Emergency Medical System (EMS) - Forms

Nevada Online Grant Management System ROCS

The State of Nevada completed the transition to an online grant management system, ROCS. In order to be awarded a grant from the Nevada EMS Program, your organization and users must be registered in the ROCS system. Follow the below ROCS subrecipient instruction manual and complete the organization registration and user registration forms if you and your organization is not already registered in ROCS.

• ROCS Subrecipient Training Manual
• ROCS Organization Registration Form
• ROCS User Account Request Form

State EMS Training Grant

• Grant Training Flyer
• Training Grant Application
• Grant Training Budget Worksheet

Nevada Emergency Medical Services for Children (EMSC) Grant

• EMSC Grant Opportunities - Pediatric Training
• EMSC Application
• EMSC Grant Budget Worksheet

EMS Provider New Expiration Dates Effective September 1, 2023

Effective September 1, 2023, the Nevada EMS Program is implementing new expiration dates for Nevada EMS certifications and licensure. With guidance from the Nevada EMS Advisory Committee in conjunction with a survey that was sent to EMS agency directors, new expiration dates will correspond with each individual provider’s date of birth not to exceed a two year period. This will not impact current providers expiration dates until providers complete and are issued an initial, renewal or reciprocal EMS application on or after September 1, 2023. Any new provider applicants applying on or after September 1, 2023, will automatically receive an expiration date corresponding with their date of birth. Please contact the State of Nevada EMS office at HealthEMS@health.nv.gov with any questions.

Certification and Licensing Forms

The Nevada EMS Program is requiring EMS Providers to complete all applications for certification and licensure through the State Online Application Portal (SOAP) at: https://nevada.imagetrendlicense.com/portal#/login 

To renew your Nevada EMS certification, you will need to provide evidence that you have completed the requirements for renewal. You must upload your CPR card, continuing education units (CEUs) and a skills verification to your online renewal application. Paramedics must upload their current ACLS, PALS, and ITLS or PHTLS cards in the same fashion.  If you are licensed as an Ambulance Attendant, it will also be necessary for you to renew your license when you renew your certification.

CURRENT FEE SCHEDULE

• Certification renewal - $24.00
• Certification and Attendant License renewal - $34.00
• Instructor Endorsement Renewal is an additional - $15.00
• Certification Late Renewal fee - $50.00
• Attendant License Late Renewal fee - $50.00

• EMS Application Guide
• Skills Verification Form *online applications*
• Physician Statement *online applications*
• Instructor Hours Tracking Log
• Provider Paid Fingerprint Request Form and Instructions
• Agency Paid Fingerprint Request Form and Instructions
  • Law Enforcement Fingerprinting Sites
  • Private Fingerprinting Vendor Sites

Reciprocal Certification for Out of State Providers

• Reciprocity Instructions
• Verification of Out of State EMS Certification/License Form

Nevada Shared Radio System Updates

• Nevada Shared Radio System Updates Memo
• Radio Grant Assistance Program
  • Radio System Grant Contacts Map

Agency Permit Applications and Forms

The State of Nevada EMS Office requires all permit applications to be submitted online using the State Online Application Portal at:https://nevada.imagetrendlicense.com/lms/public/portal#/login. If are a new service seeking a EMS permit in Nevada, email our office at: healthems@health.nv.gov and our office will work with your agency to set up your service account in our ImageTrend licensing system.

• Initial Permit Application Documents for Online Applications
  • Letter of Explanation
  • Statement of Volunteer Ambulance Service
  • Statement of Financial Worth
• Permit Renewal Application Documents for Online Applications
  • Ambulance Service Agreement Form
  • Hospital Agreement Form
  • Mechanical Safety Form
  • Verification of Current Protocols
  • Variance Review Form
  • Physician Director Agreement Form
• CLIA Disclosure of Ownership

Clinical Laboratory Improvement Amendments (CLIA)

• CLIA Website
• Application
• Instructions for Completing Disclosure of Ownership and Control-Form 1513
• Example Agency Policy
• Example Glucometer Testing Program
• Example Glucometer Testing of Staff
• Example Quality Control Log
• Example Temperature Log
• EMS Glucose Testing Checklist
• Fingerstick Devices-Technical Bulletin

NEVCORD Radio Channel

• NEVCORD Approval Letter