WALWORTH FIRE DEPARTMENT AMBULANCE
MEDIC CLEARANCE CARD
Name: ________________________________
EMT#: _____________________
I. Prerequisites:
Sign Off:
Name/Date
A. Candidate must be a certified EMT/EMT-I/EMT-CC/EMT-P
B. Candidate must be certified in one of the following:
1. NYS-Red Cross CPR For the Professional Rescuer
2. AHA Healthcare Provider (CPR & AED)
3. AHA Heartsaver AED (CPR & AED)
C. Candidate must complete the following courses within 12 months:
1. Bloodborne Pathogens
2. HazMat Original
3. Any required ICS Courses
4. SCRAM Training
II. Knowledge Requirements:
A. Candidate must have knowledge of all ambulance SOG’s.
B. Candidate must have knowledge of all gauges, switches, and
controls in the cab and in the patient compartment.
C. Candidate must have knowledge of FLREMAC Protocols.
D. Candidate must have knowledge of “Order of Apparatus Response”.
E. Candidate must have knowledge of end-of-call procedures.
F. Candidate must have knowledge of base radio procedures.
G. Candidate must have knowledge of hospital procedures.
III. Knowledge and Location Requirements:
A. Candidate must demonstrate knowledge and location of the
following equipment:
1. Main Oxygen Tank and Valve
2. Helmet & Fire Coat
3. Portable Radio
4. Spotlight
5. Fire extinguisher
6. Hazmat Response Guidebook
7. Injury Report clipboard
8. Winter Weather Equipment
9. SCRAM
10. Multiple causality incident kit
11. Extrication Equipment (KED, splints, Hare traction splint)
12. Backboards, Headblocks, & Collars
13. Portable Suction
14. Portable Oxygen Tanks
15. BLS Medic’s Bag
IV. Skill Requirements:
A. Candidate must demonstrate their ability to complete the following
equipment operations (on calls or w/trainer):
1. Operate both high band & low band radios (in cab & box)
2. Hospital radio report (and which hospitals apply)
3. Turn on/off main oxygen tank & read pressure (min. pressure)
4. Operate the gurney (demo all adjustments)
5. Operate the stair chair (demo all adjustments)
6. Part 800.24 rig check (using inspection checklist)
B. Candidate must demonstrate the following patient care procedures
using Walworth Ambulance equipment:
(This may be accomplished on calls or in a simulation w/trainer.)
1. Trauma patient assessment (w/full set of vitals)
2. Medical patient assessment (w/full set of vitals)
3. AED utilization for cardiac arrest
4. Rescue breathing using a BVM and mouth-to-mask
5. Spinal Immobilization with a backboard & KED
6. Long bone immobilization
7. Joint injury immobilization
8. Traction splint application
9. Bleeding control / shock management
10. Airway management with OPA, NPA, and suction
11. Oxygen therapy using a NRB and nasal cannula
12. Albuterol nebulizer treatment
13. EpiPen administration
14. Blood glucose testing
15. Documentation using PCR’s
V. Practice:
A. Candidate should participate in six (6) EMS calls with a medic
trainer (each must include patient transport to the hospital).
1. First Ambulance Call (assists w/ PCR)
2. Second Ambulance Call (assists w/ PCR)
3. Third Ambulance Call (assists w/ PCR)
4. Fourth Ambulance Call (complete entire PCR)
5. Fifth Ambulance Call (complete entire PCR)
6. Sixth Ambulance Call (complete entire PCR)
VI. Approval:
A. Instructor’s name, signature, and date:
B. Director of Operations’ name, signature, and date: