1425 South "D" Street
San Bernardino, CA 92415-0060
(909) 388-5823
(909) 388-5825  FAX
Mapquest: http://mapq.st/xIffkN

EMS Administrator
Tom Lynch

Medical Director
Reza Vaezazizi, MD

Governing Board
Josie Gonzales, Chair
Robert A. Lovingood
Janice Rutherford
James Ramos
Gary Ovitt

Hours of Operation:
Certification/Accreditation Hours
8:00 am to 4:00 pm, Monday-Friday

Business Hours
8:00 am to 5:00 pm, Monday-Friday

2013 Holidays - OFFICE CLOSED:
January 1 & 21, February 18,
May 27, July 4, September 2,
October 14, November 11, 28 & 29,
December 24, 25 & 31

Mission Statement

To ensure an effective system of quality patient care and coordinated emergency medical response by planning, implementing and evaluating an effective emergency medical services system including fire department and public ambulances, prehospital providers and hospitals, including specialty care hospitals, such as trauma and cardiac care hospitals.
Home > Forms & Applications

Forms/Applications

Forms & Applications

Release Date
EMT Livescan Form2/16/2012
Speciality and Optional Scope Program Approval Application8/9/2012
Flight Nurse (FN) Application for Authorization1/30/2012
EMR Livescan Form2/16/2012
NSRC Application for Approval as an ICEMA Designated Stroke Center11/2/2011
EMT Course Record5/10/2012
Personnel Authorized to Verify Skills Competency3/1/2012
CSAM Evaluation Form9/29/2011
STEMI Center Application for Designation7/11/2011
Duplicate Card Application1/17/2013
Paramedic Training Program Approval Application Packet1/31/2012
EMT Training Program Approval Packet8/6/2012
EMR/FR Application for Certification1/30/2012
MICN Training Program Approval Packet9/10/2012
MICN Course Record9/10/2012
Special Event Ambulance Providers - SE Treatment Log Form8/9/2012
EMT Supplemental CE Form1/30/2012
ICEMA Hospital Dashboard List of Users Form1/18/2013
ICEMA DNR Form8/9/2012
EMT Skills Verification Form10/13/2011
Change of Address or Employer Reporting Form3/1/2012
Coroners Worksheet of Death - EMS Report of Death Protocol Reference #120109/13/2012
Advanced EMT Application for Recertification / Reciprocity2/27/2013
EMT Application for Initial Certification2/27/2013
Monthly Continuing Education Class Log Report Form3/1/2012
A-EMT Course Record5/10/2012
Drug Shortage Waiver Request Form5/16/2013
MICN / MICN-A Certification Form5/2/2013
EMS CE Provider Application for Approval1/30/2012
Emergency Medical Responder (EMR) Course Record5/12/2012
EMS MISS Toughbook Damaged, Lost or Stolen Equipment Report Form8/9/2012
Fire Line Paramedic Deployment Notification Form8/9/2012
Quarterly Declaration2/1/2011
CALIF Approved POLST Form4/1/2011
Continuing Education Class Roster Form5/15/2012
EMT-P Continuous Accreditation Reverification Renewal Form for those Expiring after March 31, 20132/19/2013
Advanced EMT Application for Initial Certification2/27/2013
EMT Application for Recertification / Reciprocity2/27/2013
ALS Provider Agency Changes in Personnel Quarterly Report Form1/30/2012
HPP Reimbursement Training1/15/2013

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