NOC-AE-16003416, Change to Emergency Plan Implementing Procedure, Revision 9 to 0PGP03-ZA-0106, Emergency Medical Response Plan
| ML16300A151 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 10/12/2016 |
| From: | Crain J South Texas |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| NOC-AE-16003416, STI: 34382059 | |
| Download: ML16300A151 (40) | |
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Nuclear Operating Company IMJ Ill -
South Texas Project Electric Generating Station P.O. Box 285' Wadsworth, Texas 77483 October 12, 2016 NOC-AE- 16003416 10 CFR 50.4(b)(5) 10 CFR 50.54(q)(3)
U.S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, DC 20555-0001 South Texas Project Units 1 and 2 Docket No. STN 50-498 and STN 50-499 Change to STP Emergency Plan Implementing Procedure In accordance with 10 CFR 50.4(b)(5) and 10 CFR 50.54(q)(3), STP Nuclear Operating Company (STPNOC) hereby submits the attached STP Emergency Plan Implementing Procedure revision.
The revision to the attached Emergency Medical Response Plan, reassigns the responsibility for oversight of the Emergency Medical Technicians.
These changes do not represent a reduction :in effectiveness and do not require NRC approval prior to implementation in accordance with the provisions of 1O GFR 50.54(q).
- There are no commitments in this letter.
A description of changes/summary of analysis and a copy of OPGP03-ZA-0106, Emergency Medical Response Plan, Revision 9 are attached to this letter. If there are any questions please contact Scott Korenek at (361) 972-7152 or me at (361) 972-4001. *
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~hnM.Crain Manager, Emergency Response Mk Attachments:
- 1. Description of Changes/ Summary of Analysis
- 2. Procedure: OPGP03-ZA-0106, Emergency Medical Response Plan, Revision 9 STI: 34382059
NOC-AE-16003416 Page 2 of 2 cc:
(paper copy) (electronic copy)
Regional Administrator, Region IV Morgan. Lewis & Beckius LLP U.S. Nuclear Regulatory Commission Steve Frantz, Esquire 1600 East Lamar Boulevard Arlington, TX 76011-4511 U.S. Nuclear Regulatory Commission Lisa M. Regner Lisa M. Regner Senior Project Manager NRG South Texas LP U.S. Nuclear Regulatory Commission Chris O'Hara One White Flint North (08H04) Jim von Suskil 11555 Rockville Pike Skip Zahn Rockville, MD 20852 CPS Energy NRC Resident Inspector Kevin Pollo U.S. Nuclear Regulatory Commission Cris Eugster P. 0. Box 289, Mail Code: MN116 L. D. Blaylock Wadsworth, TX 77483 City of Austin Elaina Ball John Wester Texas Dept. of State Health Services Helen Watkins Robert Free
. i
NOC-AE-16003416 Attachment 1 Attachment 1 Description of Changes/ Summary of Analysis
NOC-AE-16003416 Attachment 1 Page 1of2 Description of Changes I Summary of Analysis Emergency Response Implementing Procedure OPGP03-ZA-0106, Revision 9 Emergency Medical Response Plan Change Reason Revised OPGP03-ZA-0106, Emergency The current STP Emergency Plan Table C-1 Medical Response Plan, to reflect a change in specifies 2 individuals from Plant Protection ownership for the responsibility of maintaining maintain responsibility for the Major Functional Emergency Medical Technicians onsite. The Area of Rescue Operations and First Aid. The Plant Protection Organizational will remain position has the following note: These positions responsible for the overall Emergency Medical may be covered by on-shift personnel assigned Response Plan. other functions.
Prior to this change, the Plant Protection Organization was required to maintain at least . I one officer trained to provide emergency medical care on each crew. This change will require a trained Emergency Medical Technician (EMT) to be onsite at all times. The EMT will report to the Safety Organization for routine duties and to the Security Force Supervisor if the Emergency Medical Response Plan is entered. This relieves the Plant Protection Organization of the responsibility for maintaining EMT qualified officers on shift.
NOC-AE-16003416 Attachment 1 Page 2of2 Description of Changes I Summary of Analysis Emergency Response Implementing Procedure OPGP03-ZA-0106, Revision 9 Emergency Medical Response Plan 10 CFR 50.54(q) Summary of Analysis Evaluation Changes have been evaluated and the determination made that:
- The changes do not affect the licensing basis. A review of the Technical Specifications, UFSAR and Emergency Plan for requirements related to onsite emergency pre-hospital care was completed. The review of these documents did not indicate any requirement that would be affected by implementing this change.
- The changes do not affect any function or element of a Planning Standard and do not affect an Emergency Preparedness commitment. This change does not alter the station process for satisfying requirements contained in NUREG-0654/FEMA-REP-1 Planning Standards. The method of satisfying these standards are unchanged and contin.ue to be met. The emergency functional area of Rescue Operations and First-Aid in Table B-1 of NUREG-0654/FEMA-REP-1 remains satisfied. The review for this change did not identify Station Commitments related to onsite emergency pre-hospital care.
- The changes do not affect the meaning or intent of the Emergency Plan, facilities, equipment, or any processes. This change will not alter the current process governing station facilities or medical supplies used for emergency first aid treatment. The station will continue to maintain medical service providers qualified to handle radiological emergencies onsite.
- This Emergency Plan continues to comply with regulations. This change does not alter the station process for satisfying requirements contained in NUREG-0654/FEMA-REP-1, Rev. 1 and Appendix E to 10CFR Part 50. On-shift staffing numbers are not impacted.
The emergency functional area of Rescue Operations and First-Aid in Table 8-1 of NUREG-0654/FEMA-REP-1 remains satisfied.
Based upon the evaluation, the changes do not represent a Reduction in Effectiveness of the Emergency Plan.
NOC-AE-16003416 Attachment 2 Attachment 2 OPGP03-ZA-0106, Emergency Medical Response Pl~n, Revision 9
SOUTH: TEXAS PROJECT ELECTRIC GENERATING STATION D0527 STI 34345681 Rev. 9 Page 1 of34 I OPGP03-ZA-0106 Emergency Medical Response Plan Quality I Non Safety-Related I Usage: Available Effective Date: 09/14/2016 C. Wire N. Cashion NIA Plant Protection PREPARER TECHNICAL USER COGNIZANT ORGANIZATION Table of Contents
1.0 Purpose and Scope
.......................................................................................................................... 3 2.0 Definitions ....................................................................................................................................... 3 3.0 Responsibilities ............................................................................................................................... 4 3 .1 Plant Protection ...................................................................................................................... 4 3.2 Personnel' Safety Group .......................................................................................................... 4 3.3 Control Room ......................................................................................................................... 4 3.4 Health Physics ........................................................................................................................ 5 3.5 Security Force Supervisor (SFS) ............................................................................................ 5 3.6 Security Supervisor ................................................................................................................ 5 3.7 Emergency Medical Services Coordinator. ............................................................................ 5 3.8 Emergency Medical Technician ............................................................................................. 6 3 .9 Ambulance Driver .................................................................................................................. 6 3.10 Security Officers .................................................................................................................... 7 3.11 EMS Medical Director ........................................................................................................... 7 4.0 Notes and Precautions ..................................................................................................................... 7 5.0 Prerequisites***********************************************.************************************************************************************* 7 6.0 Procedure ................................................................ :........................................................................ 9 6.1 Activation of the Emergency Medical Response Plan ........................................................... 9 6.2 Assessment and Treatment ................................................................................................... 10 6.3 Response to Offsite Medical Emergencies .......................................................................... 14 6.4 Medical Response Equipment and Waste ............................................................................ 15 6.5 Exit from the Emergency Medical Response Plan ............................................................... 16 6.6 Medical Emergency Response Tracking .....................................................'......................... 17
- 6. 7 Documentation ..................................................................................................................... 18
- 7. 0 References ..................................................................................................................................... 21 8.0 Documentation .............................................................................................................................. 21
OPGP03-ZA-0106 Rev. 9
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Page 2 of34 Emergency Medical Response Plan 9.0 Support Documents .............................................................. '.******************************************************** 21 Addendum 1, Waiver of Medical Attention .................................................................................. 22 Form 1, Waiver of Medical Attention ........................................................................................... 23 Form 2, Emergency Medical Response Report (Sample) ............................................................. 25 Form 3, Ambulance Inventory ...................................................................................................... 28 Form 4, Medical Bag Inventory***********************************************************:**************************************** 32 Form 5, Ambulance Activity Log ................................................................................................. 34
OPGP03-ZA-0106 Rev. 9 - Page 3 of34 Emergency Medical Response Plan
1.0 Purpose and Scope
1.1 This procedure establishes the onsite Emergency Medical Response Plan (EMRP) for the South Texas Project Electric Generating Station (STPEGS).
