Ky.gov

Kentucky Board of Emergency Medical Services

Forms

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Agency License & Vehicle Inspection Manual V2.2KBEMS-OPS11

Guidance for ground agency & vehicle inspections.

Inspection Critical Violation ListKBEMS-OPS11-1

Agency License & Vehicle Inspection Critical Violation List

Air Ambulance Service Inspection FormKBEMS-OPS5

Checklist of all required items required for Air Ambulances.

Air Ambulance Inspection FormKBEMS-OPS6

Checklist of all required items required for Air Ambulances.

Cease Operations NoticeKBEMS-A2

Form for EMS agencies to serve legal notice of intent to cease operations.

EMS Agency ApplicationKBEMS-A1

Application for an EMS Agency license. DO NOT USE THIS APPLICATION FOR RENEWALS! Go to your KEMSIS Account to apply for Renewals.

Agency Inspection FormKBEMS-OPS24

List of required documents for annual agency inspection.

Class I ALS Equipment ListKBEMS-OPS12

Checklist of required items for Class I ALS Ambulances

Class I BLS Equipment ListKBEMS-OPS13

Checklist of required items for Class I BLS Ambulances

Class II BLS Equipment ListKBEMS-OPS14

Checklist of required items for Class II BLS Ambulances

Class III Adult Critical Care Equipment ListKBEMS-OPS15

Checklist of required items for Class III Adult Critical Care Ambulances

Class III Neonatal Specialty Care Equipment ListKBEMS-OPS16

Checklist of required items for Class III Neonatal Specialty Care Ambulances

Class III Pediatric Specialty Care Equipment ListKBEMS-OPS17

Checklist of required items for Class III Pediatric Specialty Care Ambulances

Class IV ALS Equipment ListKBEMS-OPS18

Checklist of required items for Class IV ALS Ambulances

Class IV BLS Equipment ListKBEMS-OPS19

Checklist of required items for Class IV BLS Ambulances

Class VI ALS Equipment ListKBEMS-OPS20

Checklist of required items for Class VI ALS Ambulances

Class VI BLS Equipment ListKBEMS-OPS21

Checklist of required items for Class VI BLS Ambulances

Class VIII ALS Equipment ListKBEMS-OPS22

Checklist of required items for Class VIII ALS Ambulances

Class VIII BLS Equipment ListKBEMS-OPS23

Checklist of required items for Class VIII BLS Ambulances

Medical Director RequirementsKBEMS-OPS10

Checklist of requirements for Medical Directors for TEIS and Agencies.

Partial Adoption of State Protocols WorksheetPartial Adoption of State Protocols

Licensed Ambulance agencies wishing to "opt-out" of certain portions of the approved Kentucky State EMS Protocol.

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

Continuing Education RequestKBMES-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.

Course Roster (Initial)KBEMS-E23-Initial

This is a roster of the attendees for an initial certification course (EMR, EMT, AEMT, & Paramedic). This must be submitted to KBEMS within 14 days of the start of the course.

Course Roster (Final)KBEMS-E23-Final

This is a roster of the attendees for an initial certification course (EMR, EMT, AEMT, & Paramedic). This must be submitted to KBEMS within 30 days of the course completion date as part of the Course Summary application.

Continuing Education FormKBEMS-E10

This optional form has been created to assist you with tracking continuing education hours.

Course Roster (Continuing Education)KBEMS-E16

Roster to document class attendance for Continuing Education Courses.

TEI Level 1 Equipment ListKBEMS-E12-L1

Checklist of mandatory equipment needed to operate a TEI Level 1

TEI Level 2 Equipment ListKBEMS-E12-L2

Checklist of mandatory equipment needed to operate a TEI Level 2

TEI Level 3 Equipment ListKBEMS-E12-L3

Checklist of mandatory equipment needed to operate a TEI Level 3

TEI Level 4 Equipment ListKBEMS-E12-L4

Checklist of mandatory equipment needed to operate a TEI Level 4

TEI Pre-Inspection WorksheetKBEMS-E45

Level 1-4 EMS-TEIs Only

TEI Pre-Inspection WorksheetKBEMS-E46

CE Level EMS-TEIs Only

How to Upload Policies

Step by step instructions on how to upload policies to KEMSIS.

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.

EMR Skills Portfolio

This form is for the EMR Skill Portfolio preparatory competencies.

EMT Skill Portfolio

This form is for the EMT Skill Portfolio preparatory competencies.

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