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AMR Federal Emergency Response Team and Incident Management Team Application
(Please type or print. It is recommended that you complete this form electronically. Sections will expand automatically as you type.)
Thank you for expressing interest in joining our Federal EMS Team either as an Emergency Response Team (ERT) member or Incident Management Team (IMT) member. ERT members are usually non-leadership positions who are deployed to the Forward Operating Base (FOB) during disasters. They can be EMTs, paramedics, PBS, dispatchers, mechanics, IT, etc. IMT members usually function in leadership roles at the FOB or our National Command Center (NATCOM). They require advanced training in the Incident Command System (ICS) and serve on the EMS ICS General Staff or Command Staff. They must also be proficient in knowledge of the National Incident Management System (NIMS) as well as the National Preparedness System (NPS). This form can be used for both ERT and IMT applicants. The final decision will be made by OEM leadership.
Primary Work Address (Street, apt. #)
Other Phone or Pager
Home Address (Street, apt. #)
Emergency Contact Phone Number
Emergency Contact Email Address
AMR Rural Metro Other (Please specify):
AMR Region (for AMR and Rural Metro use only)
Current Job Title/Position
Employee ID #
Name of Manager
Name of Human Resources Representative
Name of Education/Training Specialist or Manager
I am applying for: Emergency Response Team (ERT) Incident Management Team (IMT) Both ERT & IMT
Desired position within ERT: (check all that apply)
Paramedic – Ground Ambulance
Paramedic – Critical Care
Paramedic – Fixed Location Support
Emergency Medical Technician (EMT)
EMT – Ground Ambulance
EMT – Fixed Location Support
Advanced Emergency Medical Technician
Emergency Medical Responder (EMR)
Air Medical Transport Paramedic
Air Medical Transport RN
Air Medical Transport Physician
Air Medical Transport Manager
Air Medical Transport Mechanic
Air Medical Transport Pilot (rotorcraft)
Air Medical Transport Pilot (fixed-wing)
Air Medical Evacuation Team
Public Information Officer
Fleet & Support Services
EMS Strike Team
EMS Task Force
Incident Management Team – Field
Incident Management Team – EOC
EMS Incident Management Team
Registered Nurse (Emergency)
Registered Nurse Advanced Practice
Physician - Emergency Medicine
Physician - Other
Fire Officer I/II
Fire Officer III/IV
Urban Search & Rescue (US&R)
Logistics Support Personnel
Medical Supply Coordinator
Federal ERT / IMT Applicant - The following documents/credentials and questions are requirements of Emergency Medical Services personnel in order to participate in the Federal EMS Response Team. However, not all certifications are required for every position. Submit this form along with copies of your certifications, licenses, and supporting documents to the AMR Office of Emergency Management (OEM).
Valid State EMS Certification (For multiple states, use state of primary practice. Provide a copy.)
Valid State Driver’s License (list driver’s license number)
Emergency Vehicle Operations Course (EVOC) or equivalent, e.g., CEVO, DDC4 (Provide a copy)
Date Course Completed
FEMA Training Certifications (Check all that apply. Provide a copy of each certification.)
IS-100.b: Introduction to Incident Command System
IS-701.a: NIMS Multiagency Coordination System (MACS) course (required for IMT applicants)
IS-200.b: ICS for Single Resources and Initial Action Incidents
IS-703.a: NIMS Resource Management (required for IMT)
ICS 300: Intermediate ICS for Expanding Incidents
(required for IMT applicants)
IS-800.b: National Response Framework, An Introduction
ICS 400: Advanced ICS for Command and General Staff
IS-809: Emergency Support Function (ESF) #9 – Search and Rescue
IS-700.a: National Incident Management System (NIMS) An Introduction
Other: (Provide a copy)
The Practice and Implementation of EMAC certification (online course provided at
http://www.emacweb.orgwww.emacweb.org. Provide a copy of course completion certificate.)
Strike Team Leader or Task Force Leader Training (This training is highly recommended but not required. Provide a copy.)
Hepatitis B Vaccine Series (3 injections), or
Hepatitis B Signed Declination Statement (Provide a copy of completed series or signed declination)
Date series completed or date of Signed Declination Statement
Hepatitis Records On File At (be specific)
Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) capabilities (Provide a copy)
How many years of experience do you have as an EMS provider (non-supervisor)?
Number of Years
How many years of supervisory experience do you have in a health setting or EMS setting?
HazMat Training (Check all that apply. Awareness Level is the minimum standard required certification. Provide a copy of each certification.)
NFPA Training Certifications (Check all that apply. Applicable only to members who are enrolling as Firefighters. Provide a copy of each certification.)
