HomeMy WebLinkAboutbocc.con.056.2003 LICENSE AGREEMENT NO. 056-2003
PITKIN COUNTY AMBULANCE LICENSE FOR:
BASALT 7 RURAL FIRE PROTECTION DISTRICT MEDIC
41, MEDIC 42, MEDIC 43, MEDIC 44
GRANT OF LICENSE/PERMIT
The undersigned, representing tile Board of County Comtnissioners of l~itkin County,
Colorado, do hereby grant a license to the above named applicant to provide ambulance
service within Pitkin County. Fhis license shall have upon it any restrictions listed
below, shall be granted ally waivers listed below, and shall be valid ['or ihe dates lislcd
below, unless revoked hy Iht Ihmrd pllrsttallt Io Ihe llrt~vision {DJ' Pitkin ('mini?
I~cs~luli{m r',h). 87-7 and any ',q~plicablc laws tll' Ihe 51ate ~1'( '~lm':tth~
I~ESTRIC'TIONS:
WAIVERS GRANTEI):
Tills LICENSE IS VALID IrROM: .lanuary I, 20(13 th]'m~gh December 31. oF 2003
Al)PROVED BY THE PI'YKIN COLINI'¥ BOARI) OF COUNTY
COMMISSIONERS ON
March 26, 2003
J)gc,,lk Hattield, Chai~han
PiPkin County Board of County Commisisoncrs
?.;TKZ CO
APPLICATION
FOR
AMBULANCE SERVICE LICENSE
GENEIL&L INFOPC,I:*,TION
I
ST~ET*O BOX CIW srA% ZIP CODE
O~cc Co--un,cations: ~7~ .vo~c~7~'t - c ~.y .- f~,'.FAXZ~'t- c~ ~.~-
Service D[:ector:._]~i~-
N:nber oc,~_bul~nces_,~ Licensad: ,
PHYSiCiAN ADVISOR !NFO~3!AT!ON
ST~,~O BOX C~f ~ STA~ ZIP CODE
5ce Comm,mnicadons: ~ 70- c,'/~s- - &-~'--~ Y
VOICE FAX E -MAIL ~ ~_N'~
I hereby certify that the information provided in this application is true to the best of my knowledge and betief and
contains no willful misrepresentation or falsification. Determination that -" ,t }-,,t~ "~ Se,'wice License has been issued
on false inf°rmaii°n__7 ,~ ~ ~_.., ,t~c°nstitutes grounds for license revocation, suspension of oqerations and possible criminal prosecution.
SERVICE DI~OR'S SIGNATU~ / D~TE ' 'DA~
([OR E~s COeVaL USg
Date Received: .t I / 5'/a ;t__ >_?.bulance Permits A~ached:
EMS Comncil Co~ents: ~
.,~%IS Council Chal~erson Signatm-e: ~ . ~ (~:~
~ / NAME DA~
u~ Refe~ed to ~oCC: BoCC Action: Date:
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE INFORMATION
STREET/PO BOX CITY STATE ZIP CODE
Office Communications: q'7o- 7o't -~:,'Z~-- 7So- ?o,~
VOICE FAX E-MAiL ~TERNET
5HICLE INFORMATION
Designation: )~lt~,,.- q~l License Ptate:_~ESW ~')o VINe /~]~]/x~kL'× .~-
Insurance Company: fl}pets ~-7' T~x &,L.,.[3 Policy Number: ~0'2.,SL3 7 ~c-. I Expiration:
STRZ~r,~O BOX C~ ST*~ ZW
, ~OUEST FOR 'W.MS~R (include re.on for request)
)
SERVICE DIRECTOR'S SIGNATURE DATE
(ZOR $,,~t'~L'L^~CS ~,'~S~ECTOa'S t'SZ OSL'O
Clear CCIC: ClearNCIC:__ Insurance Card Present:" Registration Card Present: '--
x/ Permit Fee Attached
,,/ Basic Life Support Required Equipment List Aaached
>' Mechmscai Condition Certification Attached
y Advance Life Support Provider Requi.r.ed Equipment Certification Attached
C o mine nts/'Rec orm'nendatio n:
PITKIN CO UIIT
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
Diagnostic:
)~ Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes.
3. Stethoscopes in adult and pediatric sizes.
'~' Pulse oximeter oath adult and pediatric sensors.
Immobilization & Splinting:
'/.' One lower extremity traction splint.
y. Upper and lower extremity splints of any type (vacuum, air, SAM, ~4re, board, etc.)~
,,y Long spineboard, vacuum mattress or equivalent with appropriate accessories to Lmmobilize patients
from head to heels.
¥ One orthopedic stretcher (scoop).
~ _ Short spineboard. KED or equivalent with appropriate straps to immobilize patients from head to pelvis.
y_ Pediatric :;pineboard or adult :;pineboard adaptable to pediatric use..
Y~ Ad,dr and pediatric sized head immobilization equipment for each long spineboard an&/or scoop stretcher
carried.
~ Rigid cer%cal immobilization collars in tall adult through infant sizes.
Wound Care:
Y,. Bandages, including but not limited to, roller gauze, tNangular and el~tic per agency needs.
