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HomeMy WebLinkAboutbocc.con.072.2008CONTRACT #07,? ` O S" LICENSE AGREEMENT NO. °a< -2008 PITKIN COUNTY AMBULANCE LICENSE FOR: ASPEN AMBULANCE DISTRICT MEDIC 1, MEDIC 2, MEDIC 3, MEDIC 4, MEDIC 5 GRANT OF LICENSE/PERMIT The undersigned, representing they 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 Boazd pursuant to the provisions of Title Six (Health and Safety-Ambulance Licensing) of the 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 THIS LICENSE IS VALID FROM: January 1, 2008 through December 31, 2008. APPROVED BY THE PTTHIN COUNTY BOARD OF COUNTY `LP_~~s~Li~~ / ~ DOS MICHAEL M. OWSLEY, Chair Pitkin County Boazd of County Commissioners 33 ti M ~!TliilN COUNTY Ambulance Permit EMTAC Service Name ~ S p tot Ann "v -.Nac,~ ~srn.~eT Date Received L~FS,, i z 2cao, EMTAC Comments• ~ ~ti- EMTAC Recommendation: (~ c t_ i~~ ~~ PraS --~.. ~NSO~-.~„o R~ MG! Y7 ~-Q`(.1 Y~C1J 4l. c { AU- (o -~ 11 L1 ' S`Vj . AP1~*'~vco JNAN~MOVS .~~ tY`n e~l~N~/ 12.~ IZ.' o"' E AC Chairperson Signature: -~ ~ J^~-`Q'Pd ~, Date Referred to Board of County Commissioners: /~/~L/ o~.~.~ ~~~,~ ~ ~~: COu+1ty CCJOMM~>a~.v~4Li «'I{~~ i c7 Board Action Date Pi tkin County Ambulance Service Name ~sp~l Arv,-~ Innr• >•,, ~,Y,_e, Service Area: ASt,my (~,.~,a,, lam ,n, sxx r r=,,., ~ ~ar~,c-~ Full year Partial year Emergent _~ Transfer ~ Special Event_~ Number of Ambulances Licensed: Is this Service Licensed in other Locations? N List Locations: If other than Special Taxing District list Owners with Addresses and Contact Information: Physician Advisor; 1) n G>3 , S M~~~~ _ , Address: JtrcctlY.U. Ifox Ccl -Ip) Y;ity rq 1,~)state 7,in ASpc-~ ~ g Ilo 11 Contact Information: 5y~ _ ~ y ~...1 ~\,~~ _ „9 0 - - Voice Fax E-Mall Colorado Medical License Number: 3 Q ~T,3 I hereby certify that the information provided in this application is true to the best of my knowledge and belief and contains no willful 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 prosecution. Service Director's Signature: jam---~ (A J~~ 1 i ~ ~' o "~ ~ Date Physician Advisor's Signature ` , ~Z/~ ~i 7 M~~c. t PITKIN COUNTY Application for Ambulance Permit Service Information Service Name /~~~~ raM „~~« ,~ ~, ~ Address Q o S[reeVl'.O. ry~e~ City ~C~-I~) Sh[e zip Communication_ ~ ~{..{ _ 1 ~~ o ~ y.~ _ \ S ~ $ VUIeC Vehicle Information Faz E-Mail Radio Call Sign M t 1 License Plate ~ 1 ~ ~ ~a (;~ VIN ~_ F ~ ~ 1= ~ -~ ~ •-1 1 c~~ 1 15 S ~ 4X4 Yes ~ No ( ) ~'`ori~ 1~3$° Year z o a ~ Make p,~ c r-~,~ rh t w,~ Type .~ $I(o1\ Where will Vehicle be Stationed~M~ , iA ,t ,:, ~~ ga L o~~ ; ~~~ I ~~ ~~ iAso~; Co. 811( Waiver Request (include Reason for Request) R 1 C'Jl- l ~ l A K ~~ ~~~~[~1.+~ ~i~i IMrs 11 l~ °"( Servim Dmec[or's Name Signature Date (Ambulance Inspector Use Only) Valid Insurance Card Yes No ( ) Valid Registration Card Yes (~{ No ( ) Inspection Fee $50.00 1x- Mechanical Condition Certificate Attached ~' Required BLS Equipment List Attached (~[ Required ALS Equipment List Attached (~ Pass Inspection ~ Fail ()Reason for Failure Pi tkin County Required Advanced Life Support Equipment List Inspector ~ntc a~~.a.~.( Date l L e~~ ~ Vehicle Radio Call Sign~~,~r t Minimum Equipment Requirement for Advanced Life Support Ambulances J/~ 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 G.0-8.0 per Physician Advisor protocol. Laryngoscope and blades, straight, and/or curved of sizes 0-4. yj` Adult and pediatric magill forceps. End tidal COz detector or alternative device, approved by the FDA, for determining correct tube placement, Patient Assessment Equipment S~ Portable, battery operated cazdiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. Electronic blood glucose measuring device. Intravenous Equipment Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. Adult and pediatric intravenous arm boards. Pharmacological Agents )~ 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 AS ~l ~,4,;tiu „ ,~~ ni ,,.