1.2 This procedure describes the roles, responsibilities and staffing requirements for the various organizations that support emergency medical response for onsite emergency pre-hospital care.
1.3 Non-emergency medical treatment should be provided by Health Services when staffed during normal business hours. Emergency Medical Technicians (EMT) may provide non-emergency medical treatment during backshifts and other periods Health Services is not staffed.
1.4 This procedure implements the STP Emergency Plan. (CAQ-D CR 12-5821) 2.0 Definitions 2.1 EMERGENCY MEDICAL RESPONSE TEAM (EMRT): The EMRT is comprised, at a minimum, of one qualified Emergency Medical Technician (EMT) and one qualified ambulance driver.
2.2 EMERGENCY MEDICAL SERVICES (EMS) COORDINATOR: Individual designated by the Personnel Safety group that has overall responsibility for implementation of the pre-hospital care process.
2.3 MEDICAL EMERGENCY: Pre-hospital en;iergency care is required to stabilize an injured or ill individual for transport to an off site medical facility for further medical evaluation and/or treatment.
2.4 MEDICAL NON-EMERGENCY: Pre-hospital emergency care is NOT required to stabilize an injured or ill individual. An EMT may provide medical non-emergency care during backshifts and weekends. The individual is NOT transported to an off site medical facility by emergency medical response personnel for further medical evaluation and/or treatment.
2.5 OFF SITE: As applied to this procedure, off site is areas beyond the Owner Controlled Area boundary.
2.6 ONSITE
As applied to this procedure, onsite is areas within the Owner Controlled Area boundary.
2.7 SOUTH TEXAS PROJECT (STP) EMERGENCY MEDICAL SERVICE (EMS)
PROTOCOLS: Protocols and clinical policies that reflect the standard of out-of-hospital care rendered by Emergency Medical Services personnel during Medical Emergencies at the South Texas Project. These protocols and policies are approved by the Matagorda County EMS Medical Director for STP.
I OPGP03-ZA-0106 I Rev. 9 I Page 4 of34 Emergency Medical Response Plan 3.0 Responsibilities 3 .1 Plant Protection responsibilities include:
- Implementation of onsite pre-hospital emergency medical response.
- Provide a qualified ambulance driver to support onsite pre-hospital emergency medical response.
3.2 Personnel Safety group responsibilities include:
- Provide a qualified EMT for onsite pre-hospital emergency medical care.
- Ensure contract EMT understands medical and radiological procedural requirements.
- Provide an ambulance onsite, and arrange for alternate coverage when the onsite ambulance is out of service.
- Ensure the ambulance is maintained in a functional condition.
- Provide emergency medical supplies and equipment.
- Provide documentation to the site Health Services personnel, as required.
- Provide oversight of the Emergency Medical Response Program.
- Scheduling of EMT' s.
- Budget of EMT program.
3 .3 Control Room responsibilities include:
- Implement OPOP04-ZO-OOO~, Personnel Emergencies, in parallel with this procedure for onsite emergency medical response.
- Coordinate the response to the onsite medical emergency.
- Contact Health Physics, Fire Brigade, Maintenance, Spill Response Team, Security, or other site or off site departments or agencies if additional assistance is requested by the EMRT.
- Maintain communications with personnel on the scene.
I OPGP03-ZA-0106 I Rev. 9 I Page 5 of34 Emergency Medical Response Plan 3.4 Health Physics responsibilities include:
- Control radiological contamination during an emergency medical response.
- Issue required dosimetry to off site agency responders, as required.
- Provide support during emergency medical response per OPRPl 1-ZR-0010, Radiation Protection Support of Medical Emergency Response.
3.5 Security Force Supervisor (SFS) responsibilities include:
- Provide support to the Emergency Medical Response Team (EMRT) during an onsite emergency medical response. *
- Ensure an EMT is on site.
- Ensure ambulance drivers are qualified prior to assuming duty. (CAQ-D CR 09-16764) 3 .6 Security Supervisor responsibilities include:
- Enter the Emergency Medical Response Plan (EMRP) when notified of a Medical Emergency.
- Direct EMRT members to the location of the medical emergency.
- Document in the Shift Log Data information associated with off site emergency response personnel and/or vehicles that enter the Protected Area.
- 3. 7 Emergency Medical Services (EMS) Coordinator responsibilities include:
- Maintain and monitor the Emergency Medical Response Program.
- Communicate EMS needs to the Personnel Safety group Supervisor.
- Ensure the department budget includes EMS needs.
- Ensure EMT's are qualified prior to assuming duty. (CAQ-D CR 09-16764)
OPGP03-ZA-0106 Rev. 9 Page 6 of34 Emergency Medical Response Plan 3.8 Emergency Medical Technician (EMT) responsibilities include:
- Enter the Emergency Medical Response Plan (EMRP) when notified of a Medical Emergency.
- Maintain EMT qualifications AND ensure qualified prior to assuming duty.
(CAQ-D CR 09-16764)
- Contact SFS via Channel 8 or extension 8991 when reporting for shift.
- Ensure the ambulance or similar licensed vehicle and equipment is maintained in a clean and operable condition.
- Ensure the scene is safe prior to beginning assessment and treatment.
- Provide emergency medical care using approved medical protocols as guidelines.
- Coordinate patient care with the Control Room and off site medical resources.
- Ensure the Control Room is notified of patient status, transport status, contamination status, destination and when the ambulance is back onsite AND in service.
- Perform inventories of medical equipment and supplies using Form 3, Ambulance Inventory and Form 4, Medical Bag Inventory.
3.9 Ambulance Driver responsibilities include:
- Maintain qualifications as an ambulance driver.
- Remain familiar with the ambulance operation, equipment and transportation routes.
- Safely operating the ambulance or other similar licensed vehicle, when required.