~ v D,~ssmgs, including but not Emited to, a'am"na, ABD, gauze, occlusive and bandaids per agency needs.
Sterile burn sheets.
./ Povidone and alcohol swabs or equivalent.
Adhesive tape, includLr~g but not limited to, I" and 2" per agency needs.
Sterile irrigation solution.
~ Ostetrical Supplies:
x~, Sterile OB kit to include: towels, 4x4s, mmbilical tape or cord clamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
'~' Silver Swaddler and stocking cap or equivalents.
i~ection Control:
'3' Exam gloves in small, medium and large sizes.
x,,/ Face and eye shields.
)c~ Fluid-proofgowns wi~ full length sleeves or equivalent.
"~ Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
Oral glucose.
Activated charcoal.
Heavy duty bandage scissors or shears capable of cutting ~ : ~,
,.,ot~h,n=, belts, boots, etc.
Spill-proof emesis container with at least 1 liter capacity.
universal cr separate male and female urinals.
-4 MultMevel. wheeled gumey
Blankets. ,
% Patient compartment heate,.
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUIPMENT
,~. One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been
serviced within the last year per NFPA 10 Section 4.
One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced
within the last year per NFPA 10 Section 4..
Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
Set of 3 reflective warning devices.
-/ One reflective vest, coat or equivalent for each member of the crew normally assigned.
y_ At least one "SHARPS" container, clearly labeled -and easily accessible in the patient compartment.
_ Restraining devices for all items not in a securable cabinet
F~.aSIF,,i~ WARNING EO UIPMENT
Audible war'rting device (siren) with at least 2 different tones.
Visual warning devices (lights) wSth alternating red ~nd/or blue tlashing or ro~:ing visible from al! sides
simultaneously ~_nd clear flaslfing or oscillating visible from front.
COMMUNICATIONS EOUIPMENT
') .~ Mobile VHF radio ;~th appropriate 5~ate, Pitkin Count)' and individu~ agency frequencies.
'7- Mobile UHF radio with appropriate State, Pi'g. in Count)', hospital ~md individual agency frequencies.
,,, Portable radio with charger and/or celiut~ phone for back-up communications ,,,,5th dispatch and
hospitals.
.4EDICAL' EQUIPMENT AND SL~PL[ES
Aim'ay:
Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction
tip with sizes from 5 Fr. to 14 Fr.
Portable suction system ,,,,5th wide bore tubing, rigid phar!'ngeaI curved suction tip and soft catheter
suction tip with sizes/'rom 5 Fr. to I4 Fr.
~ Bulb Syringe.
¥' Nasopharyngeal airways in pediatric and adult sizes.
,¥ Oropha_D'ngeal airways in pediatric and adult sizes.
)c Bite stick or equivalent (oropharyngeal airway).
Fixed oxygen system with a minimum storage capaciLy of 125 cubic feet (M cylinder) and a minimum
deliver')' capability for three patients simultaneously at flow's of at least I-15 LPM.
Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) mad a minimum
deiivew capabiiiW for one patient at flows of at least 1-15 LPM.
X Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks.
.... K Adult Bag.-Vaive-Mask with 1000cc bag, reservoir and adult mask.
**Al! mask anachm .... s m,st be 15md,**
) )~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows o£ at least 1-15
LPM. ..
?ITE ¢O ENZT'
ADVANCED LIFE SUPPORT PROVIDER
RE QUIRED EQUIPMENT CERTIFICATION
REQUIRED AI,S EOUIPMENT
1. All equipment a~xd supplies listed on the B~ic Life Support. Required Equipment List.
2. Pediatric diagnostic equipment, age/weight"vita! signs ch~'t and d~ag dosage/equipment size Iist.
approved for this mmbuI~ce
......... s~,o. :~ummenr ~nd :,~pphes ~ -~-h..n~d m mea~.:at ~rotocols
) approved fh, r al:i: mmb. ul~ncc
~ )m,,'addidonafequipment~nd ~ ,- 'i~ ~ ~ to , -
" - ouspL~S n~deu pe~o~ ofiner proced-~-es ~ auLnonz~d in medical
protocols approved for ~2s ~mbutmncs sec'ice.
As Phyaici~ Advisor for_. ~ ~ ~ - ]~z-~Z ~., I ce~i~' ~at this ~buI~ce
c~es ~e equipment ~nd supplies listed above ~d meets $,e' minim~ requirements, esmb!ished by
of Colorado ~nd Pitkin Cc, runty,
Adv~ced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-7I %6,
Section 4 "Medical Acts Allowed EMTs mhd Pm-remedies."
