Forms

Request to change items wishing to purchase with Grant funds. Request must be made and approved PRIOR to purchase. This form will be available in KEMSIS only.

FY 2022-2023 Agency Grant ApplicationKBEMS G-2

Application used by AGENCIES for Ambulance Grant Funding Must be submitted with G-1 from your County. This form is completed in KEMSIS. Detailed instructions available soon.

Substitute W-9 FormKCTCS Sub W-9

Must be completed ONLY if the payment information has changed since the prior grant cycle. This information must be on file for the distribution of Ambulance Grant Fund and must include direct deposit information.

FY 2022-2023 County Grant ApplicationKBEMS G-1

Application used by COUNTIES for Ambulance Grant Funding. Must be completed and submitted with G-2 in KEMSIS for each agency applying for funding.

Emergency Medical Responder (EMR)

Emergency Medical Responder (EMR)ApplicationElectronic KBEMS-E1

Application for all levels of certification and licensure. This includes Emergency Medical Responder, Emergency Medical Technician (EMT), Paramedic, Critical Care Paramedic, Instructor, and Evaluator.

EMR Supplemental Spinal ImmobilizationKBEMS-E4

Mandatory Supplemental Curriculum Objectives for the EMR use of spinal immobilization.

Initial Course Completion VerificationKBEM-E47

This is for students who have completed a KBEMS approved certification course that were not issued a course completion certificate from their training institution.

Patient Assessment -TraumaNREMT-r201/10-16

Station #1: Trauma Patient Assessment/Management Skill Sheet

Patient Assessment - MedicalNREMT-r202/10-16

Station #2: Medical Patient Assessment/Management Skill Sheet

BVM of Apneic PatientNREMT-r203/10-16

Station #3: Bag Valve Mask Ventilation of an Apneic Patient Skill Sheet

Oxygen AdministrationNREMT-r204/10-16

Station #4: Oxygen Administration by Non-Rebreather Mask Skill Sheet

Cardiac Arrest Management/AEDNREMT-r215/07-17

Station #5: Cardiac Arrest Management/AED Skill Sheet

Spinal Immobilization (Supine)NREMT-e212/10-16

Station #6: Spinal Immobilization (Supine Patient) Skill Sheet

Joint ImmobilizationNREMT-e216/10-16

Station #7: Random Skills - Joint Immobilization Skill Sheet

Long Bone ImmobilizationNREMT-e217/10-16

Station #7: Random Skills - Long Bone Immobilization Skill Sheet

Skill Sheet BundleNREMR

All NREMT EMR Exam Skill Sheets

EMR PsychomotorNREMR

Pyschomotor Examination User Guide

Emergency Medical Technician (EMT)

EMT Skills VerificationKBEMS-E11

his form is used to verify skills for EMT reinstatement purposes.

EMT Supplemental Advance Airway Management-BIAD'sKBEMS-E37

Mandatory Supplemental Curriculum Objectives for the EMT performance of advance airway management-BIAD's.

EMT Supplemental Using a Noninvasive EtCO2 Monitoring DeviceKBEMS-E39

Mandatory Supplemental Curriculum Objectives for the EMT using noninvasive EtCO2 monitoring device.

EMT Supplemental Care of a Saline Lock IV Infusion SiteKBEMS-E40

Mandatory Supplemental Curriculum Objectives for the EMT providing care of a saline lock IV infusion site.

EMT Supplemental Administration of EpinephrineKBEMS-E42

Mandatory Supplemental Curriculum Objectives for the EMT administration of Epinephrine.

EMT Supplemental Curriculum Training Verification FormKBEMS-E44

Verification of Supplemental Training for EMTs

Initial Course Completion VerificationKBEMS-E47

This is for students who have completed a KBEMS approved certification course that were not issued a course completion certificate from their training institution. Same as Paramedic, Training, and AEMT.

