Forms & Protocols

Memos from the Medical Director

Diltiazem memo making it suggested but optional (PDF - 565.8 KB)

Covid-19 Policy per OSF Saint Francis Medical Center

Peoria Area EMS Forms

Peoria Area EMS logo All providers in the PAEMS System must go through the process of system entry before providing emergency medical care with any member agency.

Once your form(s) and required documentation are processed; you and your member agency will receive a letter allowing you to function in the PAEMS System. You may not function until you receive the system entry letter.

System Entry, Non Transport PCR, Roster, and Misc. Forms
PAEMS System Entry / Agency Enrollment Form

Agency Roster - Electronic

Agency Roster - Paper

Non Transport PCR Policy and Procedure (PDF - 117.8 KB)

Non Transport PCR Fillable PDF (PDF - 1010.2 KB)

Non Transport Fax Cover Sheet (PDF - 451.9 KB)

PAEMS/ OSF Pharmacy restock sheet (PDF - 147.6 KB)

Change of Address Form 2023 (PDF - 260.5 KB)

IDPH Request For Reciprocity Form

IDPH Administrative Code Section 515.610 EMT Reciprocity
PAEMS Forms + Agency QA/QI Reporting Forms
PAEMS Refusal Forms Printable (PDF - 81.6 KB)

Updated 2022 QAQI Manual (PDF - 609.2 KB)

QAQI Report to be filed with the EMS office (PDF - 194.0 KB)

PAEMS Incident Report Form to be submitted to EMS office

Cardiac Arrest Registry to be submitted to EMS office

Airway Management Data Collection to be submitted to EMS office

Glucometer Log Sheet

Region 2 EMS Stroke Assessment Tool

Communicable Disease Incident Form to be submitted to EMS office (DOCX - 13.0 KB)

Emergency Childbirth Record

Multi Casualty Release (School Bus Form) (PDF - 464.8 KB)
Lead Instructor Education Forms
Continuing Education Training Program Application (PDF - 417.9 KB)

Course Roster (DOC - 317.0 KB)

Student Enrollment 2023 (PDF - 258.4 KB)

CE Eval Sheet Sign In Sheets.xls (XLS - 324.0 KB)

Testing & Licensure

IDPH EMT Testing Instructions
Apply and Pay - State of Illinois EMT Exam

Apply and Pay - NREMT Exam

If you have not received a renewal notification 60 days out from your renewal please check your license status and address on www.IDPH/EMS
Testing for initial licenses are done through the NREMT. Please refer to them for information on scheduling and results.

IDPH License Renewal Process
Appropriate documentation of continuing education, meeting the continuing education requirements, and following the PAEMS re-licensure policy are the responsibilities of each provider. This responsibility cannot be transferred to your agency, training officers or another individual. In other words, if you do not get the required paperwork submitted on time, you will be responsible for any late fees and you could lose your license. Each individual provider is responsible to know when their license expires.

You should receive your license renewal notice from IDPH two or three months in advance of the expiration of your license.

1. When you receive the notice, you must:

a. Sign the Child Support Statement (PDF - 131.2 KB)

b. Enter your Social Security Number, Drivers License Number, and Date of Birth on the Child Support Statement.

c. Verify the name and address printed on the form. Print any changes on the lines provided.

d. Make a copy of the form for your records.

e. Return the original form to:

Peoria Area EMS System Office

530 N.E. Glen Oak Avenue

Peoria, IL 61637

f. Start gathering all your documentation of continuing education together for submission to the EMS Department.

2. If you have not received your license renewal notice by two months prior to your license expiration, obtain from the web site a blank form. Print your license expiration date under Due Date, your nine digit license number under ID Number, your legal name, address, city, state and zip code in the space on the upper left portion of the form and complete as in step 1 above.

3. At least 60 days prior to your expiration date, submit the following information to the Peoria Area EMS System Office:

a. Appropriate Recertification Checklist (PDF - 167.8 KB)

b. A copy of your child support statement (preferred).

c. Documentation supporting appropriate number of continuing education hours (24 hours for FR-D, 60 hours for EMT-B, 80 hours for EMT-I, 100 hours for EMT-P & 100 hours for PHRN) using the PAEMS Continuing Education Form signed by the Training Officer of your agency.

d. Copy of your current license.

e. Copies of CPR cards covering the entire previous licensure period. Each CPR card represents 3 hours of CE to a maximum of 6 hours in four years (3 hours every two years). Cards must be American Heart Association Healthcare Provider Course (including AED), or equivalent.

f. Copies of any required ITLS/PHTLS, AHA ACLS or PEPP/AHA PALS cards. (EMT-Intermediates or Paramedics)

(Include certificates for ACLS, BTLS/ PHTLS, PEPP indicating number of hours, date, location, etc. for hourly credit.)

Within three weeks of submitting the above information to the EMS office you should receive notification of re-licensure approval from the EMS office. Included with this notice will be a copy of the electronic transaction card submitted to IDPH. Please check name, license, level of license, expiration date and address for correctness. Notify the EMS office immediately if any errors are found. Notify the EMS office if you do not receive this notice.

When you receive your license, check the license for accurate name, level of license and expiration date. If within 30 days of submitting your re-licensure paperwork to the EMS office, you have not received your new license, contact the EMS office immediately.

If you do not re-license by the expiration date on your license, you may re-license within 60 days of your license expiration date by submitting all the above documentation to the EMS office and a check made payable to the Illinois Department of Public Health for FIFTY DOLLARS.

Any EMT whose license has expired for a period of more than 60 days will not be re-licensed, and must complete all aspects of the initial training program required for licensure, pay the fees required for initial licensure and pass the State exam.

The EMS office requests you submit all required information to the EMS office sixty days prior to the expiration of your license. Submitting your re-licensure information to the Peoria Area EMS System Office less than 30 days prior to the expiration of your license may result in late submission of your re-licensure request and the requirement for you to pay the fifty-dollar late fee to the Illinois Department of Public Health. The Illinois Department of Public Health requires providers functioning on an ambulance to have a current license. You should submit your re-licensure information in a timely manner to allow for processing.

The EMS office is formalizing the re-licensure process to provide you with notification of what is happening with your license after you apply for renewal. In order to make this process work, we need your cooperation in submitting the appropriate documentation in a timely manner.

If you have any questions, please contact the Peoria Area EMS System Office at (309) 655-2113.
Peoria Area EMS System Initial & Relicensure Forms
Child Support Statement (PDF - 131.2 KB)

Continuing Education Report (XLS - 104.0 KB)

Peoria Area EMS System Recertification Checklist (PDF - 167.8 KB)

State EMS License Request Form (PDF - 59.3 KB)