EMS Division Forms

Oklahoma EMS Training Program Renewal Forms

EMS Personnel Forms

Initial Application Forms	Renewal Forms
EMS - State License Application and Instructions	EMS Personnel Renewal
EMR - Emergency Medical Responder Application and Instructions	EMR - Emergency Medical Responder Renewal
EMS Instructor Application	EMS Instructor Renewal
Duplicate License Application	License Extension Request Form
Military Waiver Initial Application	Affidavit of Lawful Presence
	Emergency Medical Personnel Renewal

EMS Agency License & Registration

EMS - Ground Agency Application
EMS - Air Ambulance Service Application
EMS - Stretcher Aid Van Service Application
EMS - Specialty Care Service Application
Pre-hospital EMRA Pre-hospital EMRA's will operate as part of an Emergency Medical System, responding to requests for service within a response area,supporting and being supported by a licensed ambulance service.
EMRA Stand-by Application Stand-by EMRA's will operate or contract for on-site medical care at locations that are open to the public or that will respond to the public.These types of EMRA's are certified to standby at a location or site and provide medical care to the public.
Agency Amendment Forms EMS Agency Amendment form - for Ground, Air, Stretcher Aid and Specialty Care agencies EMRA Amendment form - for Prehospital and Standby EMRA's.
Oklahoma EMS Training Program Application Oklahoma EMS Training Program Renewal

EMS Inspection Requirements

EMRA Equipment/Record Review

EMS Ground Agency Records Review

EMS Ground Ambulance Inspection Form

EMS Air Agency Records Review

EMS Air Ambulance Inspection Form

Specialty Care Agency Records Review

Specialty Care Ground Ambulance Inspection Form

Specialty Care Air Ambulance Inspection Form

Stretcher Aid Van Ambualnce/Records Review

EMS Education & Training Forms

CAN - Course Authorization	2011 EMT National Registry Practical
Distance Learning Site Data	2012 EMR National Registry Practical
Course Modification Form	Practical Site Summary
Course Roster (Initial - Final - Amended)	Verification of Training to test at an Alternate Site
State EMR Training and Testing Verification

All Other EMS Division Forms

Death Benefit Beneficiary Form

Exposure Control Plan - Communicable Disease (sample)

2018 OSDH Protocols Application - Includes directions for Individual Protocols

Medical Director Checklist

Referral Form - QI Intake Form

RTAB - Authorized Rep Form

Run Report - EMS Patient Care Report (sample)

Run Report - EMR (sample)

T3 Algorithm

TReC - Trauma Referral Center Flier

Contact Information

Emergency Systems
Oklahoma State Department of Health
123 Robert S Kerr Ave, Suite 1702
Oklahoma City, OK 73102-6406
Office: (405) 426-8480
Fax: (405) 900-7560 or 4059007560@Xmedius.com (using email)
Esystems@health.ok.gov