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Facilities Planning Board - Application for Exemption Change of
Licensure - PDF
Our mission is to protect and promote the lives of Illinois consumers. Apprenticeship Application Under JAC- PDF
Lead Training Course Application - PDF - Instructions
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Service Improvement Form - Fillable PDF
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Accredited - PDF, Asbestos Training Course Instructor Application - PDF, Asbestos Training Course Provider
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PDF, Affidavit of No Employees - PDF
Please allow 2-4 business days for your license to post in our systems and your license status to update. and patient care in emergent and non-emergent settings. Trauma Nurse Specialist Course Coordinators (TNSCC) Testing Application Submission
Complaint Form - PDF
Hospice Administrative Staff Changes - PDF
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Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Hospice
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IDPH Administrative Code on EMT Licensure, Frequently Asked Questions Transition to National Registry Testing, IDPH Administrative Code on License Renewals, IDPH Change of Address & License Renewal Brochure, Region 11 EMS Medical Directors Consortium Memos, Mobile Integrated Healthcare Community Paramedic (MIH-CP). qY]X~3|?tPb]GX6|prD c\ptw@=)=VytzwM0 Home Health
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Agency Medicare Certification - PDF
A person currently licensed as an EMT, Intermediate, or Paramedic may only use their EMS license in 1st payout on 1st payroll check. PROVIDING LIFE SAVINGS SOLUTIONS SINCE 2009. Emergency Department Approved for Pediatrics (EDAP) Physician Waiver - Fillable PDF
Vision Rescreening Worksheet -
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Birth Record Files of a Deceased Infant, Application for Search of - Fillable PDF*
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Agency Branch Questionnaire - Fillable PDF*
Citizenship or Lawful Presence of an Alien. If you already have an account, log in. Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Foreign Nurse Application - PDF
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Assessor, Application - PDF - Instructions
Updating information online? \(pMU\z8pNs0*I(lf`H.x\FJ:~7aXP&H}RF^N4oa5y_[8- ][Z\/fm}s^Xoh7PRUn_JpU{uWIV*g2Y
this must be processed with the IDPH EMS Division directly by contacting them at (217)785-2080. UCIA Background Check Form
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Name/Address Change _____ Name . Military Personnel Application - PDF
Application for Retired - PDF
Irrigation Employee, Application for Registration for - PDF
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Instrument Dispenser Inactive Status Request Form, Hearing
Trauma Nurse Specialist (TNS) Examination Application, End Stage Renal
In observance of our nation's birthday, the Will County Office Building will be closed on Wednesday, July 4. Instrument Dispenser License Application Form, Hearing
Instructions
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Initial Licensure IDPH Administrative Code on EMT Licensure 2020 Transition to National Registry Testing (NREMT) IDPH Memo - July 2019 IDPH Board. Emergency Medical Services (EMS) Systems Licensing. 26 0 obj Application for Exemption from Certificate of Need Review and Permit
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Child Support Statement: HWms8b_-F%olePoflYuK.:*,nut! J0Lq;g! License, Application for Examination for, Plumber's License,
Structural Pest Control Certificate of
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Lead Contractor Application
Address Change. Emergency Department Approved for Pediatrics (EDAP) Nurse Practitioner Waiver - Fillable PDF
- Partnership - PDF
Personal History Statement: Have you ever been convicted or plead guilty of any felony offense? Vision Conservation Annual
Health Agency - Hospice Add or Remove Geographic Service Areas - PDF
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Submit copies of acceptable legal documents that verify the name change. xref
Instrument Dispenser License Application Form - PDF
EMS - Service Information. Application, Apprentice, Plumber's
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Facility Medicare Certification - PDF
Lead Training Course Notification Form - PDF
Springfield: 217-52 4-DoIT (217-524-3648) Chicago: 312-81 4-DoIT (312-814-3648) Technical Support Week Days (8A-5P, Monday-Friday) Contact the IDPH Helpdesk at 866-220-5247 or via email at DPH.Helpdesk@illinois.gov for Portal access and web-based application support. Water Well Construction Report - Fillable PDF*
Lead Risk Questionnaire, Childhood - En Espaol - En franais - PDF
Waiver Application - PDF
