6. Fee structure for FY

_________ We do not charge any fees

_________ Our fee structure is:

First responder certification $

EMS dispatcher certification

EMT-I certification

EMT-I recertification

EMT-defibrillation certification

EMT-defibrillation recertification

EMT-II certification

EMT-II recertification

EMT-P accreditation

Mobile Intensive Care Nurse/

Authorized Registered Nurse (MICN/ARN)

certification

MICN/ARN recertification

EMT-I training program approval

EMT-II training program approval

EMT-P training program approval

MICN/ARN training program approval

Base hospital application

Base hospital designation

Trauma center application

Trauma center designation

Pediatric facility approval

Pediatric facility designation

Other critical care center application

Type:

Other critical care center designation

Type:

Ambulance service license $

Ambulance vehicle permits

Other: ______________________________

Other: ______________________________

Other: ______________________________

7. Complete the table on the following two pages for the EMS agency staff for the fiscal

year of _______.

EMS System: Reporting Year:

CATEGORY	ACTUAL TITLE	FTE POSITIONS (EMS ONLY)	TOP SALARY BY HOURLY EQUIVALENT	BENEFITS (% of Salary)	COMMENTS
EMS Admin./Coord./Dir.
Asst. Admin./Admin. Asst./Admin. Mgr.
ALS Coord./Field Coord./Trng Coord.
Program Coord./Field Liaison (Non-clinical)
Trauma Coord.
Med. Director
Other MD/Med. Consult./Trng. Med. Dir.
Disaster Med. Planner

Revision #1 [2/16/95]

CATEGORY	ACTUAL TITLE	FTE POSITIONS (EMS ONLY)	TOP SALARY BY HOURLY EQUIVALENT	BENEFITS (% of Salary)	COMMENTS
Dispatch Supervisor
Data Evaluator/ Analyst
QA/QI Coordinator
Public Info. & Ed. Coord.
Ex. Secretary
Other Clerical
Data Entry Clerk
Other

TABLE 3: SYSTEM RESOURCES AND OPERATIONS -- Personnel/Training Revision #3 [2/16/95]

EMS System:

Reporting Year:

NOTE: Table 3 is to be reported by agency.

	EMT - Is	EMT - IIs	EMT - Ps	MICN	EMS Dispatchers
Total certified
Number newly certified this year
Number recertified this year
Total number of accredited personnel on July 1 of the reporting year
Number of certification reviews resulting in:
a) formal investigations
b) probation
c) suspensions
d) revocations
e) denials
f) denials of renewal
g) no action taken

1. Number of EMS dispatchers trained to EMSA standards: ______

2. Early defibrillation:

a) Number of EMT-I (defib) certified ______

b) Number of public safety (defib) certified (non-EMT-I) ______

3. Do you have a first responder training program? yes no

Revision #1 [2/16/95]

TABLE 4: SYSTEM RESOURCES AND OPERATIONS -- Communications

EMS System:

County:

Reporting Year:

Note: Table 4 is to be answered for each county.

1. Number of primary Public Service Answering Points (PSAP)

2. Number of secondary PSAPs

3. Number of dispatch centers directly dispatching ambulances

4. Number of designated dispatch centers for EMS Aircraft

5. Do you have an operational area disaster communication system? yes ____ no ____

a. Radio primary frequency ___________________________

b. Other methods ___________________________________

c. Can all medical response units communicate on the same disaster communications system?

yes ____ no ____

d. Do you participate in OASIS? yes ____ no ____

e. Do you have a plan to utilize RACES as a back-up communication system?

yes ____ no ____

1) Within the operational area? yes ____ no ____

2) Between the operational area and the region and/or state? yes ____ no ____

Revision #1 [2/16/95]

TABLE 5: SYSTEM RESOURCES AND OPERATIONS

Response/Transportation

EMS System:

Reporting Year:

Note: Table 5 is to be reported by agency.

TRANSPORTING AGENCIES

1. Number of exclusive operating areas

2. Percentage of population covered by Exclusive Operating Areas (EOA) %

3. Total number responses

a) Number of emergency responses (Code 2: expedient, Code 3: lights and siren)

b) Number non-emergency responses (Code 1: normal)

4. Total number of transports

a) Number of emergency transports (Code 2: expedient, Code 3: lights and siren)

b) Number of non-emergency transports (Code 1: normal)

Early Defibrillation Providers

5. Number of public safety defibrillation providers

a) Automated

b) Manual

6. Number of EMT-Defibrillation providers

a) Automated

b) Manual

Air Ambulance Services

7. Total number of responses

a) Number of emergency responses

b) Number of non-emergency responses

8. Total number of transports

a) Number of emergency (scene) responses

b) Number of non-emergency responses

TABLE 5: SYSTEM RESOURCES AND OPERATIONS -- Response/Transportation (cont'd.) Revision #1 [2/16/95]

SYSTEM STANDARD RESPONSE TIMES (90TH PERCENTILE)

Enter the response times in the appropriate boxes.	METRO/URBAN	SUBURBAN/RURAL	WILDERNESS	SYSTEMWIDE
1. BLS and CPR capable first responder.
2. Early defibrillation responder.
3. Advanced life support responder.
4. Transport Ambulance.

Revision #1 [2/16/95]

TABLE 6: SYSTEM RESOURCES AND OPERATIONS

Facilities/Critical Care

EMS System:

Reporting Year:

NOTE: Table 6 is to be reported by agency.

Trauma

Trauma patients:

a) Number of patients meeting trauma triage criteria

b) Number of major trauma victims transported directly to a trauma

center by ambulance

c) Number of major trauma patients transferred to a trauma center

d) Number of patients meeting triage criteria who weren't treated

at a trauma center

Emergency Departments

Total number of emergency departments

a) Number of referral emergency services

b) Number of standby emergency services

c) Number of basic emergency services

d) Number of comprehensive emergency services

Receiving Hospitals

1. Number of receiving hospitals with written agreements

2. Number of base hospitals with written agreements

TABLE 7: SYSTEM RESOURCES AND OPERATIONS -- Disaster Medical

EMS System:

County:

Reporting Year:

NOTE: Table 7 is to be answered for each county.

SYSTEM RESOURCES

1. Casualty Collections Points (CCP)

a. Where are your CCPs located?

b. How are they staffed?

c. Do you have a supply system for supporting them for 72 hours? yes ____ no____

2. CISD

Do you have a CISD provider with 24 hour capability? yes ____ no____

3. Medical Response Team

a. Do you have any team medical response capability? yes ____ no ____

b. For each team, are they incorporated into your local

response plan? yes ____ no ____

c. Are they available for statewide response? yes ____ no ____

d. Are they part of a formal out-of-state response system? yes ____ no ____

4. Hazardous Materials

a. Do you have any HazMat trained medical response teams? yes ____ no ____

b. At what HazMat level are they trained?

c. Do you have the ability to do decontamination in an

emergency room? yes ____ no ____

d. Do you have the ability to do decontamination in the field? yes ____ no ____

OPERATIONS

1. Are you using a Standardized Emergency Management System (SEMS)

that incorporates a form of Incident Command System (ICS) structure? yes ____ no ____

2. What is the maximum number of local jurisdiction EOCs you will need to

interact with in a disaster? __________

Revision #1 [2/16/95]

3. Have you tested your MCI Plan this year in a:

a. real event? yes ____ no ____

b. exercise? yes ____ no ____

4. List all counties with which you have a written medical mutual aid agreement.

5. Do you have formal agreements with hospitals in your operational area to

participate in disaster planning and response? yes ____ no ____

6. Do you have a formal agreements with community clinics in your operational

areas to participate in disaster planning and response? yes ____ no ____

7. Are you part of a multi-county EMS system for disaster response? yes ____ no ____

8. If your agency is not in the Health Department, do you have a plan

to coordinate public health and environmental health issues with

the Health Departent? yes ____ no ____

TABLE 8: RESOURCES DIRECTORY -- Providers

EMS System: County: Reporting Year:

NOTE: Make copies to add pages as needed. Complete information for each provider by county.

