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.

Ambulance Services
Form Name Form Number Form Description
Agency & Vehicle Inspection Manual KBEMS-OPS11 Guidance for ground agency & vehicle inspections.
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 KBEMS-OPS4 Checklist of all required items required for Ground Ambulance Services.
Medical Director Requirements KBEMS-OPS10 Checklist of requirements for Medical Directors for TEIS and Agencies.
Vehicle Change Form

Paper KBEMS-V1

Electronic KBEMS-V1

Form used to notify KBEMS of the addition or replacement of ground ambulances or aircraft.

This form is also available electronically through KEMSIS. Log in to your account and apply online.

Ambulance Grant Funding
Form Name Form Number Form Description
FY 2016-2017 County Grant Application KBEMS G-1 Application used by COUNTIES for Ambulance Grant Funding. Must be completed and submitted with G-2 in KEMSIS for each agency applying for funding.
FY 2016-2017 Agency Grant Application KBEMS G-2 Application used by AGENCIES for Ambulance Grant Funding Must be submitted with G-1 from your County. This form is completed in KEMSIS. Detailed instructions are available here.
Substitute Item Request KBEMS G-3 Request to change items wishing to purchase with Grant funds. Request must be made and approved PRIOR to purchase. This form will be available in KEMSIS prior to July 1, 2016.
FY 2014-2015 Accountability of Funds KBEMS G-4 Form used to provide proof of expenditure of grant funds. This form is completed in KEMSIS. Detailed instructions are available here.
Substitute W-9 Form KCTCS Sub W-9 Must be completed ONLY if the payment information has changed since the prior grant cycle. This information must be on file for the distribution of Ambulance Grant Fund and must include direct deposit information.
Emergency Medical Responder (EMR)
Form Name Form Number Form Description
Emergency Medical Responder (EMR)Application

Electronic 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.
Emergency Medical Responder Checklist KBEMS-E3 Checklist of requirements for Emergency 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.
Comprehensive Skill Evaluation KBEMS-E25 Comprehensive Skill Evaluation Report
Skill Evaluation EMR Student KBEMS-E27 Skill evaluation for one student.
EMR Supplemental Administration of Medication using Nasal Atomization Device KBEMS-E33 Mandatory Supplemental Curriculum Objectives for the EMR administration of medication using nasal atomization device.
EMR Supplemental Spinal Immobilization KBEMS-E34 Mandatory Supplemental Curriculum Objectives for the EMR use of spinal immobilization.
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 Management/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 (EMT)
Form Name Form Number Form Description
EMT Application

Electronic 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 Skills Verification 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.
Comprehensive Skill Evaluation KBEMS-E25 Comprehensive Skill Evaluation Report
EMT Supplemental Acquisition and Transmission of 12 Lead ECG KBEMS-E35 Mandatory Supplemental Curriculum Objectives for the EMT acquisition and transmission of 12 lead ECG.
EMT Supplemental Administration of Naloxone using Nasal Atomization Device KBEMS-E36 Mandatory Supplemental Curriculum Objectives for the EMT administration of Naloxone using a nasal atomization device.
EMT Supplemental Advance Airway Management-BIAD's KBEMS-E37 Mandatory Supplemental Curriculum Objectives for the EMT performance of advance airway management-BIAD's.
EMT Supplemental Advance Airway Management-Monitoring & Securing a ETT KBEMS-E38 Mandatory Supplemental Curriculum Objectives for the EMT performance of advance airway management-monitoring and securing an ETT.
EMT Supplemental Using a Noninvasive EtCO2 Monitoring Device KBEMS-E39 Mandatory Supplemental Curriculum Objectives for the EMT using noninvasive EtCO2 monitoring device.
EMT Supplemental Care of a Saline Lock IV Infusion Site KBEMS-E40 Mandatory Supplemental Curriculum Objectives for the EMT providing care of a saline lock IV infusion site.
EMT Supplemental Sampling of Blood Glucose using a Glucometer KBEMS-E41 Mandatory Supplemental Curriculum Objectives for the EMT sampling of blood glucose using a glucometer.
EMT Supplemental Administration of Epinephrine KBEMS-E42 Mandatory Supplemental Curriculum Objectives for the EMT administration of Epinephrine.
EMT Supplemental Administration of Albuterol using a Nebulizer KBEMS-E43 Mandatory Supplemental Curriculum Objectives for the EMT administration of Albuterol using a nebulizer.
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
Oxygen Administration NREMT-e203/10-12 Station #3: Oxygen Administration Skill Sheet
Ventilation Management KBEMS Vent-Man Station #4: Ventilatory Management Apneic Patient with BVM and BIAD 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

Advanced EMT (AEMT)

Form Name Form Number Form Description
AEMT Checklist KBEMS-E5 Checklist of requirements for AEMTs applying for Initial Certification.
AEMT Renewal Checklist KBEMS-E5R Checklist of requirements for AEMTs applying for renewal certification.
AEMT Supplemental Initial Training Verification KBEMS-E26 Verification of Supplemental Training for AEMTs.
AEMT Skills Verification KBEMS-E28 Verification of skills for AEMTs.
AEMT 12-Lead ECG Supplemental KBEMS-E29 Mandatory Supplemental Curriculum Objectives for the AEMT using a noninvasive monitoring device – Application of 12 lead electrocardiogram electrodes and monitor
AEMT ETCO2 Monitoring KBEMS-E30 Mandatory Supplemental Curriculum Objectives for the AEMT using a noninvasive monitoring device – Application and interpretation of quantitative capnography and end tidal carbon dioxide monitoring
AEMT Intraosseous Adult KBEMS-E31 Mandatory Supplemental Curriculum Objectives for the AEMT using intraosseous infusion in the adult
AEMT BiPAP-CPAP KBEMS-E32 Mandatory Supplemental Curriculum Objectives for the AEMT using Bi-level Positive Airway Pressure and Continuous Positive Airway Pressure Devices
Paramedic
Form Name Form Number Form Description
Paramedic Application

Electronic 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.
Paramedic Renewal Checklist KBEMS-E6R Checklist of requirements for Paramedics applying for renewal licensure.
Paramedic Verification of Competency 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

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 a Kentucky EMS Educator (Formerly known as Instructor) certification.
Evaluator Checklist KBEMS-E21 Checklist that contains 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.

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

Continuing Education Request

KBEMS-CE

This form is to be used by non-affiliated Emergency Medical Services-Training and Educational INstitutions to request EMS conference/symposium continuing education approval. The completed form and supporting documentation must be submitted to the Director of Education and Training at least 30 days prior to the start of the training.

Course Notification

Electronic KBEMS-E22

Course Notification and Number Request can now be completed online!

Course Roster (Initial Certification Courses) KBEMS-E23 This is a roster of the attendees for an initial certification course (EMR, EMT, AEMT, & Paramedic). This must be submitted to KBEMS at the onset & completion (as part of Course Summary) 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.
CourseRoster (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.
Medical Director Requirements KBEMS-OPS10 Checklist of Requirements for EMS Agency and TEI Medical Directors.
Paramedic Course Completion KBEMS-E19 This form is used to verify successful course completion for Paramedic Students.
TEI Equipment List KBEMS-E12 Checklist of mandatory equipment needed to operate a TEI
TEI Pre-Inspection Worksheet KBEMS-E35 EMS-TEI Pre-Inspection Worksheet (Level 1-4)
TEI Pre-Inspection Worksheet KBEMS-E36 EMS-TEI Pre-Inspection Worksheet (CE Only)