~., , 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. Service Director's Signature Pi tkin County Required Basic Life Support Equipment List Inspector ~~~ NON S~ Date / z/ rod ~ ~ Vehicle Radio Call Sign {h~,~~ 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 / 21mm fittings in the following sizes; f(~ SOOcc bag with transparent masks for infant and neonate. f/~ 750cc bag with transparent masks for children. /(~' 1000cc bag with transpazent masks for adult. f~ Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. ~,~J 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. Stethoscope in adult and pediatric sizes. Penlight. ~(%f Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment Lower extremity traction splint. ~j' Upper and lower extremity splints. ~' Long board with equipment to immobilize the patient from head to heels. (jJ 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. Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials ~(~f 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. ~(~' Alcohol swabs or equivalent. Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. Sterile irrigation solution. Obstetrical Supplies ,,(/j Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thennal absorbent blanket. /('~ Neonate stocking cap or equivalent. Miscellaneous Equipment Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. heat source for the ambulance patient compartment. ical Treatment Protocols. ~f Oral glucose. (a- Activated charcoal. /~' Spill proof emesis container. ~) Universal and/or separate male /female urinals. ~) Stair Chair Two working flashlights Blankets and appropriate f,/j Ambulance Service Med Communications Equipment ~Y 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 (/f medical control facility or a physician ~' receiving facilities 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 eyewear. V) Non-sterile surgical masks. Fluid proof gowns with full-length sleeves or equivalent. ,(rj Disinfectant spray or wipes For personnel and equipment. ~(/f Sharps containers for the appropriate disposal and storage of medical waste and biohazards. ") Particulate respirator, N95 type or better. Safety Equipment f,/f A set of three (3) warning reflectors. 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. ,~(~ Child safety seat or equivalent (/f Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. Properly secured patient transport system (i.e. wheeled stretcher). ( 'j Triage tags as approved by the Colorado Department of Public Health and '~ Environment. Restraining devices for all items not in a securable cabinet. ~' Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one inpatient compartment. L) Reflective vests, coat or equivalent for each member of the crew normally /` assigned. Pitkrrl County Vehicle Safety and Operability Certification Ambulance Service _ {~sa~ ~m;~viaNC,.~ t~ur,~,U Vehicle Radio Call Sign 11U.~:m ~ ~ System Acceatable Non Acceutable Comment Susyension (X) ( ) Brake System (xl ( 1 Parkinu Brake (~ ( ) Ston/Tum/Brake Lts. (Zq ( ) Visual Warning Lights (yam) ( 1 Audible Warning OCl ( ) Electrical System M1~1 r Exhaust System (k[} ( ) Glass/Mirrors ~Cl ( 1 Body & Sheet Metal (~ Ll General Present Condition, Excellent Good () Moderate () Poor ( ) Mileage w//hen /Inspec~te/d /~~8~ I, ~(~rl / AGuCI,c r , 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 be in a safe and working condition. Agency/Company y» ~~ ~s ~~s ,26 s~r,,,~-_ ~K~- ~z~P, ~~a-Q ~ Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance M t=om t c z- PITKIN COUNTY Application for Ambulance Permit Service Information Service Name (~I,~ ~t„~3ut~t..c~ ~tsrrz~c~ naaress C a As ~, 0 5Q~ Ca. Street/P.O. ~9 ~° \ City ~°~ Z a \ State Zip ~ ~ ~ \ 1 Communication 5 _ /tag ~ 7y~ _/\ 5~ g Voice Fax E-Mail Vehicle Information ~ci \o - ~V T. Radio Call Sign IYl ~ ~e Z License Plate u8~i - 13 E'C VIN ~ ~ D y,} ~ 3 7 F ~ LE.