Forms & Protocols

Education Forms

Illinois Department of Public Health Forms

Testing and Initial Licensure

  • Education Program Students

  • Under Section 515.530(b) of the Emergency Medical Services and Trauma Center Code [77 Ill. Adm. Code 515.530(b)], Emergency Medical Technicians (EMT) candidates have the choice of taking either the State of Illinois examination or the National Registry of Emergency Medical Technicians (NREMT) examination.

    After completion of the Education Program, the Student will register for the testing process with staff at the Program Office.

    The State of Illinois Licensure Exam is a computer based test.

    If you are asking for a Volunteer License Fee Waiver, the application must be submitted and approved before signing up for the testing process.

    Volunteer License Fee Waiver

    Emergency Medical Services (EMS) Systems Military Licensure Request

    This form shall be completed by military medics seeking licensure as an Emergency Medical Technician (EMT) in the state of Illinois. Requests for licensure of medics are determined on a case-by-case basis.

    Attach the following items to the completed application:

    • Training course curriculum
    • Course completion certificate(s)
    • Documentation of clinical experience
    • Letter of verification of documentation from a military educator
    • Current CPR card

    Military Licensure Request

    EMT Reciprocity

    If you have been trained by an emergency medical services (EMS) system in Illinois and have taken the National Registry exam, you do not need to apply for reciprocity. The EMS system coordinator for the system where you were trained needs to submit the necessary documentation to the attention of the Licensure Section. Reciprocity is only for those who have not received training in Illinois.

    In order to obtain Illinois reciprocity:

    • Complete Part I of the EMT Reciprocity Application.
    • Attach photocopies of your EMT certificate or license and current American Heart Association Healthcare Provider Cardiopulmonary Resuscitation (CPR) card or equivalent.
    • Provide a letter from the EMS medical director indicating that you are in good standing and up-to-date with continuing education hours if you currently participate in an EMS system under an EMS medical director. If you cannot obtain a letter of recommendation, you will need to request a waiver as described in item 4.
    • If you have not functioned as an EMT or under the direction of an EMS medical director, include a letter with your signature stating that you have never worked as an EMT or under an EMS medical director and request that the letter of recommendation be waived. Also, if you are requesting a waiver, you will need to provide photocopies of all continuing education you have completed during your current license/certification period.
    • Complete Part III and Part IV of the application. This information is required. Application will not be processed if incomplete and/or requested documents are not provided. Other applicable forms are available at www.idph.state.il.us.

    EMT Reciprocity Application

Re-licensure

  • Renewal Process

  • On-Line Renewal and Payment Can Be Made At .

    This request for information is only the first part of the renewal process. Renew on-line or return this completed form, with the appropriate fee, to the address provided below. Proof of your continuing education hours MUST be submitted to your EMS System Coordinator or Trauma Nurse Specialist Course Coordinator (whichever applicable) for review and approval.
    If you are an independent, this form and proof of continuing education hours MUST be submitted to the address below.

    Applicant must complete the Renewal Notice / Child Support / Personal History Statement and submit to OSF Northern Region EMS.

    Renewal Notice/Child Support/Personal History Statement

    If you are asking for a Volunteer License Fee Waiver, the application must be submitted with re-licensure paperwork.

    Volunteer License Fee Waiver

    Independent Renewal

    This form shall be completed by an individual EMS provider denied relicensure by an EMS system/EMS medical director or individuals not affiliated with or functioning in an Illinois approved EMS system. Independent license renewals shall be processed by the Illinois Department of Public Health.

    Independent Renewal

    Extension Request 

    Request for Duplicate License Certificate

Agency System Entry

  • Contact Information Agency

  • System Entry Agencies wishing to enter the OSF Northern Region EMS System should contact:

    Susan Fagan
    OSF Northern Region EMS Director
    OSF Northern Illinois EMS office
    (815) 395-5254

Provider System Entry

  • Application Information

  • Providers from Illinois who received their training in Region 1

    Applicant must complete and submit the OSF Northern Region EMS Provider System Entry Application (PDF - 98.4 KB) .

    • Provider System Entry Application
    • Current State of Illinois License
    • Driver's License or State-issued Photo ID
    • Letter of Agency Affiliation
    • Letter of Good Standing from Current EMS System (ILS/ALS only)
    • Current CPR Certification
    • Current ACLS Certification (ILS/ALS only)
    • Current ITLS or PHTLS Certification (ILS/ALS only)
    • Current PALS or PEEP Certification (ILS/ALS only)

    Providers from Illinois who received their training outside of Region1.

    Applicant must complete and submit the OSF Northern Region EMS Provider System Entry Application (PDF - 98.4 KB) .

    • Provider System Entry Application
    • Current State of Illinois License
    • Driver's License or State-issued Photo ID
    • Letter of Agency Affiliation
    • Letter of Good Standing from Current EMS System (ILS/ALS only)
    • Current CPR Certification
    • Current ACLS Certification (ILS/ALS only)
    • Current ITLS or PHTLS Certification (ILS/ALS only)
    • Current PALS or PEEP Certification (ILS/ALS only)

    *If individual has never had or is not current in ACLS – PALS – or PHTLS they will have 3 months to gain this certification after granted entry to the OSF NREMS System.

    Applicant will be required to pass a Skills Validation and Region 1 SMO exam.

    Applicant may be required to meet with the OSF NREMS Medical Director.

    Providers from outside of the state of Illinois.

    Providers must have a State of Illinois license, if not, they must complete State of Illinois Reciprocity first.

    Applicant must complete and submit the OSF Northern Region EMS Provider System Entry Application (PDF - 98.4 KB) .

    • Provider System Entry Application
    • Current State of Illinois License
    • Driver's License or State-issued Photo ID
    • Letter of Agency Affiliation
    • Letter of Good Standing from Current EMS System (ILS/ALS only)
    • Current CPR Certification
    • Current ACLS Certification (ILS/ALS only)
    • Current ITLS or PHTLS Certification (ILS/ALS only)
    • Current PALS or PEEP Certification (ILS/ALS only)

    *The individual will need to apply to and received an Illinois License at the level they have been trained prior to being accepted into the OSF NREMS System.

    *If individual has never had or is not current in ACLS – PALS – or PHTLS they will have 3 months to gain this certification after granted entry to the OSF NREMS System.

    Applicant will be required to pass a Skills Validation and Region 1 SMO exam.

    Applicant may be required to meet with the OSF NREMS Medical Director.

System Modification

  • Modify / Amend an Approved EMS Plan

  • To modify / amend an currently approved EMS system plan, the System Modification Form must be completed by the agency.

    Forms must be typed in PDF file, printed, signed and submitted to OSF Northern Region EMS.

    System Modification Form

  • Electric Patient Care Report (ePCR)

  • ePCR / Data Reporting

    OSF Northern Region EMS provides electric Patient Care Report (ePCR) solution to all of its system agencies. This solutions is called LifeQuest LEADERS.

    LifeQuest Leaders Illinois

    Submissions

    OSF Northern Region EMS is required by state statute to submit patient care data to the State of Illinois

    OSF Northern Region EMS Agencies are required to provide OSF Northern Region EMS ePCR data in a format that we can use to send to the state.

    OSF Northern Region EMS Agencies who choose to not utilize our ePCR solution must submit their ePCR data directly to the State of Illinois - Department of Public Health.

    National EMS Information System v2.2. The Illinois Department of Public Health is in the process of implementing NEMSIS v3.0.

    NEMSIS.org