Applications and Forms

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QUICK LINKS

Online Application and License Search

EMS Personnel                         EMS Providers  Designation    

EMS Certification- Initial 

EMS Provider Guidelines   

Maternal Designation

EMS Certification- Renewal

EMS Patch Information Neonatal Designation

EMS Coordinator/Instructor/Education Program Certification    

First Responder Organizations     Stroke Designation
  Trauma Designation
Additional Links

Helpful EMS Materials 

Public Records
Complaint/Criminal History Forms
Regional Advisory Councils  

 

EMS CERTIFICATION/LICENSURE FORMS

Initial applications
EMS personnel: ECA, EMT, Advanced EMT, EMT-P or LP 
            Apply Online
Texas Fingerprint Service Code FormTo 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 Send a request to EMSCert@dshs.texas.gov.
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 Email for application.   
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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FIRST RESPONDER ORGANIZATIONS

Click here for FRO applications 

Notification / Change

PDF Form     

FRO Administrator Information         

PDF Form

FRO Medical Director Information

PDF Form

FRO Personnel

PDF Form


 

HELPFUL EMS MATERIALS

Brochures and Documents
CCMP (Recertification Option 5) presentation in PowerPoint PowerPoint PDF
START Triage Student Manual Word format (zipped)
Websites and links
Child Abuse Prevention and Safety Resources
EMS Media Catalog
EMSC Resources
Leadership Guide to Quality Improvement in EMS
Looking for Out-of-Hospital DNR forms?
New Reporting Requirements for Bloodborne Pathogens
Bloodborne Pathogen Rules/Forms for Reporting
Handbook on Birth Registration

 

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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 

STROKE FACILITY DESIGNATION APPLICATION

All Levels                                                                 

PDF 

COMPREHENSIVE (LEVEL I) AND PRIMARY (LEVEL II) 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


 
SUPPORT (LEVEL III) RESOURCE DOCUMENTS
Stroke Facility Designation Process Level-III PDF
Stroke Designation Survey Process PDF
Support (Level III) Stroke Facility Designation Criteria
Guidance on Essential Criteria for Level III 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

 


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Last updated November 8, 2022