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HomeMy WebLinkAboutC09-337B ambulance service licenses.-~y.~ ~ nay nniuuiau~.c uroNc~uull LWl °ublic Health Division 4/(97 Eagle County AMBULANCE INSPECTION LIST District: ~~ ~. ~ ~ Ambulance: ~ ~ Date: ~ ~ df °~ Time: ~ Z ~ BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit o/ b. Bulb syringe ~ c. Portable oxygen each with a variable flow regulator "' 02 bottles ,,.- house 02 ~ d. Transparent, non-re breather fixed oxygen (vehicle) Vr 02 mask, cannula for adult _~02 mask, pediatric / e. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard. 15mm/21 mm fittings in the following sizes: +~ 500 cc bag with newborn and infant x.750 cc bag for children ~ 1000 cc bag with adult mask r-"' Transparent masks for infants, ~eerra~~e patients, children and adults '/ f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr ~~ g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT a. Blood pressure cuffs to include large adult, regular adult, child, and infant ~~ b. Stethoscope ~_ c. Penlight III. SPLINTING EQUIPMENT _~ a.~Lower extremity traction splint ~! b. Upper and lower extremity splints ;/ c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis ~ d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis ~~ e. Pediatric spine board or adult spine board that can be adapted to pediatric use /' f. Adult & pediatric head immobilization equipment g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol I V . DRESSIIVG IVIA I ERIALS ~~ a. Bandages, various types & sizes -/ b. Dressings, various sizes / c. Sterile burn sheets =~ d. Adhesive tape Eagle County Ambulance Inspection List -°'~ 0 Public Health Division / 0 4/07 V. OBSTETRICAL SUPPLIES _~/ a. Sterile OB kit to include / towels, 4x4 dressing, / umbilical tape or cord clamps ~Lscissors v bulb syringe v sterile gloves thermal absorbent blanket / b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT ~~ a. Heavy bandage scissors/shears b. Two working flashlights _~ c. Thermal absorbent blankets/blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT ~~a. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. / b. Two-way communications that will enable the ambulance personnel to communicate with: ~/ Dispatch / Medical control facility or a physicians Receiving facilities ~_Mutual aid agencies VIII. EXTRICATION EQUIPMENT ~a•~pKiate-f6i'-t~ie~- QK1~;~~~~SS~-tha a?Pnr~~~,rn~z-4d~S. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) / a. Non-sterile disposable gloves, to include a minimum 1 box of latex free gloves. / b. protective eye wear mac. Non-sterile surgical masks ~~d. Safety protection gear for extrication V' e. Sharps containers for appropriate disposal and storage of medical waste and biohazards. ~f. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT a. A set of 3 warning reflectors b. One ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. / c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. d. Properly secured patient transport system (i.e., wheeled stretcher) _~ e. Triage tags 2 Public Health Division 4/07 ADVANCED LIFE SUPPORT -INTERMEDIATE ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII (Check) II. VENTILATION EQUIPMENT a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol. +~°~ b. Laryngoscope blades, straight & curved, sizes 0-4 ~' c. Adult and pediatric magill forceps _~ d. End tidal C02 detector~or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT ~ds~ a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities i° b. Pulse oximeter with adult and pediatric probes. ~ c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT ~- a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol ~/ b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS _,~ a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS i. DISPLAYS%IDENTIFICATION -~ a. Each ambu-ance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. b. Audible and visible warning. devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the ambulance is in safe operating condition. b. Tires are safe and approved snow tires or chains are available when weather conditions demand. .~...~.v vv Illy III VIC(/II.G IIIJ~.JG(I(IVII LIJL Public Health Division 4/~J7 ,- Eagle County .AMBULANCE INSPECTION GENERAL INFORMATION District: ~~~! ~; Date: o t ~ ,: ! ~~~ i , V. MUTUAL AID AGREEMENT /A written, contractual agreement between two licensees to supplement services in each other's response districts. VI. DESTINATION GUIDELINES ~' The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH 5 CouNT APPLICATION FQR AMBULANCE VEI3ICLE PERMIT DATE:/ 12 / 2 06 -I NAME OF VEHICLE OWNER: Eagle Countv Health Service . Distri c NAME OF AMBULANCE SERVICE: ~ e C_~: V ~cl~_~ G'.0. ~ +S C ~ V ~ C e 'y t •5'~ f ti G '~ ADDRESS: P • 0. Box .990. CITY Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970) 926-5270 DESCRIPTION OF AMBULANCE: "/ YEAR:2~ MAKE: Ford MODEL(type): III 4 WHEEL DRIVE(Y/I~:~T MANUFACTURERS IDENTIFICATION NUMBER (V,LN.): , F D W E 3 Jr- P 2 ? ~ $ O 7 ~O ~ ~1 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): ~ ~ ~ - ~ W REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n): Y DESCRIBE COLOR SCHEME, INSIGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING CHARACTERISTIC: Red,.. yellow, and oramge stripes on a white background. District logo on the front .portion of the ~iaa2snt compar m n x e ;cr Stars of life on the: rear doors and mirrored ~A~bulance" on the frnn DATE AMBULANCE PLACED INSERVICE:/ ~ / d g NORMAL LOCATION OF AMBULANCE: `~ Q 1 INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached_ Insurance Certificate B. AGENT: C. BODILY INJLJRY:$ / $ D_ PROPERTY DAMAGE:$ / $ ~~Si4:ist1)~~~ .,``` ~ ~, l.: ~ t. Sri T I-T~'A~R'V CERTIFY ?Y 4TT.