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HomeMy WebLinkAboutbocc.con.067.2008CONTRACT #~~0~ LICENSE AGREEMENT NO. O 3 -2008 PITKIN COUNTY AMBULANCE LICENSE FOR: BASALT/RURAL FIRE PROTECTION DISTRICT MEDIC 41, MEDIC 42, MEDIC 43, MEDIC 44 GRANT OF LICENSE/PERMIT The undersigned, representing the Boazd of County Commissioners of Pitkin County, Colorado, does hereby grant a license to the above-named applicant to provide ambulance service within Pitkin County. This license shall have upon it any restrictions listed below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the Board pursuant to the provisions of Title Six (health and Safety-Ambulance Licensing) of Pitkin County Code and any other applicable County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, C.R.S. RESTRICTIONS/CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable TIiIS LICENSE IS VALID FROM: January 1, 2008 through December 31, 2008. APPROVED BY THE PITHIN COUNTY BOARD OF COUNTY COMMISSIONERS //J ,/tl~Jt3f,et /,~~°~OD7 ~~ MICHAEL M. OWSLEY, Chair Pitkin County Boazd of County Commissioners ~~~q5 ~177fINCOUNTY Ambulance Permit EMTAC Sign-Off ~ 1 Service Name: r):~ fkT~ i ~ A4 , /, ,-r~_~/~ ~ / J/S7. Date Received: l~ / ~.~~ ~ y~ Number of Ambulance Permit packages included: `~~ EMTAC Comments: ~ o~'~ ~('r~ov~ U:.1/an1\mOJS~y ~~ ~rra.r M.cr,in`~ i1~\-,-I°7 EMTAC Recommendation: AUG. '•{ k~ut~ i'4~si~1 iNS~.~~~a ~Cf.~..nnMa~~ Aponcyt,al e~ talS.'t ~•~. l 1 C~sc3. EMTAC Chairperson Signature: /~.ou:vc Date Referred to Board of County Commissioners: -~. 1 ~ L o ~~ Board Action: Date: ~ITIfINCOl11VTY Ambulance Service Name d'~:i~~~ \~ ~~,.-~,.1 E=,r-e ~ o~~~:~,~w.~i3~ti-~"~- Service Area• ~ ~• ` ~ - ~ ~~ Full years Partial year Emergent X Transfer ~ Special Event '~ Number of Ambulances Licensed: ~ ~ d-~,.~,-l Is this Service Licensed in other Locations? J~; List Locations: If other than Special Taxing District list Owners with Addresses and Contact Information: Physician Advisor: StreeNP.O. Box City "~ Stete Zi P Contact Information: ~1~'r ~-- ~~~,' Voice Fax E-Mail Colorado Medical License Number: ~ti~~ i "~ I hereby certify that the information provided in this application is true to the best of my knowledge and belief and contains no winful misrepresentation or falsification. Determination that an Ambulance Service License has been issued based on false information constitutes grounds for license revocation, suspension of operations and possible criminal prose£ution. Service Director's Signature: Physician Advisor's Signature n ~ i~--~ i 2~<< l ~ ~ Dale ~ITIfIP COll1VTY Application for Ambulance Permit Service Information \ Service Name ~4~ic.ti\~ ~~~~ c.\ ~ ~~ 2 ~~<<-`~+~.. ~,~~-•~~~~' Address 10 ~~~ •- ~~ \ti ~r•.~ ~ ~iat"\~~ ~,~!~~e ~LC ; ~~\ ~ 2.-.~ StrecUP.O. City Stste Zip Communication~~k) •~<1- l: ~ ~ ~ ~~ ~ )cFok- C~C- 2`; Voice Fax E-Mail Vehicle Information Radio Call Sign ~tti1 r~~~~ ~{~ License Plate iJ> Z - ~ .i { ~' VIN 1 ~'w5 r ;3 ~ i = 1 ~l Ea ~i6L 1 L 4X4 Yes (~ No ( ) Year ZC`CC Make t=~ c-~L Type Where will Vehicle be Stationed ZC `4~r~,\ `~~• ~-:;~~-,1~ ~t~. t'lbZl Waiver Request (Include Reason for Request) Inspection Fee $50.00 (y'' Mechanical Condition Certificate Attached (~) Required BLS Equipment List Attached M Required ALS Equipment List Attached (~' Pass Inspection (Z.) Fail ()Reason for Failure 'fit L~i! ~ri l1w' - ~~ ~ +~-~D-~7 _ Inspector's Namt Signature Date tnmvuuucc mapccw~ we w.Vl Valid Insurance Card Yes M No ( ) Valid Registration Card Yes (1~' No ( ) ~ITKIIV COUNTY Vehicle Safety and Operability Certification Ambulance Service~+.