Forms

The Kentucky Board of Emergency Medical Services has a variety of forms that can assist you in many aspects of your dealings with the office. We have compiled all of the forms that we offer here in one location.

Form Name	Form Number	Form Description
Ambulance Services
Air Ambulance Inspection Form	KBEMS-OPS6	Checklist of all required items required for Air Ambulances.
Air Ambulance Service Inspection Form	KBEMS-OPS5	Checklist of all required items required for Air Ambulance Services.
Cease Operations Notice	KBEMS-A2	Legal notice if a service is going to cease operations.
EMS Agency Application	KBEMS-A1	Application for an EMS Agency license. DO NOT USE THIS APPLICATION FOR RENEWALS! Go to your KEMSIS Account to Apply for Renewals.
Extrication Equipment	KBEMS-OPS7	List of requirements of extrication equipment for EMS Agencies.
Ground Ambulance Inspection Form	KBEMS-OPS3	Checklist of all required items required for Ground Ambulances.
Ground Ambulance Service Inspection Form	KB EMS-OPS4	Checklist of all required items required for Ground Ambulance Services.
Annual Inspection Information Update	KBEMS-OPS9	List of information inspectors will be updating during the 2013 Inspection cycle.
Ground Regulations with Explanations	KBEMS-OPS8	List of ground ambulance regulations with explanations to assist the provider in meeting regulatory requirements.
Protocols	KY State Protocols	The complete Kentucky State Protocols.
Protocol Update	2010 AHA Updates	Pages that update the Kentucky State Protocols to the 2010 AHA Standards.
Run Report 8A	KY Run Report 8A	The paper version of the Kentucky Approved Run Report Form 8A
Run Report 8B	KY Run Report 8B	The paper version of the Kentucky Approved Run Report Form 8B
Vehicle Change Form	Electronic KBEMS-V1 KBEMS-V1	THIS FORM IS NOW AVAILABLE ELECTRONICALLY THROUGH KEMSIS! Log in to your account and apply online. This will expedite the process and you have the additional option to pay with Credit Card if you want! Form used to notify KBEMS of the Addition or Replacement of ground ambulances or aircraft.
Ambulance Grant Funding
Form Name	Form Number	Form Description
COUNTY Grant Application	KBEMS-G1C	Application used by COUNTIES for Ambulance Grant Funding. Must be submitted with G1-A for each agency applying for funding.
AGENCY Grant Application	KBEMS-G1A	Application used by AGENCIES for Ambulance Grant Funding Must be submitted with G1-C from your County.
Substitute Item Request	KBEMS-G3	Request to change items wishing to purchase with Grant funds. Request must be made and approved PRIOR to purchase.
W-9 Form	KCTCS-Sub W-9	Must be completed and on file for the distribution of Ambulance Grant Funds. Must include Direct Deposit information.
Emergency Medical Responder (EMR)
Form Name	Form Number	Form Description
Emergency Medical Responder (EMR) Application	Electronic KBEMS-E1 KBEMS-E1	Application for all levels of certification and licensure. This includes Emergency Medical Responder, Emergency Medical Technician (EMT), Paramedic, Critical Care Paramedic, Instructor, and Evaluator.
Audit Continuing Education Checklist	KBEMS-CEREQ	Continuing Education Requirements for all levels of Certification or Licensure.
Audit Report	KBEMS-CEREPORT	Form to be submitted with Audited Paperwork.
Emergency Medical Responder Checklist	KBEMS-E3	Checklist of requirements forEmergency Medical Responders applying for Initial Certification. This includes graduates from a Kentucky approved course, reciprocity applicants, reinstatement applicants, and temporary applicants.
Emergency Medical Responder Renewal Checklist	KBEMS-E3R	Checklist of requirements for Emergency Medical Responders applying for renewal certification.
KEMSIS Logon Information	KBEMS-E2	Step by step directions on how to create a KEMSIS account.
Continuing Education Form	KBEMS-E10	This optional form has been created to assist you with tracking continuing education hours.
NREMT Transition Document	EMR Transition Certificate	Fillable certificate requested by NREMT for transition from First Responder to Emergency Medical Responder. Additional Information Can be Found Here: Transition Information
Emergency Medical Technician (EMT)
Form Name	Form Number	Form Description
Audit Continuing Education Checklist	KBEMS-CEREQ	Continuing Education Requirements for all levels of Certification or Licensure.
Audit Report	KBEMS-CEREPORT	Form to be submitted with Audited Paperwork.