~ INFORIvIATION PP.OVIDED Itv TIu'S APPLI^.A;TOIv' IS TRUE TO ;TAE BEST OF ;.f`,' i~~iLiv~?''~.cZi~C~.ri'rii`~C'j BELIEF AND CONTAINS NO WILLFUL MISREPRES AT[ONS OR FALSIFICATION. SUBSEQUENT DETERMIN.~~xJj}fTI'f~ PERMIT HAS BEEN ISSUED BASED ON F ONSTI S GROUNDS FOR PERMIT REVOC~It~t~. ~ _~ •'; '~ SIGNATURE OF APPLICANT DATE:/ I ~/ .a~T,LG r 4 ; • sc FIRMED BEFORE '~Q. 0......, ti SUBSCRIBED AN AF 3 ~ ~ i ~ ME THIS t DAY OF 19= IN THE COUNTY OF 4 ~ ~, F CO ~ STATE OF COLORADO. -~ .. ~ ljr~! Iti~, SIGNATURE OF NOTARY: My Commission Expires: a / 3 / ayl3 (FOR OFFICE USE ONLY) Date Received: / / Documentation Verified: Inspection Satisfactory. (y/n): Date: / / Holci For: Recozrimend Approval of Permit (y/n): Comments: SIGNATURE ~$2 CERTIFICATE OF MOTOR VE~IICLE CONDITION DATE:/ ~/ ?~ The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and deter-mined that this vehicle is iri safe operating condition. Said evaluation does NOT warrantee future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFICATION 1vu1V~ER (v.I.N.): ~ F flw ~ 3$ P~ 7 D g~? 6 ~ 9 VEIIICLE OWNER: ~Q (e ~ov~n-c-y I~e~ i+h Se cv ice I.~ ,~5~ c, ct EVALUATION CIIECK LIST MECHANIC: ~ ~ . ~[CJ (SIGNA"FURE) AGENCY ~ ~~~ ,ADDRESS 1055 ~ dwacd,s Ut~l (aae ~l~rd . Eclwcccd~ co $1632 ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering t/ . Alignment Suspension / Brakes / Hand Brake I.lghts Electrical System !/ .Glass / E~:haust System ~ Fvel System j/ Body & Sheet Metal / ~~ cay~e ~ounryHmourance rnspecnon ust Public Health Division 4/0'7 Eagle County AMBULANCE INSPECTION LIST .~ 5~ r District: ~..-~-~~ Ambulance: ~ ~~`~ _ Date: %~, ~ Time: ~ ~ rti ~~ BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT ~,,~a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit fib. Bulb syringe i.~-j'c. Portable oxygen each with a variable flow regulator ~-- 02 bottles ~fluse 02 l~-~- d. Tra~psparent, non-re breather fixed oxygen (vehicle) 02 mask, cannula for adult X02 mask, pediatric tee. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard 15mm/21 mm fittings in the following sizes: ~00 cc bag with~riew6orn~a~nd infant t---750 cc bag for cnild~-~" !_----1000 cc bag with adult mask ~--Transparent masks for infants, neonate patients, children and adults "~ f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr _~-°°°"`g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT _ ~~''~ a. Blood pressure cuffs to include large adult, regular adult, child, and infant i.,~--'b. Stethoscope Vic. Penlight III. SPLINTING EQUIPMENT l~° a. Lower extremity traction splint ~' b. Upper and lower extremity splints . _~ c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis ~~-° d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis ~ e. Pediatric spine board or adult spine board that can be adapted to pediatric use _j~ f. Adult & pediatric head immobilization equipment ~-'~g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol IV. DI~{ESSINCU MA I EI-{IALS ''^ a. Bandages, various types & sizes 1/ b. Dressings, various sizes ~ c. Sterile burn sheets ~-- d. Adhesive tape ' Eagle County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES ~--~-~°' a. Sterile OB kit to include L<~fbwels, l-- 4x4 dressing, Umbilical tape or cord clamps _~.,.~scissors ~-Bulb syringe rile gloves thermal absorbent blanket ~-"""b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT 1.-a: -Heavy bandage scissors/shears I--~--`y6. Two working flashlights ~~,,.c. Thermal absorbent blankets/blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT ~:~-~All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. L---t~"7`wo-way communications that will enable the ambulance personnel to communicate with: ~ Dispatch , ~ Medical control facility or a physicians Receiving facilities lsMutual aid agencies VIII. EXTRICATION EQUIPMENT t~--a. Appropriate for the level of extrication service the agency provides. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) ~~. Non-sterile disposable gloves, to include a minimum 1 box of latex free gloves. protective eye wear ~,~-e-i~"ot~=sterile surgical masks ~,,`~: Safety protection gear for extrication t.--°e. Sharps containers for appropriate disposal and storage of medical waste and biohazards. ~' HEPA masks, which can be of universal size X. SAFETY EQUIPMENT ~_ a. A set of 3 warning reflectors L''b' One ten pound (10 Ib.) or two five pound (5 Ib:} ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and ~~~icle exterior. ~ild safety seat or appropriate protective restraints for patients, crew, ~~,.,~.