~~ ~~.4 Radio Call Sign 1`~ep~ ~ ~-~l S stem Acce table Non Acce table Comment Tires ) ( ) Wheels ~(~) ( ) Alignment ~N) ( 1 Suspension ~Ev) ( ) Brake System ~~) ( ) Parkin Brake ~~i) () Headlights ~(/) ( 1 Stop/Turn/Brake Lts~F.) ( ) Visual Warning Liehts ) ( ) Audible Warning ~lv) ( 1 Electrical S stem Exhaust Svstem \ ) ( ) Fuel Svstem \'Nl ( ) GlasslMirrors T~+) O - Bodv & Sheet Metal ~) ( ) General Present Condition, Excellent )Good ()Moderate ( )Poor ( ) Mileage when Inspected ~30aM I, ~~-~~-~ ~E>~a~. ,professing to be a motor vehicle technician with training in the syste listed above, have evaluated the condition of all systems and- ha-ve~fo d them to m a safe and working con((~~di~~tion. (~`'' /" ~~~ I`\S1~L~i ~iHSal1 f~~C IBC R~(,Zt Signature Agency/Company` Phone Address Date ' This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. ~ITIfIPCOUN7'Y Required 6A~ dvanced Life Support Equipment List Inspector °-~ ~ C 1 ~ rPr ~ Ul`-~ Date ~ (~ ~~' - ~ 7 Vehicle Radio Call Sign ~~t E<<~ ~ '-+l Minimum Equipment Requirement for Advanced Life Support Ambulances (1.) All Equipment Listed In BLS Equipment list Ventilation Equipment (~} Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0-8.0 per Physician Advisor protocol. (~.) Laryngoscope and blades, straight, and/or curved of sizes 0-4. 6,,.)- Adult and pediatric magill forceps. (L)- End tidal COZ detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (4) Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (y- Electronic blood glucose measuring device. Intravenous Equipment (L) Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (y'' Adult and pediatric intravenous arm boards. Pharmacological Agents (~) Pharmacological agents and delivery devices per Physician Advisor protocol. (tj~ Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for ~.~~\~ ~- ~~~ ~ \ 4-~.~e:~r~~r~~c,.~,~k:..~ , I certify that this ambulance carries the equipment listed above. This ambulance meets the minimum requirements established by the State of Colorado and Pitkin County to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Name Signature >~rr~rr~veor~rY Required Basic Life Support Equipment List Inspectorjcc~-t f~.r~'bt'-~ Date ~~'~~`-~7 Vehicle Radio Call Sign 1~1 a@ :~: ~ i Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (v_ Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (t,) Bulb syringe. (i~ House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2-patients simultaneously through 2 variable flow regulators with capacity at flows of a least I-15 L.P.M. (l~- Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P,M. (L) Transparent, non-rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag-valve mask resuscitators with oxygen reservoirs and standazd I Smm / 21 mm fittings in the following sizes; (~) SOOcc bag with transpazent masks for infant and neonate. (t,) 750cc bag with transpazent masks for children. (~} 1000cc bag with transpazent masks for adult. (~j Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (t~` Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and lazge adult. Patient Assessment Equipment (~ Blood pressure cuffs to include lazge adult, regular adult, child, infant, and neonatal sizes. (~) Stethoscope in adult and pediatric sizes. (~.} Penlight. (v}~ Pulse oximeter with adult and pediatric sensors. Splinting Equipment (l) Lower extremity traction splint. (-~ Upper and lower extremity splints. (t) Long boazd with equipment to immobilize the patient from head to heels. (~} Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (t) Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (1a' Pediatric immobilizafion device or adult immobilization device that can be adapted for pediatric use. (L) Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (~ Bandages -various types and sizes per agency needs and Physician Advisor protocol. (t~ Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (~) Sterile burn sheets. (~) Alcohol swabs or equivalent. (e,} Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (~- Sterile irrigation solution. Obstetrical Supplies ~„ } Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. ~) Neonate stocking cap or equivalent. Miscellaneous Equipment (1.}" Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (y Two working flashlights. (~}~ Blankets and appropriate heat source for the ambulance patient compartment. (~} Ambulance Service Medical Treatment Protocols. (~}~ Oral glucose. (~' Activated charcoal. (~) Spill proofemesis container. (y Universal and/or separate male /female urinals. ('~} Stair Chair 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. Two-way communications that will enable the ambulance personnel to communicate with: (~) ambulance service's dispatch (~) medical control facility or a physician (4) receiving facilities (v) mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; {t,a- Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (~) Protective eyewear. (~.) Non-sterile surgical masks. (~) Fluid proof gowns with full-length sleeves or equivalent. (u) Disinfectant spray or wipes for personnel and equipment. (t-)' Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (~- Particulate respirator, N95 type or better. Safety Equipment (,.)' A set of three (3) warning reflectors. (~ One (1) ten pound (10 Ib.