- Ensure the scene is safe for response and provide assistance to the EMT, as needed.
- Remain with the operating ambulance, while inside the Protected Area, or transfer control of the ambulance to another security individual during a medical emergency.
- Complete Form 5, Ambulance Activity Log each time the company ambulance is operated.
OPGP03-ZA-0106 I Rev. 9 I Page 7 of34 Emergency Medical Response Plan 3 .10 Security Officer responsibilities include:
- Ensure off site emergency vehicles and personnel are authorized access prior to Protected Area entry by contacting the Security Force Supervisor.
- Maintain observation and positive control of escorted off site emergency personnel and vehicles that enter the Protected Area for the medical emergency.
- Assist the Emergency Medical Technician, as needed.
3 .11 EMS Medical Director responsibilities include:
- Provide oversight of the STP EMS medical program (from an off site physician).
Protocols.
4.0 Notes and Precautions 4.1 Due to equipment in the ambulance requiring continuous power the ambulance should remain running during a medical emergency.
4.2 Emergency Medical Response Team personnel's weapons, ammunition, pepper spray and other required equipment is to be stored in an authorized storage facility OR turned over to an Armed Security Officer prior to STP Emergency Medical Service (EMS) personnel going off site.
4.3 Medical emergencies take precedence over radiological assessment and controls.
4.4 Revisions to this procedure are to follow the requirements of OPGP05-ZV-OO 10, Emergency Plan Change. (CAQ-D CR 12-5821) 4.4.1 OPGP05-ZV-OO 10 requires Emergency Plan Implementing procedure revisions be 50.54(q) screened to determine whether an effectiveness evaluation is required.
5.0 Prerequisites 5.1 The Plant Protection Department: (Reference 7.2)
- Ensures that an EMT is on site on a 24-hour I 7-day per week basis
- Providing a qualified ambulance driver
- Contacting the Duty Safety Specialist to satisfy EMT staffing Requirements.
OPGP03-ZA-0106 I Rev. 9 I Page 8.of34 Emergency Medical Response Plan 5.2 Ambulance Drivers are:
- Badged for STPNOC unescorted access
- Have a valid Texas Class< C >driver's license (on person)
- Trained on ambulance operation (certification FAT012)
- Qualified in first aid, Cardiopulmonary Resuscitation (CPR) and on the Automatic External Defibrillator (AED) (certification FAT016) 5.3 Emergency Medical Technicians (EMT) are:
- Badged for STPNOC unescorted access
- Have a valid Texas Class< C >driver's license (on person)
- Trained on ambulance operation (certification FAT012)
- Qualified by the National Registry of Emergency Medical Technicians (NREMT) and/or Texas Department of State Health Services (DSHS) (certification 4600)
- Qualified as prescribed in OPGP03-ZT-0139, Emergency Preparedness Training Program 5.4 Contract Emergency Medical Technician (CEMT) (CAQ-D CR 09-16764)
- Used to staff, at a minimum, an EMT position when additional resources are needed.
- Badged for STPNOC unescorted access.
- Have a valid Texas Class <C> driver's license (on person).
- Qualified by the National Registry of Emergency Medical Technicians (NREMT) and/or Texas Department of State Health Services (DSHS) (certification 4600).
- Qualified as prescribed in OPGP03-ZT-0139, Emergency Preparedness Training Program.
I OPGP03-ZA-0106 I Rev. 9 I Page 9 of34 Emergency Medical Response Plan 6.0 Procedure 6.1 Activation of the Emergency Medical Response Plan 6.1.1 An onsite medical emergency is reported to the Control Room, as outlined in OPOP04-Z0-0004, by calling extension 911.
6.1.2 The Control Room Staff ACTIVATES and COORDINATES the Emergency Medical Response Plan (EMRP) per OPOP04-Z0-0004, Personnel Emergencies, when a medical emergency has been reported to the Control Room.
6.1.3 The Control Room Staff notifies of the medical emergency per OPOP04-Z0-0004.
6.1.4 Upon notification of a medical emergency, a Security Supervisor directs the Emergency Medical Response Team (EMRT) to respond to the scene of the medical emergency AND other personnel to support the EMRT.
6.1.4.l The following announcement or other similar message will be communicated over the security radio network by an alarm station.
6.1.4.2 A brief summary of the medical emergency should be provided to theEMRT.
6.1.4.3 The EMRT, upon notification, is to promptly respond to the location of the medical emergency.
6.1.4.4 Security officers responsible for OR as assigned gatehouse vehicle entry/exit are directed to stand by the applicable Vehicle Entrapment Area (VEA).
6.1.4.5 Pick up required dosimetry, e.g. EPDs, etc., including for off site agency responders.
OPGP03-ZA-0106 Rev. 9 Page 10 of34 Emergency Medical Response Plan 6.2 Assessment and Treatment 6.2.1 EMTs, including contract EMTs, are to assess AND treat patients per the approved South Texas Project (STP) Emergency Medical Services (EMS)
Protocols.
6.2.2 IF the EMT's assessment of the patient determines the event is NOT a Medical Emergency AND NO immediate medical treatment is required, THEN perform the following:
6.2.2.l Refer the patient to Health Services for non-medical emergency treatment during normal business hours.
OR 6.2.2.2 Provide the patient non-emergency medical treatment (typically during business off hours, i.e. nights, weekends and holidays).
6.2.2.3 IF the patient refuses non-emergency medical treatment, THEN have the patient sign Form 1, Waiver of Medical Attention.
Provide a copy of Addendum 1, Waiver of Medical Attention to the patient.
6.2.2.4 IF providing non-emergency medical treatment, THEN utilize Form 2, Emergency Medical Response Report.
6.2.2.5 GO TO section 6.5 for exiting from the Emergency Medical Response Plan.
NOTE Steps in section 6.2.3 may be performed in the order necessary to support the patient's treatment.
6.2.3 IF the EMT's assessment of the patient determines the event is a Medical Emergency, THEN perform the following:
6.2.3.1 Administer medical treatment per the approved STP EMS Protocols.
Utilize Form 2, Emergency Medical Response Report, to record patient assessment and treatment information.
OPGP03-ZA-0106 Rev. 9 Page 11 of34 Emergency Medical Response Plan NOTE e Specific information about the medical condition and patient is confidential.
- The EMT's priority is with the patient. Notifications by the EMT to the Control Room or ERO Security Manager will occur after patient stabilization and may be via radio or telephone.
6.2.3.2 Provide updates, when possible, to the affected Control Room and ERO Security Manager (if the Technical Support Center (TSC) is activated). Utilize a telephone OR the following Control Room radio channels.
- Unit 1 channel 7
- Unit 2 channel 10
- a. Provide OR ensure the Shift Manager, Security Force Supervisor and the Technical Support Center (TSC)
Security Manager (if the TSC is activated) is provided the following information, as applicable.
- Arrival time at location of medical emergency
- Contamination status of patient
- Patient's badge number AND status (unrestricted information)
- Time patient departed the site
- Time patient was transferred to an off site EMS organization
- Time the patient arrived at the receiving medical facility
- With the approval of the attending physician AND patient, the general condition of the patient.
