The objectives of this study were 1) to determine the number and characteristics of emergency medical services (EMS) agencies within the 200 largest US cities that sanction EMS-initiated refusal of transport; and 2) to determine the extent of no-cost alternative transport mechanisms among those agencies that allow EMS-initiated refusal of transport. EMS agencies located within the 200 largest US cities were contacted via telephone and surveyed as to whether their agency sanctioned EMS-initiated refusal of transport (EMS-IROT). Agencies with a policy were further questioned regarding its components and usage patterns. The telephone survey contacted 100% (200) of the target population. Currently, 7.0% (14) of EMS agencies have EMS-IROT protocols, with 64% (9) of those requiring direct medical oversight. Five (2.5%) of the 200 agencies sanctioned EMS-IROT without requiring online medical approval. Average annual call volume of the five agencies not requiring direct medical oversight was 70,800; their EMS-IROT protocols have been in existence a mean of 19.8 years. None of these agencies had a no-cost alternative transport mechanism. Three (1.5%) agencies terminated EMS-IROT protocols in the past. EMS-initiated refusal of transport continues to be a rare entity among US EMS agencies. Those that do not require direct medical oversight tend to have well-established programs, though no agency offered a formal no-cost alternative transport mechanism.