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EMS Forms

Submit an EMS Support Ticket

317-234-7322 emscertifications@dhs.in.gov

Select a category below to find EMS applications and forms. There are many forms, so it may take a few moments for this page to load completely.

Note: Some documents, once selected, will automatically download. Check your device's downloads folder if unsure whether a document was downloaded.

Accident Report

AED Registration

AEMT Application

AEMT Continuing Education Report

AEMT Course Checklist

Air Ambulance Certification Application

Air Ambulance Equipment Checklist

Air Ambulance Medical Director Approval

Air Ambulance Service Provider Application

ALS Affiliation Application

ALS Application

ALS Medical Director Approval

ALS Non-Transport Vehicle Equipment Checklist

Application for Advanced Life Support

Application for Air Ambulance Certification

Application for Air Ambulance Service Provider

Application for BLS Service Provider

Application for Green Light Permit

Application for Memorial State Flag

Application for Mobile Integrated Health Program

Application for Supervising Hospital Certification

Application for Trained Driver Renewal

Application for Training Institution

Application for Vehicle Certification

Application for Waiver of EMS Commission Rules

Applications for EMS Grants

Award Nominations

BLS Medical Director Approval

BLS Non-Transport Emergency Equipment Checklist

BLS Service Provider Application

Checklist for AEMT Course

Checklist for Emergency Vehicle Operators Course

Checklist for EMR Course

Checklist for EMT Course

Checklist for Paramedic Course

Checklist for Primary Instructor Candidate Internship

Checklist for Primary Instructor Candidate Student Teaching Internship

Checklist of Air Ambulance Equipment

Checklist of ALS Non-Transport Vehicle Equipment

Checklist of Emergency Vehicle Equipment

Checklist of Psychomotor Skills Quality Control

Complaints

Continuing Education Report for AEMT

Continuing Education Report for EMR

Continuing Education Report for EVOC

Continuing Education Report for Paramedic

Continuing Education Report for Primary Instructor

There are no topics beginning with "D"

Emergency Equipment Checklist for BLS Non-Transport

Emergency Vehicle Equipment Checklist

Emergency Vehicle Operators Course Checklist

EMR Continuing Education Report

EMR Course Checklist

EMR Psychomotor Skills Exam Report

EMS Complaints

EMS Data

EMS Provider Organization Renewal Application

EMS Provider Staff Roster

EMS Status Verification

EMS Vehicle Accident Report

EMT Continuing Education Report

EMT Course Checklist

EMT Renewal Application

EMT Skills Exam Report

EVOC Checklist

EVOC Renewal

There are no topics beginning with "F"

Grant Applications

Green Light Permit Application

There are no topics beginning with "H"

Insurance - Proof of Vehicle Insurance

Internship Affiliation - Primary Instructor Candidate

There are no topics beginning with "J"

There are no topics beginning with "K"

Line of Duty Death

Medical Director Approval for Air Ambulance

Medical Director Approval for ALS

Medical Director Approval for BLS

Memorial State Flag Request

Mobile Integrated Health Program Application

National Registry Registration

There are no topics beginning with "O"

Paramedic Application

Paramedic Continuing Education Report

Paramedic Course Checklist

Personnel for Provider Organization Roster

Primary Instructor Candidate Internship Checklist

Primary Instructor Candidate Student Teaching Internship Checklist

Primary Instructor Continuing Education Report

Primary Instructor Internship Affiliation

Primary Instructors Roster

Program Directors - National Registry Registration

Proof of Insurance for Vehicle

PSID Application

Psychomotor Evaluator Roster

Psychomotor Exam Roster for EMR

Psychomotor Exam Roster for EMT

Psychomotor Skills Quality Control Checklist

There are no topics beginning with "Q"

Reciprocity Application

Registry of AEDs

Remediation Statement - Didactic

Remediation Statement - EMR Skills

Remediation Statement - EMT Skills

Renewal Application for EMR

Renewal Application for EMS Provider OrganizationPDF

Renewal Application for Green Light Permit

Request for Special Recognition

Roster for EMR Psychomotor Exam

Roster for EMS Provider

Roster for EMT Psychomotor Exam

Roster for Primary Instructors

Roster for Psychomotor Evaluator

Roster of Personnel for Provider Organization

Skills Exam Report for EMR

Skills Exam Report for EMT

Special Recognition Nomination

Staff Roster Form

Star of Life Recognition

State Flag Request

State Form 18220

State Form 19634

State Form 46089

State Form 46604

State Form 51816

State Form 51818

State Form 52319

State Form 53299

State Form 53300

State Form 53301

State Form 54410

State Form 54411

State Form 54413

State Form 54414

State Form 54418

State Form 54424

State Form 54426

State Form 54428

State Form 54434

State Form 54502

State Form 54507

State Form 54594

State Form 54597

State Form 54693

State Form 551

State Form 55329

State Form 55330

State Form 55586

State Form 55588

State Form 55590

State Form 55593

State Form 55594

State Form 55595

State Form 56080

State Form 56677

State Form 56924

State Form 57843 (54407)

State Form 67

Statement of Remediation - Didactic

Statement of Remediation - EMR Skills

Statement of Remediation - EMT Skills

Stop the Bleed Training Report

Student Teaching Internship Checklist - Primary Instructor Candidate

Supervising Hospital Application

Training Grants

Training Institution Application

Training Report - Stop the Bleed

There are no topics beginning with "U"

Vehicle Accident Report

Vehicle Application

Vehicle Proof of Insurance

Verification of EMS Status for Reciprocity

Waiver of EMS Commission Rules

There are no topics beginning with "X"

There are no topics beginning with "Y"

There are no topics beginning with "Z"