San Benito County, CA
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Application Forms
These are the forms that the EMS Agency requires for processing EMT Certification, Recertification and Paramedic Accreditation.
Emergency Medical Technician Basic (EMT-B) Certification and Re-Certification
- Initial Application Process
- Renewal Application Process
- EMT Application
- Skills Competency Verification Form (For Re-Certification Only)
Paramedic (EMT-P) Accreditation and Re-Accreditation
- Paramedic Application Form. Be sure to sign and date the Health & Safety Code Section 1798.200(c) affidavit on page 4 of the application.
Ambulance Application
Other Forms
- 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)]
- 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.
- Naloxone Administration Report – First Responders must complete and return this form to EMS within 24-hours of administering Naloxone.
- Epinephrine Administration Report – First Responders must complete and return this form to EMS within 24-hours of administering Epinephrine.
- 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 website.
Maddy (EMS) Fund
- EMSF Physician Certification Claim – This document is the cover sheet required to request reimbursement for Emergency Medical Services rendered by a physician in a hospital in San Benito County wherein no payment has been received from any source for the services being claimed and is paid. Maddy Funds SB476.
Automatic External Defibrillator Program Forms
- Public Access Defibrillator Program Implementation Guidelines
- 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 (PDF or Fillable PDF) - Use this form to report any incident that may occur outside of the ordinary. All submissions will be investigated promptly.
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