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.
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.
Medical Director Requirements      KBEMS-OPS10  Checklist of requirements for Medical Directors for TEIS and Agencies.
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

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. KEMSIS. Log in to your account and apply online.

Ambulance Grant Funding
Form Name Form Number Form Description
FY 2014 COUNTY Grant Application  KBEMS-G1 Application used by COUNTIES for Ambulance Grant Funding. Must be submitted with G1-A for each agency applying for funding.
FY 2015 COUNTY Grant Application  KBEMS-G1  Application used by COUNTIES for Ambulance Grant Funding. Must be submitted with G1-A for each agency applying for funding.
FY 2014 AGENCY Grant Application  KBEMS-G2 Application used by AGENCIES for Ambulance Grant Funding Must be submitted with G1-C from your County.
FY 2015 AGENCY Grant Application  KBEMS-G2  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.
Accountability of Funds  KBEMS-G4 Form used to provide proof of expenditure of grant funds.
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

Advanced EMT (AEMT)

     Form Name     Form Number                                  Form Description
AEMT Checklist KBEMS-E5 Checklist of requirements for AEMTs applying for Initial 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  Kentucky Ambulance Service Specific Supplemental Curriculum for the AEMT using a noninvasive monitoring device – Application of 12 lead electrocardiogram electrodes and monitor
AEMT ETCO2 Monitoring KBEMS-E30  Kentucky Ambulance Service Specific Supplemental Curriculum 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 Kentucky Ambulance Service Specific Supplemental Curriculum for the AEMT using Bilevel Positive Airway Pressure and Continuous Positive Airway Pressure Devices 
AEMT BiPAP-CPAP KBEMS-E32  Kentucky Ambulance Service Specific Supplemental Curriculum for the AEMT using intraosseous infusion in the adult
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 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.
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.
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 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
First Responder Skill Sheets
Comprehensive Skill Evaluation         KBEMS-25  Comprehensive Skill Evaluation Report
 Skill Evaluation EMR Student     KBEMS-E27  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
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