< accompanying family members or other vehicle occupants. d. Properly secured patient transport system (i.e., wheeled stretcher) Vie. Triage tags ~w~.., ..,,,.,,.r ,,,,, u u, Public Health Division 4/®7 ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII (Check) II. VENTILATION EQUIPMENT ~.M~a: Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol. `~ b. Laryngoscope blades, straight & curved, sizes 0-4 ~~` c. Adult and pediatric magill forceps _~' d. End tidal C02 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT 1~°` a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities G'"£b. Pulse oximeter with adult and pediatric probes. ~'°"~ c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT f-~'~a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol l-~''b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS ~_ _. a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) t`.~.- b: Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYSiIDENTIFICATION L~ a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. ~' b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE (.>-~ a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifvina the ambulance is in safe operating condition. v ----b. Tires are safe and approved snow tires or chains are available when weather conditions demand. ' Eagle County Ambulance Inspection List Public Health Division 4/07 III. INSURANCE: -o ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: -Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 Eagle County Ambulance Inspection List Public Health Division 4/07' Eagle County AMBULANCE INSPECTION GENERAL INFORMATION District: ~ _~' ~~'~.; V. MUTUAL AID AGREEMENT . ~A written, contractual agreement between two licensees to supplement services in each other's response districts. VI. DESTINATION GUIDELINES ~-..--The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH 5 COUNTY APPLICATION FQR AM~3ULANCE VEHICLE PERMIT DATE:/ 12 / 2 06 ~ NAME OF VEHICLE OWNER: Eagle County Health Service- D~ t ; NAME OF AMBULANCE .SERVICE: L~~.,,_C O U ~(I +Y _ I'~ C~ Gl ~ ±_I'~;,;_SC C V ~ G e (71~5~~1 G'J"' ADDRESS: P.O. Box 990` CITY:Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970).926-5270 DESCRIPTION OF AMBULANCE: 7~ YEAR:L~IMAKE: Ford MODEL(type): III 4 WHEEL; DRIVE(Y/I~:~T MANUFACTURERS IDENTIFICATION NUMBER (V.LN_): ~ F ~ W E~ 5pp P I 1 D ~3 OO /¢ 4 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): (~ I Z .. F W REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n): Y DESCRIBE COLOR SCHEME, CHARACTERISTIC: Red., y District logo on the fr >IGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING low, and ora~xge stripes on a white backcround. portion. doors any zt.:. i ......... n tars of life DATE AMBULANCE PLACED IN SERVICE: U / ~ / NORMAL LOCATION OF AMBULANCE: ~ ~ W a1~ ~ S INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached_ Insurance Certificate B. AGENT: C. BODILY INJIIRY:$ D: PROPERTY DAMAGE:$ / $ I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KN( ~1 BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINA~ ~ ,~:` ~~'~ PERMIT HAS BEEN ISSUED"BASED ON TION CONSTI'#ETF'ES GROUNDS FOR FERM[T REVOC~(~; •''~ • ~ rJ'' ^^~~~ i 'y • ~ SIGNATURE OF APPLICANT ~ DATE:/~/~~/ ~~T~~ ' O ..~.. (3 ~1 `'' • 1'CrBL~G ~' a SUBSCRIBED AN AFFIRMED BEFORE ME THIS DAY OF ~`'~ ] 9_ IN THE COUNTY OF X~ '•~, i ~~~ STATE OF COLORADO . V ~i~,~~' ~~ CO~Q``i~~ SIGNATURE OF NOTAR~ ~`'~- My Commission Expires: ~ / ~ %~0~~-~E~I~~~~`~ (FOR OFFICE USE O1~TLY) Date Received: / /. Documentation Verified: Inspection Satisfactory. {y/n): Date: / / Hold For: Recommend Approval of Permit (y/n): Comments: SIGNATURE condition o the identified ambulance and determir,PA. that rhie ~~P~;,:~o ,~ ;~ ....~~ _~ _~_~~_ - . ` °~ ~~ CERTIFICATE OF MOTOR VEHICLE CONDITION DATE:_J / I ~ 0~ The undersigned, professing to be motor vehicle mechanic, has of this :date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee. future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFICATION NUMBER (V.I.N.): I F D w E 3 5 .P '17 D$ oo?~ ~ VEHICLE OWNER: ~aq 1e Co ~~ ~+ •~ F~ ea I+h Sec v,ce ~ ,'s~c--~ -}' EVALUATION CIiECK LIST MECHANIC: ~ ~~ (SIGNA"fURE) AGENCY ~ C ~ Q , ADDRESS_1055 Cd~kti`C~5 ~;1(Qge. (vd . ~.clwacd5, Co `~ 1632 ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires / Steering Alignment ~/ Suspension Brakes Hand Brake Lights Electrical System Glass Exhaust System Fuel System Body & Sheet Metal ~~ Public Health Division ' .x _4!~7.. ~ r•. 5 Eagle County . AMBULANCE INSPECTION LIST District: ~ ~ .~ Ambulance: / ~_ Date: ~ ~ ~ c Time: ~ ~ `~~ BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT i/ a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit t/' b. Bulb syringe ~' c. Portable oxygen each with a variable flow regulator 02 bottles ~_house 02 i'' d. Transparent, non-re breather fixed oxygen (vehicle) ~~02 mask, cannula for adult v 02 mask, pediatric Vie. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard 15mm/21 mm fittings in the following sizes: 500 cc bag with newborn and infant v 750 cc bag for children ~ 1000 cc bag with adult mask ~,~Transparent masks for infants, neonate patients, children and adults t*` f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr / g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT ~ a. Blood pressure cuffs to include large adult, regular adult, child, and infant ~' b. Stethoscope .ter c. Penlight III. SPLINTING EQUIPMENT .F a. Lower extremity traction splint / b. Upper and lower extremity splints ~- c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis ,~ d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis /`~ e. Pediatric spine board or adult spine board that can be adapted to pediatric use r~ f. Adult & pediatric head immobilization equipment g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol iV. DRESSING MATEHiALS ~'" a. Bandages, various types & sizes ~ b. Dressings, various sizes if r c. Sterile burn sheets +~ d. Adhesive tape l b.~ E4~le County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES .~ a. Sterile OB kit to include towels, _4x4 dressing, _~umbilical tape or cord clamps scissors bulb syringe sterile gloves ~/ thermal absorbent blanket b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT ~ a. Heavy bandage scissors/shears ~'' b. Two working flashlights n~ c. Thermal absorbent blankets/blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT Via. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. ~ b. Two-way communications that will enable the ambulance personnel to communicate with: V' Dispatch '° Medical control facility or a physicians ~"' Receiving facilities Mutual aid agencies VIII. EXTRICATION EQUIPMENT a. A~pret~#~t~e--I -s~er~ri~t e a q-pr~ovades. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) a. Non-sterile disposable gloves, to include a minimum 1 -box of latex free gloves. ~` b. protective eye wear ' ~' c. Non-sterile surgical masks d. -S~afet or ex nca for ?./ e. Sharps containers for appropriate disposal and storage of medical waste and biohazards. ~ f. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT ter; a. A set of 3 warning reflectors / b. One ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. mod. Properly secured patient transport system (i.e., wheeled stretcher) ~/~e. Triage tags 2 Public Health Division r =- ,4/~7q ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII _~ (Check) II. VENTILATION EQUIPMENT '-''' a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol. E/ b. Laryngoscope blades, straight & curved, sizes 0-4 _~ c. Adult and pediatric magill forceps ~,~ d. End tidal C02 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT ~/' a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities ~--~- b. Pulse oximeter with adult and pediatric probes. ~/ c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol ~~ b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS ~ a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS/IDENTIFICATION _~ a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. '''~ b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE v~' a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the amb~!lance is in safe operating condition. /~ b. Tires are safe and approved snow tires or chains are available when weather conditions demand. . n g` E'agle..~ountyAmbu/ance Inspection List Public Health Division 4/07 III. INSURANCE: _~No ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: -Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 Cagle County Ambulance Inspection List Pr~blic Health Division '~ 4/0?Yr~ Eagle County AMBULANCE INSPECTION GENERAL INFORMATION ,; District:~.J ~ l~ ~ Date: ~ z ~ c, V. MUTUAL AID AGREEMENT ~A written, contractual agreement between two licensees to supplement services in each other's response districts. VI. DESTINATION GUIDELINES The Medical Director of the ambulance service shall. establish destination guidelines that conform to state. and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH 5 ~- . COUNT' APPLICATION FOR AIVIBULANCE VEHICLE PEP:MIT DATE: ~ /'2 .l 2OCjq' NAME OF VEHICLE OWNER Eagle County Health Service . D; str; ct NAME OF AMBULANCE;SERVICE:~~_~ U ~/. _~~alt_ ~1 ~e~c y~ ~ l'~I Sfi F~C~- ADDRESS: P • 0. Box' 990 CITY:Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970)926-5270 DESCRIPTION OF AMBULANCE: r o YEAR:MAKE: Ford MODEL(type): III 4 WHEEL: DRIVE(Y/I~: I`~L MANUFACTURERS IDENTIFICATION NUIVIBER (V,I.N_): I F ~w ~ 3 rJ 2 rI b A Q ~c 4" `Z S COLORADO STATE LICENSE"NUMBER (REGISTRATION N0.): ~ 1 l ~ V w REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n}: Y DESCRIBE COLOR SCHEME, INSIGNIA, NAME, MONOGRAM AND OTTER DISTINGUISHING CHARACTERISTIC: Red, yellow, and orange stripes on a white background. District logo on the front portion of the 'y~t~.gn.t compartment exter;or Stars of life on the rear doors and m;rrored x',Ainhulance" nn thefrnnt_ DATE AMBULANCE PLACED IN SERVICE: ~ / ~ l ~~~ l NORMAL LOCATION OF AMBULANCE: ~ D W A ~ ~ S INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached. Insurance Certificate B. AGENT: C. BODILY IN.IURY D: PROPERTY DAMAGE:$ / $ I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN TI-IIS APPLICATION iS i xiiE Tv Tn'E SEST OF ir.`Yii30WLEDGE ARID BELIEF AND CONTAINS NO WILLFUL MISREP TIONS OR FALSIFICATION. SUBSEQUENT DETERMINATION THAT A PERMIT HAS BEEN ISSUED BASED ON ~ ON CONSTIZU'IES GROUNDS FOR PERMIT REVOCATION. ~ ~; t s t i i ~ t t fj, ~~~`~E;~_~~fi SIGNATURE OF APPLICANT DATE:/ ~/~~~ :• '~••' • h',~'~ SUBSCRIBED AN AFFIRMED BEFORE ME THIS C~._ DAY OF ~~9 IN THE COUNTY OF ~ "~ •' ~..