- Arrival time back on site
- When the ambulance is in service
I OPGP03-ZA-0106 I Rev. 9 I Page 12 of34 Emergency Medical Response Plan
- b. Request assistance through the Shift Manager of the affected Control Room. Assistance may include (list is not inclusive):
- Health Physics
- Spill Response Team
- Fire Brigade
- Maintenance
- High angle/confined space rescue
- Life Flight GO TO OPGP03-ZS-0001, Vehicle, Material and Personnel Access Control for access requirements for emergency response personnel and vehicles.
6.2.3.3 IF off site emergency response personnel and/or vehicles enter the protected area after authorization, THEN a Security Supervisor documents the following in the Shift Log Data.
- Enter the date and time of entry AND exit of emergency response personnel and/or vehicles.
- Enter the Shift Manager name authorizing entry of emergency response personnel and/or vehicles.
- Enter the Security Manager OR Security Force Supervisor name authorizing entry of emergency response personnel and/or vehicles. ,
6.2.3.4 The EMT is to direct the ambulance driver to transport the patient, as required, to the appropriate medical facility based upon the patient assessment. Medical facilities include but are not limited to:
- Health Services
- Pre-designated area for transfer of patient care to an off site EMS organization
- Off site medical facility
I OPGP03-ZA-0106 I Rev. 9 I Page 13 of34 Emergency Medical Response Plan NOTE
- Matagorda County Regional Medical Center is the preferred medical facility for receiving contaminated patients other than those transported by life flight.
- Memorial Herman Hospital (Texas Medical Center campus) is the preferred medical facility for receiving contaminated patients transported by life flight.
6.2.3.5 IF the patient is determined to be contaminated, THEN notify the receiving medical facility that the patient is contaminated.
IF the contaminated patient is to be transported to Matagorda County Regional Medical Center, THEN consider transporting the patient to avoid contaminating other personnel, vehicles and equipment. ,
6.2.3.6 Contact the receiving medical facility AND provide the following information:
- Clearly make identification as a STP EMS unit
- Patient's age and gender
- Patient's chief complaint and brief history of present illness or injury
- Mechanism of Injury, if known, e.g. falls, vehicle accident, etc.
- Pertinent significant past medical illness or injury history
- Patient's mental status
- Pertinent findings of medical exam
- Treatment and/or interventions
- Baseline vital signs
- Patient's response to treatment
- Estimated Time of Arrival (ETA) 6.2.3.7 IF advanced life support is required during STP EMS transport of a patient, THEN it is permissible that a qualified higher level EMT board the STP ambulance to provide advanced life support.
I OPGP03-ZA-0106 I Rev. 9 I Page 14 of34 Emergency Medical Response Plan 6.2.3.8 IF the STP EMS transports the patient to a pre-designated area to transfer patient care, THEN the normal transfer point is the east entrance to the Nuclear Training Facility (NTF).
NOTE Changes in receiving medical facility are typically determined by the Shift Manager and/or Security Force Supervisor.
6.2.3.9 IF the STP EMS transports the patient to an off site medical facility, THEN the normal travel route is via FM 521, to FM 1468 (Buckeye Road), THEN to HWY 35.
A Security Supervisor is to notify the ambulance driver and/or EMT of changes in the receiving medical facility.
6.3 Response to Off Site Medical Emergencies 6.3 .1 IF requested to respond off site, THEN the Security Force Supervisor performs the following prior to response.
6.3.1.1 Verify another EMT AND ambulance driver 'are on site AND available to respond to a medical emergency at STP.
IF there is NOT another EMT and ambulance driver, THEN do NOT respond off site.
6.3.1.2 Verify security staffing allows for another EMT and ambulance driver to be removed from the security shift schedule.
IF security staffing is insufficient to allow a second EMT and ambulance driver to depart the site, THEN do NOT respond off site.
6.3.1.3 Consider circumstances leading to the request for off site medical assistance.
6.3.1.4 Establish an .estimated time of return, if possible.
6.3.2 Obtain approval from the Unit 1 Shift Manager.
6.3.3 ' IF the conditions listed in sections 6.3.1 and 6.3.2 are met, THEN the Security Force Supervisor may allow the off site medical response.
I OPGP03-ZA-0106 I Rev. 9 I Page 15 of34 Emergency Medical Response Plan 1
6.4 Medical Response Equipment and Waste 6.4.1 IF the ambulance is used to transfer a patient to a medical facility, THEN clean and disinfect the vehicle and equipment used.
6.4.1.1 Utilize Form 3, Ambulance Inventory, to account and restock the ambulance after medical emergencies AND during (calendar) weekly inventories.
6.4.1.2 Utilize Form 4, Medical Bag Inventory to account and restock the medical bag(s) after medical emergencies AND during (calendar) weekly medical bag inventories.
6.4.1.3 IF reusable equipment is used, THEN place the equipment in a red plastic bag (separate from biohazardous waste), labeled and taken to the Site Medical Facility for cleaning and disinfecting.
6.4.2 Biohazardous waste shall be collected and placed in red plastic bags and labeled for appropriate disposal.
6.4.2.1 Non-radioactive contaminated waste may be discarded in an appropriate receptacle at the off site or Site Medical Facility.
6.4.2.2 Coordinate with Health Physics for the proper handling and disposition/disposal of radioactive material.
I OPGP03-ZA-0106 I Rev. 9 I Page 16 of34 Emergency Medical Response Plan 6.5 Exit from the Emergency Medical Response Plan 6.5.1 IF after assessment of the patient the EMT determines the situation is NOT a medical emergency, THEN request the Shift Manager exit from the EMRP.
OR 6.5.2 IF after assessment of the patient the EMT determines medical transport to a medical facility is NOT required, THEN request the Shift Manager exit from the EMRP.
OR 6.5.3 After return to the site AND the ambulance is in service, notify the Shift Manager and request exit from the EMRP.
6.5.4 Upon return to the site OR after exiting from the EMRP, as applicable, the EMT and ambulance driver are to return to the primary security radio channel.
6.5.5 A Security Supervisor is to perform a radio check on the primary radio channel with the EMT and ambulance driver after returning to site OR after exiting from theEMRP.
6.5.6 Complete Form 2, Emergency Medical Response Report.
Page 17 of34 I OPGP03-ZA-0106 Rev. 9 Emergency Medical Response Plan 6.6 Medical Emergency Response Tracking 6.6.1 A tracking Condition Report should be used to track responses to onsite and off site medical emergencies.
6.6.2 For each medical emergency, document the following in the current year's medical response Condition Report.
"' _Date and time the Emergency Medical Response Plan was entered
- Date and time of notification of a medical emergency
- Date and time the EMT departed to the location of the medical emergency
- Location of the medical emergency
- Date and time the EMT arrived at the location of the medical emergency
- Contamination status of the patient
- Date and time the patient was transported to a medical facility OR the time the patient was transferred to an off site EMS organization
- Destination, including redirection of medical facilities
- Date and time the EMT was back onsite AND in service
- Date and time the ambulance was back onsite AND in service
- Date and time the Emergency Medical Response Plan was exited 6.6.3 Utilize Form 5, Ambulance Activity Log to record each time the ambulance is used, e.g. medical emergencies, fuel, run engine, etc.
I OPGP03-ZA-0106 I Rev. 9 I Page 18 of34 Emergency Medical Response Plan 6.7 Documentation 6.7.1 Instrnctions for completing Form 1, Waiver of Medical Attention 6.7.1.1 IF the patient refuses assessment, treatment, or transport, THEN this form is required to be completed.
