psychomotor (Practical) Exam Skill Sheets  
RN and PA: EMS Licensure and Exam Application for RNs and PAs For use by an individual holding a current RN or PA license and interested in gaining EMS licensure in Vermont. 5/14/14
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

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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 5/14/14
EMS Transition Course Approval App. Use this form to apply to teach a transition course to the new scope of practice at any level. 5/14/14
Exam Coordinator Guide This guide is intended to assist you with planning and executing a successful exam site at the Emergency Medical Responder, Emergency Medical Technician and Advanced Emergency Medical Technician levels. 6/1/13
Exam Request (See Request for Independent Exam Site below)    
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
Request for Independent Exam Site A district may use this form to schedule an an additional (“independent”) exam site, separate from the standardized annual exam schedule. The exam request must be received by the EMS office at least two months before the exam date. Independent exam sites require a minimum of 20 initial-attempt candidates unless expressly waived by the EMS office.  7/18/13
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

Application for Reciprocity

Document Name Description Updated
Reciprocity Application For All Levels

Use this form if would like to use your National Registry card to gain Vermont licensure at any level.

5/14/14

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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 Form (Updated) This is the form VT EMS uses when performing ambulance inspections 8/14/13
Ambulance -
Temporary Vehicle License Application

[PDF] [XLSX]
Application for a temporary vehicle license, in accordance with Vermont Emergency Medical Services Rule 5.5 6/26/14
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. 11/12/13
HEART Safe Community

Completed applications may be returned to the Vermont EMS Office, in care of Mike Leyden. Questions may be directed to 802-863-7310.

12/20/12
License Status Change Form Use this form if you would like to change the level of care a Vermont licensed service can provide (upgrading or downgrading). 5/1/14
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.

Vermont EMS Stroke Alert form

Revised 10/8/13

 

 

Protocol Education The Vermont EMS Protocol Resource Kit and some of the protocol training modules may be found on the 2013 Protocol Education page. 10/15/13
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. 8/26/13
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

Temporary Ambulance Inspection

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

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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
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.

 

 

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