~ r... ; n STATE OF COLORADO . ~ ' ~ V''t p~LiG : a y y~+ SIGNATURE OF NOTAR My Commission Expires: ~ / 3 /~~''' F.C©ti0~ ~•` i~trit4w~t (FOR OFFICE USE ONLI~ Date Received: / / Documentation Verified: Inspection Satisfactory. (y/n): Date: / / Hold For: Recommend Approval of Permit (y/n): Comments: SIGNATURE F • ~~~ CERTIFICATE OF MOTOR VEHICLE CONDITION DATES/j2 / Oq The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition: Said evaluation does NOT warrantee. future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFICATION NUMBER (v.I.N.): I F Dw E 35 2~ D A~ ~, 4 2 5 vExICLE OWNER: ~4It'_ e ou~n -t y ~-~ Coq ~-} h Se cv,~e p ,'s-I c ~c-1- EVALUATION CHECK LIST ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Al bPnment Suspension I/ Brakes Hand Brake Lights Electrical System Glass Exhaust System Fuel System Body R. Sheet Metal ~~ MECHANIC: /-. ~~ (SIGNATURE) AG~ENCY ~ C ~ ADDRESS f 055" .~du.Ctfc~s ~o ,-..~,.- ... ,,.y i I,AJUIGI,VG NIJr.JGI,UVII L/Jl Public Hea/th Division ~ m 4/07... Eagle County AMBULANCE INSPECTION LIST .3~. ~` -~- District: ~~~ Ambulance: ~~- ~ _ Date: ~~i`Z3 Time:~`t..~ BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT 1'"a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit ~"'b. Bulb syringe L--c. Portable oxygen each with a variable flow regulator ~°- 02 bottles ~ house 02 ~"d. Tra~arent, non-re breather fixed oxygen (vehicle) 02 mask, cannula for adult ~--"L52 mask, pediatric fie. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard 15mm/21 mm fittings in the following sizes: ' 500 cc bag wit , newbo and infant ~~ i~C~ GC~U~C~-~'ti..I~~_ c_.- 750 cc bag for chi L--1000 cc bag with adult mask transparent masks for infants, neonate patients, children and adults `~ f. Nasopharyngeal airways in adult sizes. 24 fr. through 32.fr -~-°-g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT t--~- a. Blood pressure cuffs to include large adult, regular adult, child, and infant ~''' b. Stethoscope t/ c. Penlight III. SPLINTING EQUIPMENT a. Lower extremity traction splint ~. Upper and lower extremity splints ~~ c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis ___(~.-d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis L--~e. Pediatric spine board or adult spine board that can be adapted to pediatric use ~ f. Adult & pediatric head immobilization equipment _~--g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol iV. DHESSIivG MATEPIALS a. Bandages,. various types & sizes ~.- b. Dressings, various sizes ~ c. Sterile burn sheets ~.-d. Adhesive tape °Lag/e•CQuntyAmbu/ance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES ~' a. Sterile OB kit to include U towels, 114x4 dressing, 1~ambilical tape or cord clamps ~" scissors ~--bulb syringe L'sterile gloves dermal absorbent blanket L.i b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT a. Heavy bandage scissors/shears L/ b. Two working flashlights c. Thermal absorbent blankets/blanket and appropriate heat source ~ ~-y VII. COMMUNICATIONS EQUIPMENT tea. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. ~G. Two-way communications that will enable the ambulance personnel to communicate with: Dispatch t_-,Medical control facility or a physicians c--Receiving facilities t_-Aflutual aid agencies VIII. EXTRICATION EQUIPMENT a. Appropriate for the level of extrication service the agency provides. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) ~a-l~lon-sterile disposable gloves, to include a minimum 1 box of latex free gloves. T~fi. protective eye wear ~. Non-sterile surgical masks l~-d. Safety protection gear for extrication .~: Sharps containers for appropriate disposal and storage of medical waste and biohazards. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT a. A set of 3 warning reflectors ~-~b~ne ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and icle exterior. c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. ~. Properly secured patient transport system (i.e., wheeled stretcher) Triage tags cay,c ~.uurny runuuiance rnspecrron usr Public Health Division X4/07.::~, ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII (Check) II. VENTILATION EQUIPMENT ~'-' a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol. Z"'b. Laryngoscope blades, straight & curved, sizes 0-4 L'"~c. Adult and pediatric magill forceps ~~End tidal C02 detector or alternative device, approved by the FDA, for . determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT 1r-'a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder t~,,, and adult and pediatric EKG electrodes and defibrillation capabilities b. Pulse oximeter with adult and pediatric probes. z/ c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT L-a:' Adult and pediatric intravenous solutions and administration equipment per medical director protocol _~. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS/IDENTIFICATION ~° a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. l'~ b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE _..,~a. At the time of application for permit, the ambulance services shall submit to the County rertifjcate prenarArl(,iy a grialjfier~l me~rhaniC ~artifying the amb~,!IanCe is in cafe operating condition. fib. Tires are safe and approved snow tires or chains are available when weather conditions demand. caglL aunty Ambulance Inspection List Public Health Division 4/07 III. INSURANCE: ~iVo ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: -Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 tag~e c;ountyAmbu/ance Inspection List Public Health Division .g ' 4/07-.~@ Eagle County AMBULANCE INSPECTION GENERAL INFORMATION District: ~~~ Date: ~ V. MUTUAL AID AGREEMENT ~ written, contractual agreement other's response districts. between two licensees to supplement services in each VI. DESTINATION GUIDELINES ~ -.The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH 5 coUNTY APPLICATION FOR AMBULANCE VEHICLE PE~2IVITT DATE: ~ / ~ 2 ~ 2 OO NAME OF VEHICLE OWNER Eagle County Health Service_ D; str; ct NAME OF AMBULANCE SERVICE: ~Q~.O U c1G~Q I fi ~...,5~._~v ~ c e ~ 15 ~r'- C ~- ADDRESS: P • ~ • Box 99 CITY Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: - (970) 926-5270 DESCRIPTION OF AMBULANCE: ` U S yEq~L~;~q~; Ford MODEL(type): III 4 WHEEL: DRIVE(Y/I~:~ MANUFACTURERS IDENTIFICATION NUMBER (V,LN ): ~ F~ Q w n E 3 5 F 5 3 N A ~0 C~ 1 O COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): O / ~ T L- REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n): Y DESCRIBE COLOR SCHEME, INSIGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING CHARACTERISTIC: Red, yellow, and orange stripes on a white background District logo on the .front portion of the na~si~rarar rnm~n~rtmnnt cv~-o,-; ~,.- Stars of life on the rear doors and mirrored I'Ambulanre" on the front_ DATE AMBULANCE PLACED IN SERVICE: ` / ~ / 2ao NORMAL LOCATION OF AMBULANCE: ~ d ~ Q~ d S - INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached_ Insurance Certificate B. AGENT: C. BODILY INJURY:$ / D: PROPERTYDAMAGE:$ /$ ~~~':~ ~.' '>.. ~~ I FrFg FBY CERT'iFV 'i'Iae~T TIC INFOR1vIATION PROVIDED IN TICS APPLICATION IS TRUE TO TIC BEST OF MY~C - ~' BELIEF AND CONTAINS NO WILLFUL;Mi PRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMIN.~T~~I T'FI,4~~- ; C PERMIT HAS BEEN ISSUED BASED O ALS ON CONSTITUTES GROUNDS FOR PERMIT REVOCA"f~ON .• r~~L1G ~~ ~ SIGNATURE OF APPLICANT DATE:/ ~/ ~' © -" p~„'`. SUBSCRIBED AIv' AFFIRMED BEFORE ME THIS C.3 DAY OF~!~ / rrr THE COUNTY OF ~I'~ STATE OF COLORADO . SIGNATURE OF NOTAR ~ My Commission Expires: a. l 3 / a0 (3 ~- { (FOR OFFICE USE O1~IL~ Date Received: / / Documentation Verified: Inspection Satisfactory. (y/n): Date: / / Hold Far: Recommend Approval of Permit (y/n): Comments: SIGNATURE X1$5 p CERTIFICATE OF MOTOR VEIICI.E CONDITION DATE: S / I? / d~ The undersigned , professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe .operating condition . Said evaluation does NOT warrantee. future status of the ambulance due to .conditions beyond my control. VEHICLE IDENTIFICATION NUMBER (V.I.N.): I F Dw E 35'. ~ 53. H A 60$?0 VEHICLE OWNER: z Q ~~ Coca ~ ~1 e G~ (~} Se ~ y ~ C.e D ~'s~r ~ c. fi .. EVALUATION CIiECK LIST ~ 1 ~ MECHANIC: I ~ / (SIGNANRE) AGENCY ~ C ~~ ADDRESS l~ 5c5 ~ ~~ard 5 , (lore e. ( lyc~ , dwacds. CO 81632 ITEMS ACCEPTABLE NOT ACCEPTABLE. COMMENTS Wheels & Tires Steering Alignment Suspension Brakes Hand Brake Lights Electrical System Glass Exhaust System Fuel System Body & Sheet Metal 1~ r?ublio b~alth Division 4/(ii' Eagle County AMBULANCE INSPECTION LIST District: ~CA (~ Ambulance: ~ ~~ Date: S Z~ vg Timer BASIC LIFE SUPPORT (..VENTILATION EQUIPMENT a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit `/ b. Butb syringe "` c. Portable oxygen each with a variable flow regulator 02 bottles _~house 02 d. Transparent, non-re breather fixed oxygen (vehicle) v 02 mask, cannula for adult / 02 mask, pediatric ~ e. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard 15mm/21.mm fittings in the following sizes: X500 cc bag with newborn and infant __.750 cc bag for children . / 1000 cc bag with adult mask ~~7TT~~Transparent masks for infants, eee patients, children and adults f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr _~/ g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT / a. Blood pressure cuffs to include large adult, regular adult, child, and infant / b. Stethoscope ~/ c. Penlight III. SPLINTING EQUIPMENT / a. Lower extremity traction splint / b. Upper and {ower extremity splints ti c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis r d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis ~ e. Pediatric spine board or adult spine board that can be adapted to pediatric use ~G f. Adult & pediatric head immobilization equipment /~ g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol i~'. DRESSING iviATERiALS _~ a. Bandages, various types & sizes ~!' b. Dressings, various sizes / c. Sterile burn sheets d. Adhesive tape Eagle County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES ~,~ a. Sterile OB kit to include L~, towels, 2-4x4 dressing, ~---umbilical tape or cord clamps L~scissors bulb syringe t---sterile gloves thermal absorbent blanket . ~~ b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT Via. Heavy bandage scissors/shears ~ b. Two working flashlights //-c. Thermal absorbent blankets/blanket and appropriate heat source VI1. COMMUNICATIONS EQUIPMENT ~a;_ All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. lr'b. Two-way communications that will enable the ambulance personnel to communicate with: ~--Dispatch ~...