2012 Reinstatment

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Required State EMS Forms

The following forms can be printed and used as needed.  These forms are reviewed and updated periodically.  Please note that the license application forms for EMT-Basic, Intermediate-Technician, Intermediate, and Paramedic licensure and for Emergency Medical Responder Certification have been redesigned into one form.

License Applications

• Note: All individual license applications are now only accepted electronically by following the Wisconsin E-licensing link.

Service Credentialing Forms

• RN, PA and MD Verification Form - F-00614 (Word, 60 KB)
• EMS Training Center Training Permit Eligibility Certification – For Electronic In Class Training Permits - F-00646 (Word, 58 KB)
• Service Director License Proxy for Individuals - F-00114 (Word, 71 KB)
• Patient Side Training Report - F-00703 (PDF, 80 KB)

Funding Assistance Forms

• EMS Funding Assistance Program 2011 Application - F-47255 (Word, 116 KB)
• EMS Funding Assistance Program Expenditure Report - F-47257 (Word, 103 KB)

Miscellaneous Forms/Applications

• Ambulance Run Report Form F-47119  (PDF, 86 KB) 
• Ambulance Report Skills / Extended Comments Form F-47300 (PDF, 56 KB)   
• Change of EMS Medical Director Form - F-47470 (PDF, 65 KB)
• Determination of Exposure to Blood/Body Fluids - WKC 8165 is not available on-line.  Ordering Information
• EMS Patient Care Worksheet F-47489 (PDF, 56 KB)
• EMS Provider Application and Operational Plan
• Waiver of Administrative Rule for Licensure - F-00569 (Word, 52 KB)

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Last Revised:  March 15, 2013