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About IDPH

Instructions for Completing the 2023 EMS Week Years of Service Certificate Request Form

Download 2023 EMS Week Years of Service Certificate Request Form
  1. Ensure names are spelled correctly, the level of licensure is correct and the number of years of service is correct and included for each entry (five-year increments only – 5, 10, 15, 20, 25 etc.).
  2. Use only the 2023 EMS Week Years of Service Certificate Request Form (submissions using any other format will be returned).
  3. Do not hand-write your submissions.
  4. The form must be submitted in Word form by e-mail as an attachment.
  5. Faxes and scanned copies (PDF) will not be accepted.
  6. Do not type in all caps.
  7. If you get to the last box and need to continue-click on the Tab key to insert another row.
  8. The EMS 2023 Template EXAMPLE displays two examples.
    1. The green example is correct. The NAME column must be in First Name / Last Name format. License level must be spelled out as shown below.
    2. The red example is incorrect. Do not include abbreviations. The years of service must be in FIVE- year-number only, format.
  9. Email completed forms to: DPH.emsweek@illinois.gov.

Information on the certificate will be printed exactly as it is submitted. It will not be altered in any way.

Type the license levels in the manner shown below:

Emergency Medical Responder (formerly known as First Responder, or FR Defibrillator)
Emergency Medical Technician (formerly known as Basic)
Emergency Medical Technician - Intermediate
Advanced- Emergency Medical Technician
Paramedic
Pre-Hospital Registered Nurse
Emergency Medical Dispatcher
Emergency Communications Registered Nurse
Lead Instructor
Trauma Nurse Specialist