6.7.1.2 IF data fields are Not Applicable, THEN enter NI A.
6.7.1.3 Enter information in the applicable data fields in Section A.
6.7.1.4 Enter information in the applicable data fields in Section B.
6.7.1.5 Enter information in the applicable data fields in Section C.
6.7.1.6 The patient, a witness and the primary EMT prints and signs their name and enters the cunent date in Section D.
6.7.1.7 Enter information in the applicable data fields in Section E.
6.7.1.8 Enter information in the applicable fields for Medical Control.
6.7.1.9 The ambulance driver, primary EMT and secondary EMT, if needed, prints and signs their name and enters the current date in the Medical Control section.
6.7.1.10 Provide a copy of Addendum 1, Waiver of Medical Attention, if the patient refuses assessment, treatment, or transport.
6.7.1.11 Forward the completed form to the EMS Coordinator.
6.7.2 Instrnctions for completing Form 2, Emergency Medical Response Report 6.7.2.1 IF the patient does NOT refuse assessment, treatment, or transport, THEN this form is required to be used.
6.7.2.2 IF data fields are Not Applicable, THEN enter NIA.
6.7.2.3 Enter information in the applicable data fields in Section A.
6.7.2.4 Enter information in the applicable data fields in Section B.
6.7.2.5 Enter information in the applicable data fields in Section C.
6.7.2.6 Enter the name of the individual requesting EMS support AND the name of the individual receiving the EMS request for support in Section C.
I OPGP03-ZA-0106 I Rev. 9 I Page 19 of34 Emergency Medical Response Plan 6.7.2.7 Enter the name of the organization the patient was transferred to AND the name of the organization transferring patient responsibility in Section C.
6.7.2.8 Enter the name of the medical facility the patient was transp01ied to and the name of the external EMS individual boarding the STP ambulance, if any, in Section C.
6.7.2.9 The ambulance driver, primary EMT and secondary EMT, if needed, prints and signs their name and enters the current date in Section C.
6.7.3 Instructions for completing Form 3, Ambulance Inventory 6.7.3.1 IF data fields are Not Applicable, THEN enter NIA.
6.7.3.2 Enter the expiration date OR shelf life date, as applicable and as necessary.
6.7.3.3 Enter the quantity of the item accounted during the inventory.
6.7.3.4 Enter the difference between what should be in the ambulance compared with what actually is in the ambulance.
IF there is no difference, THEN enter <O> or <NIA>.
6.7.3.5 Check the <Yes> or <No> box indicating ifthe item(s) were restocked.
- Items should be restocked as soon as practical.
- Notify the EMS coordinator if any item(s) cannot be restocked due to shortfalls in supply, etc.
6.7.3.6 The individual performing the inventory prints and signs their name and enters the date the inventory was completed.
6.7.3.7 The Security Force Supervisor conducts a review of the form to ensure the form is accurate and complete, and then prints and signs their name and enters the date the review was completed.
6.7.3.8 Forward the completed form to the EMS Coordinator.
OPGP03-ZA-0106 Rev. 9 Page 20 of34 Emergency Medical Response Plan 6.7.4 Instructions for completing Form 4, Medical Bag Inventory 6.7.4.1 IF data fields are Not Applicable, THEN enter NIA.
6.7.4.2 Check the applicable box indicating whether the medical bag is located in the ambulance or carried by the 915 patrol.
6.7.4.3 Enter the expiration date OR shelf life date, as applicable and as necessary.
6.7.4.4 Enter the quantity of the item accounted during the inventory.
6.7.4.5 Enter the difference between what should be in the ambulance compared with what actually is in the ambulance.
IF there is no difference, THEN enter <O> or <NIA>.
6.7.4.6 Check the <Yes> or <No> box indicating ifthe item(s) were restocked.
- Items should be restocked as soon as practical.
- Notify the EMS coordinator if any item(s) cannot be restocked due to shortfalls in supply, etc.
6.7.4.7 The Security Force Supervisor conducts a review of the form to ensure the form is accurate and complete, and then prints and signs their name and enters the date the review was completed.
6.7.4.8 Forward the completed form to the EMS Coordinator.
6.7.5 Instructions for completing Form 5, Ambulance Activity Log 6.7.5.1 IF data fields are Not Applicable, THEN enter NI A.
6.7.5.2 Enter the current date.
6.7.5.3 Enter the current time.
6.7.5.4 Enter the name of the ambulance driver.
6.7.5.5 Enter the reason for operating the site ambulance.
6.7.5.6 Enter any comments relevant to the operation of the site ambulance.
6.7.5.7 WHEN all rows of the form is completed, THEN forward the completed form to the EMS Coordinator.
The retention period begins from the last date on the form.
I OPGP03-ZA-0106 I Rev. 9 I Page 21 of34 Emergency Medical Response Plan 7.0 References 7.1 Physical Security Plan 7.2 STPEGS Emergency Plan Table C-1 7.3 SPR 920054 - ESF Power Availability Documentation Not Completed within Required Time Period 7.4 OPGP03-ZS-0001, Vehicle, Material and Personnel Access Control 7.5 OPGP03-ZT-0139, Emergency Preparedness Training Program 7.6 OPOP04-Z0-0004, Personnel Emergencies 7.7 OSDP02-ZS-0042, Rope Rescue Program 7.8 OPRPl 1-ZR-0010, Radiation Protection Support of Medical Emergency Response 7.9 OPGP05-ZV-0010, Emergency Plan Change 7.10 CAQ-D CR 09-16764, Contract EMT not qualified to perform ERO (EMT) position 7.11 CAQ-D CR 12-5821, Procedure not revised per OPGP05-ZV-0010 7.12 South Texas Project (STP) Emergency Medical Services (EMS) Protocols 8.0 Documentation Upon completion, the Ambulance Report and the Waiver of Medical Attention will be retained for seven (7) years. Security will maintain these documents.
9.0 Support Documents 9.1 Addendum 1, Waiver of Medical Attention 9.2 Form 1, Waiver of Medical Attention 9.3 Form 2, Emergency Medical Response Report 9.4 Form 3, Ambulance Inventory 9.5 Form 4, Medical Bag Inventory 9.6 Form 5, Ambulance Activity Log
Page 22 of34 I OPGP03-ZA-0106 I Rev. 9 I Emergency Medical Response Plan Addendum 1 I Waiver of Medical Attention I Page 1of1
- PATIENT COPY**
Refusal of Care Information Sheet
- 1. The evaluation and/or treatment(s) provided to you by this EMS unit are not a substitute for medical evaluation and treatment by a physician. We advise you to get medical treatment by a physician.
- 2. Your condition may not seem as bad to you as it actually is. Without treatment your condition or problem could become worse. If you are planning to get medical treatment, a decision to refuse treatment or transport by the EMS unit may result in delay that could make your condition or problem worse.
- 3. Medical evaluation and/or treatment may be obtained by calling your doctor, if you have one, or by going to any hospital emergency department in this area, all of which are staffed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day by emergency physicians. You may be seen at these emergency departments without an appointment.
- 4. If you change your mind or your condition becomes worse and you decide to accept treatment and/or transport by the EMS unit, please do not hesitate to call us back. We will do our best to help you.