~3 3 a} 1 z3 4X4 Yes ~ No ( ) f~>zo F- 3 S~ Year z o o L Make Type Where will Vehicle be Stationed ~,~v~tJC~ a~sc ~y p~~Cras~lr--c~~yr,~ F~54~,~a. $Itn\i Waiver Request (Include Reason for Request) Service Director's Name Signa[u re Dale (Ambulance Inspector Use Only) Valid Insurance Card Yes QQ No ( ) Valid Registration Card Yes (~ No ( ) Inspection Fee $50.00 ~ Mechanical Condition Certificate Attached QQ Required BLS Equipment List Attached Required ALS Equipment List Attached (~ Pass Inspection,( Fail ()Reason for Failure rr~~n.sen IZ--~ _~~ Pi tkin County Required Advanced Life Support Equipment List Inspector ~tz~c_ ~An~s r~.~ Date i ~, ~ 1 Vehicle Radio Call Sign~~,~ z Minimum Equipment Requirement for Advanced Life Support Ambulances (i'j~ 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. Adult and pediatric magill forceps. ~(if' End tidal COZ detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment f~ 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 ~- Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. ~(~' Adult and pediatric intravenous arm boards. Pharmacological Agents Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for , I certify that this ambulance carries the equi ment listed above. This ambulance meets the minimum requirements established by the State of Colorado and Piikin County to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Signature =~ Date Pitkin County Required Basic Life Support Equipment List Inspector t'-rw Ns ti:~ Date ~ v Vehicle Radio Call Sign M ~, a 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. Bulb syringe. /(/f 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. 1~' Portable oxygen system with a minimum storage capacity of 15 c.£. (D cylinder) ,/ and a minimum delivery capability for 1-patient at flows of a least 1-15 L.P.M. J%J Transparent, non-rebreather oxygen masks and nasal cannulas in adult and ./ pediatric sizes. 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. ~ 1000cc bag with transparent masks for adult. Nasophazyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. Oropharyngea] airways in adult and pediatric sizes to include: infant, child, small adult, adult and large 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. ,(/~ Pulse oximeter with adult and pediatric sensors. Splinting Equipment ~) Lower extremity traction splint. ~} 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. ~(~j Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. (~f Adult and pediatric cervical spine and head immobilization equipment. /Dressing Materials yj Bandages -various 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. Sterile bum sheets. (~ Alcohol swabs or equivalent. Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. f,/j Sterile imgation 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 ~' Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. ~f Two working flashlights. /~') Blankets and appropriate heat source for the ambulance patient compartment. Ambulance Service Medical Treatment Protocols. ~' Oral glucose. Activated charcoal. Spill proof emesis container. ~` 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: ,(/f ambulance service's dispatch ~i) medical control facility or a physician ,(/f receiving facilities mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (/j Non-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ,(~) Protective eyewear. f~ Non-sterile surgical masks. (~- Fluid proof gowns with full-length sleeves or equivalent. (~ Disinfectant spray or wipes for personnel and equipment. ~(ij Sharps containers for the appropriate disposal and storage of medical waste and biohazards. ,(~ Particulate respirator, N95 type or better. Safety Equipment ~(ij A set of three (3) warning reflectors. ~" 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. f/r 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. }' 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. Prtkrn County Vehicle Safety and Operability Certification Ambulance Service ,_ cs l~rv~a.,1n+~~ ~_ x~ s rn,~~ Vehicle Radio Call Sign Mc.o« L Parking Brake (^~ ( ) Headlights (vl' ( 1 Sto~Tum/Brake Lts (~ ( ) Visual Warning Lights (Y ( ) Audible Warning (~ ( ) Electrical System (~ ( ) Exhaust System (~ ( ) Fuel System (~ ( ) General Present Condition, Excellent (~ Good () Moderate () Poor Mileage when Inspected 5 7 I, ~ fi. iyt,t' S L? I (~ 14YVV ,professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found..thooe~~m tw~o be in a safe and working conditionGG. //'' / Agcncy/Company 4-.