EMS Agency Forms

• Advanced Airway CQI Form(PDF, 134KB)

• Ambulance Staging Resources Status(PDF, 30KB)

• Cal Tahoe Response Time Exception Report(PDF, 66KB)

• Cardiac Arrest Incident Form(PDF, 96KB)

• Controlled Substance Daily Log(PDF, 188KB)

• Controlled Substance Tracking Log(PDF, 193KB)

• CQI Medical Event Report(PDF, 25KB)

• DEA -106 Form

• EDC EMS Agency Continuing Education (CE) Documentation Form(PDF, 90KB)

• EMS Event Analysis(PDF, 45KB)

• ICS 214 Form(PDF, 30KB)

• Live Scan Application(PDF, 164KB)

• Mandated Suspicious Injury Report Form(PDF, 304KB)

  • Mandated Suspicious Injury Report Form Instructions(PDF, 65KB)

• Medicare Signature East Slope(PDF, 204KB)

• Medicare Signature West Slope(PDF, 217KB)

• Paramedic PCR Addendum Report(PDF, 60KB)

• Physician's Medical Necessity Certification Form(PDF, 90KB)

• Physician Orders for Life-Sustaining Treatment (POLST)(PDF, 63KB)

• Prehospital Do Not Resuscitate (DNR) Form(PDF, 360KB)

• Quarterly Report(PDF, 213KB)

• Report of Suspected Dependent Adult/Elder Abuse(PDF, 320KB)

• Search Questionnaire ICS 302(PDF, 171KB)

• STEMI Individual Patient Data Form (Hospital)(PDF, 247KB)

• STEMI Individual Patient Data Form (Paramedic)(PDF, 103KB)

• Student Intern Application(PDF, 88KB)

• Suspected Child Abuse Report

  • Instructions for Suspected Child Abuse Report Form(PDF, 122KB)

• Tiered Dispatch QI Form(PDF, 44KB)

• Transfer of Care Form(PDF, 152KB)

• Trauma Triage Report Form(PDF, 62KB)

• West Slope Response Time Exception Report(PDF, 158KB)