~Medical control facility or a physicians t= Receiving facilities ~---Mutual aid agencies VIII. EXTRICATION EQUIPMENT JU a. Appropriate for the level of extrication service the. agency provides. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) a-Non-sterile disposable gloves, to include a minimum 1 box of latex free gloves. ~. protective eye wear ` c. Non-sterile surgical masks i--~d-. Safety protection gear for extrication 1~Sharps containers for appropriate disposal and storage of medical waste and biohazards. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT ~-;~a: A set of 3 warning reflectors 1.-krone ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and ~~ vehicle exterior. - c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. mod. Properly secured patient transport system (i.e., wheeled stretcher) ye. Triage tags ~_~._ _...,. .) ......... ~..,,,.....r,...,...,.. ~.... FP/ablic.Hea/th Division 4/3,7 ., ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII _,~(Check) II. VENTILATION EQUIPMENT ~'° a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol. b. Laryngoscope blades, straight & curved, sizes 0-4 c. Adult and pediatric magill forceps _~ d. End tidal C02 detector or alternative device, approved by the FDA, for • determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT _~ a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities ~ b. Pulse oximeter with adult and pediatric probes. ~ c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT _~~a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol _~/ b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS _~„~ a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) ~/ b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS/IDENTIFICATION / a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. _~ b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE _~ a. At the time of application for permit, the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the ambulance is in safe operating condition.. b. Tires are safe and approved snow tires or chains are available when weather conditions demand. . ~ Eagle County Ambulance Inspection List Public Health Division 4/07 III. INSURANCE: ~No ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: -Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 4 3 r COUNT APPLICATION FQR AMBULANCE VEHICLE PERMIT DATE: y /'2 ./ z o~q NAME OF VEHICLE OWNER. Ea~lCe County Health Service... D' tr; NAME OF AMBULANCE SERVICE: L a ~~ - _L~ O V ~ H ea ,l ~ ~ Secy ~ ee 1'' ~ 5'~~' l C~t' ADDRESS: P • 0. Box 990 CITY Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970).926-5270 DESCRIPTION OF AMBULANCE: 7 (~ YEAR:Z~~MAKE: Ford MODEL(type): III 4 WHEEL DRIVE(Y/I~:~T . MANUFACTURERS IDENTIFICATION NUMBER (V,I.N ): ~ ~ D ul1 E 3S P d ~H±± ~ 1 2 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): ©2 2 N Q t.7" REGISTERED WITH THE STATE 'OF COLORADO AS AN EMERGENCY VEHICLE? (y/n}: Y DESCRIBE COLOR SCHEME,. INSIGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING CHARACTERISTIC: Red, yellow, and orange stripes on a white background. District logo on the front. portion of the paa2ent compartment exterior. ___ Stars of life on the rear doors and mirrored ~Ainbulance" DATE AMBULANCE PLACED IN SERVICE: I/ ~ l 2 ~~~ NORMAL LOCATION OF AMBULANCE: `~ ~ 1• INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached-. Insurance Certificate B. AGENT: C. BODILY IN3LJRY:$ D: PROPERTY DAMAGE:$ / $ I i-IEREBY CERTiF i Ts'-iAT~ i~ I?:FCR..".ATION °ROl7IDED IN TINS A°PLICATICA: IS TP.'JE TO THE BE.cT OF ".~fY I:P;O~'~wfllNff I~~`:y/ BELIEF AND CONTAINS NO WILLFUL;MISREP SENTATIONS OR FALSIFICATION. SUBSEQUENT DETERMINATIOj~t',~I,A~ ~L, ~~r~ PERMIT HAS BEEN ISSUED BASED ON F E N CONSTITUTES GROUNDS FOR PERMIT REVOCATI O .•''"•~•• '••.~ ~ _ ~ .• OTAR •. O SIGNATURE OF APPLICANT DATE:/,~/ = i• ~~,~„~ •:`~' / ~v;% ~C SUBSCRIBED AN AFFIRMED BEFORE M£ THIS (~ DAY OF ~ ~~9: IN THE COUNTY OF ~~1 ~~ +~~•_ ~~LY~ r,zt{` STATE OF COLORADO . ~-'+i ~' --•..-.•••''p~ ~` SIGNATURE OF NOTAR '~" ~`'"~- My Commission Expires:°2 / 3 /~v ~`~rri~~F~t~° d_ ''7g~ - - CERTIFICATE OF MOTOR VEHICLE COI~TDITiON DATE:/ T?/ Oq The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified. ambulance and determined that this vehicle is in safe .operating condition. Said evaluation does NOT warrantee. future status of the ambulance due to conditions beyond my control. VEIIICLE IDENTIFICATION NUMBER (V.I.N.): I F Dw E 35 ~ D~, H A 9 2 4 4 S vExICLE OWNER: ~~ ~~' ~ o v ~ r? ~ S e~ ~, ce D ~'s ~ ~ 'c-f EVALUATION CIiECK LIST MECHANIC: ~ ~ (SIGNATURE) AGENCY ~ C Iq ~ ,ADDRESS f ~ 55 ~d~r'ds V~,'((ag,e Qlvd , ~ elwatds~. CD $ (632 ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Alignment / Suspension Brakes Hand Brake Lights Electrical System Glass Exhaust System ~/ Fuel System Body & Sheet Metal )~ „ Eagle County Ambulance Inspection List ' Public Health Division 4/07 a _ Eagle County AMBULANCE INSPECTION LIST ~/ ~ District: ~Ct~d~ Ambulance: ~~ Date:~!