Patient Assessment - TraumaNREMT-e201/10-16

Station #1: PATIENT ASSESSMENT/MANAGEMENT – TRAUMA

Patient Assessment - MedicalNREMT-e202/10-16

Station #2: PATIENT ASSESSMENT/MANAGEMENT – MEDICAL

Oxygen AdministrationNREMT-e204/10-16

Station #3: OXYGEN ADMINISTRATION BY NON-REBREATHER MASK

Ventilation ManagementNREMT-p304/09-16

SUPRAGLOTTIC AIRWAY DEVICE

Ventilation ManagementNREMT-e203/10-16

Station #4: BVM VENTILATION OF AN APNEIC ADULT PATIENT

Cardiac Arrest Management / AEDNREMT-e215/07-17

Station #5: CARDIAC ARREST MANAGEMENT / AED

Bleeding ControlNREMT-e213/10-16

Station #6: BLEEDING CONTROL/SHOCK MANAGEMENT

Joint ImmobilizationNREMT-e216/10-16

Station #6A: JOINT IMMOBILIZATION

Long Bone ImmobilizationNREMT-e217/10-16

Station #6B: LONG BONE IMMOBILIZATION

EMT PsychomotorNREMT Guide

Examination User Guide Learn more about exam process URL: https://www.nremt.org/rwd/public/document/psychomotor-exam

Skill Sheet BundleEMT Exam Skill Sheet Bundle

All NREMT EMT Exam Skill Sheets

Advanced EMT (AEMT)

EMT Skills VerificationKBEMS-E11

This form is used to verify skills for AEMT reinstatement purposes.

Initial Course Completion VerificationKBEMS-E47

This is for students who have completed a KBEMS approved certification course that were not issued a course completion certificate from their training institution. Same as in Paramedic and Training sections.

Paramedic

Paramedic Verification of CompetencyVerification

This must be completed to ensure that a Paramedic is competent. This needs to be completed for Reinstatement Applicants.

Critical Care ChecklistKBEMS-E7

This Checklist assists the applicant in meeting the requirements of obtaining the Critical Care Endorsement.

Critical Care Program ObjectivesCritical Care Program Objectives

This document outlines the objectives for Critical Care courses in order to minimally meet the requirements of the UMBC CCEMTP Program

Critical Care Program VerificationKBEMS-E-8

This form must me filled out to apply for the critical care endorsement. See Critical Care Checklist in the Paramedic section.

Initial Course Completion VerificationKBEMS-E47

This is for students who have completed a KBEMS approved certification course that were not issued a course completion certificate from their training institution. Same as in Training and Educational Institutions (TEIs) section.

Educator (Instructor) / Evaluator

Lecture/Skill ValidationKBEMS-E20

This form must be completed by a KBEMS certified educator during a KBEMS approved initial certification course (EMR, EMT, AEMT or Paramedic) to verify that you have completed the required teaching required by 202 KAR 7:601, Section 16. EMS Educators.

Miscellaneous

DNR - EnglishDNR-English

Kentucky's approved DNR form in the English version.

DNR - SpanishDNR-Spanish

Kentucky's approved DNR form in the Spanish version.

Legal

Complaint FormKBEMS-L1

This form is required if you want to file a complaint with KBEMS. This form must be signed and notarized.

Training and Educational Institutions (TEIs)

Continuing Education RequestKBEMS-CE

This form is to be used by non-affiliated Emergency Medical Services-Training and Educational INstitutions to request EMS conference/symposium continuing education approval. The completed form and supporting documentation must be submitted to the Director of Education and Training at least 30 days prior to the start of the training.