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (~' Child safety seat or equivalent (t-) Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (~J Properly secured patient transport system (i.e. wheeled stretcher). (~.) Triage tags as approved by the Colorado Department of Public Health and Environment. (~ Restraining devices for all items not in a securable cabinet. (ta' Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one inpatient compartment. (1Jf Reflective vests, coat or equivalent for each member of the crew normally assigned. 31 ti ti_u!.~i1:::~ ~q;fti.tir.i.;' ~rrx~vcor~~rrY Application for Ambulance Permit Service Information \ Service Name ~l~Cl~~ `~"\~~7vi.\ 1--~+2C ~u~-e~~hi~> >cS~~ck' Address _ l~~ E <:1 _j C•.~ A XiV ~; ~:~t~k~s.,.~c~` 2 (i.C ~ 1 •2. Streef/P.O. City Slsle Zip Communication .,~'~! OL }`'~ dew- U!c 2.`.~ Voice Vehicle Information Fax E-Mail Radio Call Sign ~ ~ - '~1 Z-. License Plate Q~} ~ ~ a \= VIN 1 1= ~sU r 3~~ iaiL~ % 1 4 ~~~ 3 4X4 Yes ~ No ( ) Year ZGO(: Make i=cc~~ Type ~~- Where will Vehicle be Stationed ~C Waiver Request (Include Reason for Request) "_~~~. ti Z 2.3 Inspection Fee $50.00 ~' Mechanical Condition Certificate Attached (y Required BLS Equipmeut List Attached (I,); Required ALS Equipmeut List Attached (~}~ Pass Inspection (ia- Fail OReason for Failure Inepator's Name Signature Date Valid Insurance Card Yes (~ No ( ) Valid Registration Card Yes (y' No ( ) ~ITlfI1V COUNTY Vehicle Safety and Operability Certification Wheels ~Nl ( ) AlietLment ~) ( ) Suspension ~) ( ) Brake System ~h) ( ) Pazkine Brake ~) ( ) Headli hts ~) O - Stop/I'urn/Brake Lts~ti) ( ) Visual WaminQLi~,h~) ( ) Audible Warnine ~ 1 ( ) _Electrical Svstem ~l ( ) Exhaust Svstem ~) ( ) Fuel Svstem ~) ( ) Glass/Mirrors ~) ( ) Body & Sheet Metal) ( 1 General Present Condition, Excellen )Good ()Moderate ( )Poor ( ) Mileage when Inspected ~~~ i ° I, ~SR~~r~ ~C~ ~o,~ ,professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to b~ a safe and working condition. ?cN ~~ae ~1s~0.wC~ Signature Agency/Company Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's conh~ol. Ambulance Service~psA~~ ~~E Radio Call Sign mt~u ~1~- ~ITKIPCOIl~VTY Required Advanced Life Support Equipment List Inspector J C C.TE'}"~ ~.r'~ t~ c,/ Date II -'. U-C)~l Vehicle Radio Call Sign {1'1e,~,c, Ai.. Minimum Equipment Requirement for Advanced Life Support Ambulances (~ All Equipment Listed In BLS Equipment list Ventilation Equipment (:~- Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0-8.0 per Physician Advisor protocol. (i.) Laryngoscope and blades, straight, and/or cwved of sizes 0-4. ( y- Adult and pediatric magill forceps. (t) End tidal COz detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (t.•j Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (~) Electronic blood glucose measuring device. Intravenous Equipment (y Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (y- Adult and pediatric intravenous arm boards. Pharmacological Agents (tj Pharmacological agents and delivery devices per Physician Advisor protocol. (•„) Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. BLS 1'~~:;utd 13q:~',;r~,; As Service Duector for }~ix~\~ E~~,; o~ i=~ct~:1-e~~w.,.~;;;~c,~ . I certify that this ambulance carries the equipment listed above. This ambulance meets the minimum requirements established by the State of Colorado and Pitkin County to provide medical caze and transportation of the sick and injwed at the Advanced Life Support level. >PITIfINCOUIV7'~' Required Basic Life Support Equipment List Inspector ~'rcfl As }L~~ Date 1 -'~~~ ~ ~~ Vehicle Radio Call Sign ~1lzcl~~: 4-z. Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (~) Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (t,) Bulb syringe. (L) House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2-patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1-15 L.P.M. (~) Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P.M. (~-) Transparent, non-rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag-valve mask resuscitators with oxygen reservoirs and standard I Smm / 21 mm fittings in the following sizes; (L) SOOcc bag with transpazent masks for infant and neonate. (la 750cc bag with transparent masks for children. ll.} 1000cc bag with transparent masks for adult. (L) Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (~) Orophazyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (~} Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (l.)- Stethoscope in adult and pediatric sizes. (a~ Penlight. (t~~ Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment (`~) Lower extremity traction splint. (y' Upper and lower extremity splints. (;,) Long board with equipment to immobilize the patient from head to heels. (~) Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (~) Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (~) Pediatric immobilization device or adult immobilization device that can be adapted for pediatric use. (J,: Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (4) Bandages - vazious types and sizes per agency needs and Physician Advisor protocol. (~ Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (L) Sterile bum sheets. (ti.) Alcohol swabs or equivalent. (~} Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (la- Sterile imgation solution. Obstetrical Supplies (tr) Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (i~ Neonate stocking cap or equivalent. Miscellaneous Equipment (i) Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (~) Two working flashlights. (t..) Blankets and appropriate heat source for the ambulance patient compartment. (t,~ Ambulance Service Medical Treatment Protocols. (i} Oral glucose. (+~' Activated charcoal. (~.,) Spill proof emesis container. ('~ Universal and/or separate male / female urinals. (~ Stair Chair 3 Communications Equipment (~) All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving cleaz voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (,,) ambulance service's dispatch (:-) medical control facility or a physician (ia receiving facilities (~ mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (t,) Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum I box of latex free gloves. (J Protective eyewear. ~) Non-sterile surgical masks. (t,) Fluid proof gowns with full-length sleeves or equivalent. (~) Disinfectant spray or wipes for personnel and equipment. (u} Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (~) Particulate respirator, N95 type or better. Safety Equipment (e) A set of three (3) warning reflectors. (~ }~ One (1}ten pound (10 Ib.) or two (2} five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (~) Child safety seat or equivalent (t} Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (;.) Properly secured patient transport system (i.e, wheeled stretcher). (~) Triage tags as approved by the Colorado Department of Public Health and Environment (a- Restraining devices for all items not in a securable cabinet. (y ~ Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one in patient compartment. (~,)' Reflective vests, coat or equivalent for each member of the crew normally assigned. ~ITKINCOUNTY Application for Ambulance Permit Service Information ` Service Name F~n,Scti~~ ~~~.~o\ l~~ ~~1 ct\i=~~ti~,~s,~c~~` 4 Address_ 1(_~'~ .•~~+~i~~c~.v 2: ~~c~\13c~.c'4,\E ~' ~Itrz-3 StreeUP.0. City State Zip Communication ,~~`~- C'(.; ~`; ~ c~{ - c t~ ZS I Voite Vehicle Information Fax )':Mail Radio Call Sign { ~~ QCt~1l ~ 1 3 License Plate y > ~ ' ~ t~ :- VIN 1 F= 7:jL .~ t='}1"1 ~1~ ci:~ ~F:S- 4X4 Yes 4Q No ( ) Year ~~1~{~ Make f'~~rc.