Name, address & telephone:			Primary Contact:
Written Contract: yes no	Service: Ground Air Water	Transport Non-Transport	Air classification: auxilary rescue air ambulance ALS rescue BLS rescue	If Air: Rotary Fixed Wing	Number of personnel providing services: ______ PS ______ PS-Defib ______ BLS ______ EMT-D ______ LALS ______ ALS

Ownership: Public Private

Medical Director: yes no

If public: Fire Law Other explain:_____________

If public: city; county; state; fire district; Federal

System available 24 hours? yes no

Number of ambulances: _________

Name, address & telephone:			Primary Contact:
Written Contract: yes no	Service: Ground Air Water	Transport Non-Transport	Air classification: auxilary rescue air ambulance ALS rescue BLS rescue	If Air: Rotary Fixed Wing	Number of personnel providing services: ______ PS ______ PS-Defib ______ BLS ______ EMT-D ______ LALS ______ ALS

Ownership: Public Private

Medical Director: yes no

If public: Fire Law Other explain:_____________

If public: city; county; state; fire district; Federal

System available 24 hours? yes no

Number of ambulances: _________

TABLE 9: RESOURCES DIRECTORY -- Approved Training Programs Revision #1 [2/16/95]

EMS System: County:Reporting Year:

NOTE: Table 9 is to be completed by county. Make copies to add pages as needed.

Training Institution Name			Contact Person telephone no.
Address

Student Eligibility: *

Cost of Program Basic __________ Refresher __________

**Program Level: Number of students completing training per year: Initial training: Refresher: Cont. Education Expiration Date:

Number of courses: Initial training: Refresher: Cont. Education:

Training Institution Name			Contact Person telephone no.
Address

Student Eligibility: *

Cost of Program Basic __________ Refresher __________

**Program Level: Number of students completing training per year: Initial training: Refresher: Cont. Education Expiration Date:

Number of courses: Initial training: Refresher: Cont. Education:

* Open to general public or restricted to certain personnel only.

** Indicate whether EMT-I, EMT-II, EMT-P, or MICN; if there is a training program that offers more than one level complete all information for each level.

TABLE 10: RESOURCES DIRECTORY -- Facilities Revision #1 [2/16/95]

EMS System: County: Reporting Year:

NOTE: Make copies to add pages as needed. Complete information for each facility by county.

Name, address & telephone: Primary Contact:

Written Contract yes no

Referral emergency service Standby emergency service Basic emergency service Comprehensive emergency service

Base Hospital: yes no

Pediatric Critical Care Center:* yes no

EDAP:** yes no

PICU:*** yes no

Burn Center: yes no

Trauma Center: yes no

If Trauma Center what Level:****

Name, address & telephone: Primary Contact:

Written Contract yes no

Referral emergency service Standby emergency service Basic emergency service Comprehensive emergency service

Base Hospital: yes no

Pediatric Critical Care Center:* yes no

EDAP:** yes no

PICU:*** yes no

Burn Center: yes no

Trauma Center: yes no

If Trauma Center what Level:****

* Meets EMSA Pediatric Critical Care Center (PCCC) Standards.

** Meets EMSA Emergency Departments Approved for Pediatrics (EDAP) Standards.

*** Meets California Children Services (CCS) Pediatric Intensive Care Unit (PICU) Standards.

**** Levels I, II, III and Pediatric.

TABLE 11: RESOURCES DIRECTORY -- Dispatch Agency Revision #2 [9/14/95]

EMS System: County: Reporting Year:

NOTE: Make copies to add pages as needed. Complete information for each provider by county.

Name, address & telephone: Primary Contact:

Written Contract: yes no

Medical Director: yes no

Day-to-day Disaster

Number of Personnel providing services: _______ EMD Training _______ EMT-D _______ ALS _______ BLS _______ LALS _______ Other

Ownership: Public Private

If public: Fire Law Other explain:_____________

If public: city; county; state; fire district; Federal

Name, address & telephone: Primary Contact:

Written Contract: yes no

Medical Director: yes no

Day-to-day Disaster

Number of Personnel providing services: _______ EMD Training _______ EMT-D _______ ALS _______ BLS _______ LALS _______ Other

Ownership: Public Private

If public: Fire Law Other explain:_____________

If public: city; county; state; fire district; Federal

APPENDICES

APPENDIX 1: System Assessment Form

APPENDIX 2: Trauma Planning Guidelines

APPENDIX 3: Exclusive Operating Area Guidelines

APPENDIX 4: Pediatric Subsystem Planning Guidelines

APPENDIX 1: System Assessment Form

An example of a completed System Assessment form follows this page.

STANDARD:

(THE STANDARDS FROM THE EMS SYSTEM STANDARDS AND GUIDELINES ARE AVAILABLE ON DISK.)

CURRENT STATUS:

COORDINATION WITH OTHER EMS AGENCIES:

NEED(S):

OBJECTIVE:

TIME FRAME FOR MEETING OBJECTIVE:

Short-range Plan (one year or less)

Long-range Plan (more than one year)