2018-574-E Emergency Svc - South orange Rescue Squad operational agreement

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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD ORANGE COUNTY EMERGENCY SERVICES If sz APPLICATION FOR Fire Department Level EMS Credentialing E -'-- Please Mark Category: Level of Agency Credentialing ❑ EMT ❑ EMT Intermediate ❑ Paramedic Department Name: Primary Department Address: (If different) Physical Address City/State/Zip: Telephone number at local base of operations: Name of Primary Contact Person Telephone number for Primary Contact Person: Required Application Attachments 1. Completed attestation that department is maintaining active and up to date roster in the State Office of EMS, Credentialing information system. 2. A full description of the type and level of service to be provided including the location of the place or places from which it is intended to operate. 3. Department attests to the ability to provide at least one certified person on each first due apparatus. A description of the applicant's capability to provide twenty-four hour coverage, seven days per week for the request level of service in the first due area covered by the department. 4. Attestation that the department has the appropriate equipment to operate at the requested level of service (see attached equipment lists) 5. A copy of the applicant's written operational protocols for the management of equipment, supplies, and medications 6. Attach the department's continuing education plan (including skill maintenance plan) 7. Attach the Training Officer designation form. 8. Provide a written explanation of the department's patient care documentation capability, retention of patient care documentation policy, and transfer of information process. 9. Provide a copy of the Department's Infection Control Policy (a written Infectious Disease Control Policy as defined in Rule .0102(33) of this Subchapter and written procedures which are approved by the EMS System medical director that address the cleansing and disinfecting of vehicles and equipment that are used to treat or transport patients) or completed attestation that the department will follow the Orange County EMS System Infection control policy.