~ljLa ~ 574s 7~O SP~~rre ~tni~cr' l°~3/~~ Phone Address ~5~~~«• ~~(r ~/ Datc This evaluation will not guarantee future safety and or operability of this ambulance M of 3 PITKIN COUNTY Application for Ambulance Permit Service Information Service Name ~~~. ~~ AM~J IAN c->= ~~Sm.ct ~ V - - L o streeuP-o. ~9l°)~ city (r1~°) state ~- 8+b~~ Zip Communication 5 `t~ - ~ 58 ~ ~'i ~t - 1 5 ~ 8 voice Fax F--Mail Vehicle Information Colt, - Y. tx,>,1 Radio Call Sign fV~~tc ?, License Plate O z5 A3 1 ViN j~ ~~ IG 3 e} ~-' g./ r O 3'i- 1 z° 4X4 Yes ~ No ( ) Year ~'~~ ~ ~ ~ 9~ Make~lccn ~~ , u a~a TYPe T Where will Vehicle be Stationed (~M3v~ ~aaicsxTOy-off CASTIr-C~mc Rn.AstcolG ~~bl\ Waiver Request (Include Reason for Request) Service DireROr's Name Signature Dale (Ambulance Inspector Usc Only) Valid Insurance Card Yes ~ No ( ) Valid Registration Card Yes (Xl No ( ) Inspection Fee $50.00 ~ Mechanical Condition Certificate Attached (~() Required BLS Equipment List Attached Required ALS Equipment List Attached ~j Pass Inspection Fail ()Reason for Failure ~ _~ Pitkin County Required Advanced Life Support Equipment List Inspector Ea, c ~ N~ c~J Date~i~ ,~ ~~ Vehicle Radio Call Sign (ham Minimum Equipment Requirement for Advanced Life Support Ambulances All Equipment Listed In BLS Equipment list Ventilation Equipment ~(iJ 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. ~ Adult and pediatric magill forceps. )' End tidal COZ detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment ~" 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 Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. Adult and pediatric intravenous arm boards. Pharmacological Agents } Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for ~p ~1.? 1\r~:tiv ~ v?ce< i'S ~ ~,-rc+c r , 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. b/ o Service Director's Name Pi tkin County Required Basic Life Support Equipment List Inspector ~., ISM s ~ Date ! ~ Vehicle Radio Call Sign~~o ~e 3 Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment ~ J' Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid phazyngeal 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 / 21mm fittings in the following sizes; ~(/s SOOcc bag with transparent masks for infant and neonate. (i) 750cc bag with transparent masks for children. ~) 1000cc bag with transparent masks for adult. Nasophazyngeal 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 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. fi)' Penlight. ~' Pulse oximeter with adult and pediatric sensors. z Splinting Equipment ,~ ~ Lower extremity traction splint. ,(~ Upper and lower extremity splints. ,(i~ 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. ~' Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials ~/f 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. ~j Alcohol swabs or equivalent. ~' 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, Two working flashlights. ~' Blankets and appropriate heat source for the ambulance patient compartment. ~~J Ambulance Service Medical Treatment Protocols. ~)' Oral glucose. Activated charcoal. (~ Spill proof emesis container. ~ Universal and/or separate male /female urinals. ~' Stair Chair scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. ~ Neonate stocking cap or equivalent. Miscellaneous Equipment ^{.