- 5. Don't wait! When medical attention is needed it is usually better to get it right away.
CALL 911 FOR MEDICAL EMERGENCIES HERE AT STP AND OFF SITE
- PATIENT COPY**
I OPGP03-ZA-0106 I Rev. 9 I Page 23 of34 Emergency Medical Response Plan Form 1 (Rev. 0) I Waiver of Medical Attention I Page I of2
. SECTIONA "'"";NOTIF:ICA:OCJONS ,;<;:: : ' n. ;: ', *.;';*; '.;:.,f: '*:*.**.**., ,; '
.*y' t( .. ;;<**
Incident Incident EMT Time EMTTime EMTTime EMT/Amb. Control Room Date Time Notified En Route on Scene In Service Notified Time SECTION B.:.. EMPLOYEE INJi'QRMAT!ON .
- . *~< *& ** ..
Last Name First Name M.I. Badge No. CR No.
D Male Date of Birth D Female Age Employer Department Supervisor
$ECTI0N'C.SfATIENTINFO:RMATIQJN :* * ...... l:":,i*: H'*U/;,.:;
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Advised l)escription Disposition Description 0Yes0No EMS assessment needed 0Yes0No Refused EMS assessment 0Yes0No EMS treatment needed 0Yes0No Refused EMS treatment 0Yes0No EMS transport needed 0Yes0No Refused EMS transport 0Yes0No Harm may occur if EMS care is refused 0Yes0No Released to self 0Yes0No Refusal of care is against EMS advise 0Yes0No Released to supervisor 0Yes0No Transport by other means may result in harm 0Yes0No Released to relative or friend Supervisor's Name (Print):
Relative's or Friend's Name (Print):
Relative's or Friend's Contact Number(s):
SECJ:'ION)).~'REFUSAL ()F CARE ** * ' *ij
- v* .. ,.
~. <
.~; < ,;; ' ')
- 1. The evaluation and/or treatment(s) provided to you by this EMS unit are not a substitute for medical evaluation and treatment by a physician. We advise you to get medical treatment by a physician.
- 2. Your condition may not seem as bad to you as it actually is. Without treatment your condition or problem could become worse. If you are planning to get medical treatment, a decision to refuse treatment or transport by the EMS unit may result in delay that could make your condition or problem worse.
.J. Medical evaluation and/or treatment may be obtained by calling your doctor, if you have one, or by going to any hospital emergency department in this area, all of which are staffed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day by emergency physicians. You may be seen at these emergency departments without an appointment.
- 4. If you change our mind or your condition becomes worse and you decide to accept treatment and/or transport by the EMS unit, please do not hesitate to call us back. We will do our best to help you.
- 5. Don't wait! When medical attention is needed it is usually better to get it right away.
I have declined assessment, treatment and/or transportation officered to me by an EMS unit. I have received and understand the instructions J!ive11 to me (Addendum 1, Waiver of Medical Attention) bv EMS personnel.
Patient:
Print Name Signature Date Witness:
Print Name Signature Date Primary EMT:
Print Name Signature Date This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 24 of34 Emergency Medical Response Plan Form 1 (Rev. 0) I Waiver of Medical Attention I Page 2 of2
- ,$)£CJTI0;N,;E'-'-' EY(\1
- 8iJ:NJl;cfRi\iA'.tfPN * .*.'. ; ;~' ':'. *czt;c!; . . *>'l* .~, .* ,...r'.:s;tf .*....* .\7. ~'." s:***. ;~:::. :;:m:<i'Y\*"'* ;.,?:~:::" .* *~1'*<:' . .: **~*:::*
I Name taking EMS service request I Name requesting EMS services I.*.;.>** :*. .,.. . :, .*'.
MEDICAL coNn~oL :., : . :* .. *:
Contacted by phone at (Extension):
Contacted by radio at (Time):
Unable to Contact (Reason):
0Yes0No Provided copy of Addendum 1, Waiver of Medical Attention to the patient.
0Yes0No Medical Control Contact or Orders Necessary. IF yes, THEN list the medical control orders below.
./' .*
.' .*~
MEDICAL CONTROL'Q;RDERS. . }<'***. c,: ** . *
,, :* *,. *.* * ,**.*sg**
NARRATIVJf . / *.','*:: *..,:
.. *.*****'*:'* .. >*C*
D Ambulance Fueled D Ambulance Cleaned and Disinfected D Ambulance/Medical Bag restocked Ambulance Driver Print Name - Signature Date Primary EMT Print Name Signature Date Secondary EMT (ifneeded) Print Name Signature Date This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 25 of34 Emergency Medical Response Plan Form 2 (Rev. 0) I Emergency Medical Response Report I Page 1 of3 0Yes 0No Incident Date Incident Time EMT Time EMT Time EMTTime Contamination Notified En Route on Scene Status EMT Departed Patient Transfer Patient Arrived at EMT/Amb. In Control Room Site Time Time Med. Fae. Time Service Notified Time Last Name First Name M.I. Badge No. CR No.
D Male Date of Birth D Female Age Employer Department Supervisor Location of Incident:
MOI Chief Complaint (CC):
History (HX): D Yes D No Prior Aid Signs & Symptoms (SS):
Last Meal (what & when):
Allergies:
Event(s):
Medications: Time: Route: Dosage:
Time: Route: Dosage:
Basic Life Support (Check all that apply):
D 1. Bandaging D 2. Splinting D 3. Neck/Spine Immobilization D 4. Minor Bleeding Control D 5. Major Bleeding Control D 6. Shock Management D 7. Suction D 8. Airway Maintenance D 9. Assist Ventilation D 10. Oxygen D 11. CPR D 12. Psych Assist D 13. Bum Management D 14. Traction D 15. Emergency Child Birth D 16. Restraints D 17. Defibrillation (AED) D 18. M.A.S.T.
Defibrillation: I Time: I Attempts: I AUSC Reg Tlu*eady Reg Full PALP lrreg Strong Irreg Shallow Time BP Pulse Bounding Resp. Labored 02/SAT NUERO (AVPU)
AUSC Reg Thready Reg Full PALP Irreg Strong lrreg Shallow Time BP Pulse Bounding Resp. Labored 02/SAT NUERO (AVPU)
AUSC Reg Thready Reg Full PALP Irreg Strong Irreg Shallow Time BP Pulse Bounding Resp. Labored 02/SAT NUERO (A VPU)
This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 26 of34 Emergency Medical Response Plan Form 2 (Rev. 0) I Emergency Medical Response Report I Page 2 of3
- BEC
- YJONC-"PATIENtl~FORMATJON(Coiif.)':*:*.: yo:;:; . . \ * < *** .:;c < L}ri ' .. *>T .1'"' . "; .;:1+' .,:c:'"t' Glasco Coma Scale I Revised Trauma Scale: 1) I I 2) I I 3) I Best Motor Best Verbal Respiratory No. Eye Opening Coma Scale Systolic BP Response Response Rate
- 0. *' :. 3 0 0
. ; . ; ' ' ;' *i< "*"': ,;,*: ; ......
}\ *, ***: '
- 1. None None None 4-5 1-5 1-49
- 2. Exterior Posturing Incomprehensible To Pain 6-8 6-9 50-75 Words
- 3. Flexion Inappropriate To Voice 9-12 >29 76-89 Words
- 4. Withdraws from Confused Spontaneous 13-15 10-29 >89 Pain
- 5. Localizes Pain Oriented <*
- , \
'.{' *r\< .*(f ., ; '
- )*:.~
,6. Follow Commands ** .. '.