~. Type Where will Vehicle be Waiver Request (Include Reason for Request) ~._ ~'1-~21 Vand Insurance Card Yes (y' No ( ) Valid Registration Card Yes ~., No ( ) Inspection Fee $50.00 (~ Mechanical Condition Certificate Attached (i~ Required BLS Equipment List Attached (+.) Required ALS Equipment List Attached (. ) Pass Inspection (~ Fail ()Reason for Failure Inspector's Neme Signeturc Dale I ~ITKIP COI/NTY Vehicle Safety an/d Operability Certification Ambulance ServiceILcA>_< r `~~ Radio Call Sign n'~t;a~ L y3 System Acceptable Non Acceptable Comment Tires ~) ( ) Wheels ~) ( ) Alignment ~+) ( ) Suspension ~(v) ( ) Brake System ~ti) ( ) Parking Brake ~) ( ) Headlights ~) ( ) Stop/"I'um/Brake Lts ~) O Visual Warning Ligh~3`(.1) ( ) Audible Warning ~) ( ) Electrical System ~) ( ) Glass/Miaors ~') ( ) Body & Sheet Metal) ( ) General Present Condition, Excellent ( )Good ()Moderate ( )Poor ( ) Mileage when Inspected ~ 5"13 8 I, ~)Z~AU ~E~ ;,,,,~ ,professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have fou them to m a safe and working condition. `\~ ~)'~~~"e~ ~Yds~~~ASAL~ ~Ff. `V IS~a.1 L~.I Signature Phone Address Dl This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. ~ITIfINCOUPTY Required Advanced Life Support Equipment List Inspector !~ (~~ 4~ }~~- ~ w Date 1 ~ - ~~ -b-1 Vehicle Radio Call Sign (Vl ec~,it ~3 Minimum Equipment Requirement for Advanced Life Support Ambulances (1~)' All Equipment Listed In BLS Equipment list Ventilation Equipmeut (ti) Adult and pediatric endotracheal intuba6on equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0-8.0 per Physician Advisor protocol. (~) Laryngoscope and blades, straight, and/or curved of sizes 0-4. (~) Adult and pediatric magill forceps, (ti) End tidal COZ detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (i,) Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. () Electronic blood glucose measuring device. Intravenous Equipment (t) Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (~) Adult and pediatric intravenous arm boards. Pharmacological Agents (1.) Pharmacological agents and delivery devices per Physician Advisor protocol. p-) Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. 1LS 1'eyu?id Lye':i;rn,: n; As Service Director for~J~~~ct\~ •tK;~„ ~,\ )-~i ~. ~ ~~~~u..~~;.~t~~:.1- , I certify that this ambulance carries the equipment listed above. This ambulance meets the minimum requirements established by the State of Colorado and Pitkin County to provide medical care and transportation of the sick and injured at the Advanced Life Support level. 4 .__. d 6a6AY' VOY~~~ a Required Basic Life Support Equipment List Inspector J ~ ~.'t•~ 1~+~-1 htir Date 1 l - ~~~ - ~`-7 Vehicle Radio Call Sign y11~`~~ y~ Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (~ Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (~) Bulb syringe. (~.)- House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2-patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1-15 L.P.M. (~) Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P.M. (~' Transparent, non-rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm / 21 mm fittings in the following sizes; (~) SOOcc bag with transparent masks for infant and neonate. (~) 750cc bag with transparent masks for children. (~) 1000cc bag with transparent masks for adult. (L) Nasopharyngeal airways in pediatric and adult sizes 12 fr, through 32 fr. (~~) Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (t) Blood pressure cuffs to include large adult, regulaz adult, child, infant, and neonatal sizes. ~.) Stethoscope in adult and pediatric sizes. (..) Penlight. (~) Pulse oximeter with adult and pediatric sensors. z Splinting Equipment ('Y.} Lower extremity traction splint. (t) Upper and lower extremity splints. (1.) Long boazd with equipment to immobilize the patient from head to heels. (t~ Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (y Short boazd or equivalent, with the ability to immobilize the patient from head to pelvis. (+-j Pediatric immobilization device or adult immobilization device that can be adapted for pediatric use. (i.)' Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (j~- Bandages -various types and sizes per agency needs and Physician Advisor protocol. ('„j Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (~) ~ Sterile burn sheets. (t) Alcohol swabs or equivalent. (t,)' Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (t~ Sterile irrigation solution. Obstetrical Supplies (`c) Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (1~ Neonate stocking cap or equivalent. Miscellaneous Equipment (~ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (t~ Two working flashlights. (i) Blankets and appropriate heat source for the ambulance patient compartment. (V) Ambulance Service Medical Treatment Protocols. (t) Oral glucose. (~) Activated chazcoal. (<~ Spill proof emesis container. (~) Universal and/or sepazate male !female urinals. (~ Stair Chair - .... ,.. ..... Communications Equipment (~) All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving cleaz voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (~) ambulance service's dispatch (~j medical control facility or a physician (~-) receiving facilities (t.)•" mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (l.) Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (L) Protective eyeweaz. (L) Non-sterile surgical masks. (~) Fluid proof gowns with full-length sleeves or equivalent. (t.) Disinfectant spray or wipes for personnel and equipment. (~) Sharps containers for the appropriate disposal and storage of medical waste and biohazazds. (L) Particulate respirator, N95 type or better. Safety Equipment (~) A set of three (3) warning reflectors. (1.)' One (1) ten pound (101b.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous yeaz per NFPA 10 section 4. (tr) Child safety seat or equivalent (~) Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (~) Properly secured patient transport system (i.e. wheeled stretcher). (~-) Triage tags as approved by the Colorado Department of Public Health and Environment. (~)" Restraining devices for all items not in a securable cabinet. (1.) Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one inpatient compartment. (~Y Reflective vests, coat or equivalent for each member of the crew nom~ally assigned. :~L. n..t,li71'~:~,_ct;ihliSJ.:! ~ITIfl1V COUATY Application for Ambulance Permit Service Information ~ Service Name ~c.~.SC~~~ '~-1{~~r::~~ t- (t 2 1 ci ~E~:~k+~. ~ ~~s wf' Address 10`1 ~lti•.~-~,;~. C',,.\~:,~.~1c.+.\e- LC.. ~^I~:L- str«ue.o. city state Zip Communication '~(s}-c;(, ~S ~q-C~z.i Voice Vehicle Information Fax Radio Call Sign lti ~ E?C~CC~ ~ License Plate, VIN IG~~K~~i1~44 ~ i~tZ`i?,Ft 4X4 Yes( No ( ) Year r + .~ Z~CC~y Make `l~kv V Type Where will Vehicle be Waiver Request (Include Reason for Request) E-Mail 44 Inspection Fee $50.00 (~) Mechanical Condition Certificate Attached (L}" Required BLS Equipment List Attached (i r Required ALS Equipment List Attached (L Pass Inspection Nj Fail ()Reason for Failure Iaspector'a Name Signature Date Valid Insurance Card Yes M No ( ) Valid Registration Card Yes (i..)~No ( ) ~'ITlfIN COUNTY Vehicle Safety and Operability Certification Ambulance Service liSPi.Z ~,k Radio Call Sign McA~ ~ H`i Svstem Acceptable Non Acceptable Comment Tires 'f~l 1 Wheels 1~) ( ) Ali¢nment ~.) ( 1 Suspension ~G) ( ) Brake Svstem ~) ( ) PazkinQ Brake ~,) ( 1 Headlipltts ~) ( ) Stop/TurnBrake Lts~~) ( ) Visual Warning Litthts f`) ( ) Audible Warning ~:) ( ) Electrical Svstem ~) ( ) Exhaust Svstem ~:) ( ) Fuel System ~) ( ) Glass/Mirrors ~) ( 1 Bodv & Sheet Metal.) ( ) General Present Condition, Excellent~~Good ()Moderate ( )Poor ( ) Mileage when Inspected Z1Z~~1 I ~Stto~ ~ wYc,~t , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have fo nd them to m a safe and working con},dition1. l ~~ W31'~N I ~~d1Ai~ ~IIU ~Dl: Signature X71 Phone Address ~~ Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. ~777fINCOUATY Required Advanced Life Support Equipment List Inspector_ ~C c~ ~ ~-hw Date I I -~i) -~''~] Vehicle Radio Call Sign 1'4\ ~c\c~ ysj Minimum Equipment Requirement for Advanced Life Support Ambulances (~.}'' All Equipment Listed In BLS Equipment list Ventilation Equipment ('~j' Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0-8.0 per Physician Advisor protocol. (L} Laryngoscope and blades, straight, and/or curved of sizes 0-4. (=) Adult and pediatric magill forceps. (~-) End tidal COZ detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (~j Portable, battery operated cazdiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (1-) Electronic blood glucose measuring device. Iutravenous Equipment (iy Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (L) Adult and pediatric intravenous arm boards. Pharmacological Ageats (i.