~'" Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. Communications Equipment S 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: ,(/f ambulance service's dispatch medical control facility or a physician ~' receiving facilities (~ 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 eyewear. ~ Non-sterile surgical masks. Fluid proof gowns with full-length sleeves or equivalent. Disinfectant spray or wipes for personnel and equipment. ~~ Sharps containers for the appropriate disposal and storage of medical waste and biohazards. ~i~ Particulate respirator, N95 type or better. Safety Equipment A set of three (3) warning reflectors. )'~ 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. ,(~ Child safety seat or equivalent ~(~ Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. ,(/f Properly secured patient transport system (i.e. wheeled stretcher). ~' Triage tags as approved by the Colorado Department of Public Health and Enviromnent. (~ Restraining devices for all items not in a securable cabinet. /(may 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. Pitkin County Vehicle Safety and Operability Certification Ambulance Service Pc~~,~~„nn~~~n-c~ m,srtz.~cr Vehicle Radio Call Sign -~/1w ~t~~ System Acceptable Non Acceptable Comment Wheels (X) ( 1 Alignment 0~) ( ) Susaension (K) ( ) Brake Skstem (f'~yyU ( ) Parking Brake ~T) ( ) Headlights bC) ( ) r Ston/Turn/Brake Lts ~l (_) Visual Warning Li is (~ ( ) Audible Warning k1 ( ) Electrical System -~Q ( ) Exhaust System ~) ( ) Fuel System (X) ( ) Glass/Mirrors (~ ( ) Body & Sheet Metal ~Q ( 1 General Present Condition, Excellent () Good ~ Moderate () Poor ( ) Mileage when Inspected !~ /y `~•~~ I, ,~hhe~`~ ~~(/ o r ,professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems/and have found the to be •n a safe and working co-n~dition. Agcncy/Company Ldp Phonc Address -3a- Date This evaluation will not guarantee future safety and or operability of this ambulance PITK-N COUNTY Application for Ambulance Permit Service Information Service Name ~p~ IArvs3.~ (.ot1^.~ ~isxr~.eT Address C.`o (mss _• Jfa tr-,, 1~s~t~-r~L o~ot C,~aSV(~CAt~kR~ RsPc~ Co. q $'Itrs 11 StreetlP.O. C`+-1al City ~ 11°~ Sta[c Zip Communication jyy` _ i //S 8 c St-t ~-F - 1 S ~ P Voice Vehicle Information Faz E-Mail C~,la - ~.r r. Radio Call Sign~~ -o~c. ~ License Plate 5 z ~ A~11.1 VIN ~~,I3't'ie ~~, ~,.I Fo~elt5 4X4 Yes(xj No ( ) -r- cN~,ly Year ~q ci Make ~c~y iY~~(~~,dTYPe t. Where will Vehiclo be Stationed~~~rtt ~~ m`to 3 CAS~ic.Crics~ Rid, !~p=.W ( e'~1l Waiver Request (Include Reason for Request) ~~aa flame ~ Signature (Ambulance Inspector lse Only) Valid Insurance Card Yes Q(j No ( ) Valid Registration Card Yes (X} No ( ) Inspection Fee $50.00 ~1Q Mechanical Condition Certificate Attached Required BLS Equipment List Attached Required ALS Equipment List Attached Pass Inspectioli'~ Fail ()Reason for Failure oate `t Pi tkin County Required Advanced Life Support Equipment List Inspector,, rate i-1~ ti ~~l Date / Z- ro ~-7 Vehicle Radio Call Sign M ~~~•-K 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. k"S Laryngoscope and blades, straight, and/or curved of sizes 0-4. Adult and pediatric magill forceps. k=) ~ 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 y ~ Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. ~if Adult and pediatric intravenous arm boards. Pharmacological Agents ~(~f Pharmacological agents and delivery devices per Physician Advisor protocol. ~(~ Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for ~Sn,~ J~n~ ~v~.+rn- -~~ ~~`c r- _~ I certifythat 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. Service Director's Name Signature "Date Pitkin County Required Basic Life Support Equipment List Inspector ra,c ~N cal Date -L ~ a Vehicle Radio Call Sign M Laic. T Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment ,(•'j~ Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid phazyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. Bulb syringe. f/j 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 ]east 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 / 21mm fittings in the following sizes; {f f SOOcc bag with transparent masks for infant and neonate. ~j' 750cc bag with transparent masks for children. (ij 1000cc bag with transpazent masks for adult. 