Orange County NC Website
Browse       Search
ORANGE COUNTY EMERGENCY SERVICES <br />APPLICATION FOR Fire Department Level <br />EMS Credentialing <br />Please Mark Category: <br />Level of Agency Credentialing <br /> EMT EMT Intermediate Paramedic <br />Department Name:______________________________________________________________________ <br />Primary Department Address:_____________________________________________________________ <br />(If different) Physical Address City/State/Zip:_________________________________________________ <br />Telephone number at local base of operations:________________________________________________ <br />Name of Primary Contact Person___________________________________________________________ <br />Telephone number for Primary Contact Person: _______________________________________________ <br />Required Application Attachments <br />1. Completed attestation that department is maintaining active and up to date roster in the State Office of <br />EMS, Credentialing information system. <br />2. A full description of the type and level of service to be provided including the location of the place or <br />places from which it is intended to operate. <br />3. Department attests to the ability to provide at least one certified person on each first due apparatus. A <br /> description of the applicant’s capability to provide twenty-four hour coverage, seven days per week for <br /> the request level of service in the first due area covered by the department. <br />4. Attestation that the department has the appropriate equipment to operate at the requested level of <br />service (see attached equipment lists) <br />5. A copy of the applicant’s written operational protocols for the management of equipment, supplies, and <br /> medications <br />6. Attach the department’s continuing education plan (including skill maintenance plan) <br />7. Attach the Training Officer designation form. <br />8. Provide a written explanation of the department’s patient care documentation capability, retention of <br /> patient care documentation policy, and transfer of information process. <br />9. Provide a copy of the Department’s Infection Control Policy (a written Infectious Disease Control Policy <br /> as defined in Rule .0102(33) of this Subchapter and written procedures which are approved by the EMS <br /> System medical director that address the cleansing and disinfecting of vehicles and equipment that are <br /> used to treat or transport patients) or completed attestation that the department will follow the Orange <br /> County EMS System Infection control policy. <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD