Docstoc

Ambulance Service of NSW Ride-Along Forms - The University of

Document Sample
Ambulance Service of NSW Ride-Along Forms - The University of Powered By Docstoc
					                            AMBULANCE RIDE-ALONGS
Medical students are very welcome to join an Ambulance or Intensive Care Paramedic crew for
a day to gain an insight into the role. Hours of observation are limited to 0700-2400 hours each
day.

Northern Sydney Sector Ambulance Stations are located at:

       Auburn
       Avalon
       Balgowlah
       Belrose
       Blacktown
       Castle Hill
       Lane Cove
       Naremburn
       Narrabeen
       Parramatta
       Riverstone
       Ryde
       St Ives
       Wahroonga

If you would like to take part, please complete and sign the attached
     • Observer/Ride-a-long Application Form (15a)
     • Occupational Assessment, Screening & Vaccination Program Verification Form (188)
        and
     • Indemnity Form (15b)


N.B.: The Executive Officer or Education Support Officer at Northern Clinical School must
      witness the indemnity form.


Please fax the completed application forms to:

Logistics Officer
Tel: (02) 9487 8056
Fax: (02) 9487 8051

Email: SydNorthLogistics@ambulance.nsw.gov.au


Applications must be received at the Sector Office no later than 28 days prior to the
requested visit.

As Ride-Along is voluntary and not a compulsory part of the medical degree, the University's
Insurance will not cover students for any injury sustained whilst being an observer. The
Ambulance Service of NSW will also not be held reponsible (see Indemnity Form). Therefore, it
is recommended that students arrange their own insurance cover.

The actual Ride-A-Long will then be arranged through the Ambulance Service of NSW
Northern Sydney Sector Office at Wahroonga who will contact you directly.
Please call the Logistics Officer should you have any questions.
                                                         Standard Operating Policy



         WORK EXPERIENCE / OBSERVER / RIDE-A-LONG PROCEDURES

APPLICATION

Persons wishing to make application to observe Ambulance Officers perform clinical duties in the
field must make application using Form 15 (1 & C) available from the Operations Manager.

An Indemnity Form (Form 15 b) must be completed at the time of application.

Applications must be received at the Sector Officer no later than 28 days prior to the requested
visit.

Once the application is received the applicant will be contacted by the Operations Manager /
delegate to advise of their success/non success and the appropriate dates. (Form 15 d).

The Ambulance Service reserves the right to refuse applications at any time.

All persons applying for work experience, observation or ride-a-longs must show evidence of
compliance with NSW Health policy regarding occupational assessment, screening & vaccination
against specified infectious disease. Form 188 must be completed and submitted at the time of
the application. Appropriate evidence of vaccination and screening status should be attached to
form 188. Form 188 must then be verified by the Service’s Infection Control Officer or delegate
prior to placement observation. Failure to provide adequate evidence will result in the application
being refused due to patient safety reasons.

INDEMNITY

The Ambulance Service of NSW in granting permission to accompany an Ambulance crew in their
work requires an observer to abide by the following conditions:

Not to disclose to any person any patient information gained during period of observation

Assist the Ambulance Officer/Paramedic only if requested and act only as directed

No photographs, video sound recordings or patient interviews are permitted unless authorised by
the Divisional Manager.

Dress must be clean, neat casual clothing during the course of the ride-a-long. Officers from
another recognised authority will wear normal uniform. Vest and other protective equipment must
be worn when appropriate.

The Ambulance Service of NSW will not be held responsible by the observer/visitor for injury
sustained, illness contracted during the term, or damage to personal property except for third
party vehicular accident claims.
                                                         Standard Operating Policy


Priority of observers on Helicopter

Helicopter Crew Trainees
Ambulance Officer Trainees (Level IV/V)
Observers/visitors to Ambulance Service (as described in Paragraph 3)
Observers/visitors to Helicopter Service

All applications for visits/observations solely on helicopter flights must be submitted to the
Operations Manager.


MISCELLANEOUS

All observers/visitors must be suitably and neatly attired during visits. Comfortable casual clothing,
long pants with flat-soled shoes.

Personnel who would normally wear a uniform, excluding nursing staff, during their course of
employment must wear same during the course of the ride-a-long.

Visitors/observers must report to the Senior Officer on commencement of shift, which will ensure
appropriate documentation is completed and the attendance book is signed. The visitor/observer
will also be issued with a visitor’s identification badge. Following this, the observer/visitor will
undergo a pre-shift familiarization safety check. A safety vest will issued where appropriate.

Hours of observation are limited to 0700 – 2400 each day, and should not exceed a normal
rostered shift. Observation between 2400 – 0700 is not permitted.
                                                                                                                      FORM:15 (a)
                                                                                                          Issue Date: 30 July 1999


                  OBSERVER / RIDE-A-LONG - APPLICATION FORM

This form is to be completed by all persons making application to the Ambulance Service of
NSW to accompany ambulance crews as an observer/visitor.


SURNAME: ......................................................FIRST NAME: ..............................................

ADDRESS:
...............................................................................................................................................

.........................................................................         POST CODE: .........................................

CONTACT PHONE (Hm) ............................. (Wk)..................................(If Applicable)


UNIVERSITY / COURSE ENROLLED
.................................................................................……………………………………………...

................................................................................................................................................

COURSE / SUBJECT COORDINATOR...........................................................…....................

CONTACT PHONE..................................................................................................................

Preferred
Dates:........................................................................………….............…...............................

Preferred Station/s:................................................................................................................


All applicants must agree to the requirements set out in the indemnity form. The Ambulance Service
reserves the right to withdraw approval at any time.



SIGNATURE OF APPLICANT: ..................................................                                           Date: /            /


Office use Only                                Sector Manager


Approved / Not Approved ..............................................................                     Date:       /     /




Observer/ Ride-A-Long Application Form                                                                                           Page 1 of 4
                                                                                                           FORM: 15 (b)
                                                                                                Issue Date: 30 July 1999



                                                  INDEMNITY FORM




The Ambulance Service of NSW, in granting observers permission to accompany an
ambulance crew in their work, requires the observer to abide by the following conditions:

1.         Not to disclose to any person any patient information gained during period of
           observation.


2.         Assist the Ambulance Officer/Paramedic only if required.


3.         No photographs, video sound recordings or patient interviews are permitted unless
           authorised by a senior officer of the Ambulance Service.


4.         Dress must be clean, neat casual clothing during the period of observation. Officers
           from another recognised authority will wear their uniform.


The Ambulance Service of NSW will not be held responsible by the observer/visitor for injury
sustained, illness contracted during the term, or damage to personal property except for third
party vehicular accident claims.




I .............................................................................................., agree to abide to the
conditions as stated above.


Signature:...............................................................................       Date:           /       /        .


Witness:.................................................................................       Date:       /       /        .


Sector Manager:.....................................................................            Date:       /       /        .




Observer/ Ride-A-Long Indemnity Form                                                                                        Page 2 of 4
                                                                                                                                    FORM: 188
                                                                                                                        Date issued: 26-4-2010
                                                                                                                    Issued by: Clinical Services




Occupational Assessment, Screening
& Vaccination Program Verification Form
 Name:                                                                        Date of Birth:          Contact Phone Numbers:

                                                                                                      Home:

                                                                                                      Mobile:



NSW health care workers must be protected against some specific infectious diseases because of both
OH&S and Patient Safety risks. The requirements listed below are a NSW Health instruction and all ASNSW
employee and clinical placement applicants must provide evidence of compliance with the criteria listed
below. Compliance with these requirements also provides additional public health benefit. Please complete
the questionnaire below and provide all evidence as an attachment.

Acceptable evidence includes blood test results or copies of vaccination records or cards. Statutory
declarations are not acceptable. Attach the evidence to this form.
You may need to visit your GP to complete all aspects of this program


□   You must have had an adult dTPa (diphtheria / tetanus / pertussis) booster vaccination. Attach a
    vaccination record. (A blood test is not acceptable evidence. An ADT vaccine is not acceptable – the vaccine
    must contain pertussis/whooping cough.)


□   You must have completed a hepatitis B vaccination course suitable for the age that you had it (ie 2 doses if
    given to you as an adolescent, or 3+ doses for any other age). Attach the vaccine records or provide as much
    information as you know about when or where you had the vaccine course.
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    □     After the hepatitis B vaccination course, you must have had a blood test “for immunity” to determine if the
          hepatitis B vaccination was successful. Attach a copy of the blood test result (hepatitis B Surface
          Antibody).


□   If your year of birth is before 1966, disregard this Measles Mumps Rubella (MMR) section. Go to the Chicken
    Pox section. If your year of birth is 1966 or after, either attach records for 2 doses of MMR vaccine given at any
    stage of your life (minimum 1 month apart), or copies of positive immunity blood test results for Measles,
    Mumps and Rubella.


□   Have you had Chicken Pox at any stage in your life (circle correct answer)?                             YES        NO        DON’T KNOW
                a. If YES, Move on to the Tuberculosis section
                b. If NO or DON’T KNOW, has a doctor ever diagnosed you with shingles? YES                                     NO
                c.   If YES, move on to the TB section
                d. If NO, either attach records for 2 doses of chicken pox vaccine given minimum 1 month apart, or
                   copies of a positive immunity blood test result for chicken pox (varicella Zoster IgG).




Page 1   of 2
                                                                                                         FORM: 188
                                                                                             Date issued: 26-4-2010
                                                                                         Issued by: Clinical Services



□   Tuberculosis (TB) Were you born in/ have you lived or worked for more than 3 months in one of the countries
    listed below? YES NO
                a. If NO move on to the final instructions below.
                b. If YES – attach TB screening evidence (Tuberculin Skin Test / TST / Mantoux Test). TB Screening
                   can be obtained through your local Chest Clinic.
Afghanistan                       Ethiopia                          Nigeria                  Uganda
Bangladesh                        India                             Pakistan                 UR Tanzania
Brazil                            Indonesia                         Philippines              Viet Nam
Cambodia                          Kenya                             Russian Federation       Zimbabwe
China                             Mozambique                        South Africa
DR Congo                          Myanmar                           Thailand


Final Instructions – please check the enclosed information and attachments and ensure that all criteria are
addressed and that evidence is provided. Ensure your name is on all attachments. (Provide copies only and keep
your originals.) Sign and date the form below
Signature:                                          Date:

Employee applicants - forward this form and attachments to Recruitment


Clinical Placement Applicants – forward this form and attachments with your Ride-along Application to the relevant
Ambulance Department.


 Ambulance use only

                 Evidence Verified      Evidence Not Verifiable       Comments


 Signature:

 Date:




Page 2   of 2

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:6
posted:12/31/2012
language:English
pages:7