DPH: Emergency Medical Services

DPH: Emergency Medical Services - Forms

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Department of Public Health

410 Capitol Avenue

Hartford, CT 06134

Phone:

(860) 509-8000

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Emergency Medical Services - Forms


Adobe PDF Format	Microsoft Word Format
EMS Provider Activity Report Form	EMS Provider Activity Report Form
Need for New or Expanded Services Application
Application for Change in Authorization (MIC)	Application for Change in Authorization (MIC)
Equipment Grant for Emergency Medical Services Application Package
Emergency Vehicle Short-Form Application	Emergency Vehicle Short-Form Application
Parental Consent/Age Waiver Application	Parental Consent/Age Waiver
MARK 1 Nerve Agent Antidote Kit Program Application


Short Form Rate Application & Instructions 2010 Rate Application Spreadsheet

Instructor Forms
Adobe PDF Format	Microsoft Word/Excel Format
Emergency Medical Services- Instructor Application	Emergency Medical Services- Instructor Application
	EMS Instructor Logbook
	Topic Category Code Table
	T-4 Course Completion Form

Licensure Forms
Adobe PDF Format	Microsoft Word/Excel Format
EMT Practical Certification Examination Review and Retain Form
MRT, EMT & EMT-I Certification Application
Out of state refresher verification (Form 204)	Out of state refresher verification (Form 204)
Paramedic Application

Please Note: Some files are in Portable Document Format (pdf). You will need Adobe Acrobat Reader in order to view and print the information.

Content Last Modified on 10/2/2009 12:52:47 PM

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Left Corner Photos by Jack McConnell.