Applications and Forms

Loading...

iew privacy notification, file viewing information, and zip file download instructions.

Texas Department of State Health Services Regulatory Philosophy: The purpose of this philosophical statement of the Texas Department of State Health Services is to give guidance to the regulatory programs within the department on the ideal manner of conducting state business. 


 

QUICK LINKS

Online Application and License Search

EMS Personnel                         EMS Providers Trauma & Stroke Designation    

EMS Certification- Initial

EMS Provider Compliance Guidelines   

Regional Advisory Councils

EMS Certification- Renewal

EMS Patch Information Stroke Designation

EMS Coordinator/Instructor/Education Program Certification    

First Responder Organizations     Trauma Designation
Aditional Links

Helpful EMS Materials

Injury Prevention

Open Records

Complaint/Criminal History Forms

 

EMS CERTIFICATION/LICENSURE FORMS
Initial applications

EMS personnel: ECA, EMT-basic, EMT-I, EMT-P or LP

PDF        Read procedure            
FAST Pass- Fingerprint form PDF Fingerprinting FAQs
Inactive certification/licensure PDF Read procedure
Out-of-state reciprocity  PDF Read procedure

Apply Online

**UPGRADE ALERT**

IF YOU HOLD AN EMS CERTIFICATION AND WANT TO UPGRADE FOR CERTIFICATION AT A HIGHER LEVEL, YOU MUST SUBMIT THE INITIAL PAPER APPLICATIONUPGRADES IN CERTIFICATION CANNOT BE SUBMITTED ELECTRONICALLY AT THIS TIME.  TO ACCESS THE PAPER INITIAL EMS CERTIFICATION APPLICATION.

Supplemental Forms

ECA High School/GED Exemption- for candidates who meet volunteer criteria     PDF
Address/Name change PDF
Rule Exemption- Request exemption from EMS rules     PDF
Volunteer Sign-off form PDF
Wallet card replacement PDF
EMS Criminal History Pre-Screening PDF

 

EMS RECERTIFICATION/RELICENSURE FORMS
Renewal Applications

EMS personnel: ECA, EMT-basic, EMT-I, EMT-P or LP

PDF          Read procedure    
Inactive EMS certification/licensure PDF Read procedure
Volunteer-to-Paid Status Change- No longer exclusively a volunteer, you must pay cert fee PDF

Renew Online

Supplemental Forms and Documents

Downgrade Statement form- Apply for lower level of certification PDF
Skills Proficiency Form for Late Renewal PDF
Recertification options presention PowerPoint     PDF

 


EMS Complaints/Criminal History Forms
Click for more information on complaints and criminal history
Complaint Form PDF
Word  
FAST Pass- Fingerprint Form PDF   
Criminal History Documentation Guide PDF   
Community Supervision Form PDF   
Criminal History Form PDF   
Work History Form PDF   

Criminal History Report Form

  • This form is intended for EMS certificants/licensees to self-report an arrest, indictment, charge, conviction, deferred adjudication community supervision, and/or deferred disposition                 
PDF   

EMS Criminal History Pre-Screening

  • This form is intended for evaluating criminal history prior to taking an EMS course to determine eligibility for EMS certification
PDF   

 

To the Top


 

EMS COORDINATOR/INSTRUCTOR/EDUCATION PROGRAM FORMS
Initial and Renewal Applications
Initial coordinator, instructor and information operator instructor PDF    Process
Renewal coordinator, instructor and information operator instructor PDF Process
Educator Fee Exemption PDF
Education Program Applications

EMS Education Program Application (Initial and Renewal)

Word  

PDF

Continuing Education Program Application - Initial and Renewal  PDF

Request to offer a DSHS approved National Registry of EMT Transition Course(s)

Word PDF
EMS Education Manual and Skill sheets
EMS Education and Training Manual (for coordinators)- Zipped file Word format
Skills Criteria and Score Sheets- Basic Levels-
This document is not copyrighted- Zipped file
Word format
Skills Criteria and Score Sheets -Advanced Levels-
This document is not copyrighted- Zipped file
Word format
National Education Standards and Instructional Guidelines

Current release of National Education Standards and Instructional Guidelines all levels.

Note - On August 16, 2012, DSHS adopted the use of the National EMS Education Standards and Instructional Guidelines
replacing the use of DOT National Standard Curriculum.  Remember, Texas ECA  courses use the EMR Standards/Guidelines
with additional requirement in EMS rule; Texas Intermediate courses use the AEMT Standards/Guidelines with additional
requirements in EMS rule.