~'' Pharmacological agents and delivery devices per Physician Advisor protocol. (y Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for~,x,\~ 3 tC.,c•~ t=,: c.\ r~ z~~ir~. ~,'~c ~~~ I certify that this ambulance carries the equipment listed above. This ambulance meets the minimum requirements established by the State of Colorado and Pitkin County to provide medical care and transportation of the sick and injured at the Advanced Life Support level. ~~t-x~vcoulvr~' Required Basic Life Support Equipment List Inspector 5c ~'tl ~ '' ~~ ~-' Date 1 ~ - • (;~- (,~7 Vehicle Radio Call Sign i1~1 ec~~ t • -4 ~ Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (v) Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. O Bulb syringe. (y~ House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2-patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1-15 L.P.M. (l.Y Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P.M. (1~ Transpazent, non-rebreather oxygen masks and nasal cannulas in adult and pediatric sites. Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; (~ j SOOcc bag with transparent masks for infant and neonate. (~ 750cc bag with transparent masks for children. (la • 1000cc bag with transpazent masks for adult. (~.) Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (ta-• Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (~-j Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (1~" Stethoscope in adult and pediatric sizes. (ta- Penlight. (f~ Pulse oximeter with adult and pediatric sensors. z Splinting Equipment (a Lower extremity traction splint. (~) Upper and lower extremity splints. (~) Long board with equipment to immobilize the patient from head to heels. (t) Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (i) Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (:) Pediatric immobilization device or adult immobilization device that can be adapted for pediatric use. (/) Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (1.)' ~ Bandages -various types and sizes per agency needs and Physician Advisor protocol. (L) Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (L}' Sterile bum sheets. (~ Alcohol swabs or equivalent. (L} Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (~}~ Sterile imgation solution. Obstetrical Snpplies (~}' Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (y Neonate stocking cap or equivalent. Miscellaneous Equipment ~~'~ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (t~' Two working flashlights. (+.)' Blankets and appropriate heat source for the ambulance patient compartment. (!~) Ambulance Service Medical Treatment Protocols. (a Oral glucose. (t.)- Activated charcoal. (;,) Spill proof emesis container. (~}' Universal and/or separate male /female urinals. (~ Stair Chair ral c ;'_ ~ • ..... . Communications Equipment (y} All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving cleaz voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (~ ambulance service's dispatch (~ medical control facility or a physician ( ~) receiving facilities (iJ mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (~..)-" Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (~,.) Protective eyeweaz. (ia- Non-sterile surgical masks. (J Fluid proof gowns with full-length sleeves or equivalent. () Disinfectant spray or wipes for personnel and equipment. (t~ Sharps containers for the appropriate disposal and storage of medical waste and biohazazds. (q.) Particulate respirator, N95 type or better. Safety Equipment ('a A set of three (3) warning reflectors. (y" One (1) ten pound (10 lb.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (Uf Child safety seat or equivalent (t~" Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (~} Properly secured patient transport system {i.e. wheeled stretcher). (~)' Triage tags as approved by the Colorado Department of Public Health and Environment. (ti~ Restraining devices for all items not in a securable cabinet. Q.?'" Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one inpatient compartment. (~ Reflective vests, coat or equivalent for each member of the crew normally assigned.