EMS For Children

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Certification

Information for:

  - FRs and EMTs

  - Managers

   - Public

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Wisconsin Ambulance Services by County

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, IV-Tech, Intermediate, and Paramedic licensure and for First Responder Certification have been redesigned into one form.

License Applications

• Ambulance Service Provider License Application - DPH 07133 (PDF, 18 KB)
• Emergency Medical Technician License Application - DPH 07477 (PDF, 19 KB)
• Emergency Medical Technician License Application Electronic Addition To A Roster - DPH 07478 (PDF, 17 KB)
• First Responder Certificate Application - DPH 07477 (PDF, 19 KB)
• First Responder Certification Application Electronic Addition To A Roster - DPH 07478 (PDF, 17 KB)

Training Permit Applications

• Emergency Medical Technician - Basic Training Permit Application - DPH 07128 (PDF, 22 KB)
• Emergency Medical Technician - Basic IV Technician Training Permit Application - DPH 07464 (PDF, 31 KB)
• Emergency Medical Technician - Intermediate Training Permit Application - DPH 07125 (PDF, 22 KB)
• Emergency Medical Technician - Paramedic Training Permit Application - DPH 07141 (PDF, 22 KB)

Miscellaneous Forms/Applications

• Ambulance Run Report Form
  DPH 07119   (PDF, 86 KB)  DPH 7119I (instructions), Data Definitions, Ordering Information
• Ambulance Report Skills / Extended Comments Form DPH 07300 (PDF, 56 KB)  DPH 7119I (instructions), Data Definitions, Ordering Information
• Change of EMS Medical Director Form - DPH 07470 (PDF, 9 KB)
• Determination of Exposure to Blood/Body Fluids - WKC 8165 is not available on-line.  Ordering Information
• EMS Funding Assistance Program Expenditure Report -
  DOH 07257 (PDF, 15 KB)
• EMS Provider Application and Operational Plan
• Emergency Medical Technician Verification of Licensure - DPH 07471 (PDF, 12 KB)

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Last Revised:  January 03, 2008

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Wisconsin Department of Health and Family Services
Protecting and promoting the health and safety of the people of Wisconsin