Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY
JUN 2 9 2016
ADMINISTRATIVE ORDER
No. 2016- ODJ,.q

SUBJECT: Rules and Regulations Governing the Licensure of Ambulances and

Ambulance Service Providers

I. BACKGROUND AND RATIONALE

Section VI. A. 4. of Administrative Order No. 2010-0003 entitled ''National Policy on
Ambulance Use and Services" states that the "Bureau of Health Facilities and Services shall
establish licensing standards for ambulance services and ensures their implementation
through regulation. The license of hospital-based ambulance service shall be part of the
hospital license. All other ambulance services shall require a separate license."

The current licensing standard requires hospital facilities to provide ambulance services.
However, it has been observed that the term 'ambulance' has been misused. There are ambulances
that operate without competent personnel, appropriate equipment and life-saving drugs capable of
responding to medical emergencies.

Regulation is the first step to ensure that health facilities and services comply with the
quality standards that will not put patients' lives at risk. It is in this light that the Health Facilities
and Services Regulatory Bureau (HFSRB) sets the basic requirements as well as the minimum
structural inputs in relation to ambulance design, physical facilities, manpower, and equipment for
the operation of ambulance and ambulance service providers that support the right of patients to
safe and quality health care.

In view of the above, this Order aims to establish mandatory minimum requirements for
ambulances and ambulance service providers in line with the Kalusugan Pangkalahatan
(Universal Health Care) strategic thrust to improve access to safe, quality and affordable health
services.

II. OBJECTIVE
These rules and regulations are promulgated to protect the public and assure the safety of
patients and personnel by:

1. By setting the minimum standards and requirements for ambulances and ambulance
service providers; and

2. Ensuring the safety of patients, personnel and the general public.

ill. SCOPE AND COVERAGE

These rules and regulations shall apply to all government and private land ambulances and
.JI ambulance service providers.
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Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 ManDa eTrunk Line 651-7800 Direct Line: 711-9501
Fax: 743-1829;743-1786 • URL: http://www.doh.eov.ph; e-mail: osec@doh.eov,ph
IV. DEFINITION OF TERMS
For purposes of this Order, the following terms, abbreviations and definitions apply:

1. Ambulance - a vehicle designed and equipped for transporting sick or injured patients
to, from, and between places of treatment by land, water or air, affording safety and
comfort to the patients and avoiding aggravation of illness or injury. This excludes
rapid response vehicles such as, but not limited to, motorcycles, cars and other
vehicles designed to transport patients but are not equipped to respond to
medical emergencies.

2. Advanced Cardiac Life Support (ACLS) - a group of interventions used to treat and
stabilize adult victims of life-threatening cardiorespiratory emergencies and to
resuscitate victims of cardiac arrest. These interventions include CPR, basic and
advanced airway management, tracheal intubation, medications, electrical therapy
and intravenous (IV) access.

3. Automated External Defibrillator (AED) - an external computerized defibrillator

designed for use in unresponsive victims with no breathing and no signs of
circulation.

4. Basic Life Support (BLS) - a group of actions and interventions used to resuscitate
and stabilize victims of cardiac or respiratory arrest. These BLS actions and
interventions include recognition of a cardiac or a respiratory emergency or stroke,
activation of the emergency response system, CPR and relief of foreign-body airway
obstruction.

5. Cardio-Pulmonary Resuscitation (CPR) - any maneuvers or techniques designed to

restore circulation, or a technique combining artificial ventilation and chest
compressions designed to perfuse vital organs or restore circulation to a victim of
cardiopulmonary arrest.

6. Department of Health - License to Operate (DOH-LTO) - a formal authority issued

by DOH to an individual, agency, partnership or corporation to operate an ambulance.
It is a prerequisite for accreditation of a health facility or service provider by any
accrediting body recognized by DOH.

7. Emergency Medical Services (EMS) - medical service designed to provide timely

pre-hospital or out of hospital acute medical care and/or transport to definitive care, to
patients with sudden and life-threatening injuries or emergencies.

8. First Aid - initial emergency care given to a person who is injured or suddenly
becomes ill.

9. Health Facilities and Services Regulatory Bureau (HFSRB)-the Bureau of DOH

charged with the implementation of these rules and regulations.

10. Medical directive - a system of physician-directed quality assurance that provides

~-professional and public accountability for medical care in pre-hospital setting.

Page 2 of 11 fA/(
 11. Medical emergencies - any acute or life-threatening condition that requires
immediate intervention by a competent personnel

12. Regional Office (RO)- the Regional Health Office of DOH.

13. Signage - any form of written announcement installed, posted, hanged, painted or
otherwise displayed in a public place.

V. IMPLEMENTING MECHANISMS

A. GENERAL GUIDELINES
1. Ambulance service providers shall secure registration for all vehicles at the Land
Transportation Office (LTO) prior to application for license to operate.

2. Ambulance service providers shall secure DOH-LTO per vehicle to be issued by

HFSRB.

3. Ambulance service providers shall ensure that they are part of a functional referral
network within the area/vicinity where they are allowed to operate.

4. Stakeholders shall strictly comply with the standards, criteria and requirements
prescribed in the Assessment Tool for licensure of ambulances and ambulance
service providers.

5. The DOH-LTO of ambulance service providers shall be valid for three (3) years,
from January of the first year to December of the third year.
a. Institution-based ambulance services shall be included in the One-Stop Shop
(OSS) licensure system for hospitals and other health facilities. The DOH-
LTO of the ambulance shall be reflected in the health facility DOH-LTO.
Hence, a separate DOH-LTO is not required.
b. Non-institution-based ambulance service providers shall secure a separate
DOH-LTO.
c. The plate or conduction sticker number AND Certificate of Registration (CR)
number of each ambulance vehicle shall be reflected in the DOH-LTO of the
ambulance service providers

6. Ambulance vehicles from non-licensed ambulance service providers shall be

forwarded to the Land Transportation Office for appropriate action.

