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F-1 Ambulance Service License and Ambulance Permits

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F-1 Ambulance Service License and Ambulance Permits August 2018 Attestation of Medical Oversight required by CRS2S-3.S-308 and Colorado Dept. of Health and Environment, Rules pertaining to EMS section 12.8.2 I, Dr. Andrew Yeowell, Board Certified Physician, do attest that I will provide Medical oversight to Ouray County EMS and those EMTs and paramedics operating within said organization for the next ambulance license year, as long as they follow Ouray County EMS protocol and show good clinical and ethical judgment, while doing so. Breeches in protocol, standard practice, or judgment will be brought to the attention of the County administrator and EMS director, and disciplinary action will be decided upon at that time. I also attest that I will review Patient Care Reports and provide feedback and Quality Assurance (CQI) to the active members of Ouray County EMS. Signature EMERGENCY MEDICAL SERVICES 251 Railroad Street Rjdgway. CO 8)432· eo Box 572 Ouray Colorado 81427 · 970·325·7275· Fax 970·325·9967 August 6th. 2018 Attestation of Ambulance Inspection: I, ...Jg,-""o\;M.""":::.l<..J.;Qo;eM~.L-lBo""",{-tJ,,,-___, Ouray County Emergency Manager, do attest to the fact that Ouray County EMS has at least the minimum ALS and BLS equipment required by the State of Colorado, on each of four in-service ambulances. I have personally inspected these ambulances to ensure the required equipment i in place. Signed -t.~J4;.--":::..::j"---Ir..:::....+-____________ Date: 8/6/2018 Ruth Stewan. Paramedic Dura)' County EMS PO box 124 Ridgway. CO 81432 970·325-7275 970-626-4014 fax State of Colorado Fee: None Ouray County Ambulance Service License This license is issued under the authority pursuant to C.R.S. 25-3.5-301 et seq to the following: OURAY COUNTY EMERGENCY MEDICAL SERVICES P,O, Box 572 Ouray, CO 81427 The above named ambulance service is hereby licensed to provide ambulance service in the County of Ouray, State of Colorado. This license shall be posted in a conspicuous place on the business premises. This license is non-transferable. License Expiration: August 31. 2019 Authorized by the Ouray County Board of Commissioners on this 28th day of August 2018 Attest: BOARD OF COUNTY COMMISSIONERS, OURAY COUNTY, STATE OF COLORADO (Seal) Michelle Nauer, County Clerk and Recorder By: Hannah Hollenbeck, Deputy Clerk of the Board Don Batchelder, Chair No. ~ Slale of Colorado Fee; None Ouray County AMBULANCE PERMIT This permit is issued under the authority of and pursuant to C.R.S. 25-3.5-301, et seq to: OURAY COUNTY EMERGENCY MEDICAL SERVICES P.O. Box 572 Ouray, CO 81427 This permit is issued on the basis of a current annual inspection of the vehicle and the equipment and services provided by the above named ambulance service. This inspection and permit shall not excuse compliance with the requirements of other applicable Colorado laws. This permit shall be displayed within the vehicle at all times, and is not transferable to another vehicle. Vehicle Make: Ford-Type 2 Year: 1998 Vehicle Identification No.: 1FDSS34F7WHC04738 License No.: 291AVN Permit Expiration: August 31, 2019 Authorized and issued by the Ouray County Board of Commissioners on this 28" day of August 2018. Attest: BOARD OF COUNTY COMMISSIONERS OURAY COUNTY, STATE OF COLORADO (Seal) Michelle Nauer, County Clerk and Recorder Don Batchelder, Chair By: Hannah Hollenbeck, Deputy Clerk of the Board 4l l \ Ouray County Certificate of Motor Vehicle Condition The und~rsigned, professing to be a motor vehicle mechanic, has of this date, l)8 / /8 evaluated the mechanical condition of the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future status of the ambulance after signing of this document, due to unforeseen conditions. Vehicle Identification Number (VIN) /FPS:5.:y!,c7w'I!CO¥7.3B Vehicle Owner --.>=O:.o:CI.:..:..'.eA.:::...;..:....Y---o::01:::....-C/._'Al_'1Y..:....... ________ EVALUATION CHECKLIST NOT ITEMS ACCEPTABLE ACCEPTABLE COMMENTS Wheels & Tires ,/ Steering ./ Alignment r Suspension v Brakes ,/ Emergency Brake ,/ Lights / Electrical System / Glass ,/ Exhaust System .,/ Fuel System ,/ - Body & Sheet Metal ,/ Inspector: ;.ffGllla IIND/?aVs,: ~ Agency: ouMY' ~(),v-rY ,e: Ii <;;. Address: Phone: 4 t \ \ ANNUAL AMBULANCE INSPECTIONS FOR BLS AND ALS LEVEL STATE REQUIRED EQUIPMENT Ventilation and airway equipment Where located 0'" Portable suction Kits cabinet ;,/ House suction Counter top Suction equipment * With portable /' M Wide bore tubing suction units ijl'" Rigid tip suction catheter * Intubation kits ,.[!( Soft suction catheter sizes 6-14 French v: Bulb syringe * BLS kit \;;... - 0- ~ ••••• _ ",._ •• _ •• ' ._._._," ••• _._._ __.