Vol. 32 Iss. 21 - June 13, 2016

Chapter 31

REGISTRAR'S NOTICE: Forms used in administering the following regulation have been filed by the Department of Health. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.

Title of Regulation: 12VAC5-31. Virginia Emergency Medical Services Regulations.

Agency Contact: Michael D. Berg, Manager, Regulation and Compliance, 1041 Technology Park Drive, Glen Allen, VA 23509-4500, email

FORMS (12VAC5-31)

EMT Clinical Training Summary Record, EMS.TR.05 (rev. 8/2012)

Training Program Complaint Form, EMS.TR.30 (rev. 1/2011)

Course Approval Request, EMS.TR.01 (rev. 4/2016)

CTS Payment Request Form, EMS.TR.CTS.001 (rev. 6/2012)

Psychomotor Examination Payment Request Form, EMS.TR.CTS.001 (rev. 3/2013)

EMS Variance/Exemption Application for Providers, EMS 6036 (rev. 6/2011)

EMS Variance/Exemption Application for Agencies, EMS 6037 (rev. 6/2011)

Course Summary Form, EMS.TR.03 (rev. 6/2011)

EMS Certification Application, Form A (undated)

EMS Training Program Enrollment Form, Form E (undated)

EMS Continuing Education Registration Card (undated)

Application for EMS Agency License (rev. 8/2012)

Application for EMS Vehicle Permit and Instructions (rev. 8/2012)

Application for EMS Agency License (undated)

Application for EMS Vehicle Permit with Instructions, EMS 6022 (rev. 8/2015)

Complaint Report Form (rev. 11/2010)

Operational Medical Director Agreement (rev. 8/2012)

ALS-Coordinator Application, EMS.TR.31 (rev. 11/2011)

Emergency Medical Services Medical Record (rev. 6/2010)

BLS Course Student Information Package, EMS.TR.09 (rev. 5/2012)

ALS Course Student Information Package, EMS.TR.10 (rev. 5/2012)

BLS Individual Age, Clinical and Skill Performance Verification, EMS.TR.33 (rev. 1/2011)

Student Permission Form for BLS Students Less than 18 Years Old, EMS.TR.07 (rev. 7/2011)

Physician Assistant & Nurse Practitioner Paramedic Challenge Competency Summary, EMS.TR.37 (rev. 2/2012)

Program Accreditation Application, Instructions and Self Study - Paramedic (rev, 7/2012)

Program Accreditation Application, Instructions and Self Study - Intermediate (rev. 7/2012)

Alternative Site Application for EMS Programs in Virginia (rev. 7/2012)

Rescue Squad Assistance Fund Grant Application, Office of Emergency Services (

EMS System Initiative Award Application, Office of Emergency Services (

OEMS Grant Program Memorandum of Agreement (rev. 1/2012)

VA.R. Doc. No. R16-4726; Filed May 19, 2016, 2:39 p.m.