We encourage anonymous reporting from any individual who encounters or recognizes a situation in which a safety event occurred while a patient was being cared for by the EMS (emergency medical services) system.
Please email all forms to email@example.com or fax to 814-337-0871.
Ambulance Service LicensureEmergency Medical Services Office (EMSO) License Renewal Application – Click Here. The PA Department of Health, Emergency Medical Services Office, licenses air and ground ambulances and certifies quick response services. The following lists identify agencies in the EMMCO West region that meet the minimum standards for licensure or certification.
- Listing of Licensed Ambulance Services
- Listing of Licensed Air Ambulance Services
- Listing of Recognized QRS Services
- Mailing Labels for Download
- Mailing List of Licensed or Recognized Services
EMS Vehicle Collision and/or Personnel Injury Report FormThe EMS regulations, §1005.10(e)(i) requires ambulance services to report, in a form or manner prescribed by the Department, to the appropriate regional EMS council an ambulance vehicle accident that is reportable under 75 Pa.C.S., and an accident or injury to an individual that occurs in the line of duty of the ambulance service that results in a fatality, or medical treatment at a medical treatment facility. This revised form has been adopted by the Pennsylvania Department of Health, EMS Office to meet the requirements of the regulations. Instructions for Completion of the EMS Vehicle Collision And/or Personnel Injury Report Form EMS Vehicle Collision and/or Personal Injury Report *Requires FREE Adobe Acrobat Reader
Adding or Updating EMSVO Rosters
EMS agencies needing to add practitioners to their EMSVO rosters need to do the following:
Provide documented proof of completion of a Pennsylvania Department of Health approved Emergency Vehicle Operator Course(EVOC)
- Copy of original course completion certificate OR
- Recorded on Provider Continuing Education Record in Pennsylvania Emergency Medical Services Registry System (EMSRS) OR
- EMS Education Institute Course Roster OR
- Approved EMS Agency Licensing Application Personnel Roster
Complete the Student Application located on the EMS Portal.
Current driver’s license, a clear copy must be submitted to Regional Council with EMS Provider certification application.
- If the provider has been convicted within the last 4 years prior to the date of application of driving under the influence of drugs or alcohol, a copy of the practitioner’s driving record must be submitted.
- If the provider has been convicted within the last 2 years prior to the date of application been convicted of reckless driving or had a driver’s license suspended due to use of drugs or alcohol or a moving traffic violation, a copy of the practitioner’s driving record must be submitted.
- Online EMS Certification Verification
- CCT Checklist from PA Bulletin 5
- IALS Checklist-PA Bulletin
- Certification by Endorsement
Regional EMS Services
- ALS Ambulance 09-01-2019
- BLS Ambulance 09-01-2019
- IALS Ambulance 09-01-2019
- ALS SQUAD 09-01-2019
- BLS SQUAD 09-01-2019
- CCT Ambulance 09-01-2019
- IALS Squad 09-01-2019
- QRS Agency 09-01-2019
- Air Ambulance 09-01-2019
- Reserve Ambulance Checklist 10/01/2019
- Station Checklist 10/01/2019
- Testing Portable & On Board Suction Units
- Form Modification of Vehicle Replacement
- Overview of the Ambulance Service Licensure Program
- SAMPLE Licensure Policies
- PSAP Reporting forms A & B
- List of Approved Emergency Vehicle Operator Courses July 1 2009
- Request for an Exception
- Application for VRSR 2008
- VRSR – General Administrative Guide March 2009
- VRSR – Vehicle and Machinery Rescue March 2009
- VRSR – Swiftwater Rescue and Flood Evacuation March 2009
- Epi Pen DOH Approved Process
- Epi Pen Reconciliation Form
- Epi Pen Personnel Roster
- Epi Pen Training Requirements
- Epi Pen Training Policy
- Memo on Reconciliation Requirements
- Medical Directors Agreement 10/22/15
- Sample ALS Authorization Form FY 2013