KBEMS Check Payment Register for Services and TEIs KBEMS-FIN1

KBEMS Check Payment Register for IndividualsKBEMS-FIN2

KBEMS Journal Entry Register for KCTCS Agencies and TEI’sKBEMS-FIN3

Charge ScheduleKBEMS Charges

Agency License & Vehicle Inspection Manual V2.1KBEMS-OPS11

Air Ambulance Inspection FormKBEMS-OPS6

Air Ambulance Service Inspection FormKBEMS-OPS5

Cease Operations NoticeKBEMS-A2

EMS Agency ApplicationKBEMS-A1

Agency Inspection FormKBEMS-OPS24

Class I ALS Equipment ListKBEMS-OPS12

Class I BLS Equipment ListKBEMS-OPS13

Class II BLS Equipment ListKBEMS-OPS14

Class III Adult Critical Care Equipment ListKBEMS-OPS15

Class III Neonatal Specialty Care Equipment ListKBEMS-OPS16

Class III Pediatric Specialty Care Equipment ListKBEMS-OPS17

Class IV ALS Equipment ListKBEMS-OPS18

Class IV BLS Equipment ListKBEMS-OPS19

Class VI ALS Equipment ListKBEMS-OPS20

Class VI BLS Equipment ListKBEMS-OPS21

Class VIII ALS Equipment ListKBEMS-OPS22

Class VIII BLS Equipment ListKBEMS-OPS23

Medical Director RequirementsKBEMS-OPS10

Partial Adoption of State Protocols WorksheetPartial Adoption of State Protocols

FY 2019-2020 Accountability of FundsKBEMS G-4

Substitute Item RequestKBEMS G-3

FY 2022-2023 Agency Grant ApplicationKBEMS G-2

Substitute W-9 FormKCTCS Sub W-9

FY 2022-2023 County Grant ApplicationKBEMS G-1

Emergency Medical Responder (EMR)ApplicationElectronic KBEMS-E1

EMR Supplemental Spinal ImmobilizationKBEMS-E4

Initial Course Completion VerificationKBEM-E47

Patient Assessment -TraumaNREMT-r201/10-16

Patient Assessment - MedicalNREMT-r202/10-16

BVM of Apneic PatientNREMT-r203/10-16

Oxygen AdministrationNREMT-r204/10-16

Cardiac Arrest Management/AEDNREMT-r215/07-17

Spinal Immobilization (Supine)NREMT-e212/10-16

Joint ImmobilizationNREMT-e216/10-16

Long Bone ImmobilizationNREMT-e217/10-16

Skill Sheet BundleNREMR

EMR PsychomotorNREMR

EMT Skills VerificationKBEMS-E11

EMT Supplemental Advance Airway Management-BIAD'sKBEMS-E37

EMT Supplemental Using a Noninvasive EtCO2 Monitoring DeviceKBEMS-E39

EMT Supplemental Care of a Saline Lock IV Infusion SiteKBEMS-E40

EMT Supplemental Administration of EpinephrineKBEMS-E42

EMT Supplemental Curriculum Training Verification FormKBEMS-E44

Initial Course Completion VerificationKBEMS-E47

Patient Assessment - TraumaNREMT-e201/10-16

Patient Assessment - MedicalNREMT-e202/10-16

Oxygen AdministrationNREMT-e204/10-16

Ventilation ManagementNREMT-p304/09-16

Ventilation ManagementNREMT-e203/10-16

Cardiac Arrest Management / AEDNREMT-e215/07-17

Bleeding ControlNREMT-e213/10-16

Joint ImmobilizationNREMT-e216/10-16

Long Bone ImmobilizationNREMT-e217/10-16

EMT PsychomotorNREMT Guide

Skill Sheet BundleEMT Exam Skill Sheet Bundle

EMT Skills VerificationKBEMS-E11

Initial Course Completion VerificationKBEMS-E47

Paramedic Verification of CompetencyVerification

Critical Care ChecklistKBEMS-E7

Critical Care Program ObjectivesCritical Care Program Objectives

Critical Care Program VerificationKBEMS-E-8

Initial Course Completion VerificationKBEMS-E47

Lecture/Skill ValidationKBEMS-E20

DNR - EnglishDNR-English

DNR - SpanishDNR-Spanish

Complaint FormKBEMS-L1

Continuing Education RequestKBEMS-CE

Course Roster (Initial)KBEMS-E23-Initial

Course Roster (Final)KBEMS-23-Final

Comprehensive Skill EvaluationKBEMS-E25-EMR

Comprehensive Skill EvaluationKBEMS-E25-EMT

Continuing Education FormKBEMS-E10

Course Roster (Continuing Education)KBEMS-E16

Paramedic Course CompletionKBEMS-E19