Documents, Forms and Meeting Minutes

Important information about the documents provided here:

Original signatures are required on all licensing documents.
The EMS office does not accept faxed or scanned/emailed versions. Licensing applications must be printed and mailed.
Altering these documents in any way is prohibited.
These documents are updated regularly. To make sure you have the most recent version, download a new application each time you need one rather than keeping copies on file.
If you have questions, or would like a paper copy mailed to you, email the EMS office.

V ermont Statewide EMS Protocols - 2020 Version (Effective May 15, 2020)

Photo/Video Release Forms

COVID-19 Provisional License Applications

Provisional EMR License Application - For OEC-Certified Personnel

Provisional EMS License Application - For EMS Students with a Provisional NREMT Certification

Provisionally Reinstated EMS License Application - For EMS Practitioners Who Retired Since June 30, 2018

Provisionally Reinstated EMS License Application - For EMS Practitioners Who Retired in 2016 or 2017

Apply to Take a Practical Exam

Use these forms to apply for a Vermont EMR or EMT practical examination. These forms also serve as license applications, so you do not need to submit additional paperwork after completing the licensing requirements. AEMT and Paramedic candidates register for a practical exam through their course instructor.

If you are a Registered Nurse or Physician Assistant, you can apply to challenge the exam and obtain a Vermont license at any level without taking a course. Challenging the exam will not result in a National Registry certification.

RN & PA Challenge Application

Apply for an Initial EMS Personnel License

Use these forms to apply for an initial Vermont EMS license AFTER you have obtained a National Registry of EMTs certification at that level:

Renew an EMS Personnel License - 2016 NCCP Standard

Use one of the following EMS License Renewal Applications if your license is due to expire after 2018:

Critical Care Paramedic Endorsement

Paramedics who hold an approved Critical Care Paramedic certification may apply for a CCP endorsement if they are affiliated with a Paramedic level agency that has been approved to function at the CCP level and have the approval of that agency's District Medical Advisor.

Critical Care Endorsement Application Form

EMS Agency Administration

EMS Rule (effective January 1, 2018)
Vermont Statewide EMS Protocols - 2020 Version (Effective May 15, 2020)
Vermont Statewide EMS Protocols - 2018 Version (Valid through September 30, 2020)
Course Tuition Voucher/Course Enrollment Form
Vermont EMS District Map
Agency License Level Change Application: Use this form to obtain approval from the Vermont Board of Health to change your EMS agency's license level.
Temporary Ambulance Vehicle License Application: Use this form if your EMS agency has acquired a new ambulance. Upon approval, it will serve as the vehicle’s license to operate until an inspection can be conducted.
First Response Agency Recommended Equipment Lists
- EMR
- EMT
- AEMT
- Paramedic
Vermont Ambulance Inspection Form: This is the form used by Vermont ambulance inspectors. It is based on the National Equipment List for Ambulances and modified to adhere to Vermont’s Statewide EMS Protocols.
GSA Ambulance Design Specifications (KKK-1822F): This document describes the required specifications for all Vermont licensed ambulances. See GSA Change Notices for new requirements issued by the GSA since publication of this document
SIREN Downtime Run Form: Use this form to record EMS incidents in the event that the SIREN system is not available.
Vermont EMS Stroke Alert Screening Tool
Rule Waiver Request - General: Use this form if you would like to obtain a waiver of any section of the EMS Rule.
Rule Waiver Request - Research: Use this form if, as part of a research project, you would like to obtain a waiver of any section of the EMS Rule.
Agency License Application - Sample Operational Letter of Agreement: This is a template for an Operational Letter of Agreement, which is a requirement for obtaining an EMS agency license.
Agency License Application - Sample Public Notice & Instructions: This is a template for posting a public notice in local newspapers when applying for a new EMS agency license.
Ryan White CARE Act Provision: This document provides guidelines for exposure to infectious diseases.

Instructor/Coordinator Resources

EMS Course Approval Application: Use this form if you are an instructor who is applying for approval to hold a Vermont EMS course for initial state licensure.
AEMT Testing and Licensing Information: This document guides AEMT instructors on course completion requirements, preparing students for National AEMT testing and applying for Vermont AEMT licensure.
EMS Student Manual: This manual provides important information to students in initial EMS courses about course logistics and prepares them for examinations and licensure.
Course Enrollment Form/Tuition Voucher Request: Instructors must have students complete this form and return it to the EMS Office within the first week of the course
Instructor/Coordinator License Application: Use this form to apply for a Vermont Instructor/Coordinator license
Peer Mentor Evaluation Form - Presentation (I/C Bridge Course): Use this form if you are an existing Instructor/Coordinator who is mentoring/evaluating a student in an I/C Bridge Course. A separate form must be completed for each presentation the I/C Bridge candidate leads.
Peer Mentor Evaluation Form - Comprehensive (I/C Bridge Course): Use this form if you are an existing Instructor/Coordinator who is mentoring/evaluating a student in an I/C Bridge Course. This form is to be completed as an overall assessment of the candidate after he or she has delivered all presentations.
Instructor/Coordinator Administrative Guide: This handbook describes the administrative aspects of being a Vermont EMS Instructor/Coordinator, including course and exam site approval, registering students for exams and renewing an I/C license.
Vermont EMS Rapid Sequence Intubation Course Manual: This manual outlines the RSI education and CQI program requirements for both RSI paramedics and RSI assistants.

Practical Exam Site Resources

Independent Practical Exam Site Approval Application: Use this form to obtain approval to hold a practical exam site that is in addition to the regularly scheduled sites of the Standardized Exam Schedule.
Exam Coordinator Guide: This manual provides comprehensive information to help exam coordinators plan and execute a successful EMS practical exam site.
National Registry Practical Exam Score Sheets - EMR, EMT, AEMT and Paramedic: These are the practical exam scoring sheets used at all Vermont EMS practical exam sites.

Become a HEARTSafe Community

Refer to the documents in this section to apply to become a Heart Safe Community:

Please send completed HEARTSafe applications to the Vermont EMS Office by emailing vtems@vermont.gov or by mailing to Vermont EMS, PO Box 70, Burlington 05402-0070.

Public Access Defibrillation (PAD)

PAD Registration Form: Use this form to notify the Vermont Department of Health that a public access defibrillator has been placed at your location.
PAD Legislation: This is the text of legislation that created the Public Access Defibrillation program and provides instructions for registering defibrillators with the Vermont Department of Health.

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Meeting Minutes

EMS Advisory Committee

Monthly EMS Leadership Conference Calls

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