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Warning: You don't need to pay a separate company to change your address. Agency Add or Removes Services, Hospice Residence Initial/Renewal Application, Irrigation Contractor, Application for Registration for, Contractor's Test Certificate Lawn Sprinkler System, Irrigation Contractor Application Child Support Certification, Plumbing Contractor Registration Online Renewals, Irrigation Employee, Notice of Cancellation of Employment Registered, Irrigation Employee, Application for Registration for, Lawn Sprinkler System, Contractor's Test Certificate, Communicable Diseases Laboratory Test Requisition, Request for Respiratory/Influenza Testing, Lead Abatement/Mitigation Project, Notice of Commencement, Lead Assessment Form, Public Health Nurse Home, Lead Program Contact Record and Order Form, Lead Contractor Application
Printed by Authority of the State of Illinois P.O.#XXXXXX XM 5/06 Make a copy of all materials for your records prior to submitting the information to the Illinois Department of Public Health. About Us Back; Stakeholders Relations; Services . endobj Instructions
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Explanation of Technician Examinations - PDF
Dialysis Medicare Certification, End Stage Renal Dialysis Medicare Certification, Freestanding Emergency Center (FEC) Initial Licensure Application, Freestanding Emergency Center (FEC) Renewal Licensure Application, Project Submission Form for Freestanding Emergency Center, Health
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Adhere to the state guidelines of the IDPH licensure scope of practice. Intended Mother Form - PDF
EMS System Application Instruction Guide
Nursing Education
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Under the menu, go to Desktops or Apps, click on Details next to your choice and then select Add to Favorites. Home
Division of EMS and Highway Safety's on-line licensing site. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[0.0 0.0 792.0 612.0]/Type/Page>> Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. 0000040410 00000 n
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How do I renew my EMT license if I am affiliated with an Illinois EMS system? The Alabama Department of Public Health will verify an applicant's immigration status or naturalized/derived citizenship status using the SAVE Program effective August 1, 2016. Request for Duplicate License Certificate - Fillable PDF
Illinois Emergency Medical Systems (EMS) license enclosed License #_____ I have attached my written request to the EMS medical director for inactive status. Lead Supervisor, Inspector, Risk
The Department also licenses stretcher vans, which must meet a defined set of safety feature requirements. 0000072995 00000 n
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IDPH licenses Emergency Medical Services provider agencies and their transport and non-transport vehicles to ensure compliance with equipment and staffing requirements, along with minimum build standards as adopted by the state and enforced through an inspection process. 0000002109 00000 n
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Medicare Certification - PDF
Reciprocity with the City of Chicago, Application for -
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Facility Information Change Form - Fillable PDF*
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No If yes, contact IDPH, Division of Highway Safety at 217-785-2080 and request a personal history review packet. Dental Examination Waiver Form - PDFEn Espaol - PDF, Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of Involuntary Transfer or, Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form - En Espaol - Fillable PDF*, Alternate Rural Staffing and Response Authorization Request - Fillable PDF
Pregnancy Termination Renewal Licensure - Fillable PDF*
Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with . 0000048066 00000 n
Applicant Information Last Name: First Name: MI: Home Mailing Address: City: State: Zip Code: Area Code and Phone Number: Email Address: License, permit, certification or registration will be mailed when eligibility has been established. Instrument Dispenser License Correction Form - PDF, [New Combined Home Health, Home Services, Home Nursing and Placement Agency Initial Application is now available. Home Health
Application Licensure - Fillable PDF*
Plumber's License,
<>/Border[0 0 0]/H/N/Rect[290 335.28 492.875 325.28]/Subtype/Link/Type/Annot/URI(http://www.dph.illinois.gov/topics-services/emergency-preparedness-response/ems/licensing)>> <>/Border[0 0 0]/H/N/Rect[26 166.811 228.875 156.811]/Subtype/Link/Type/Annot/URI(http://www.dph.illinois.gov/topics-services/emergency-preparedness-response/ems/licensing)>> Vision Examination Report (V-4) -
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The most important duties and responsibilities you'll want to include in a job description are: Preventing, combating and extinguishing fires with the goal of protecting . 0000044047 00000 n
