QUICK LINKS:

EMS Home

A to Z Index

EMS Boards

EMS For Children

Enforcement Action

Exam Schedule

Forms

Licensing/ Certification

Information for:

- FRs and EMTs

- Managers

- Public

Medical Director Resources

Numbered Memo Series

Prevention/Safety

Staff Listing

Training Information

Trauma System

WARDS

Wisconsin EMS providers 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, Intermediate-Technician, Intermediate, and Paramedic licensure and for Emergency Medical 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)
• Emergency Medical Responder Certificate Application - DPH 07477 (PDF, 19 KB)
• Emergency Medical 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 - Intermediate 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

• Ambulance Report Skills / Extended Comments Form DPH 07300 (PDF, 56 KB)  DPH 7119I (instructions), Data Definitions
• 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 Patient Care Worksheet DPH 0489 (PDF 
• EMS Provider Application and Operational Plan
• Emergency Medical Technician Verification of Licensure - DPH 07471 (PDF, 12 KB)

 PDF: The free Adobe Acrobat Reader software is needed to view or print portable document format (PDF) files.  Learn more.

Return to Wisconsin EMS homepage 

Last Revised:  November 19, 2008