NFPA 1001: Standard for Fire Fighter Professional Qualifications
NFPA 472: Standard for Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents (OSHA 1910.120 Hazmat Operations or equivalent)
NFPA 1002: Standard for Fire Apparatus Driver/Operator Professional Qualifications
NFPA 1021: Standard for Fire Officer Professional Qualifications
NFPA 1981: Standard on Open-Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services.
NFPA 1041: Standard for Fire Service Instructor Professional Qualifications.
Bloodborne Pathogens and Airborne Pathogens training per OSHA 29 CFR 1910.1030 or equivalent. Provide a copy of course completion certification.
Weapons of Mass Destruction (WMD) Awareness Training (AWR 160) This training is provided by The Department of Homeland Security and is required to be refreshed every 5 years.
Air Medical Evacuation Team Training Course (AMR provided course. Applicable only to members who are enrolling as Air Medical Evacuation Team members. Provide a copy of completed course certification.)
Airframe and Powerplant Mechanic Certification (Provide a copy)
Valid Pilot’s License or Certification (Provide a copy)
Military or Public Use Pilot
How many years of supervisory, management, or administrative experience do you have in air medical transport service?
Respiratory Therapist - Valid State Certification (For multiple states, use state of primary practice. Provide a copy)
Registered Nurse - Valid State Licensing (For multiple states, use state of primary practice. Provide a copy.)
Clinical Nurse Specialist (CNS)
Nurse Anesthetist (CRNA)
Nurse Practitioner (NP)
Psychiatric/Mental Health Nurse (PMH)
Public Health Nurse (PHN)
Physician Assistants - Valid National Commission Certification (for multiple states, use state of primary practice. Provide a copy.)
Physicians - Valid State License (For multiple states, use state of primary practice. Provide a copy)
Physicians - Valid Drug Enforcement Administration License (Provide a copy)
Board Certification or board-eligible in emergency medicine (or comparable specialty). Provide a copy.
Do you actively provide medical direction to an EMS service?
List all additional certifications and/or licenses not listed elsewhere. (Provide a copy of each certification and/or license.)
Color Photograph. You must submit a color photograph of yourself by forwarding a digital image to
mailto:OEP@amr.netOEM@amr.net in one of the following formats: .jpg, .gif, .bmp, .png, or .tif. If you do not have access to a digital camera or internet, mail a picture to: AMR-OEM, 12020 Intraplex Pkwy., Gulfport, MS 39503-4602 (See Photograph Guidelines at end of this document)
Incident Management Team Applicants: The following Questionnaire is intended for applicants interested in obtaining an Incident Management Team position within the ERT. Complete the questionnaire in its entirety prior to submitting your application.
What prior experience do you have in emergency management?
Have you previously served on the AMR IMT? If yes, list the event and position.
What position(s) are you interested in filling? Check all that apply.
EMS Incident Commander
Logistics Section Chief
Paratransit Branch Dir.
Planning Section Chief
Ground Ambulance Branch Dir.
Documentation Unit Leader
AMR Liaison Agency Rep.
Check-In/Demobilize Unit Leader
Operations Section Chief
Fixed Site Personnel Branch Dir.
Staging Area Manager
Finance/Admin. Section Chief
Communications Unit Leader
Air Ambulance Branch Dir.
Do you have experience related to the management of emergency incidents and events that may involve multiple jurisdictions? If yes, please explain.
Do you have experience related to managing tactical operations and large numbers of resources? If yes, please explain.
Do you have experience related to planning and preparedness, report writing, and information management? If yes, please explain.
Do you have experience related to facilities, services, and material support? If yes, please explain.
Do you have experience related to finance, administration, and cost analysis? If yes, please explain.
Describe your experience and knowledge of the principles of ICS, NIMS, and ESF8.
Additional Information / References / Resource Documents / Websites
AMR Emergency Response Team Job Descriptions:
Members of the Federal ERT should be prepared to provide mass medical care with scarce resources and to use altered standards of care. You are encouraged to review the following documents to help you prepare and respond to a mass casualty event.