~, ~ .~" ~ ~ ./
P~'SICL&N ADVISOR'S S [GNATU ~ COLO~&~ MEDI~t~ mc 'c '
.... LL~NoE NUMBER DATE
PITKIIV CO U. WTY'
V :HtCLE s. wT¥. xs Omm_ BtLITy
CERTIFICATION'
I ' SYSTEMS ACCEPT_ABLE I NOT ACCEPTABLE COblMENTS
~ Wheeis& Tires ~
Alignmen~ ~ ~
Suspension ~ ~
Se~'icc Brakes ,~
Pm-kin ~ B r~e .~/
Driving Lights .~ ]
Visual W~nz q,.'~-~ '
Audibie Wa~ng Systems .~ ~
E1ecudcal System ~~
2~aaust System ~ ~
Fuel System .~ ~
GI~s, Minors ~ [
Body & Sheet Metal ~ ~ ,
Y ' . -' ove, nave evaluated the condftion ofuhese systems on tine a~mbulance indicated above and
de,,:-mm~d ~is a-mbula,nce to be in safe operating condition. This evaiuation does not wa'-rantee the ~tx.u-e
safely aa4/or operability of this ambulance due to conditions beyond my controI.
AGENC]','C0:.,PANY PHONE NUMBER DATE
)
PITKIN CO U:VTY
APPLICATION
FOR
A_MBULAxNCE VEHICLE PERiMIT
SERVICE INFORMATION
S~ET~O BOX Cl~ STA~ ZIP CODE
Office Ca~ications :_ ~7o-- Zoq- ~.~.~ ~Zo-- 7o~-o~
]HICLE INFORMATION
VeMcle Location: :_~ ~g 0-~, be,c~ C~b.-~)~.~ co ~tb~ .~'~
S/~ET/~5 BOX C~f ST.A~ ZiP CODE
~OUES'F FOR Xt'AJVER (include r~on u~. ~u-o0
SERVICE DIRECTOR'S SIGNATURE ' - DA~E
{FOa X.~St'L.~,',C~ ~xs~zcroa's USE OXL~
Clear CCIC:~ Cie.ar NCIC: Ins,x~ce C~d Present: / Regis=afion C~d Present:
~ Pe~it Fee Anached
X B~ic Life Suppo~ Required Equipment List Attached
Mecnmmcm ~onaition uemricauon A~ched
'~ Advmnce Life Su~on Provider Reauired Ecui~ment Certification A~ached
Comments,~ecom~men~tion:
~ S P ECTO,~$ SIGNATURE .... ~][m~ON DATE
?tTKLs, r ¢0 UI'CTY
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
M C~UI~MENT .AND SUPPLIE~
Diagnostic:
..'%.
-- 'ti Blood pressure cuffs in large adult, reaular adult, child, infant an~neona'~ sizes
'w Stereoscopes in adult and pediatric sizes.
/' Pulse oximeter with adult and pediatric sensors.
Immobilization & Splinting:
).' One lower extremity traction splint.
~,- Ur=er and lower extremity s<;-t~ e .
'- . s ....... o: any ~pe (vacumm, a,.r. q a t,..4 ,Mre, board, ~*,- h
¥ Long spineboard, vacuum ma~a-~, ess or e~uivalent ~-iLh a~$ro~ria:e accesso~es ~o ;mmab;I;~,~ aatients
from head to heels. - ............
',~ Or.e orthopedic stretcher (scoop).
.... ~_ Shox spineb oard. }LED or eouivalent with appropriate strap~ to imm,~ ~;I; .... ,-~].,t.,/'rom head to
_ X' Pediatric sp ne ~ x~r:t or a;:h_r[t ::pineboard adar~table to pedia!dc use.
._'x_Z_~ _ Adult and peciiaaqc sized head i:nrp, obiIizatior,, equipment ~' _
~o, each lea,, spineboard m~d.'or scoop stretcher
c~wied.
'" Pdafd cea'lout i:mmobili2tion co!l&-s in tail ada> bm,eh ' '
~ ., t .... ~.- mxaq~ sizes.
Womnd C~e:
·' .... = ~ ....... a ,o, roi er <a~. un~n~m!~ ~nd et~tic per
' - ' - ~s~-~cy needs.
m. Y Dressings, includin2 cut :sot limited to. a-aroma ABD, ~,,~ occlusive and mnd~u~ vet ',~ -- needs.
~.~ _ Povidone ~d alcohol swabs or equh'M~nt.
~.~ AdheMve ~pe, including but ~ot limited ~o, [" ~d ~" p. =,n~:
_~__ Stefie i~gation solution.
~ ostetNca[ S upplies:
~: ~ SteN!e OB kit to include: zo',~ els, 4x4z, mmbiiical ~ase or cord cI~ps, scissors, bulb <vN~,~e
bt~et a~d steele gloves. ' -. --=
~ Silver Swaddler ~d stocking cap or equivalents.
~mecuon Control:
. ~ Ex~. gloves in small, medimn and la-ge sizes.
~: Face and eye shields.
~ Fluid-proofgo~s %5~ Pall length sleeves or ecuiv~ent.
~ Disinfect~r spray or wipes for perso~el and equipment.
L{iscellaqeous:
~ Oral glucose.
Y ,~ctiv&ed ca.coat.
.~ _ Heavy duty band~=e ~ ;
~ oc o~s or shears ca=able of euxine clo'h:~= belts. '
' ~ - · ' - = --s, ooo¢a, etc.
~ Sp~li-mroor e~s;¢ c~-~=;nor v.x{h at ;==-, ~ liter capacltv.
