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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 - F-47133 (PDF, 18 KB)
• All individual license applications are accepted electronically by following the Wisconsin E-licensing link.

Training Permit Applications

• Emergency Medical Technician - Basic Training Permit Application - F-47128 (PDF, 22 KB)
• Emergency Medical Technician - Intermediate Technician Training Permit Application - F-47464 (PDF, 31 KB)
• Emergency Medical Technician - Intermediate Training Permit Application - F-47125 (PDF, 22 KB)
• Emergency Medical Technician - Paramedic Training Permit Application - F-47141 (PDF, 22 KB)

Miscellaneous Forms/Applications

• Ambulance Run Report Form F-47119  (PDF, 86 KB)  F=47119I (instructions), Data Definitions

• Ambulance Report Skills / Extended Comments Form F-47300 (PDF, 56 KB)  F-47119I (instructions), Data Definitions

• Change of EMS Medical Director Form - F-47470 (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 - F-47257
  (PDF, 15 KB)
• EMS Patient Care Worksheet F-47489 (PDF 56KB)
• EMS Provider Application and Operational Plan

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Last Revised:  September 14, 2009