Mass Medical Care with Scarce Resources: The Essentials:
Mass Medical Care with Scarce Resources: A Community Planning Guide:
Altered Standards of Care in Mass Casualty Events:
FEMA National Emergency Responder Credentialing System: EMS Job Titles:
FEMA Typed Resource Definitions Emergency Medical Services Resources:
FEMA ICS courses online, Emergency Management Institute:
72 Hour Go Kit Recommended Packing List https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/72-hour-packing-list.pdfhttps://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/72-hour-packing-list.pdf
Required Ground Ambulance Equipment List for Federal Response https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/equipment-for-ambulances-federal-ems-2015-01-28.pdfhttps://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/equipment-for-ambulances-federal-ems-2015-01-28.pdf
EMS Scope of Practice for AMR/FEMA Federal Disaster Deployments https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/scope-of-practice-for-amr-fema-federal-disaster-de.pdfhttps://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/scope-of-practice-for-amr-fema-federal-disaster-de.pdf
Disability Evacuation Guidelines https://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/guidelines-for-evacuation-of-individuals-with-disa.pdfhttps://www.amr.net/solutions/federal-disaster-response-team/references-and-resources/guidelines-for-evacuation-of-individuals-with-disa.pdf
Unsolicited Medical Personnel Volunteering at Disaster Scenes:
DHS Austere Emergency Medical Support (AEMS) Field Guide
DHS Tactical Emergency Medical Support (TEMS) Protocols
DHS Wide EMS Basic Life Support (BLS) & Advanced Life Support (ALS) Protocols
AMR Federal EMS Deployment Handbook for Non-AMR members
AMR Federal EMS Deployment Handbook for AMR members
Crisis Standards of Care
Federal ERT Applicant Acknowledgement
I understand that this is a voluntary assignment and I am indicating my interest to be considered should a deployment need arise.
I understand that this expression of interest is not binding on me or the Company, and I understand that I may or may not ever be asked to serve in this capacity.
I acknowledge that I am fully qualified to function as a Federal ERT member based on the minimum criteria cited herein.
I understand that should I be asked to deploy, some aspects of my employment will change during the period I serve, including my shift, number of hours worked, compensation, and working conditions. If I am a unionized employee, other terms, conditions, and/or obligations may or may not apply. Except as provided herein, this does not change the terms and conditions of my employment with the Company or create an employment contract.
I understand that I must deploy within 6 hours of notification and be able to be on-site where needed within 24 hours (travel arrangements will be made and paid by AMR).
I understand that if deployed, the duration of the assignment is based on the size of the situation; a single tour may last 15-17 days.
I understand that if I am an EMT-Paramedic, I may be asked to work as an EMT-Basic if needed.
If I am a caregiver, I understand that my pay will be based on either an average national rate as specified in the Company Job Classification Wage Schedule or the wage rate specified in an applicable Federal Wage Determination, whichever is higher. I will be informed of this rate at the time I am activated.
Official AMR/FEMA ERT ID cards are property of the AMR Office of Emergency Management (OEM) and must be surrendered upon termination, date of expiration or on demand.
All aspects of the deployment are confidential; no information will be released for any reason without written consent from the OEM.
I understand that I may be subject to an oral interview to further assess my qualifications before being designated as an Incident Management Team member.
If applying for an Incident Management Team position, I acknowledge that I have received formal training and certification in the National Incident Management System & Incident Command System (NIMS ICS) at the intermediate and advanced level which includes the following topical areas:
ICS staffing and organization to include: reporting and working relationships and information flow
Transfer of Command
Unified Command functions in a multi-jurisdictional or multi-agency incident
Interagency mission planning and procurement
Command and General staff
Incident Command Deputies and assistants
Organizational relationships between Area Command, Unified Command, Multi Entity Coordination Systems, and EOCs
By signing below, I verify that I understand and agree to the above terms
Employee ID #
Federal ERT Applicant Signature
Check here if you wish to be considered for temporary assignments to other venues not associated with Federal deployments.
Once you have completed this form in its entirety, scan-email or fax (toll free) it along with copies of all certificates/credentials/documents to the AMR Office of Emergency Management (OEM). Originals and hard copies should be kept in the employee file at your primary work location
Fax (800) 399-7726; email:
Submit color photo of yourself by forwarding a digital image to
mailto:OEP@amr.netOEM@amr.net in one of the following formats: .jpg, .gif, .bmp, .png, or .tif. If you do not have access to a digital camera or internet, mail a picture to: AMR-OEM, 12020 Intraplex Pkwy., Gulfport, MS 39503-4602.
You must submit a color photograph of yourself by forwarding a digital image to
2x2 inches in size or, if digital image, 300x400 pixels
Taken within the past 6 months, showing current appearance
Must be in color
Do not wear a hat, headgear, or sunglasses
Include a full face, front view and open eyes
Take the photo in a plain white or off-white background
Face in photo should have a natural expression (closed mouth)
Submit completed application along with copies of certifications, license(s), and photograph to AMR OEM ERT Office
mailto:OEM@amr.netOEM@amr.net Office: (877) 567-4466 Fax (800) 399-7726 12020 Intraplex Pkwy., Gulfport, MS 39503-4602
***For Official Office of Emergency Management Use Only***
Approved Denied Pending
Primary Approved Position
Other Approved Positions
Revised 2016.07.25 Page 1 of 5
Revised 2016.07.25 Page 4 of 5with the Company or create an employment contract.
Take the photo