~' _ uaiversai or sepa-ate male and female annals.
- ~Muiti-levei. wheeled g~ey
Blankets.
. ~ _Patient comp~ment heater.
PITKIN CO UAGC'Y'
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAEEIS~OUIPMENT
x One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient corrmar~ment and havin~ been
serviced w-ithin the last year per NFPA 10 Section 4. ' -
,/ One 5 lb. or larger ABC fire extinguisher, accessibie from outside the vehicle and having been seN'iced
within the last yem- per NFPA 10 Section 4..
',-' Two "NO SMOKING-OXYGEN FN USE" signs, one in cab and one in patient compartment.
~- Flazhlight, 2-D cell equivalent or better wSth spare bulb and batteries or charger.
~ Set of 3 reflective warning devices.
k One reflective vest, coat or equiw.!ent for each member of the crew no~altv azsianed.
~ :,[ least one ot-L-xRPS container, clemqy labeled m~d easily accessible in the patient compartment.
sc. Resuraining devices fbr all itzm.~ not in a securable cabinet
~ Audible warming device (siren) with at least 2 diff:erent tones.
__~:_. Visuxl wmming devices (light:) with ~tem~ting red m~d."or blue flashing- or rotating visible from al! sides
simuhmqeously and cle~ fi~tfing or oscillating visible from front.
EOMMUYlCAT['ONS EOUfPMENT
?..~J, Mobile VfC~ radio '-Sd: appropriate State, Piffqin ComnU' ~qd individu~ a:encv ffeouencies.
Mobile UHW --~'
.... ~,~ wdth appropffa:e Sears. Pidgin Comqb-, hospimt &qd [ndivid~l a~encv frequencies.
M Po~ble radio wi~ char=er mn&'or ceiiu!~- phone for back-up co~mm-Scations ~5~ dis=arch mhd
hospim!s.
,[ED!CAL EQUIPMENT AND SUTPL!ES
Fixed suction s','srem with v, Sde bore tubing, Ngid ph~,'ngeal c~,'ed section rid ~d
tip x~Sth sizes from 5 Fr. to t4 Fr.
~ _ Potable suction system ~4th ~;Sde bore robing, rigid ph~D.ngeal c~,'ed suction tip ~d so~ cauheter
suction tip wi~ sizes ~>om 5 Fr. to 14 Fr.
~ Bulb Sy~nge.
_ ~ Nasoph~o'ngeai aid:vaTs in pediatric mhd adult sizes.
k Oroph~ngeal ai~vays in pedia~c mhd adult sizes.
~ Bite stick or equivalent (oroph~D. ngeat aim'ay).
Fixed oxygen system x~ith a minim~ storage casacirg of I25 cubic feet (M CTlinder) mhd a mi~fmmm
deliver' capability for iF:es patients simultmneo~slv at flows of at le~t I-15 LPM.
~ Po~able oxygen system wSth- ; '~,,
- ~ ~ re.nh,mm stora<e ca:aciw of 15 cubic feet (D c,li,d~) &nd a ' ; ,,~
deiiveo' capa~!iIU' for one patient at flows cf at le~t 1-15 LPM.
_ ~'~ Inf~t Bag-Valve-M~k with 500cc bag, rese~'oir &qd newborn, imc~t ~qd child m~ks.
~ Adult BagrValve-Mask with 1000cc bag, reset'elf mhd adult m~k.
.................. , ..... must be 1 Ewe,**
~ Oxygen masks &qd c~nulas .. '
c==aole oCdeliveNnz oxygen to adults ~d insets az l~ows oS at le~t 1-1 5
PITKIN CO U/gT
ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
REqO [ri_RED A 1,,¥ EOU!PMENT
1. All equipment and supplies listed on the Basic Life Support Required Equipment List.
2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list.
? ,x& Ir, ~,, JtaLn~ &,nd neo-nata! v,~c~n_r ~c.~.-~, .,u?vh~s and cquh, n.~nt as
approved ibr this ambulance seD'icc.
as authorized in medical protocols approved for ~fis mmbul~nce se~'ice.
L Phm-macological agents and admipSszra[ion eqxipment and ': ~ ....
--, .upv ....~ ~ufi:ofized N medical ~rotocois
) approved fl0r d~is mbulmace ser,'ice.
7. ,,Xmy additional equipment and supplies needed to pe~oml other proced:~-es as aufi:ofized in medical
protocols approved for dais ~bul~ce se~'ice.
carries the equipment and supplies listed above aid ineets the' minimum requirements, established by the State
of Colorado and Pitkin County, to provide medical care and k"ansportation of the sick and injured at the
Advanced Life Support level. Provision of Advan, ced Life Support is limited as descNbed in $-CCR-7i 3-6,
Section 4 "Medical Acts Allowed EMTs and Pazamechcs.
