STATE OF TENNESSEE

DEPARTMENT OF HEALTH

DIVISION OF EMERGENCY MEDICAL SERVICES

INSTITUTION APPROVALSURVEY

FOR

BASIC EMERGENCY MEDICAL TECHNICIAN

Date:Institution:

Address:

StreetCityStateZip

Program Director:

Medical Director:

INSTITUTIONAL APPROVAL SURVEY / YES / NO
  1. Written philosophy and purpose statement

  1. Accredited post-secondary educational institution or comparable

  1. Contracts with hospital and/or licensed ambulance service to provide clinical training

  1. Budget reflects adequate financial support for:
  2. Equipment and maintenance
  3. Facilities
  4. Administration and faculty

  1. Records maintained for each class:
  2. Attendance
  3. Examinations and scores
  4. Practical skills proficiency
  5. Clinical completion and evaluation
  6. CPR completion
  7. Course requests

  1. Course Outline follows the U.S.Department of Transportation EMT Basic Curriculum and the Extended Skills Curriculum and includes:
  2. Practical /Laboratory
  3. Class schedule dates and times
  4. Lecture assignments

  1. Instructors are qualified to assist in the instruction of the Course and/or practical skills

  1. Written agreement with physician to serve as medical director

  1. Appropriate Insurance Policy for clinical rotations

  1. Instructor/Coordinator authorized to:
  2. Process applications
  3. Schedule classes
  4. Assign instructors

ACCREDITATION SURVEY / YES / NO
  • Evaluates student’s course work
  • Prepares and develops class materials
  • Ensures equipment availability and maintains equipment
  • Lectures at least 25% of the class
  • Counsels students as needed
  • Participates in staff development
  • Provides program information to public
  • Verifies practical skills proficiency
  • Submits completed documentation for certification eligibility

  1. Students meet the admission requirements of the educational institution and are informed regarding school policies

  1. Certified/Notarized copy of high school diploma or G.E.D on file for each student. (Official college transcript if indicates date of graduation)

  1. Physical examination for each student indicates acceptable for EMS employment

  1. Student disciplinary records are maintained

  1. Adequate classroom space is available and is well-lighted and ventilated

  1. Adequate laboratory space is available for at least four practical skills areas

  1. Adequate office space is provided for faculty

  1. Clinical facilities adequate for clinical experience

  1. Storage area is adequate for equipment

  1. Required equipment available

  1. Curriculum meets or exceeds current U.S. Department of Transportation EMT Basic curriculum and includes Tennesseeextended skills curriculum

  1. Evidence of course evaluations by students

  1. Evidence of faculty evaluations by students

  1. Evidence of course review by faculty

STATE OF TENNESSEE

DEPARTMENT OF HEALTH

DIVISION OF EMERGENCY MEDICAL SERVICES

INSTITUTION APPROVAL SURVEY

FOR

BASIC EMERGENCY MEDICAL TECHNICIAN

TRAINING EQUIPMENT INVENTORY

(Based on a Class of 24)

ITEM / NUMBER
REQUIRED / NUMBER
AVAILABLE / CONDITION
  1. Manikin, Adult Intubation
/ 3
  1. Manikin, Adult CPR
/ 3
  1. Manikin, Child CPR
/ 2
  1. Airway, Assorted Oropharyngeal
/ 3 Sets
  1. Airway, Multi-Lumen
/ 6
  1. Oxygen Non Rebreather Mask Adult
/ 3
  1. Oxygen Non Rebreather Mask Child
/ 3
  1. Nasal Cannula
/ 3
  1. Bag-Valve Masks, Adult
/ 3
  1. Bag-Valve Masks, Child/Infant
/ 3
  1. Pocket Masks with O2 Connector
/ 3
  1. Stethoscope, Individual
/ 12
  1. Stethoscope, Teaching
/ 1
  1. Sphygmomanometer
/ 12
  1. Suction Unit
/ 1
  1. Pneumatic Anti-Shock Garment MAST
/ 2
  1. Scoop Stretcher
/ 2
  1. Straps (for scoop and long board)
/ 15
  1. Long Spine Board
/ 3
  1. Head Immobilizer
/ 3
  1. Cervical Collars (Rigid),assorted sizes
/ 6
  1. Clam Shell Device
/ 3
  1. Oxygen Tank and Regulator
/ 2
  1. Sager Splint
/ 1
  1. Traction Splint
/ 3
  1. Padded Board Splints 15” 36”54”
/ 3 Sets
  1. Obstetrical Emergency Kit
/ 1
  1. Epi Pen Demos
/ 6
  1. Kerlex
/ 1Case
  1. 4x4s
/ 1Case
  1. ABD Pads
/ 1Case
  1. Tape 1” rolls
/ 6
ITEM / NUMBER
REQUIRED / NUMBER
AVAILABLE / CONDITION
  1. IV Administration Tubing
/ 24
  1. IV Catheters
/ 75
  1. Intravenous Fluids
/ 48
  1. Alcohol Wipes
/ 2 Boxes
  1. Triangular Bandages
/ 48
  1. Frac-Pac
/ 1
  1. Rigid Suction Catheter
/ 3
  1. French Catheter Suction 10,14,18
/ 1 Each
  1. Nasopharyngeal Airways
/ 3
  1. Tuberculin Syringes
/ 48
  1. Normal Saline Injection Bottles
/ 6
  1. IV Arm
/ 2
  1. Pillows
/ 3
  1. Blankets
/ 3
  1. AED
/ 1
  1. VCR/TV available
/ 1
  1. Slide Projector available
/ 1

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