The New Zealand Ambulance Board

Application for Membership of Ambulance New Zealand - Air Ambulance Service – Rotary Wing

Name of Service:………………………………………………………………………….

Date of Declaration:……………………………

Section 1 Approval to conduct Air Ambulance Services

This service is approved by CAA to operate an air ambulance service:

Please provide documentation to show that you comply with all CAA rules and evidence of compliance (mod or STC) for air ambulance role equipment including stretchers and oxygen system.

Comments: …………………………………………………………………………………………..

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Section 2 Communications

a. This service can respond to urgent/emergency calls 24 hours a day, 365 days a year:

Yes/No

b. This service can be deployed/accessed through: (please tick þ).

o The Emergency Ambulance Communication Centre (EACC) located at:

………………………………………………………………………….…….

o DHB located at:

……………………………………………………………….……………….

o Another emergency provider located at:

………………………………………………………………………………..

Comments: …………………………………………………………………………………………..

Section 3 Performance Standards

When an air ambulance is deployed to transport a patient, or when a patient’s condition is known to require a minimum level of care, this service ensures that:

a. The clinical support crew or Medical Passenger (full-time or volunteer) has a minimum qualification as specified in NZS 8156 Ambulance Sector Standard. (Staff may be provided by the DHB, local emergency ambulance provider or other health service).

o Basic Life Support (BLS)

o Intermediate Life Support (ILS)

o Advanced Life Support (ALS) – this includes registered nurses and medical staff

Comments: …………………………………………………………………………………………..

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When an air ambulance is deployed to transport a patient, or when a patient’s condition is known to require a minimum level of care, this service ensures that:

b. The clinical support crew or medical passenger (full-time or volunteer) has the minimum education and training requirements as specified in Air Ambulance /Air SAR Service Standard. (Staff may be provided by the DHB, local emergency ambulance provider or other health service)

Comments: …………………………………………………………………………………………..

Section 4 Airframes

When an air ambulance is deployed to transport a patient this service ensures that:

o Patients are transported in purpose-built air ambulances, each of which carries at least one stretcher and a minimum range of lifesaving equipment (that may be specified by NZS 8156 Ambulance Sector Standard), maintained to a satisfactory standard.

o The airframe is certified by independent audit to the Air Ambulance/Air SAR Service Standard

Comments: ……………………………………………………………………………………….……..

Section 5 Clinical - Delegated Authority

This service has a process to ensure all clinical staff operate under the appropriate clinical delegation or authority.

Yes/No

Please attach a copy of this policy.

Comments: ……………………………………………….……………………………………………..

Section 6 Clinical Audit

This service is regularly audited by an independent (approved) auditor in accordance with the Air Ambulance/Air SAR Service Standard and NZS 8156 Ambulance Sector Standard.

Yes/No

Name of Auditor: ………………………………………………………………...

Frequency of Audits: ………………………………………………………………......

Date of Last Audit: ………………………………………………………………......

Comments: ………………………………………………………………………………………………

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Section 7 Compliance

This service will, as a minimum, comply with all policies and protocols specified by NZS 8156 Ambulance Sector Standard that relate to the delivery of quality care to patients (this may be demonstrated by a successful 3rd party audit conducted by an independent audit agency accredited by IANZ or JASANZ)

Comments: …………………………………………………………………………………….………..

Section 8 Declaration

This service:

a. Comprises fit and proper persons for membership and satisfies the requirements as specified in NZS 8156 Ambulance Sector Standard.

Yes/No

Comments: ………………………………………………………………………………………...………………………………………………………………………………………

………………………………………………………………………………………

b. Is a properly constituted legal entity as specified in NZS 8156 Ambulance Sector Standard, with appropriate approvals for the operation of all its air ambulances, and appropriate minimum qualifications for all clinical personnel?

Yes/No

Comments: ……………………………………………………………………………………...

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c. Has obtained at least biennially:

o A report relating to clinical revalidation of staff providing care on behalf of the service.

Please attach a copy of each of the most recent report of clinical revalidation to this declaration of eligibility.

Comments: ……………………………………………………………………………………...

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d. This declaration is made on behalf of …………………………………………….

in good faith and after a review of the procedures, documents and commitments contained in the above statements. We attest to the truthfulness and accuracy of the information.

Signed: Signed:

…………………………………………… …………………………………….

Chairperson of the applicant Chief Executive of the applicant

ambulance service ambulance service

Dated: ……………………………………. Dated: ………………………………..

Required Attachments – (copies of current/most recent documents)

o Certificate of Incorporation/Trust Deed etc

o Accreditation Certificate, eg ISO 9000, Air Ambulance/Air SAR Standard, NZS 8156

o Annual Report

o Audited Financial Statements

o Medical Advisor/Director letter of support/commitment

o Passenger Transport Licence (where appropriate)

o MoU with regional emergency ambulance (111) provider (where appropriate)

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