PH~r'SICIAN ADVISOR'S SI~-NATL'RE "'::' ·
COLORADO MEDICAL LICENSE NUMBER DATE
//
PITKIN COUNTY
VEHICLE SAFETY .~ND OPERABILITY
CERTIFICATION
Ambulance Service N~e:.~.g ~gZ-~ac,~ License Plate: ~bul~ce N,=ber: }}~-~
["' SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS
Alignment
Suspension .~,-
Pz~king Brake
Driving Lights
Visual Wa~ng Systems
AudibIe W~ing Systems
Elec~cal System
Exha~t System
Fuel System
GI~s, bli=ors
Body & Sheet Metal
I, ~__~/a.P__~ 'L_o'w-a~ tf~P... ., professing to be a motor vehici: mechmnJc ;;4th training in ail of the
systems listed above, have evaluated the condition of these systems on the mmbuJance indicated above and have
determined this arnbula-~ce to be in safe operating condition. This evaluation does not wmwmntee the future
safety an&/or operability of this ambulance due to conditions beyond my control.
E 'AGENCv/COMPA"Y PHONE NUMB£R DA~-E
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
ST~ET/PO BOX Cl~ STA~ ZIP CODE
Office Con~ications: C?To-- -7~ - ~, 7 ~
vom~ FAX s-~,am n~r~r~'
;HICLE INFOmMAT[ON
~o a~ '--'q cm¢ J ' STATE zip CODE
.)~O UEST FOR WAIVER (include reason rbr
SERVICE DHLECTOR'S SIGNATU~ DA~
FOR AMBULANCE INSPE~OR'S USE
Cie~ CCIC:~ Cie~ NCIC: ins~ce Cad Present:
x Pe~it Fee Attached
B~ic LiSe Suppo~ Required Equipment List A~ched
Mechm<cM Condition Ce~iEcation Attached
Advice Life Suppo~ Provider ~equi[.ed Equipment Ce~ification Attached
Comments~eco~mendation:
· ' ' ~' ~P'E:-"~'¥xSIGNATUKEu~ ,u,~ ~ DATE ' '
:' --POSITION
PITKI f CO UiWI
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
~ EOUIPMENT AND SUPPLIES
Diagnostic:
k' Blocd pressure cuffs in large adult, regular adult, child, infant and neonatal sizes.
'~' Stethoscopes in adult and pediatric sizes.
~ Pulse oximeter with adult and pediatric sensors.
hmnobilization & Splinting:
¥ One lower extremity traction splint.
+ Upper and lower extremity splints of may type (vacuum a;,', Sadvl wir
"4' [.OrVr ' e ~ ' " ' - " '. ' ~' .~'"' .... ;'
~ ~ spin board, vacuum mare-ess or eqmvalent x~xd~ appropriate accessories to inmmobiliT~
tram head to heels. . "
' ~ ()ne orttnopedic stretcher (scoop).
_ '/ _. Short spincboard, ~LED or equivalent wid~ appropriate straps to .mmob, i::a patients from head to pdvis.
.... '~/~__.. P~diatric spine )o:u-d or aduh spincboard adaptable to pediatric cam
Adult and pediatric sized head immobili~tion equipment fbr each Ion,= spineboard ~O'or scoop stretcher
carried.
_ V Rigid cervical ~mobili~fion collars in t~l aduIt t~ough in~.t sizes.
Wo~d C~e:
B~dages, including but not limimd to, roIIer gna=t, kSangulm- ~nd el~tic per agency needs.
Dressings, including but not limi:ed to, trx~m ABD, gauze, occlusive and bandaids pst agency needs.
Sterile bum sheets.
~ Povidone ~d alcohol swabs or equivalent.
X Adhesive rope, including but not limited to, i ~d = per a~encv needs.
.~ Sterile i~gation solution. - '
~stetrical SuppIies:
~ StcA!e OB kit to include: rowels, 4x4s, mmbiiicai tape 0r cord clamps, z.zissor~, bulb syringe, ste~e
bl~et and stcfile gloves.
~ Silver Swaddter ~d stocking cap or equiv~cnts.
in~ction Control:
~ Exm gloves in small, medimn ~d l~ge sizes.
Face and eye st~elds.
FI~d-proofgo~s w5~ ~I1 length sieeves or eouivalent.
Disinfcct~t spray or wipes for perso~el ~d equipment.
Mis'cell~eous:
X Oral glucose.
~ Activated
~ __ Heavy duty b~daze scissors or she~s capable ofcuuing clofifing, heirs. '
~ Sp'h-proofemesis container ',vkh ar least i liter capacity.
~ unR'ersa[ or sep~ate male ~d female urinals.
m Muhi-ieve wheeled g~ey
Sta.r chafr or equiv~Aent.
~- Blankets.
~* _ Parent ccmp~ment heater.
PITKIN
BASIC LIFE SUPPORT
fLEQUIRED EQUIPMENT LIST
-~kEEff_Y_EO UIP MENT
One 2-1/2 Ih. or larger ABC fire extinguisher, accessible from the patient compartment and having been
ser~'iced within the last year per NFPA 10 Section 4.
One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been seN'iced
within the last year per NFPA 10 Section 4..
Two "NO SMOK2~NG-OXYGEN I'N USE" signs, one in cab and one in patient compartment.
Fl~hlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
Set of 3 refIective warning devices.
)/"One reflective vest, coat or equivalent for each member of the crew normally azsigned.