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. Stethoscope in adult and pediatric sizes. (, )~ Penlight. Sjj Pulse oximeter with adult and pediatric sensors. Splinting Equipment Lower extremity traction splint. (/S 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. ~(i)` Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. f~' Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (~' Bandages -various types and sizes per agency needs and Physician Advisor protocol. Si} Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. r(~j' Sterile burn sheets. (~ Alcohol swabs or equivalent. Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. XS 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 ,(iJ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. ~(i) Two working flashlights. fif Blankets and appropriate heat source for the ambulance patient compartment. Ambulance Service Medical Treatment Protocols. ' Oral glucose. (~ Activated charcoal. (~' Spill proof emesis container. /~ Universal and/or separate male /female urinals. 1/) Stair Chair Communications Equipment l(~j 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: ~if ambulance service's dispatch ~(if medical control facility or a physician (/) receiving facilities ~' mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; ,(/j Nan-sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. Xf Protective eyewear. Non-sterile surgical masks. ~" Fluid proof gowns with full-length sleeves or equivalent. ,(~ Disinfectant spray or wipes for personnel and equipment. ~/f 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. ,(if 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. ~ Child safety seat or equivalent J~~' 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. ~' 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. PitJ~in County Vehicle Safety and Operability Certification Ambulance Service Agp~-ol Ar~,w~~,« iDtsrruQ,~ Vehicle Radio Call Sign M~~...~. Svstem Acceptable Non Acceptable Comment Tires Oq ( ) Wheels ~l ( ) Alignment ~C) ( ) Suspension [~ ( ) Brake System (~1 ( ) Parking Brake (~ ( ) Headlights ~ ( ) Stop/Turn/Brake Lts. {xl ( ) Visual Warning Lights ( ) Audible Watnint~(~ ( ) Electrical System ~ ( ) Exhaust Svstem 4C) ( ) Fuel Svstem (~ ( ) Glass/Mirrors (1 ( ) Body & Sheet Metal (K) ( ) General Present Condition, Excellent () Good ~ Moderate () Poor ( ) Mileage when Inspected ~L/~~ //. I, er~- ~G,i(~G'~ , professing to be a motor vehicle tec tician with tratntng in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. t ~ vtT 5' n~atfure -7/ ` ~y[ / / ) Agency/ omp/an7y 'J Phone Address ~ Datc This evaluation will not guarantee firture safety and or operability of this ambulance PITKIN COUNTY Application for Ambulance Permit Service Information Service Name ~S~ ty ~rY~3y l,aly` .z ~~,cttz. o a- Address r..l~, ~sp~l ~ ~,~, dos~,rwL o~~l WSr1~. CX~Cf-a.~ R~• /ASOr3v C;V. Sl~.ll S[reef/P.O. \~ 1 a) City ~ 1 ~l? ~ State Zip Communication S't~t - l S 43 0 ~~-t `t - 1 S 7 g Voice Vehicle Information Fas E-Mail Cob -- P, r,c,r~ Radio Call Sign IY~ ~ ~c, 5 License Plate ~{ g .~ ~ 3 v VIN (Gtr T1~~i H N Z fLE.Zt S~9 ~~ 4X4 Yes ~ No ( ) CND ~ Year (~ 4 Make l.,) N c-r1.~ Cr~raul Type ~ Where will Vehicle be Stationed Brno ~ y~y Aar p~} v ~ (t~Tli- CA~ed~ lye ASO~., C-Q. `r-'.[till Waiver Request (Include Reason for Request) Srrvice Director's Namc Signature (Ambulance Inspecmr Ilse Only) Valid Insurance Card Yes ~ No ( ) Valid Registration Card Yes (~(} No ( ) Inspection Fee $50.00 ~ Mechanical Condition Certificate Attached (~ Required BLS Equipment List Attached Required ALS Equipment List Attached Pass Inspection ~~) Fail ()Reason for Failure Uate Pi tkin County Required Advanced Life Support Equipment Ltst Inspector t='rttc . I,I-~NSr~,~ Date ! ~-1e~ ° ~ Vehicle Radio Call Sign M~.