The New Zealand Ambulance Board

Declaration of Eligibility for Membership

of Ambulance New Zealand

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

Date of Declaration:……………………………

Section 1Passenger Transport Licence

This service currently holds a valid passenger transport service licence: Yes/No

Licence Holder: ……………………………………………………………………….

Licence Number: ……………………………….

Issued On: ………………………………. Expiry Date: ……………………………….

Please attach a copy of the passenger transport licence to this declaration of eligibility. (Air applicants will need to provide a copy of their Aviation Industry Authority (AIA) Accreditation status)

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

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………

Section 2Communications

a.This service can respond to 111 calls 24 hours a day, 365 days a year: Yes/No

This service is accessed through: (please tick one). Please attach a copy of the Memorandum of Understanding (MoU) or arrangement agreed with the primary regional emergency ambulance (111) service provider in relation to this arrangement.

Dedicated communications centre located at:

………………………………………………………………………….…….

Another ambulance service located at:

……………………………………………………………….……………….

Another emergency provider located at:

………………………………………………………………………………..

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

Section 3Performance Standards

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

The first officer in the crew (full-time or volunteer) has a minimum qualification as specified in NZS 8156 Ambulance Sector Standard.

Basic Life Support (BLS)

Intermediate Life Support (ILS)

Advanced Life Support (ALS)

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

…………………………………………………………………………………………………...…………………………………………………………………………………………..

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

The second officer in the crew (full-time or volunteer) has a minimum qualification as specified in NZS 8156 Ambulance Sector Standard:

Basic Life Support (BLS)

Intermediate Life Support (ILS)

Advanced Life Support (ALS)

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

When the service station is dependent on volunteer officers and an ambulance is deployed to an emergency call, or when a patient’s condition is known to require a minimum level of care this service ensures that:

A first response arrangement is in place where the level of patient care is,

at minimum level of:

National Certificate in Ambulance or higher qualification to permit the patient’s condition to be stabilised before transport

Ambulance crew have achieved the Resuscitation and Assessment Section of the National Certificate

Requirements of 3a) and 3b) are met for 90% of deployments each year.

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

Section 4Vehicles

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

Patients are transported in purpose-built emergency 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.

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

Section 5Delegated Authority

This service has delegated authority from a registered medical practitioner appointed as this service’s Medical Advisor/Director to undertake the treatment procedures.

Yes/No

Please attach a copy of this written delegation of authority to this declaration of eligibility.

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

Section 6Clinical Audit

This service is regularly audited at not less than monthly intervals by a registered medical practitioner, appointed in accordance with NZS 8156 Ambulance Sector Standard.

Yes/No

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

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

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

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

………………………………………………………………………………………………

Section 7Compliance

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 agencyaccredited by IANZ or JASANZ)

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

Section 8Status

This service:

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

Yes/No

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

………………………………………………………………………………………

b.Is a properly constituted legal entityas specified in NZS 8156 Ambulance Sector Standard, with appropriate transport service licences for the operation of all its ambulances, and appropriate minimum qualifications for all ambulance personnel?

Yes/No

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

………………………………………………………………………………………………………………………………………………………………………………

c.Has obtained at least biennially:

A report relating to clinicalrevalidation of staff providing care.

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

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

………………………………………………………………………………………………………………………………………………………………………………

Section 9Provision of Information

This service will provide all information that is relevant to membership of the Society that is requested by Ambulance New Zealand. In the event of an audit or investigation, by auditors appointed by Ambulance New Zealand, this service will provide evidence of its compliance with the membership criteria or standards. Yes/No

The procedural stages for confirming full membership will be:

Completion of this declaration, and return by the due date of: ……………….

A review of the declaration by appointed independent persons resulting in either:

-confirmation of full membership of Ambulance New Zealand

-an investigation or audit by independent persons appointed by

Ambulance New Zealand.

If Ambulance New Zealand considers that an investigation or audit is required, the independent assessors will visit the service and, in accordance with procedures established before the visit, develop compliance recommendations for consideration by the service, and Ambulance New Zealand.

The outcome of the investigation or audit may be either:

A recommendation that the service’s membership be suspended, or
The service and Ambulance New Zealand agrees to a phased implementation plan to correct identified deficiencies.

If membership is declined or a current membership is suspended, an independent panel will be appointed and be available as an appeal authority.

Declaration

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 applicantChief Executive of the applicant

ambulance service ambulance service

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

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

Certificate of Incorporation/Trust Deed etc

Accreditation Certificate, eg ISO 9000, AIA, NZS 8156

Annual Report

Audited Financial Statements

Medical Advisor/Director letter of support/commitment

Passenger Transport Licence

MoU with regional emergency ambulance (111) provider

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