Forms

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

Guidance for ground agency & vehicle inspections.

Air Ambulance Inspection FormKBEMS-OPS6

Checklist of all required items required for Air Ambulances.

Air Ambulance Service Inspection FormKBEMS-OPS5

Checklist of all required items required for Air Ambulance Services.

Cease Operations NoticeKBEMS-A2

Legal notice if a service is going 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 Ambulance

Class I BLS Equipment ListKBEMS-OPS13

Checklist of required items for Class I BLS Ambulance

Class II BLS Equipment ListKBEMS-OPS14

Checklist of required items for Class II BLS Ambulance

Class III Adult Critical Care Equipment ListKBEMS-OPS15

Checklist of required items for Class III Adult Critical Care ambulance.

Class III Neonatal Specialty Care Equipment ListKBEMS-OPS16

Checklist of required items for Class III Neonatal Specialty Care ambulance.

Class III Pediatric Specialty Care Equipment ListKBEMS-OPS17

Checklist of required items for Class III Pediatric Specialty Care ambulance.

Class IV ALS Equipment ListKBEMS-OPS18

Checklist of required items for Class IV ALS ambulance.

Class IV BLS Equipment ListKBEMS-OPS19

Checklist of required items for Class IV BLS ambulance.

Class VI ALS Equipment ListKBEMS-OPS20

Checklist of required items for Class VI ALS ambulance.

Class VI BLS Equipment ListKBEMS-OPS21

Checklist of required items for Class VI BLS ambulance.

Class VIII ALS Equipment ListKBEMS-OPS22

Checklist of required items for Class VIII ALS ambulance.

Class VIII BLS Equipment ListKBEMS-OPS23

Checklist of required items for Class VIII BLS ambulance.

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.

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

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

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.

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-23-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.

Comprehensive Skill EvaluationKBEMS-E25-EMR

EMR Comprehensive Skill Evaluation Report

Comprehensive Skill EvaluationKBEMS-E25-EMT

EMT Comprehensive Skill Evaluation Report

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.

Paramedic Course CompletionKBEMS-E19

This form is used to verify successful course completion for Paramedic Students.

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

EMS-TEI Pre-Inspection Worksheet (Level 1-4)

TEI Pre-Inspection WorksheetKBEMS-E46

EMS-TEI Pre-Inspection Worksheet (CE Only)

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.