• Ambulance Inspection Form
• Inspection Statute and Rules related to inspection
• Ambulance Service Inspection Manual - Updated 2015

Annual Medical Director Forms

• Medical Direction Statement
• Medical Direction Statement and Variance Renewal (license renewal)
• Annual Medical Director Skill Verification
• Sample Training Log - to be included with Annual Medical Director Skill Verification and Signed Rosters
• Medical Director Skill Assessment Verification-Designee

For use by ambulance services to provide information to the EMSRB when a medical direction change occurs.

Completed forms should be sent to the EMSRB - EMS Specialist assigned to your ambulance service.

• Medical Director Change Information Form

Please use this form when replacing or re-chassis of an ambulance in your fleet. If you are adding an additional ambulance to your fleet please use the Additional Ambulance Application in the e-licensing system.

The Ambulance Replacement Form should be e-mailed or faxed to the EMSRB EMS Specialist assigned to your ambulance service.

• Replacement Vehicles and New Vehicles applications should be completed in the eLicense system.  Upon completion, you will receive a notification authorizing use of the vehicle until an inspection can be completed.

• PSA Summary Approval Application

• BLS Medication Variance Application
• ALS Hardship Variance Application - To be completed by Advanced Life Support (ALS) ambulance services applying for or renewing a Ambulance Staffing Hardship Variance in accordance with Minnesota Statutes, section 144E.101, Subdivision 7 (f).

• Complete Ambulance Service License Application (for NEW Licenses only)

• Trauma Triage and Transport Flowchart
• Deviation Request Form
• Trauma Template Guidleines

• BLS Patient Care Guidelines Template
• BLS Patient Care Guidelines Instructions
• Sample BLS Narcan Administration and Education Guidelines
• Sample ALS Pediatric Guidelines
• Sample BLS Pediatric Guidelines
• Special Events and Mass Gathering Matrix

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