Banner Image - Paramedics and Firestations Banner Image - Arrowhead Regional Medical Center and Loma Linda University Medical Center Banner Image – Emergency Medical Service Banner Image - Helicopter Rescue Banner Image – Loma Linda University Medical Center Helicopter Banner Image - Great American Shakeout Drill Banner Image - Ambulance at a Fire Banner Image – Airplane Accident Rescue Banner Image - Firefighters at Accident Scene Banner Image – Firefighter at Apartment Fire Banner Image - Boyscout Training with Helicopter Crew Banner Image - Mercy Air Rescue Banner Image – Winter Rescue Banner Image - Training Exercise Banner Image – Training Exercise Banner Image - Mercy Air Loading Patient into Helicopter Banner Image - Helicopter on Ground Loading Patient Banner Image – Highway Car Accident Banner Image - Highway Car Accident Banner Image – Mercy Air Helicopter Banner Image - Paramedics with Gurney Banner Image - Patient with Bloody Leg Banner Image – Red Cross Banner Image – Swift Water Rescue Banner Image – H-82 Flying Banner Image – Two Helicopter Rescue Banner Image – Blue Helicopter Rescue

1425 South "D" Street
San Bernardino, CA 92415-0060
(909) 388-5823
(909) 388-5825  FAX

(909) 388-5819
7:30 am to 4:00 pm*

Help Desk Support
ePCR-Credentialing-Patient Registry

Hospital HUB Help Desk

EMS Administrator
Tom Lynch

Medical Director

Reza Vaezazizi, MD

Governing Board
Robert A. Lovingood
Janice Rutherford
Dawn Rowe

Curt Hagman, Chairman

Josie Gonzales, Vice Chair

Business Operating Hours:
Monday-Friday 7:30 am to 4:30 pm*


*Excluding Holidays:

October 14,

November 11, 28, 29,
December 24, 25 & 31, 2019

Mission Statement

To ensure an effective system of quality patient care and coordinated emergency medical response by planning, implementing and evaluation an effective emergency medical services (EMS) system including fire departments, public ambulances, prehospital providers, hospitals, and specialty hospitals, such as trauma, stroke and cardiac care hospitals.


Release Date
AEMT Course Record5/10/2012
AEMT Skills Verification Form1/1/2007
AEMT Training Program Approval Packet2/9/2015
ALS Provider Agency Changes in Personnel Quarterly Report Form1/30/2012
Automated External Defibrillator (AED) Annual Usage Report Form - Public Safety7/1/2015
Automated External Defibrillator (AED) Site Notification Form8/6/2018
Automated External Defibrillator (AED) Use Notification Form7/1/2015
California Department of Public Health (CDPH) Hospital Emergency Program Flexibility Form for Temporary Permission9/26/2014
Change of Address or Employer Reporting Form3/1/2012
Continuing Education Class Log Monthly Report Form3/1/2012
Continuing Education Class Roster Form1/8/2015
Coroners Worksheet of Death - EMS Report of Death Protocol Reference #120109/13/2012
CQI FORM001 - Radio Communication Failure Notification6/1/2011
CQI FORM002 - Radio Communication Failure Investigation6/1/2011
CQI FORM003 - Paramedic Field Care Audit6/1/2011
CQI FORM004 - MICN Chart Audit6/1/2011
CQI FORM005 - Quality Improvement Log6/1/2011
CQI FORM006 - MICN Tape Evaluations Summary12/1/2011
CQI FORM007 - Quarterly Report6/1/2011
CQI FORM008 - Unusual Occurrence Confidential Case Review Request1/18/2018
CQI FORM009 - Confidential Case Review Evaluation6/1/2011
CQI FORM011 - Exceptional Performance Report6/1/2011
CQI FORM012 - Annual Report6/1/2011
CSAM Evaluation Form9/29/2011
DNR Do Not Resuscitate Form - Prehospital EMS Providers Official State Document1/1/2009
Drug Shortage Waiver Request Form5/16/2013
Duplicate Card Application1/17/2013
EMD Center Application9/24/2015
EMS Aircraft - Provision of Medical Control Permit Application5/24/2017
EMS Continuing Education Provider Approval Application (ICEMA Reference #3020)1/22/2019
EMT / AEMT Supplemental CE Form9/11/2014
EMT Course Record10/2/2015
EMT Skills Verification Form7/1/2017
EMT Training Program Approval Packet6/9/2017
EMT-P Course Completion Record7/15/2019
EMT-P Training Program Approval Packet3/30/2016
Fireline Paramedic - Deployment Notification Form9/27/2018
Hospital Hub and/or Specialty Registry - Request for Access to View ePCRs10/4/2016
Live Scan Locations in Inyo County4/29/2014
Live Scan Locations in Mono County8/2/2011
Live Scan Locations in San Bernardino County4/22/2019
Live Scan Request Form - Advanced Emergency Medical Technician (AEMT) Certification2/22/2016
Live Scan Request Form - Emergency Medical Technician (EMT) Certification2/16/2016
MICN Course Record9/10/2012
MICN Training Program Approval Packet9/10/2012
Personnel Authorized to Verify Skills Competency Request Form5/12/2015
Police Dog Transport Form12/27/2018
POLST Form - Physician Orders for Life-Sustaining Treatment (EMSA #111B)1/1/2016
Provision of Medical Control - Information Form (for New Providers only)6/8/2016
Provision of Medical Control - Information Update Form6/8/2016
Public Safety AED Service Provider Application (ICEMA Reference #16060)1/22/2019
Public Safety First Aid and CPR Training Program Approval Application (ICEMA Reference #3050)1/22/2019
Public Safety Optional Skills Course Approval Application (ICEMA Reference #3060)1/22/2019
Quarterly Declaration8/8/2013
Resource Request: Medical and Health FIELD to OA8/11/2011
Special Event Ambulance Providers - SE Treatment Log Form8/9/2012
Specialty and Optional Scope Program Approval Application (ICEMA Reference #6060 and #6110)1/22/2019
Submersion Incident Report Form SIRF (For Reporting all Drowning or Near Drowning Incidents in San Bernardino County)9/17/2013
Suspicious Injury Report - Cal OES 2-920 Confidential Document12/27/2018
Tactical Casualty Care Course Approval Application (ICEMA Reference #3070)1/22/2019
Training Program and Continuing Education FY Annual Report Form2/5/2017

ICEMA Forms & Applications are in Adobe Acrobat PDF format.
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