At least one S~-L~,_RPS container, clearly' labeled amd easily accessible tn the patient compartment.
P.e,;training d~vices for all item:; not in :~ ';c: :rablt~ cab[net
Audible :va~ming device (siren) with at l~a:;t 2 cliff:trent tones.
Visual warning devices (ligh[s) with ~tematin$ red ~x~or blue fl~hin~ or rotating visible from ali s[dez
s/mutt~eously and cle~ fishing or oscilladng ~'isibIz from front.
OM~rNICATIDNS EOUIPMENT
Mobile VHF radio wkh aparopfiate State. Pfzkin Co~v ~d individual azencv ffeguencfes.
~,'[ob~.e U~I!- radio 'Mdt appropriate State, P:-~fn Co~ty, hospital ~d lndividuaI agency frequencies.
Portable radio 'M~h ch~ger ~d/or cellular phc. ne tbr back-up co~t~cations with dispatcl: ~d
hospitals.
· z[ED~CAL. EQUIPMENT AND SUPPLIES
~ ~,~cu suction system with wide bore tubing, H~id ~i~ar,'n~eal c~'cd suction tip ~d sof~ caterer suction
tip with sizes from 5 Fr. to 14 Fr.
_ Portable suction system x~Sth wide bore tubing, rigid ph~)mgeal c~'ed suction dp md soR catheter
suction tip wi~ sizes from 5 Fr. to 14 Fr.
Bulb Syringe.
~ Nasoph~ngeaI a~r~vays in pediawic md adult sizes.
Oroph~ngeaI aim'ays in pedia~c md adult sizes.
Bite stick or equivalent (orophm~ngeal ainvay).
Fixed oxygen system x~Sth a minimm storage capac~ of t 25 cubic feet (M cylinder) m:d a mi~mm
delive~ capability for tt~ee patients simultmneously at flows of at le~t 1-15 LPM.
Potable oxygsn system wi~ a minimm storage capac[~ of I5 cubic feet (D cvI~nder)
deiiveu capab~iiD, for one patient at flows of at le~t I-15 LPM. '
!nf~t Bag-Valve-M~k wit~ 500cc ba~, reseD'e~r and newborn, i~t ~nd c~iI~ m~ks.
Adult BagrValve-Mask with 1000cc bag, rese~eir ~d adult m~k.
· * Al! ,m~k .... c~ ..........t be 15~**
Oxygen m~ks ~d c~mulas capable of delivedng oxygen to adults ~d inf~ts at flows of at le~t 1_i 5
LPM.
PITKIN COUNT]/
ADVANCED LIFE SUPPORT ?ROVIDER
REQUIi~D EQUIPMENT CERIIFICATION
RE_QUIRED 4 I',S EOUIPMENT
1. All equipment and supplies listed on the B~fc Life Support R,q~,~ed Eqm,~ment List.
2. Pediat~c diagnostic equipment, age/weight'vital signs chart mhd ~g dosage/equipment size list.
approved tbr dais ambul~ce
4. Adult, pedfathc and nco-natal end:t, tranhea!
~ approved for ~lis mmbulmnce se~'ice. '
7. Amy additional equipment aqd supplies needed to pe~o~ o[qer procedm-es ~ auuhofized in medical
p,~,to~ Is approved for ~is ~bu!ance sec'me.
carries the equipment and supplies listed above and meets the' minimmm requirements, established by the State
of Colorado and Pitkin Cotmty, to provide medical care and Xansportation of the sick and injured at the
Advanced Life Support leveI. Provision of Advanced Life Support is limited as described in 3-CCR-7I 3-6,
Section 4 "Medical Acts Allov,'ed EMTs and Paramedics."
PFII'SICIgiN ADVISOR'S SIGNATUR_E COLORADO ~,~EDIC' t I r c'=x:c= /
............ NLMBER DATE'
,)
PITKNV COUNTY'
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION 'bX "\e~t
Ambulaac¢ Sen'ice Name:./.~.h~r ~tz ]2x.~- ~._._ Licenae Plate: Ambulance
i SYSTEMS I ACCEPT*4-BLEI NOT ACCEPTABLE t COMMENTS
Suspension
Driving Lights
Visual WamM~ ~,~-~
.. Elecufical System
Fuel System
Ol~s, Minors
systems lis:ed aoove, have evaluated the condition of th~se systems on the ambuIance indicated above a~nd have
dete,.'-w.:ned ~is mmbuI~ce to be in safe operating condition. This ev~uation does not ;va'-ran~ee the
sa£eD' mqd.:or operabilit5, of this arabulmnce due to conditions beyond my control.
AGE"CY, CO,,,PANY PHONE NUMBER DATE
I
?ITKIJI ¢O UArI
APPLICATION
FOR
AMBUL.,-MNCE V-EHICLE PERMIT
SER~,qCE INFOR_NIATION
STKE£T/PO BOX CITY STATE ZIP CODE
Office Communications: c?
