These are the forms that the EMS Agency requires for processing EMT Certification, Recertification and Paramedic Accreditation.

• Application for EMS Personnel - Use this form for all First Responder & EMT Certification, recertification and Paramedic accreditation purposes. Be sure to sign and date the Health & Safety Code Section 1798.200 affidavit on page 3 of the application.

• Live Scan Form - Use this form for Live Scan fingerprint submission. The form can be filled out on your computer and then printed. Please print 3 copies and take to the Live Scan operator. One copy stays with the Live Scan operator, one copy is for your records and the third copy should be submitted to the EMS Agency along with your Application

• Skills Competency Verification Form - A completed EMT-1 Skills Competency Verification Form is required to accompany an EMT-1 recertification application for those individuals who are either maintaining EMT-1 certification without a lapse or to renew EMT-1 certification with a lapse in certification less than one year.

• Change of Address Form -  “The EMT shall be responsible for notifying the certifying entity of her/his proper and current mailing address and shall notify the certifying entity in writing within thirty (30) calendar days of any and all changes of the mailing address, giving both the old and the new address, and EMT registry number.” [California Code of Regulations, Title 22, §100079(h)]

• EMS Continuing Education Provider Application - Use this form for applying to the EMS Agency to become designated as an approved EMS CE Provider..

Child Abuse / Neglect

The California Child Abuse and Neglect Act is contained in California Penal Code Section 11164 et. seq., "The intent and purpose of this article is to protect children from abuse and neglect. In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim."

• Form SS 8572 - Suspected Child Abuse Report Form

Elder Abuse / Neglect

California Welfare and Institutions Code (W&I), Sections 15600 – 15659.  "Any health practitioner shall make a report regarding known or suspected cases of abuse and neglect of elder and dependent adults."

• Form SOC 341 - California Department of Social Services Confidential Report - Report of Suspected Dependent Adult / Elder Abuse

Do Not Resuscitate Form

• Do Not Resuscitate (DNR) - The wording on these forms are not to be modified in any way except to include the required information of patient name, date signed by patient, surrogate’s relationship to patient, physician date signed, physician printed name and physician phone number. For more information about DNR orders, see the EMS Authority web site.

Maddy (EMS) Fund

• Emergency Medical Services Fund Certification Claim Cover Sheet - This claim form is for Emergency Medical Services rendered by a physician in a hospital in San Benito County and no payment has been received from any source for the services being claimed.

Automatic External Defibrillator Program Forms

• Notice of New Automatic External Defibrillator Program - Use this form to notify the EMS Agency about new Public Access Defibrillator Programs.

• Report of AED Use to the Local EMS Agency Whenever an AED is used as part of an approved Public Access Defibrillator Program or used by a Public Safety AED Service Provider, please use this form to report to the EMS Agency.

Unusual Occurrence Reporting

Unusual Occurrence Form

Use this form to report any incident that may occur outside of the ordinary. All submissions will be investigated promptly.