EMT Application	Electonic KBEMS-E1 KBEMS-E1	Application for all levels of certification and licensure. This includes First Responder, Emergency Medical Technician (EMT), Paramedic, Critical Care Paramedic, Instructor, and Evaluator.
EMT Checklist	KBEMS-E4	Checklist of requirements for EMTs applying for Initial Certification. This includes graduates from a Kentucky approved course, reciprocity applicants, reinstatement applicants, and temporary applicants.
EMT Renewal Checklist	KBEMS-E4R	Checklist of requirements for EMTs applying for renewal certification.
EMT Reinstatement Reporting	KBEMS-E11	This form is used to verify skills for EMT reinstatement purposes.
Continuing Education Form	KBEMS-E10	This optional form has been created to assist you with tracking continuing education hours.
KEMSIS Logon Information	KBEMS-E2	Step by step directions on how to create a KEMSIS account.
NREMT Transition Document	EMT Transition Certificate	Fillable certificate requested by NREMT for transition from NREMT to Emergency Medical Technician. Additional Information Can be Found Here: Transition Information
Paramedic
Form Name	Form Number	Form Description
Paramedic Application	Eletronic KBEMS-E1 KBEMS-E1	Application for all levels of certification and licensure. This includes First Responder, Emergency Medical Technician (EMT), Paramedic, Critical Care Paramedic, Instructor, and Evaluator.
Paramedic Checklist	KBEMS-E6	Checklist of requirements for Paramedics applying for initial licensure. This includes graduates from a Kentucky approved course, reciprocity applicants, reinstatement applicants, and temporary applicants.
Audit Continuing Education Checklist	KBEMS-CEREQ	Continuing Education Requirements for all levels of Certification or Licensure.
Audit Report	KBEMS-CEREPORT	Form to be submitted with Audited Paperwork
Paramedic Renewal Checklist	KBEMS-E6R	Checklist of requirements for Paramedics applying for renewal licensure.
Paramedic Verification of Competentecy	Verification	This must be completed to ensure that a Paramedic is competent. This needs to be completed for Reinstatement Applicants.
Continuing Education Form	KBEMS-E10	This optional form has been created to assist you with tracking continuing education hours.
KEMSIS Logon Information	KBEMS-E2	Step by step directions on how to create a KEMSIS account.
Critical Care Checklist	KBEMS-E7	This Checklist assists the applicant in meeting the requirements of obtaining the Critical Care Endorsement.
Critical Care Verification	KBEMS-E8	This form verifies that the program the applicant came from is an approved program.
Educator (Instructor) / Evaluator
Form Name	Form Number	Form Description
Instructor Application	Electronic KBEMS-E1 KBEMS-E1	Application for all levels of certification and licensure. This includes First Responder, Emergency Medical Technician (EMT), Paramedic, Critical Care Paramedic, Instructor, and Evaluator.
Certified Instructor	KBEMS-E24	This form must be completed by a certified instructor to verify teaching experience.
Educator Checklist	KBEMS-E17	This checklist has all of the requirements you will need to complete your instructor certification.
Educator Reciprocity, Reinstatement, or Temporary Checklist	KBEMS-E18	This checklist includes all of the requirements you will need to complete Reinstatement, Reciprocity, or Temporary Certification as an Kentucky EMS Educator (Formerly known as Instructor) certification.
Evaluator Checklist	KBEMS-E21	Checklist that contacts all of the requirements to obtain Evaluator Certification.
Lecture and Skill Validation	KBEMS-E20	This form must be completed by a certified instructor to verify that you have completed the required teaching and skill stations.
Miscellaneous
Form Name	Form Number	Form Description
Address Change	Address Instructions KEMSIS	Click 'Address Instructions' to go to the instruction page on how to update your address. Click on the 'KEMSIS' to take you to your online account where you can update it.
Audit Report Form	Audit Form	If selected for a continuing education audit, you must complete and return this form with your documentation
Charge Schedule	KBEMS Charges	Printable list of all charges by the Kentucky Board of EMS.
DNR - English	DNR-English	Kentucky's approved DNR form in the English version.
DNR - Spanish	DNR-Spanish	Kentucky's approved DNR form in the Spanish version.
Duplicate Card	Online Instructions KEMSIS Logon	Instructions on how to apply for a duplicate card online. Link to your KEMSIS Account.
Name Change	Name Change Instructions KEMSIS Logon	Instructions on how to change your name online. Link to Your KEMSIS Account
Legal
Form Name	Form Number	Form Description
Complaint Form	KBEMS-L1	This form is required if you want to file a complaint with KBEMS. This form must be signed and notarized.