VOICE FAX E-MAiL ~2';TE~
S~/~ BOX C~[ STA~ ZiP CODE
,~O[ ~>T F~R 5V~XTR (include re.on For r:quest)
SERVICE DfEECTOR'S SIGNATUR.E DArE
(FOa x.'4~UL^NC[ txsr~zcroR's us~ O~L~9
Cie~ CCIC: Clear NCIC: lnsuc:mce C~d Present: ' ' Registrar. ion C~d Present:
..... ~ Permit Fee Attached
5 B~ic Life Support Required Equipment List Ar~ched
~ Mech~c~ Condition Ce~ification AT:ched
~ Advmnce Li~k Suppo~ Provider Requi[.ed Equipment Ceai[ication Auached
C ommsnts,'~eco~mendarion:
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
~.~[E_D_J_C.,._A~ EOUIPMENT AND SUPPLIES
Diagnostic:
';'<: Blood pressure cuffs in l~ge adult, regular adult, child, infant and neonatal sizes.
'< Sre&oscopes in adult and pediatric sizes.
Y Pulse oximeter with adult :md pediatric sensors.
Immobilization & Splinting:
x One lower extremiD' traction splint.
3 Upper and lo~ver extremity svlints of any type (vacumm. air. q,~ M w/re, bo~d_ ,-.- ~
~t Long spineboard, vacuum mare-ess or ~qui.al~nt ~nth av:ro~Nate accessories to ............ ~.. ....
from head to heels.
.~x One orthopedic stretcher (scoop).
',/ Short spineboard, KED or equivalent v,'i~ arx~ropdare st. rar]s to im.m~hHi--,~ patient:; i:ram head to
Pediatric spin'~:b,)ard or adult sp:nebo:L~d adaptable to r)ediatric
X- .<duh and podia[Nc sized head immobilimtion eqmpment for each lon~, spineboa-d at~ or scoop stretcher
~. ~dg~d ce~,'ical h~mob[li~:]on coU~s in ~l ad, :It th~,,,<~ [r2~t sizes.
Wound C~e: .......
v Bandz~;e~ i~cn,4{n~ but not limited to, roller ~a~s a~n* ,b~ mhd el~tic ~er ~,~, .... needs.
, x- Drsssinas. including but not limi:ed to, a--" ~ ABD. S_uz_, occi~ive and bandaids y~- ~, l
_ ~ Sterile bum sheets. , .......... c.,
~_ Povidone ~d alcohol swabs or eauivalent.
~ Adhesive rope, ' , ~i~ ~ ; per a~encv needs.
- _ mdu ....~ but not !imked to, I" ~d ~"
Steele f~gation solution. ~ '
-ostetficaI Supplies:
x Sterile OB kit to [ncIude: toweb, '~
~' ~ ,x,o, mmb[ifcai taue or cord cl~2s, scissors, bush sy~nze,
Silver S vadd[er ~d stockfn: cap or ~qmvaLnts.
[p~ection Control:
_ ~' . Exam gloves in small, medium mad l~ge sizes.
_. ~ Face mhd eye s~elds.
~ Fluid-proof gox~ns wi~ ~I1 iengrh sleeves or e~u[valenr.
~ Disinfect~t spray or wipes for perso~el mhd equipment.
Mfscellmneous:
~ ~ 0ral glucose.
.~ctr~ ated cn~co~l.
x/~eavv duty b~nda~e ocZoors or oh~s casable ofcu~fn~ c!ozh[ng, belts, b~s,
_ _ universal or se¢a~ate male a~J female u~nals.
_ .> Multi-level w~eeled g~ey
~ Stair chair or equivalent.
~. g~_ Patient ccmpa~ment heater.
PITKIft COUArT
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EQUIPMENT
-/ One 2-1/2 lb. or I~ger ABC fire extinguisher, accessible from ge patient compartment and ha','inz been
serviced witiin the last year per NFPA 10 Section 4. -
,w One 5 lb. or larger ABC Ere extinguisher, accessible from outside the vehicle and having been so,iced
wit_bin t_he last yea- per NFPA 10 Section 4..
> Two "NO SMOKiNG-OXTGEN FN USE" signs, one in cab and one in patient compartment.
~ Flashlight, 2-D cell equivalent or better ~4th spare bulb and ba~er-ies or ch~zer.
2~. Set of 3 reft ective warning devices.
,a One reflective vest. coat or equivalent for each member of the cr.'.v n,~,,~tly ~sfgned.
)<2 At least one "SHAP,2S" container, clearly labeled ~d easily accessible in the patient compar~ent.
-~ Restraining devices fl0r all items not in a securab.e cabinet
L. Audible w~ing device (siren) ~5~ at Jest 2 di~r:nt tones.
__L_ Visual wm-ning devices (Hghts) wi:h Mtematinz rzd mhd/or blue flcu;hing or rotafinz visible ~om all sides
mult~,_oual, ~n~ clem- fl~hing or oscillating visible ~om ~onr.
COMMUNiCATiONS EOUiPMENT
~_ .~ Mobile V}C~ radio k~Sdq approp~ate Stars. Pitkin Co~w/~nd individual agency freauencies.
~ Mobile UHFradio -~ '
_ v~:~h a~rovfiate S:zt~, P~'k~ Co~nr~', hospimt ~d individual azency ~ .....
