Free None - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7478 (05/04)

STATE OF WISCONSIN Chapter 110, 111, 112, 113, Wis. Admin. Code (608) 266-1568

FIRST RESPONDER/EMERGENCY MEDICAL TECHNICIAN APPLICATION ELECTRONIC ADDITION TO A ROSTER
This form is authorized under s. 146.50, Wis. Stats. and Chapters 110, 111, 112 and 113, Wis. Admin. Code. Completion of this form is mandatory for certification/licensure. Personally identifiable information requested on this form will only be used for licensure purposes. Provision of your social security number is required and is used by the Bureau of Local Health Support and EMS only as an identifier in the licensure database.

This form is to be used to electronically add an applicant who holds a current First Responder certificate or EMT license to your roster using the Emergency Medical Services System (EMSS). Once this applicant is added to your roster, send the completed material to the State EMS Office at the address below. INSTRUCTIONS: Type or print legibly. Complete all sections of this form and sign the application. Failure to complete all required sections of this form and attach the requested documentation will result in immediate removal of this applicant from the provider roster. RETURN COMPLETED FORM TO: DIVISION OF PUBLIC HEALTH BUREAU OF LOCAL HEALTH SUPPORT & EMS P.O. BOX 2659 MADISON, WI 53701-2659 Basic IV Provisional Intermediate (1985) MI Intermediate (1999) Former Name(s) Paramedic

License level that applies to this application (check one level only):
First Responder Last Name Mailing Address City Daytime Telephone Number WI EMT Number (required) State Zip Code County Birth Date (Month/Day/Year) E-mail Address Social Security Number (Required) Gender Male Expiration Date ( MM/DD/YYYY) Female Basic

APPLICANT INFORMATION
First Name

Other Telephone Number

CRIMINAL HISTORY ­ Failure to answer these questions will delay processing of your application.
The Fair Employment Act (sections 111.31-111.395, Wis. Stats.) prohibits employment discrimination on the basis of conviction or arrest record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or licensed activity. The information requested on this form is used to determine whether a certificate/license should be granted, approved with limitations or denied. The information you provide on this form may be verified against criminal information records. Failure to provide request information on this form will be considered a false statement on an application. Since your last application to the State EMS Office, have you been convicted of any felony or misdemeanor Yes No offense(s) in Wisconsin or in any other state OR do you have any misdemeanor or felony offense(s) pending against you at this time? If yes, list each offense below and provide the following information: copies of the police report or criminal complaint/information, judgment of conviction and sentence, verification of your compliance with all terms of each sentence, including chemical dependency assessments, if ordered by the court, and verification of your compliance/completion of probation or parole. Since your last application to State EMS Office, has your driver's license been suspended, revoked or withdrawn in Yes No Wisconsin or in any other state OR do you have current pending charges that may result in the suspension, revocation or withdrawal of your driver license? If yes, list each offense below and provide a current driver abstract obtained from the Department of Transportation (DOT) by calling (608) 261-2566*. List Arrest(s)/Conviction(s) (Attach additional sheets, if necessary) Date of Conviction Status

Applications will not be processed unless all required documentation is attached.

OVER

DPH 7478 (05/04) Page 2

APPLICANT CERTIFICATION
I certify that the above information is true and complete, that I meet the qualifications for certification/licensure under s.146.50, Wis. Stats. and Chapter HFS 110, 111, 112, 113, Wis. Admin. Code, at the level indicated on page 1 of this application. I certify that the copy of the CPR card and ACLS card, if required, is an accurate copy of that issued to me by a certified training agency.

SIGNATURE ­ Applicant

Date Signed Provider License Number

SERVICE AFFILIATION INFORMATION
Service Provider Affiliation

I certify that the above named applicant is affiliated with the service provider noted above at the FR/EMT level indicated on page 1 of this application and has been electronically added to my roster.

SIGNATURE ­Service Provider (responsible party)

Date Signed

SERVICE MEDICAL DIRECTOR
I certify that I have accepted the above named applicant for participation in an approved FR/EMT program under my direction and endorse this application at the FR/EMT level indicated on page 1.

SIGNATURE - Medical Director

Date Signed

Print or Type Medical Director's Name CHECK THE FOLLOWING TO MAKE SURE YOU ARE SUBMITTING A COMPLETE ELECTRONIC APPLICATION Have you updated any change of address in EMSS? Have you entered a current CPR (for the healthcare professional) expiration date into EMSS and retained the card? Have you entered a current ACLS expiration date into EMSS, if required, and retained the card? Is all required criminal history/DLA documentation attached to this application? Did the applicant, service director and medical director sign this application? Did you enclose a printout of the "EMT Roster Detail" page after saving this EMT to your roster? ELECTRONIC ADDITION TO ROSTER What is the license status of this applicant on your roster? This process is not complete until you have submitted all information to the State EMS Office. Yes Yes Yes Yes Yes Yes No No No No No No

*Only the Wisconsin Department of Transportation, Driver License Abstract will be accepted. If your offense(s) occurred while a resident of another state, contact that state for a Driver License Abstract. Do not send a copy of a driving record received from a local police department or other sources.