Supplemental Forms and Resource Documents 
Disability Accommodation Request-If you are taking the National Registry (NR) exam,
you must make an accommodation request to the NR office: www.nremt.org
Course Completion Roster for ECA or EMT candidates (For students who are not yet 18 years of age) Word  PDF
EMS Course Notification Word PDF


  

 

EMS PROVIDER GUIDELINES
You must contact your DSHS regional office before applying for a provider license. To find the nearest regional office, click here.      

The Clinical Laboratory Improvement Act (CLIA) of 1988 established licensing requirements for facilities (including EMS firms) performing lab tests. Even simple tests such as blood glucose testing and monitoring fall under the CLIA requirements. Fortunately, those simple tests that are commonly performed on EMS units qualify for a CLIA Certificate of Waiver. Effective September 1, 2004, EMS Providers will be responsible for securing and maintaining a current CLIA Certificate of Waiver. This applies to any firm using glucometers or other devices to test blood or other patient fluids.

Information    
Interim Policy 02-1 – Specialty Care Transport PDF
Surety Bond Form for EMS PDF


  

 

EMS PATCH INFORMATION
Patches with the Texas Department of Health name may still be worn.
Patches may be reproduced but may not be altered in any way    
Patch Vendors

Letter to Patch Vendors (06/29/2004)

Licensed Paramedic Patch Specifications
DSHS Patch Specifications- For larger image of each patch, click below.    
Licensed Paramedic Patch Emergency Care Attendant Patch
Emergency Medical Technician-Paramedic Patch     Emergency Medical Technician-Intermediate Patch    
Emergency Medical Technician-Basic Patch EMS Medical Director's Patch- DSHS non-sponsored patch    

To the Top


  

 

FIRST RESPONDER ORGANIZATIONS
Click here for FRO applications

Notification / Change

PDF Form     

FRO Administrator Information         

PDF Form

FRO Medical Director Information

PDF Form

FRO Personnel

PDF Form


 

HELPFUL EMS MATERIALS
Brochures and Documents
EMS and Trauma Systems Overview- Brochure     PDF
CCMP (Recertification Option 5) presention in PowerPoint PowerPoint     PDF    
Notice to Victims of Family Violence - English PDF
Notice to Victims of Family Violence - Spanish PDF
START Triage Student Manual Word format (zipped)
When Minutes Count: A Citizen's Guide to Medical Emergencies-
This EMS brochure features first aid tips for common medical emergencies
PDF
Dialysis Patient Triage Checklist- This form helps identify patients in need of acute dialysis treatment.     PDF
Guidelines for Field Triage of Injured Patients PDF
Websites and links
EMS Media Catalog
Leadership Guide to Quality Improvement in EMS
Looking for Out-of-Hospital DNR forms?
New Reporting Requirements for Bloodborne Pathogens
Bloodborne Pathogen Rules/Forms for Reporting
Handbook on Birth Registration
State Agency AED Placement

   


 

INJURY PREVENTION
Documents and Presentations
Overview of Injury in Texas and the Role of the EMS/Trauma Registry Report PDF     
Injury Prevention Curriculum Word format (zipped)    
The GETAC Texas Injury Prevention Plan PDF
GETAC Injury Prevention Committee - Project Starfish Word PDF

Links to EMSC Resources

Child Abuse Prevention and Safey Resources

Triage Presentation- (8,409 KB) Please be aware that this file is very large
and may take several minutes to an hour to complete downloading.

PowerPoint    

To the Top

 


 

REGIONAL ADVISORY COUNCIL DEVELOPMENT
Documents
Rule Interpretation: Regional Trauma Treatment Protocols as a component of the EMS/Trauma System Plan  PDF    
Texas Trauma System Power Point Presentation Self-extracting zip file    
EMS/Trauma System Plan: A Supplement to the Texas Trauma System Manual PDF
Regional needs assessment (HOTRAC) PDF
Facility Resource Capability Form (Coastal Bend RAC) (external site)
Systems Quality Concern Form (Coastal Bend RAC) (external site)
Affidavit Acknowledging Utilization of RAC Regional Protocols Regarding Patient Destination and Transport PDF

EMS and Trauma Care System Account and Emergency Medical Services, Trauma Facilities, and Trauma Care System Fund &
Designated Trauma Facility and Emergency Medical Services Account Documents

EMS/Trauma Care System Account- report to the 77th Legislature (2001 PDF
EMS/RAC Expenditure Report Form

(PDF) (Word)

EMS/County Expenditure Report Form (PDF) (Word)
Tobacco Expenditure Report Form

 

STROKE FACILITY DESIGNATION

COMPREHENSIVE (LEVEL I) AND PRIMARY (LEVEL II) FORMS
Complete Application for Comprehensive (Level I) and Primary (Level II) Designation     PDF       Word    