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Emergency Medical Systems Extension Application - PDF
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Lead Program Contact Record and Order Form - PDF
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Lead Risk Evaluation and Blood Lead Testing Guidelines - PDF
Multiple Hospice Location Questionnaire - PDF
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Much of the Illinois EMS licensing process can be accomplished online, using the links and forms available on this page. The Board primarily utilizes email for communication with the licensee. Injury and Illness Report - PDF. endobj Health Facilities Planning Board - Application
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Physician's Statement Form - PDF, Trauma Nurse Specialist (TNS) Examination Application - Fillable PDF
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Pediatric Lead Poisoning High-Risk ZIP Code Areas - En Espaol - PDF
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Facility Information Change Form - Fillable PDF*
Scholarship Program Application - PDF, School Physical -- Certificate of Child Health Examination Form, Integrated Pest Management Forms (See Integrated Pest Management)
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Gestational Surrogate Form - PDF
Cancellation of Employment/Supervision of Apprentice, Plumbing Contractor Application for Registration or Renewal, Allied Health Care Professional
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application, Commercial - PDF -
Requirements, Health Facilities Planning Board - Application
Home
Contractor Application - PDF -
Water Well Construction Report Instructions - PDF
Which name do I submit for licensure? Accredited, Asbestos Training Course Instructor Application, Asbestos Training Course Provider
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FAQ for IAC 131, 132, 139 and The Iowa EMS Provider Scope-of-Practice Sept 2019 2020 Rule Changes Webinar Recording Iowa Administrative Code 131 Webinar Iowa Administrative Code 132 Webinar
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This section provides guidance . for Permit - PDF, Audiogram Form
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endobj There is also a collection of 2.3 million modern eBooks that may be borrowed by anyone with a free archive.org account. EMS System Application Instruction Guide Independent EMS License Renewal Request Form - PDF Reasonable Accommodation Request for Examinees with Disabilities - Fillable PDF Renewal Notice - PDF Request for Duplicate License Certificate - Fillable PDF Stretcher Van Inspection Form - Fillable PDF Trauma Nurse Specialist (TNS) Examination Application Matrix 4A - UL Assembly Ratings - Fillable PDF*
In April 2015 the National HighwayTransportation Safety Administration reviewed Iowa's EMS system. Reasonable Accommodation Request for Examinees with Disabilities - Fillable PDF
Insurance, Structural Pest Control Technician
Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. 0000026686 00000 n
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Matrix 4E - Fire, Smoke, Fire/Smoke Damper - Fillable PDF*
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You may complete your renewal online at the website listed on the form. Workers Compensation Opt-Out Form - PDF, Portable X-ray Medicare Certification - PDF
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Employment Type: Full time Shift: Description: We are offering a $1,000 Sign On Bonus to all new hired EMT's. Bonus is payable in 2 installments of $500 each. Matrix 4D - Project Cost and Fee Verification - Fillable PDF*
IDPH EMS LICENSING BROCHURE for INDEPENDENTS For more information regarding relicensure in the Silver Cross EMS System, please contact Marilyn MacBlane, EMS Operations Coordinator at 815-300-2900 for assistance. <]>>
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Facility Information Change Form - Fillable PDF*, Application for Registration of Continuing Education - PDF
xb``g``a eP30p40! Change your address Attach documents to your license File a complaint Look up a list of licensees File a Complaint Make a complaint online. 2020 Rule Changes FAQ FAQ on the implementation of the September 2020 rule changes in Chapter 131, 132 and 139 as well as changes to provider scope-of-practice. Nursing Student Application - PDF
Insurance - PDF
Behavioral Risk Factor Surveillance System, Pregnancy Risk Assessment Monitoring System, Head/Spinal Cord and Violent Injury Registry (HSVI), EMS Dispatch Agency Certification Application, EMS Dispatch Agency Recertification Application, EMS Alternate Rural Staffing Authorization Request, EMS Ambulance Staffing Waiver Application, EMS Non-Transport Inspection Form Provider, EMS Non-Transport Application for Existing Transport Provider, Grant Accountability and Transparency (GATA). Lead
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