Training and Educational Institutions (TEI)s
Form Name	Form Number	Form Description
Course Notification	Electronic KBEMS-E22 KBEMS-E22	Course Notification and Number Request can now be completed Online! If you must use paper, (Processing time is much longer for paper submissions) This form allows you to notify the Board of EMS of courses you are holding and request a course number.
Course Roster (Initial Courses)	KBEMS-E23	This is a roster of the attendees of an Initial course. This must be submitted to KBEMS at the completion of the course.
EMT Course Completion and Test Eligibility	KBEMS-E13	This form is to be completed by the lead instructor to allow a student to verify course completion and to take the national registry exam.
Course Roster (Continuing Education)	KBEMS-E16	Roster to document class attendance for Continuing Education Courses.
KEMSIS Logon Directions	KBEMS-E2	Step by step directions on how to create a KEMSIS account.
Paramedic Course Completion	KBEMS-E19	This form is used to verify successful course completion for Paramedic Students.
TEI Inspection Form	TEI Inspection	Checklist used during a TEI inspection.
TEI Checklist	KBEMS-E15	Checklist of requirements to operate a TEI.
TEI Application	Renewal KBEMS-E14 KBEMS-E14	Logon to KEMSIS to Renew your TEI License. Application for New or Upgrading TEIs.
TEI Equipment List	KBEMS-E12	Checklist of mandatory equipment needed to operate a TEI
Education Regulations	2012 EMS Ed Regs	EMS Education Regulations with explanations that take effect on November 5, 2012
First Responder Skill Sheets
Comprehensive Skill Evaluation	KBEMS-25	Comprehensive Skill Evaluation Report
Skill Evaluation EMR Student	KBEMS-E26	Skill evaluation for one student.
EMR Complete Skill Sheet Packet	EMR-SKILL SHEETS	Complete package of all EMR Skill Sheets.
Patient Assessment -Trauma	NREMT-r201/10-12	Station #1: Trauma Patient Assessment/Management Skill Sheet
Patient Assessment - Medical	NREMT-r202/10-12	Station #2: Medical Patient Assessment/Management Skill Sheet
BVM of Apneic Patient	NREMT-r203/10-12	Station #3: Bag Valve Mask Ventilation of an Apneic Patient Skill Sheet
Oxygen Administration	NREMT-r204/10-12	Station #4: Oxygen Administration by Non-Rebreather Mask Skill Sheet
Cardiac Arrest Managment/AED	NREMT-r215/10-12	Station #5: Cardiac Arrest Management/AED Skill Sheet
Spinal Immobilization (Supine)	NREMT-212/10-12	Station #6: Spinal Immobilization (Supine Patient) Skill Sheet
Joint Immobilization	NREMT-216/10-12	Station #7: Random Skills - Joint Immobilization Skill Sheet
Long Bone Immobilization	NREMT-217/10-12	Station #7: Random Skills - Long Bone Immobilization Skill Sheet
Emergency Medical Technician Skill Sheets
Comprehensive Skill Evaluation	KBEMS-25	Comprehensive Skill Evaluation Report
EMT Test Completion	KBEMS-E13	Skill Evaluation for one student.
EMT Complete Skill Sheet Packet	EMT- SKILL SHEETS	Complete package of all EMT Skill Sheets.
Patient Assessment - Trauma	NREMT-e201/10-12	Station #1: Medical Patient Assessment/Management Skill Sheet
Patient Assessment - Medical	NREMT-e202/10-12	Station #2: Medical Patient Assessment/Management Skill Sheet
Ventilatory Management	KBEMS-VentMan	Station #3: Ventilatory Management Apneic Patient with BVM and BIAD Skill Sheet
Oxygen Administration	NREMT-e204/10-12	Station #4: Oxygen Administration Skill Sheet
Cardiac Arrest Management / AED	NREMT-e212/10-12	Station #5: Cardiac Arrest Management / AED Skill Sheet
Spinal Immobilization (Supine)	NREMT-e212/10-12	Station #6: Spinal Immobilization (Supine Patient) Skill Sheet
Spinal Immobilization (Seated)	NREMT-e211/10-12	Station #7A: Random Skills - Spinal Immobilization (Seated Patient) Skill Sheet
Bleeding Control	NREMT-e213/10-12	Station #7B: Random Skills - Bleeding Control / Shock Management Skill Sheet
Long Bone Immobilization	NREMT-e217/10-12	Station #7C: Random Skills - Long Bone Immobilization Skill Sheet
Joint Immobilization	NREMT-e216/10-12	Station #7D: Random Skills - Joint Immobilization Skill Sheet