~ ~ Minimum Equipment Requirement for Advanced Life Support Ambulances ~if~ All Equipment Listed In BLS Equipment list Ventilation Equipment (f f 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. Adult and pediatric magill forceps. End tidal COz detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment X)' 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 L ~ Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. ~(/~ Adult and pediatric intravenous arm boards. Pharmacological Agents (/f Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for ~~a' cal Mn3vt~~(,~- ~n ~ srre.rc.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. Service Director's Name ~ Signature /'-~ ~ ~° 7 Date Pitkin County Required Basic Life Support Equipment List Inspector ~ c i-1.~ TJ s~ Date i ~-f e Vehicle Radio Call Sign [h~,~.. 7 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 / 21mm fittings in the following sizes; ~/j SOOcc bag with transparent masks for infant and neonate. (/S 750cc bag with transpazent masks for children. ,(~ 1000cc bag with transpazent masks for adult. ,(if Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. ,(/f Orophazyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and lazge adult. Patient Assessment Equipment ,(~' Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. ~~ Stethoscope in adult and pediatric sizes. Penlight. ~~ Pulse oximeter with adult and pediatric sensors. z Splinting Equipment ~) ~ Lower extremity traction splint. ,(~j Upper and lower extremity splints. ,(i~ Long board with equipment to immobilize the patient from head to heels. ,(/j 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. Xj Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials Bandages -various 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. Sterile burn sheets. ,(/f Alcohol swabs or equivalent. ~i~ 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 [ape or cord clamps, ~ scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. ~/} Neonate stocking cap or equivalent. Miscellaneous Equipment Heavy bandage scissors, sheazs or equivalent capable of cutting clothing, belts, boots, etc. Two working flashlights. ~f Blankets and appropriate heat source for the ambulance patient compartment. ~(if Ambulance Service Medical Treatment Protocols. ~(/f Oral glucose. Activated charcoal. ~' Spill proof emesis container. ~f f Universal and/or sepazate male /female urinals. (y 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: (if ambulance service's dispatch (~j medical control facility or a physician ~j receiving facilities (/ mutual aid agencies. Body Substance Isolation Properly Sized To F5t 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 eyewear. !, )' Non-sterile surgical masks. Fluid proof gowns with full-length sleeves or equivalent. Disinfectant spray or wipes for personnel and equipment. /(•-) Sharps containers for the appropriate disposal and storage of medical waste and biohazards. Particulate respirator, N95 type or better. Safety Equipment O A set of three (3) warning reflectors. ,(rj~ 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. 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. ( 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. Pitkin County Vehicle Safety and Operability Certification Ambulance Service P~sr~t 4. z ,- ~~ ~_~_- Vehicle Radio Call Sign 61 ~+~ c System Acceptable Non Acceptable Comment Wheels CSC) ( ) Alignment fry ~) Suspension (~ ( ) Brake Svstem Q9 ( ) Parking_Brake PC) U Headlights (X) ( ) Stop/Tum/Brake Lts hO O Visual Wamin~ Lights OC) ( ) z.5 I ~n r.'S. General Present Condition, /Excellent () Good Moderate () Poor Mileage when Inspected 8/ ~~ I, ~~~,~r~- / 6tLV~l tr ,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 be in a safe and working condition. Phonc Address Date Tlus evaluation will not guarantee future safety and or operability of this ambulance Fuel Svstem (rQ ( ) Glass/Mirrors (k) O -- Body & Sheet Metal Oq ( 1 X37(1 h20 _5765 76 .`kry«e. ~n~-- !2P l0 ,~,5~07