Wisconsin EMS Scope of Practice Change Request Form

This form is used to propose a change in the skills, medications, or procedures allowed under the Wisconsin EMS Scope of Practice.

1. Provide the following requested information. *This question is required.

First Name

Last Name

Email Address

2. Is this request being submitted on behalf of a service provider? *This question is required.

3. Provide the following information for the service provider you are requesting on behalf of. *This question is required.

Service Name

License Level

3. Provide the following information for the service director of the service provider you are requesting on behalf of. *This question is required.

First Name

Last Name

3. Provide the following information for the service medical director of the service provider you are requesting on behalf of. *This question is required.

First Name

Last Name

Email Address

Phone Number

3. I attest that my service medical director supports this request. *This question is required.

Please provide the information requested below describing the proposed change to scope of practice you wish to submit.

3. Describe the change to scope of practice you are proposing. *This question is required.

4. Describe the therapeutic benefit to patient care and expected clinical outcomes this proposed change to scope of practice would offer. *This question is required.

5. What intended clinical applications are you proposing for use? Include at minimum the conditions, complaints, patient age, and other pertinent parameters of use. *This question is required.

6. What level of certification or licensure will be required to implement this new skill, medication, or procedure? *This question is required.

Emergency Medical Responder
Emergency Medical Technician
Advanced Emergency Medical Technician
Intermediate
Paramedic
Paramedic with Critical Care Endorsement

7. Is the skill identified in the National EMS Scope of Practice Model for the proposed level of certification or licensure? *This question is required.

8. Describe the training needed to implement this change to scope of practice. Include the estimated time needed for initial training on the new skill, medication, or procedure and recommended time needed for continuing education. *This question is required.

9. Describe the anticipated cost in dollars to service providers of additional hours of education and equipment needed to administer the new skill, medication, or procedure. *This question is required.

10. Describe how the new skill, medication, or procedure has been utilized in other healthcare settings (prehospital and in-hospital). *This question is required.

11. Summarize current evidence in support of and against implementation of the proposed change to scope of practice, including benefits and improved effectiveness of patient care. *This question is required.

12. Have there been any known issues associated with the new skill, medication, or procedure in other healthcare settings or in EMS in other states? If so, describe these. *This question is required.

13. Describe resources needed to improve practice of and quality assurance for the proposed new skill, medication, or procedure. *This question is required.

14. Describe potential metrics measurable at a state level that could be used to gauge success of the proposed new skill, medication, or procedure. *This question is required.

15. Upload copies of articles, references, or other evidence used in preparation for this request to change scope of practice. *This question is required.

File: {{filename}} delete

16. I attest that I do not have any actual or perceived conflicts of interest in submitting this proposed change to the Wisconsin EMS scope of practice. *This question is required.

17. Explain the conflict of interest. *This question is required.

Resources to assist in the completion of this form

Wisconsin Administrative Code and State Statue
Wisconsin Administrative Code Chapter DHS 110
Wisconsin Statute Chapter 256

Wisconsin and National EMS Curricula
Wisconsin EMS Training Curricula
National EMS Education Standards 2021

Wisconsin EMS Standards and Procedures resources
Wisconsin EMS Standards and Procedures 2014
Wisconsin EMS Skills and Procedures 2021

Wisconsin and National Scope of Practice
National EMS Scope of Practice Model
2023 Scope of Practice for all levels, P-00451 (PDF)
2023 Scope of Practice PowerPoint (PPT)

Wisconsin EMS Protocols
2023 Wisconsin EMS Protocols
National Model EMS Clinical Guidelines 2023