____ __. __ ." ___ " __ "p House oxygen with variable How regulator ~ ___ .... ____ •.. ~ -- .0. Portable oxygen with variable How regulator . Kits cabinet Non-rebreather masks in the following sizes Airway cabinet ~ Adult , [1fPediatric 7tf Nasal cannulas in the following sizes: .Airway cabinet ,1i3 Adult ...... .. .. .. !Hand operated Bag Valve Mask device with oxygen reservoir, standard 15mm and Airway cabinet ~/ :21mm fittings, and transparent masks in the following sizes: 2J 'u;(500cc for infants and neonates ~ 750cc for pediatrics .Il('! IOOOcc for adults .. .... ... ,.... .......... ..... ....... ..... .r- .Nasopharyngeal airways in adult sizes 24-32 French :Airway cabinet ,(' ' O~ph~nge~i airw'~y~ ' in 5 ' ~iz~s infant -I~rge adult 'Airway cabinet __ _ ••••• __ ~ •••• _0 ___ ._ •• _ ••••• __ ._._._ •• 0_ • ____ ._. _._ •• • ••• 0. _ 0_ •••••• __ ... _•• ___ , -___ 0--- __ -.-;.. ... _. _"_",_ Endotracheal intubation equipment including; Endotracheal tubes in sizes :Intubation kit 0" 2.5-5.5 uncuffed ',£ I!f 6.0-8.0 cuffed '!!f Stylets appropriate for tubes carried .... ,.rP.: !.~~e .~~~i1!~!i?~ ~~v!,:~ . Laryngoscope and blades; Intubation kit Iii'!' Straight blades sizes 0-4 V AND/OR .lIil' Curv~d blade sizes 0-4 .Magill forceps in the following sizes: Intubation kit rzr Adult [i Pediatric End tidal C02 detector or alternative FDA approved device Jntubation kit Patient assessment equipment Where located ,Blood pressure cuffs in the following sizes: :Bench seat :G1' Large adult 'BLS kit '[jY Adult 'Multi-cuff kit ·ur Child ITf Infant .....v Stethoscope 'Bench seat .. ... ~. -... -... -. ".' -. -.. -... '. -- --. ----. -.- '. -- --.- -, .---- -- ----- ---- -.- 5( Penlight Wtray .-. -.- ... -... _...... - -..' .. -.. ....... -... Portable battery operated cardiac monitor/defibrillator with: :Counter top Strip chart EKG electrodes in the following sizes: 'Ij( Adult rv [i( Pediatric 'Defibrillation capabilities for both: :I:ir Adult Pediatric ,t¥ .. _._. _.- -_ .... _-- ----_. ------ _._. --_._ ... -_ ... __ . -_ ..... -_.... -- -- -_.... ...... _..... _._ ... _. _..... __ ..... _-_ ... -_ .... _. _.... _ ...... Pulse oximeter with probes in the following sizes: Monitor ~ Adult ' W Pediatric -... -.... -- -- ---- -. ----- --- ._--_. _. -.--- -- ---- .,_. ---- --- --- --- ._---- ---_. _.. _.... _...... _. _.. --_ ...... -_ .... -_.... _.- _... _._ .. --_ ...•..... _._- -.V Electronic blood glucose measuring device :BLS kit ~ ____________~ __~ __~ S~~~~lin=~~e~qlw~i~~m~en~t__________________ ~ Wh~e~re~loo~a~t~ed~ g Lower extremity traction splint Trauma cabinet ••••• _. O"'~'_' _v..'._ ... _ .... _.......... ____ ...... _.. __ .. __ .. _..... 0 •••••• ___ ___ r"' ___ ' __ . _____ .• ____ .. __ . Upper and lower extremity splints (OeEMS uses Vacuum splints) .Kits cabinet ... - .. --.~. -- --_ .. --.- ---.----.--.. ---.----- ... --------.------ ... _---- - --.-------.--.----.-----~.-.-.--- ..-- .. --.--.-... ------.. -- ..~-.- .. --.-.---.... _. _ ...... _. Spinal immobilization equipment including ONE of the following, with Board cabinet accessories to immobilize the patient from head to heels; :Drivers side :G1 Vacuum mattress OR exterior cabinets .[3' Long spine board OR (4111 = inside by (;j- Scoop OR . captains chair) IiY Equivalent , .~-.-.- - -- Spinal immobilization equipment including ONE of the following, with Oxygen cabinet accessories to immobilize the patient head to pelvis; :(4111 =under V LQ KEDOR :bench seat) 1M Short board OR __________ _,.IV Eq~i v~~~.~_~ _______________ . ___________________ _ ._ ••• __ •... _. __ •. _._ ••• _ ..... _.... --0-- ••• ---.---.-- _0_' _______ ;. ... _____ • _____ •. ______ •.• ___ _ Pediatric spinal immobilization equipment including ONE of the following, with :Oxygen cabinet ac~ssories to immobilize the patient head to heels; :Drivers side CV" .1lY Pediatric vacuum mattress OR exterior cabinets [!!"'Pediatric spine boardOR (4111 =under .[]I" A..b!~.ity _t() . ~()~!ry. lI~~I~_ ~!z.e. _e_qu!I?_ITI~_".t _~()r a.l~e.~\atr.!~.I)atie.n~ ___ .. __ __ . __ . __ ... _~.l1'?~ . ~e.~~) .. ... .. Head immobilization equipment in the following sizes: :Head bags C(' I](Adult __ ._. ___ ... W"~~.dia~~c __ ._ .. ____ . _________ ,_ _______ _______________________________________ . ___ . ___ ______________________________________ ... __ __r Cervical immobilization equipment in the following sizes: Head bags ~ cyAdult __ ____ : CVe~iatric _____ . .. .. -.. - . ...- .. ... .. .... ---- . .. Dressi~ material Where located Bandages of various types and sizes per agency need and medical direction Trauma cabinet & .. ... .. W Multiple dressings, including occlusive, various sizes per medical direction Trauma cabinet .. rl ··_···· ................................................. ... ".- ........... --.... -.-....... " ............ ... -'0" .. .. .. .._ . Sterile burn sheet Burn kit ... ---.-. __ A.
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