RESOURCE DOCUMENTS

Policy and Procedure- Facility with Conditional Certification as Primary Stroke Center and De-Certification with The Joint Commission, Det Norske Veritas (DNV), or Healthcare Facilities Accreditation Program (HFAP)

PDF
Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Stroke Facility Designation PDF

 

 
SUPPORT (LEVEL III) FORMS 
Complete Application for Support (Level III) Designation     PDF      Word    
RESOURCE DOCUMENTS
Stroke Facility Designation Process Level-III PDF
Stroke Designation Survey Process PDF
Support (Level III) Stroke Facility Designation Criteria
Guidance on Essential Criteria for Level III Stroke Facility Designation PDF

 


 

TRAUMA FACILITY DESIGNATION
COMPREHENSIVE (LEVEL I) & MAJOR (LEVEL II)
Complete Trauma Facility Designation Application     PDF     Word     

RESOURCE DOCUMENTS

Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Trauma Facility Designation

PDF

 

 
ADVANCED (LEVEL III)     
Complete Application for Level III Designation     PDF     Word   
Process for Level III Trauma Facility Designation Application PDF
Guidance on Essential Criteria for Level III Trauma Facility Designation PDF
Criteria Checklist for Level III Trauma Facility Designation PDF
Audit Filters for Level III Trauma Facility Designation PDF
Standards of Care for Level III Trauma Facility Designation  PDF

RESOURCE DOCUMENTS

Requirements for Trauma Facility Designation Surveyors PDF
Trauma Designation Survey Process PDF
Initial/Re-designation Level III Agenda Format  PDF
Trauma Designation Upgrade  PDF
Policy – Late Applications PDF
Frequently Asked Question Regarding Trauma PDF

Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Trauma Facility Designation

PDF

 

BASIC (LEVEL IV) TRAUMA FACILITY DESIGNATION
Complete Application for Level IV Designation  PDF     Word    
Process for Level IV Trauma Facility Designation Application PDF
Guidance on Essential Criteria for Level IV Trauma Facility Designation PDF
Criteria Checklist for Level IV Trauma Facility Designation PDF
Audit Filters for Level IV Trauma Facility Designation PDF
Standards of Care for Level IV Trauma Facility Designation PDF

RESOURCE DOCUMENTS

Requirements for Trauma Facility Designation Surveyors PDF
Trauma Designation Survey Process PDF
Initial/Re-designation Level IV Agenda Format PDF
Trauma Designation Upgrade PDF
Frequently Asked Question Regarding Trauma PDF
Policy – Late Applications PDF

Guidance for Change of Legal Owner of a Hospital Facility (CHOW) and/or Change in Physical Location of a Hospital Facility and/or Impact to Trauma Facility Designation

PDF

 


EMS/TRAUMA OPEN RECORDS
TRAUMA CENTER DESIGNATION
Designated Trauma Centers PDF
STROKE CENTER DESIGNATION
Designated Stroke Centers PDF
EMS rosters are provided for informational purposes only.
Do not use these rosters to verify the current status of a license - please use our live online search, or contact the board/program office. The rosters on this page are provided in PDF and Excel, a format that can be downloaded, saved and manipulated on your computer. Making changes to a downloaded file will not result in any changes to the posted rosters, which are stored on our secure web server. The rosters are updated infrequently (generally, on a quarterly basis), and each roster lists the date it was created.
EMS ADMINISTRATORS
EXCEL PDF
EMS CE PROGRAMS
EXCEL PDF
EMS EDUCATION PROGRAMS
EXCEL PDF
EMS FIRST RESPONDER ORGANIZATIONS
EXCEL PDF
EMS PROVIDERS AGENCIES
EXCEL PDF
EMS Providers listed with Medical Director
EXCEL

To the Top


Some files are listed in a self-extracting zip format <filename.exe>. These are compressed files that must be unzipped (uncompressed). The unzipped file is the one you will use. Select the file you wish to download by placing your pointer over the file name and double-click with your left mouse button. Save the file to a directory that you select. Open Windows File Manager or Windows Explorer. Go to the directory in which you placed the file. Find the file name that you saved. You must expand the contents of this file. Place your pointer over the file name and double-click with your left mouse button. This will open the file. Press the F5 function key on your keyboard. This will "refresh" your file listing. Your new file will now be listed. Your new file is ready for use!

Once the files have been uncompressed, these document files will be in one of the following formats.

  • .pdf (personal document file) which is viewable with the Adobe Acrobat Reader

  • .dbf (database) which will import into most database programs

  • .txt (delimited text) which will import into most spread sheet programs

  • .wpd (WordPerfect document) which is viewable with Wordperfect 6.1 or later or Word 97 or later

 


For more information contact your regional office.
Go to the regional map

,

  • Loading...
Last updated June 18, 2014