_Time: ~~ --- -~~ -"/ U BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT ~--1a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit ~-~: Bulb syringe '-"'c. Portable oxygen each with a variable flow regulator l''02 bottles I-house 02 mod. Transparent, non-re breather fixed oxygen (vehicle) ~ 02 mask, cannula for adult L--02 mask, pediatric t--''e. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard, 15mXrf,!21 mm fittings in the fo wing sizes: 500 cc bag with ewborn nd infant X750 cc bag for chi 1000 cc bag with adult mask L--T"ransparent masks for infants, neonate patients, children and adults f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr ~i- g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT _~ a. Blood pressure cuffs to include large adult, regular adult, child, and infant (/b. Stethoscope c. Penlight III. SPLINTING EQUIPMENT a. Lower extremity traction splint ~~ b. Upper and lower extremity splints L--c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis _~/d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis ~''e. Pediatric spine board or adult spine board that can be adapted to pediatric use ~'f. Adult & pediatric head immobilization equipment ~` g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol IV. DRESSING MATERIALS ~ a. Bandages, various types & sizes ~.- b. Dressings, various sizes C~ c. Sterile burn sheets mod. Adhesive tape Eagle County Ambulance Inspection List Public Health Division 4/07 V. OBSTETRICAL SUPPLIES L/ a. Sterile OB kit to include 1~ towels, -4x4 dressing, umbilical tape or cord clamps scissors Ubulb syringe l-rsterile gloves ~'fhermal absorbent blanket L.~- b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT a. Heavy bandage scissors/shears ~/' b. Two working flashlights 1~ c. Thermal absorbent blankets/blanket and appropriate heat source :~ VII. COMMUNICATIONS EQUIPMENT ~-- a. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. l.~- b. Two-way communications that will enable the ambulance personnel to communicate with: L-. Dispatch ,C.._ Medical control facility or a physicians Receiving facilities _~Mutual aid agencies VIII. EXTRICATION EQUIPMENT ~,~a. Appropriate for the level of extrication service the agency provides. IX. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) --~ Non-sterile disposable gloves, to include a minimum 1 box of latex free gloves. ~rk5: protective eye wear 4 c. Non-sterile surgical masks r d. Safety protection gear for extrication tee. Sharps containers for appropriate disposal and storage of medical waste and biohazards. yf: HEPA masks, which can be of universal size X. SAFETY EQUIPMENT L~ a: A set of 3 warning reflectors ~-b: One ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. ~~c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. ~.~el. Properly secured patient transport system (i.e., wheeled stretcher) t--'e`. Triage tags Eagle County Ambulance Inspection List Public Health Division 4/07 ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII (Check) II. VENTILATION EQUIPMENT ?.,.---a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging from 6.0-8.0 per medical director protocol: ~-`TLaryngoscope blades, straight & curved, sizes 0-4 L- c. Adult and pediatric magill forceps ~~d. End tidal C02 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT ~''~a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities L/' b. Pulse oximeter with adult and pediatric probes. ~. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT ~,~ Adult and pediatric intravenous solutions and administration equipment per medical director protocol ~ b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS ~.---~ a. Pharmacological agents and delivery devices per medical director protocol (Attach protocol) `' b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS/IDENTIFICATION C,-, a. Each ambulance shall clearly display permanent markings on both sides showing the name of the ambulance service under which they are licensed. ~- b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE es a. At the time of application for permit; the ambulance services shall submit to the County certificate prepared by a qualified mechanic certifying the ambulance is in safe ~.r- operating condition. b. Tires are safe and approved snow tires or chains are available when weather conditions demand. Eagle CountyAmbu/ance Inspection List Public Health Division 4/Q7 III. INSURANCE: ~! .~lo ambulance .shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability, insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: -Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 4 v - eagle County Ambulance Inspection List Public Health Division 4/Q7 Eagle County AMBULANCE INSPECTION GENERAL INFORMATION District• ~~.~ Date: - V. MUTUAL AID AGREEMENT written, contractual agreement between two licensees to supplement services in each other's response districts. VI: DESTINATION GUIDELINES _l~The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH s