EMS Directors Survey

Emergency Medical Services Directors Survey
Preparedness for WIPP Transportation Incidents
6/99

About your service: Service Name: ____________________ County: __________
Date: ___________

Your Name: ____________________________ Phone: ____________
Fax: _____________________

Address: _________________________________________ City: ________________
Zip: _________

1.Does your service provide EMS response on WIPP Transportation Routes?
___Yes ___ No

2.If yes, describe your immediate service area on WIPP routes. ____________________________________________________________________

____________________________________________________________________

3. What level of emergency medical service do you provide?
____ Medical 1^stResponder ____Basic Life Support ____ Intermediate Life Support ___Advanced Life Support ___ All___

4.Please list the total number of licensed medical personnel in your service:
Medical First Responder________
Emergency Medical Technician-Basic________
Emergency Medical Technician-Intermediate________
Emergency Medical Technician-Paramedic________
TOTAL NUMBER________

5.Fire Service ___ Yes ___No

6.Medical Rescue ___ Yes ___ No

7.Certificated Ambulance ___ Yes ___ No

8. ___ Volunteer Service ___ Paid Service ____Combination Service (paid/volunteer)

9. Number of personnel ____ Volunteer ___ Paid ___ (If paid, number of union employees ___).

10.What is the average length of time your personnel stay within your organization?
___ less than one year ___ one to five years ____ five to ten years ___ more than ten years

11.Insurance coverage provided to workers?
___Workers compensation ___ Accident coverage ___ None

12.List the hospital(s) that your service normally transports emergency patients to:
__________________________________________________________________

__________________________________________________________________

About training:

13.Have your employees/volunteers received training on response to a WIPP transportation incident? ___Yes ___No

14.If yes to question 13, please list the courses, approximate number of personnel who attended and the approximate dates:
______________________________________________________________

__________________________________________________________________

15.Have your employees/volunteers received training on the treatment of radioactively contaminated patients? ___Yes ___ No

16.If yes to question 15, please list the courses, approximate number of personnel who attended and the approximate dates:

___________________________________________________________________

17.Does your service have a Standard Operating Guide or Policy for your employees for response to hazardous materials incidents? ___Yes ___ No

18.List the number of personnel trained at the following levels (OSHA 29 CFR 1910.120)

____ First Responder Awareness___ First Responder Operations
____ Hazardous Materials Technician___ Incident Command

19.Do you think that your service could safely respond to a WIPP transportation incident?
___ Yes ___ No

20.If no, what does your service need / recommend in order to achieve / maintain proficiency for response to a WIPP transportation incident (e.g., equipment, training, procedure/policy). Please be specific if possible.

___________________________________________________________________

21.Additional comments (use additional pages if needed):

___________________________________________________________________

Please return this survey to:
Ralph Davis
WIPP Medical Preparedness Coordinator
Injury Prevention and EMS Bureau
New Mexico Dept. of Health
P.O. Box 26110
Santa Fe, New Mexico 87502

Telephone: 505-476-7000 ex. 123
Fax: 505-476-7010
Email: ralphd@doh.state.nm.us

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