/ ,;:
<\
Head and Face Eyes and Pupils Chest D Unresponsive DPERL D Unremarkable D Crepitus D Unequal: D Chest Pain D Tenderness D Dilated: DL DR D Pacemaker D Deformity D Pinpoint: DL DR D Central Line: DL DR D Bleeding D Cataracts: DL DR D Chest Tube: DL DR D Asymmetry D Responsive: DL DR D Wounds D Wounds D Unresponsive: DL DR D Unstable ONG-Tube D Prosthesis: DL DR D Crepitus D Absent Gag Reflex D Other D Scars D Other D Tenderness D Asymmetry D Air leaking from wounds D Other ABD Pelvis Back D Unremarkable D Unremarkable D Unremarkable D Distension D Bruising D Decubitus D Bruising D Wounds D Deformity D Wounds D Deformity D Unstable D Rigidity D Lateral pelvis rims tender I unstable D Tenderness D Tenderness D Symphysis pubis tender or unstable D Bruising D Scars D Foley D Sensation Absent D G-Tube D Other D Loss of Function D Colostomy D Other D Nausea/Vomiting D Other DEXT:
This form shall be retained for seven (7) years
-- *1 OPGP03-ZA-0106 I Rev. 9 I Page 27 of34 Emergency Medical Response Plan Form 2 (Rev. 0) I Emergency Medical Response Report I Page 3 of3 NARRATIVE : ,: *. :-., . .. * . ._:-' ....
. . *. ...... ,---:-* ... >~
0 Ambulance Fueled 0 Ambulance Cleaned and Disinfected 0 Ambulance/Medical Bag restocked EMS Requested By: EMS Request Received By:
Print Name Print Name Patient Transferred To: Patient Transported By:
Print Organization Name Print Organization Name Patient transported To: EMT Board STP Ambulance:
Print Facility Name Print Name Ambulance Driver Print Name Signature Date Primary EMT Print Name Signature Date Secondary EMT (ifneeded)
Print Name Signature Date This form shall be retained for seven (7) years
Page 28 of34 I OPGP03-ZA-0106 I Rev. 9 I Emergency Medical Response Plan F01m 3 (Rev. 0) I Ambulance Inventory I Page 1of4 Expiration On-Hand Quantity Quantity Difference Item Description Restocked Date (Minimum) Present (Minus)
Outside Misc~Jlaneous ' *.. *..* ', ,i '*** ' ;. '. .*.**.' ....
Spider straps or webbing 2 0Yes 0No Long Boards (Back Boards) 2 0Yes 0No Short Board 1 0Yes 0No Stretcher 1 0Yes 0No Stair Chair 1 0Yes 0No KED with Pillow and Head Straps 1 0Yes 0No Adult Traction Splint 1 0Yes 0No Child Traction Splint 1 0Yes 0No 15" Padded Board Splint 2 0Yes 0No 48" Padded Board Splint 1 0Yes 0No Frac Pack 1 0Yes 0No Reflective Triangle Road Signs 2 0Yes 0No Fire Extinguisher with Current 1 0Yes 0No Inspection Cervical <;:oH~r B~g .... . .. *; '
Infant C-Collar 2 0Yes 0No Pediatric C-Collar 2 0Yes 0No
- No-Neck C-Collar 2 0Yes 0No
- Regular C-Collar 2 *. 0Yes 0No
- Tall C-Collar 2 0Yes 0No OR
- Adjustable C-Collars may replace 6 0Yes 0No adult sizes .
Headbeds 4 0Yes 0No Roll of2" Tape 1 0Yes 0No Roll of Duct Tape 1 0Yes 0No Linens < c( }:* x t '.* '
Pillow (Spare) 1 0Yes 0No Pillow Cases 2 0Yes 0No Blankets 2 0Yes 0No Sheets 3 .OYes 0No Towels 3 0Yes 0No Wash Clothes 3 0Yes 0No InsideMiscellaiieo~s >,;. **.:; *.' ',;-.: ; .;; :
Clip Board 1 0Yes 0No (Blank) Form 1, Waiver of Medical 5 0Yes 0No Attention (Blank) Addendum 1, Waiver of 5 0Yes 0No Medical Attention Blank Form 2, Emergency Medical 5 0Yes 0No Response Report This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 29 of34 Emergency Medical Response Plan Page 2 of4 Form 3 (Rev. 0) I Ambulance Inventory I Expiration On-Hand Quantity Quantity Difference Item Description Restocked Date (Minimum) Present (Minus)
JnsideMisc~llaneqt1s (Corit.) , . *.* .. * ' *.* ~>>, i .. .:.:.* '** .'i: : ;'. : .. . *.* ; : *. ;;
EMS current Protocol Book 1 0Yes 0No DOT Emergency Response Guidebook 1 0Yes 0No No Smoking Sign 1 0Yes 0No Flashlight (Working) 1 0Yes 0No Cell Phone 1 0Yes 0No Portable Radio Unit Charger 1 0Yes 0No Suction Unit with Canister, Tubing 1 0Yes 0No and Yanker Stretcher with Pillow and Linens 1 0Yes 0No Oxygen Equipment .* .. . *. . :. :
Spare 02 Cylinder (Sealed) 1 0Yes 0No BVMAdult 1 0Yes 0No BVM Pediatric 1 0Yes 0No BVMNeonate 1 0Yes 0No Non-Re-breather Mask (NRB) 5 0Yes 0No Nasal Canulas (NC) 3 0Yes 0No Nebulizers 3 0Yes 0No Pedi Simple Face Mask 1 0Yes 0No Infant Mask 1 0Yes 0No Oral Airway (Set 0-6) 1 0Yes 0No Pulse-ox 1 0Yes 0No Primary 02 Level: I 0Yes 0No Portable 02 Level: I 0Yes 0No L\ED Equipment/Glucometer ;;.;' /; ... .. : ...... .;
- . *. / .
AED 1 0Yes 0No AED Spare Battery 1 0Yes 0No Adult Pads 2 0Yes 0No Glucometer 1 0Yes 0No Lancets 25 0Yes 0No Test Strips 5 0Yes 0No
..,,. y ... ;** ;
\ ;. *.* ) ;*;
Bandage Equipment .. .
Bum Sheets 6 0Yes 0No Multi Trauma Dressing 6 0Yes 0No 5x9" Bandages 12 0Yes 0No 4x4" Bandages 60 0Yes 0No Roller Bandages 12 0Yes 0No Occlusive Dressings 12 0Yes 0No Rolls of Tape 4 0Yes 0No Medications * '.* '* ; ; ; .;.
Activated Charcoal (25 g) 1 0Yes 0No Albuterol (2.5 mg) 4 0Yes 0No Aspirin (81 mg) 8 0Yes 0No This form shall be retained for seven (7) years
Page 30 of34 I OPGP03-ZA-0106 I Rev. 9 I Emergency Medical Response Plan Form 3 (Rev. 0) Ambulance Inventory I. Page 3 of 4 I
Expiration On-Hand Quantity Quantity Difference Item Description Restocked Medications (Cont.)
Date (Minimum)
- '.* '* .f . :
Present
,.* . (Minus)
EpiPen 1 0Yes 0No Nitro Tablets 8 0Yes 0No Oral Glucos 2 0Yes 0No Syrup oflpacac (Bottle) 1 0Yes 0No Ammonia Inhalants 6 0Yes 0No Peroxide (Bottle) 1 0Yes 0No Sterile Water (Liter) 2 0Yes 0No Eye Wash 4 0Yes 0No Cold Packs 4 0Yes 0No Inside Wall Miscellaneous . . ... **' ' .. ,,* . *, . x... .
System 5 BP Cuff set (5) 1 0Yes 0No Stethoscope 2 0Yes 0No Pen Lights 2 0Yes 0No Bite Sticks 2 0Yes 0No Trauma Shears 1 0Yes 0No Bandage Shears 2 0Yes 0No Ring Cutter 1 0Yes 0No Waterless Hand Cleaner 1 0Yes 0No Sharps Container 1 0Yes 0No Spare Suction Canisters 2 0Yes 0No Suction Tubing 2 0Yes 0No Yankers 2 0Yes 0No Assorted Soft Suction (French Caths) 5 0Yes 0No Bed Pans 2 0Yes 0No Urinals 2 0Yes 0No Emesis Basins 2 .* 0Yes 0No Isolation Gear 2 0Yes 0No Eye Protection 2 0Yes 0No Paper Face Mask 2 0Yes 0No Sealed OB Kits 2 0Yes 0No Silver Swaddlers 2 0Yes 0No Bulb Syringes 2 0Yes 0No Disinfectant Spray 1 0Yes 0No Roll of Trash Bags 1 0Yes 0No Biohazard Bags 5 0Yes 0No Triage Kit 1 0Yes 0No Diapers 4 0Yes 0No Small Gloves 10 0Yes 0No Medium Gloves 10 0Yes 0No Large Gloves 10 0Yes 0No X-Large Gloves 10 0Yes 0No This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 31 of34 Emergency Medical Response Plan Form 3 (Rev. 0) I Ambulance Inventory I Page 4 of 4 On-Hand Quantity (Minimum)
';=)~
/':;,*,\,~ '
, , , ; *,~ ~'<,, *
,, .. , ' :>'"{'~t Brose low 1 0Yes 0No Pedi Drug Chart 1 0Yes 0No Bulb Syringe 1 0Yes 0No Delee Suction 0Yes 0No Meconium Aspirator 1 0Yes 0No Sealed OB Kit 1 0Yes 0No Silver Swaddler 1 0Yes 0No 4x4" Bandages 4 0Yes 0No Roller Bandage 1 0Yes 0No NeonateBVM 1 0Yes 0No Inventoried By:
Print Name Signature Date Safety Review:
Print Name Signature Date This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 32 of34 Emergency Medical Response Plan Page 1 of2 Form 4 (Rev. 0) I Medical Bag Inventory I D Ambulance Jump Bag D EMT Response Bag(s)
Expiration On-Hand Quantity Quantity .Difference Item Description Restocked Date I (Minimum) Present * (Minus)
Eye Protection *** 0Yes 0No Gloves (Large) (Pair) 4 0Yes 0No Surgical Filter Mask 2 0Yes 0No
.vitils ~q;uipfueitt . .. ;;*p.*
Blood Pressure 0Yes 0No Cuff/sphygmomanometer Stethoscope . ** D Yes 0No Pen Light ... ** 0Yes 0No Oxygen Bottle in Bag with Regulator D Yes 0No Non-re-breather Mask 2 *
- 0Yes 0No Nasal Cannula 2 .* ... 0Yes 0No Oral Airway Set D Yes 0No Adult Bag Valve Mask *** 0Yes 0No
'SuctlQQ Equipment. ...
- ; .******** )i;.
V- Vac Suction with Canister . D Yes 0No V- Vac Suction Extra Canister D Yes 0No 4x4" Sterile Dressing 6 0Yes 0No 5x9" Sterile Dressing 6
- D Yes 0No 8x10" Dressing 2 .*:***.* * .
- D Yes D No Occlusive Dressing 2 .: 0Yes 0No Burn Sheets 0Yes 0No Multi-Trauma Dressing 2 0Yes 0No 4" Roll Bandage 2 0Yes 0No Triangle Bandages 6 0Yes 0No 2" Plastic Tape 2 D Yes 0No Roller Gauze 4 0Yes 0No Flex Gauze 2 .. 0Yes 0No 2x2" Gauze 2 0Yes 0No Adjustable C Collars 1 D Yes 0No Sam Splint 2 0Yes 0No Head Beads 0Yes 0No This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 33 of34 Emergency Medical Response Plan Form 4 (Rev. 0) I Medical Bag Inventory I Page 2 of2 Expiration On-Hand Quantity Quantity Difference Item Description Restocked Date (Minimum) Present (Minus) ,.,,,
j!\'le<licaHOns,'-.s ,,r '*
"\,t
. **:>>:,:v z~.::;> ")J,. ,_,,, .._, :0: '._; *:;,:,; *'ll'_** *'::;:.;/'
- . <;:_f':',\~;
v >,'_'"' :,* : ::: "' '.*f" :;*, :;r-1~?::;::;-*:
. ' '.:; ' '/ "' ;
Sterile Water 250 ml 2 : .: 0Yes LJNo Oral Glucose 1 { "*. .< 0Yes . 0No
':.: /'.>
Eye Wash 1 :,****'* 0Yes 0No Ipicac Syrup 1 : : .. 0Yes 0No Activated Charcoal 1 : .DYes 0No ASA (Baby Aspirin) 10 '. '\ .: : ,* 0Yes 0No Nitro 1 "-;" ; ;.-_ .* .. '. 0Yes 0No Albuteral 3 7 0Yes 0No Misc~lian.e,ous_ '" :ct ::;~,, . . ' sf' :~.;':' *. '?;"';:.'!: **. ; ;.: >:. ::~*;;,:i;;*tf
\';'
_:;.,.. .>::1-r "
- " <t,-,1<::1*-*
- ;;;{;'; ,*
Scissors 1 *' '
0Yes 0No Trauma Sheers :--.. *.* )'*::,
1 0Yes 0No Triage Tags 4 :.:'-"' *., 0Yes 0No Bite Stick 1 \.*.* *:
- . 0Yes 0No Emesis Bag 1 0Yes 0No Bio Bags 1 : /' . 0Yes 0No Cold Packs 3 : **.*
- . 0Yes 0No Hand Cleaner 1 .-*':' .* < 0Yes 0No Peroxide 1 ..... " 0Yes 0No Writing Pad 1 *. ,.: ::' \ 0Yes 0No
- Pen 1 : :.,* :: ' 0Yes 0No Remarks\- :
Inventoried By:
Print Name Signature Date Safety Review:
Print Name Signature Date This form shall be retained for seven (7) years
I OPGP03-ZA-0106 I Rev. 9 I Page 34 of34 Emergency Medical Response Plan Form 5 (Rev. 0) I Ambulance Activity Log I Page 1 of 1 Complete this form when the ambulance is utilized, e.g. medical emergencies, getting fuel, running engine, etc.
Date Time Ambulance Driver Activity (Reason) Comments J
This form shall be retained for seven (7) years