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Forms

Common Certification/Accreditation Forms. Please note the website certification and accreditation pages contain addtional information applicants should review to ensure a smooth credentialing experience.

Note on Application Documents: To ensure efficient, accountable processing, CVEMSA utilizes an online License Management System for all EMT and paramedic applications. There is no paper-based application process available. Applicants without computer access may contact EMS Agency staff to arrange an appointment to apply at the EMS Agency office using a staff computer. Appointments are subject to staff availability and must be pre-scheduled to ensure appropriate staff are present to provide support. CVEMSA does not have the ability to support drop-in unannounced counter service, but will arrange for staff to be available to assist if an appointment is requested. 

Forms:
 Live Scan form pdf For new EMT applicants or reinstatement applicants with a certificate lapse over one year only. Renewal applicants with a Live Scan on file do not need to complete this form or repeat the Live Scan process.

Live Scan locations Locations to bring the form for the Live Scan fingerprint process. 

EMT Certification of Individuals with Criminal Conviction History pdfImportant information for applicants with any conviction history. Applicants with a criminal background are encouraged to speak with Agency staff and/or legal counsel prior to applying for a Health Care license such as an EMT Certificate or local accreditation for paramedic license.

EMS Policy #2008: Certification and Accreditation pdfCVEMSA policy for administering the Agency credentialing program

EMS Policy #2009: EMT Certification pdf CVEMSA policy for EMT Certification 

Skills Competency Verification Formpdf Required for for EMTs renewing certification or reinstating lapsed certification. NOTE: This form is only valid if completed by an EMT, Paramedic or higher level license holder expressly authorized by an EMS provider agency, EMT or Paramedic Training Program or EMS Continuing Education Provider. 

Field Orientation Sign-off Formpdf Paramedic Accreditation Orientation Sign Off. Used to document the completion of orientation to provider agency, Base Hospital orientation, Communications Center orientation and field training orientation. Required for initial Paramedic Accreditation applicants

ALS Accreditation Field Evaluation Formpdf Evaluation form documenting five ALS clinical contacts observed by a CVEMSA approved Preceptor/Evaluator. Required for initial Paramedic Applicants

Please contact EMS Agency staff with any questions or concerns regarding the forms or credentialing process or to arrange an appointment at (707) 565-6501 or via email at: This email address is being protected from spambots. You need JavaScript enabled to view it.

Contact Us

Coastal Valleys EMS Agency
195 Concourse Blvd., Suite B
Santa Rosa, CA 95403
(707) 565-6501
This email address is being protected from spambots. You need JavaScript enabled to view it.

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