_ . .~ o, mble ra~zo 'Muh cringer ~&'or ce!lulz~ phone for back-up com~m~Scarions 's~ dispatch hospim!s.
z.[ED!CAL EQU~'PMENT AND S[~PLIES
Air¢,'ay:
ixeu sucnon system ,~ ~tn 'Mde bore tubing, rigid ph~:ngeai crowed suction rio ~d soft cafe:er suction
tip ~qth sizes from 5 Fr. to t 4 Fr.
Portable suction system ~Sth x~Sde bore tubing, ~zid =hmwn:eat crow=4
- ~ .... ~ ..... ,o, ti~ ~d so~ ca~heter
suction tip with sizes from 5 Fr. to 14 Fr.
~Bulb Sy~nge.
N asoph~ ngeal air.rays in pediatric and adult sizes.
Oroph~ngeai ai~vav~ in pedia~c and adult sizes.
Bite stick or equivalent (orophaD, ngea1 ai~'ay).
Fixed oxygen system x~.Sth a minim~ storage capaciv of i25 cubic feet (M cylinder) and a mi~m~m
delive~ capability for tN-ee patients simultaneously at flows of at Ie~t 1-15 LPM.
Pon=kl~ oxv*~n system ~d~h a minL,~ storage ca:aci~ of 15 cubic reef (D cylinder)
J~iivo~' ~, , .: n~ ~atient at flows of at ie~t 1-15 L ~,.
Infant Ba~-~' alve-M~k wit~ 500cc bag, = ~ . '
- r~s.Doir and newborn, levant ~nd child m~ks.
Aduh ~ g.-~ '
~a.-~. sire-MasK with I O00cc bag, rese~'oir mhd adult m~k.
7x','~n m~ks and cannu!as ca~able ofdelivefint oxygen to adults ~nd intents at flows oF at le~t l-1 5
LPM. -
PITKIN CO UiYI
ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
A-mbulance Service Name: "~ ~'Y ?Ct-:V ~'t v~ - ~'~5- 5'~: u-w-u ,'Mnb ulan ce Desianation:.~ ~,.~
REOUIRED ALS E~ - '
1. Ail equipment and suppIies listed on the Basic Life Support Required Equipment List.
2. Pediatric diagnostic equipment, age/weightYvital signs chart and drug dosage/equipment size list.
~ a. dult, pediatric and neo-natal vn~c,,lar access ~,,~,I~o~ and ~ ' ~' ~"" ' ' ,-,,-~.,~.o.,l~
---- --~-~ .... equipment as -uth~r._.d in medical v ........
approved for this ambulance service.
4..Adult, pediatric and nco-natal endotracheal ir. mbation ~ ,,~ ~ .
- - -q-.p .... nt ac; aut!mrfzed m medical protocols
approved tbr this ambulance service.
5. ~ardtac momtor, denbnllator with printer and adult a.,~d pediatric monitoring and defibrillating ca~xbi!ities
as authorized in medical protocols approved for uSis ambulance service.
. x Phawnacological agents and administration eqmpment and supplies ~ authorized in medical vrotocols
.') approved for this ambulance service. -
7. Any additional equipment mad supplies needed to perform other procedures as authorized in medical
protocols approved for this ambulance se,vice.
.As Physician .Advisor for ~/-N,tr ~ ~u ~o_~ P-~ Ci ~ ~e < ~t~¢~, ~ , I ceni~ ~at this ~bul=ce
c~es ~e equipment ~d supplies listed above ~d meets ~e' miNm~ reouirements, established by ~e State
of Colorado ~qd Pitkin Cowry. to provide medical c~e ~d tr~spo~tion ~fthe sick ~d inj~ed at the
Adv~ced Life Support level. Provision of Adv~ced Life Support is limited a} desc~bed in 3-CCR-7I 3-6,
Section 4 "Medical Acts Allowed EMTs ~d P~edics."
~ICk~ ADV'ISOR'sSIGNATL'~ ~ 3-' X r -'
COLO~ MEDICAL LICENSE NUMBER DATE
PITKIN COUNTY'
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
· / ~'"i'- I q ~ ~mbuIance Number:
.,Mnbulance Service Name: '~'t~s'~r- ~'z /-2~S~e License Plate:
SYSTEMS ACCEPt,TABLEI NOT ACCEPTABLE ] COMMENTS
Wheels & Tires
Alignment V
Suspension
Service Brakes
Parking Brake
Driving Lights
Visual ,Warning Systems
Audible Warning Systems ,~"'
· Electrical System ',-'/'7,,
Exhaust System
Fuel System
Glass, Mirrors
_Body & Sheet Metal k/'
[,/'~------------------~A~y [..o--c~e. te_n.._, professing to be a motor vehicle mech-,,Tn.ic vdth training in ali ofthe
systems listed above, have evaluated the condition of these systems on the vwnbulance indicated above and have
determined this ambulance to be in safe operating condition. This evaluation does not warrv_ntee the future
safety and/or operability of this ambulance due to conditions beyond my control.
MECHANIC'S N 1~.~. AGENCY,'CONIPANY PHONE NUMBER