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privacy notification, file viewing information, and zip file download instructions.
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, please email emscert@dshs.texas.gov. |
| Inactive certification/licensure |
PDF |
Read procedure
|
| 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 |
PDF |
| 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
|
| Inactive EMS certification/licensure |
PDF |
Read procedure |
| 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 |
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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 |
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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
| COMPREHENSIVE (LEVEL I) AND PRIMARY (LEVEL II)
FORMS |
|
Complete Application for Comprehensive (Level I) and Primary (Level II) Designation |
PDF |
|
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 |
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 |
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So
me 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.
Go to the regional map