B. SPECIFIC GUIDELINES

1. CLASSIFICATION OF AMBULANCE SERVICE PROVIDERS

a. ACCORDING TO OWNERSHIP

1. Government - owned, managed and operated wholly by the specific

government agencies such as, but not limited to, DOH hospitals, LGU and

Page 3 of 11 rw
 LGU-run hospitals, BFP and PNP ofDILG, Coastguard ofDOTC, AFP of
DND, MMDA and others.

2. Private - owned, established and operated with funds through donation,

principal, investment or other means by any individual, corporation,
association or organization. A private health facility may be a single
proprietorship, partnership, corporation, cooperative, foundation,
religious, non-government organization and others.

b. ACCORDING TO FUNCTIONAL CAPACITY

LAND AMBULANCE - minimum of four-wheeled vehicles designed
and equipped for the provision of BLS and capable of transporting and
monitoring patients over terrain.

c. ACCORDING TO INSTITUTIONAL CHARACTER

1. Institution-based - ambulance service provider that operates as part of a

health facility (i.e. hospital, infirmary, etc.)

2. Non-institution-based - ambulance service provider that operates

independently. May be located inside or outside the premises of a health
facility.

2. STANDARDS
Every ambulance service provider shall be organized to provide safe, quality,
effective and efficient ambulance services for patients.

a. AMBULANCE SERVICE PROVIDER

1. A private ambulance service provider shall be registered with the

Department Trade and Industry (DTI) or with the Securities and Exchange
Commission (SEC), whichever is applicable. For government ambulance
services, a local government ordinance or board resolution stating
ownership of ambulance vehicles shall be required.

2. The ambulance service provider shall be housed in a business office I

" space that can also serve as the Operations Control and Dispatch Center of
the ambulances. The office shall have adequate parking spaces for the
ambulance/s they own.

3. The ambulance service provider shall have a minimum ratio of 1 set of

personnel for every 2 ambulances owned. A minimum set of personnel
consists of two (2) responders and a driver.

The ambulance service provider shall ensure that each personnel has
obtained the minimum trainings stipulated in this Order.

Page 4 ofll rvl

b. PERSONNEL
Each ambulance service provider shall have an adequate number of qualified,
trained and competent staff to ensure efficient and effective delivery of quality
ambulance services.

1. A minimum of at least two (2) responders, excluding the driver, is

required for every ambulance dispatched. Additional staff depends on the
nature of the emergency as determined by the management of the service
provider.

2. There shall be staff development and continuing education program to

upgrade the knowledge, attitude and skills of staff.

3. Responders shall be Standard First Aid, BLS, EMT and ACLS-trained

from a DOH-recognized training provider.

c. AMBULANCE

1. An ambulance vehicle shall be able to accommodate the patient, and the

required number of personnel and equipment.

2. The ambulance vehicle shall be registered with the LTO under the name of
the ambulance service provider.

3. Ambulances shall bear the following markings:

a. The word AMBULA NCE shall be seen at the back and at front of
the vehicle, which is spelled out in reverse. The height of each
letter shall be no less than 0.15 meters and the word shall be seen
at least six (6) meters away.

b. The prescribed DOH logo (Refer to Annex-A: Official DOH

Ambulance Logo). This logo shall be placed on both sides of the
ambulance. On top of the DOH Logo, the phrase LICENSED BY
DOH shall be placed.

c. Any signage and other images outside of what is prescribed by

DOH are not allowed.

4. Vehicles labeled as ambulances which are used outside of its intended

scope/purpose shall not be allowed. Violators shall be dealt accordingly.
• i.e. Funeral parlors using and misusing the term 'AMBULANCE' in
their multipurpose transport vehicles shall be reported to the concerned
Local Government Unit (LGU) or to Department of Health (DOH) for
appropriate action.

r\
f.Altmbula nce vehicles shall have Emergency Warning Light System and
iren-Public Address System.

Page5ofl~
d. EQUIPMENT, MEDICINES AND SUPPLIES
Every ambulance shall have available and operational prescribed equipment,
medicines and supplies.

1. Each ambulance shall be adequately equipped with appropriate equipment,

medicines and supplies. (Refer to Annex B: Required Emergency
Equipment, Supplies and Medicines)

2. Each ambulance shall have adequate and stable cabinet/s that can
appropriately store the required equipment, medicines and supplies. These
storage shall be easily accessible but properly secured at all times.

3. The use of Personal Protective Equipment (PPEs) and adherence to

infection control policies shall be strictly observed.

4. There shall be a program for calibration, preventive maintenance and

repair of equipment, including decontamination and disinfection.

5. There shall be a contingency plan in case of equipment breakdown and

malfunction, especially during patient transport.

e. SERVICE DELIVERY
Every ambulance service provider shall ensure that the services delivered to
patients comply with the standard quality embodied in the Assessment Tool
for licensure of ambulances, other policy guidelines and/or related issuances.

1. Each ambulance service provider shall have documented policies and

procedures on its administrative and technical Standard Operating
Procedures (SOP) for the provision of its services.

2. Each ambulance service provider shall have documented policies and

procedures on the establishment of its referral system.
a. The inter-facility referral network shall be strengthened through
linkages of all levels of care and partnerships (of hospital and EMS).
b. Ambulance service providers shall have a Memorandum of Agreement
(MOA) with hospital facilities. The MOA shall not apply when the
patient expresses preference for a certain facility and in cases of
extreme medical emergencies.

3. Ambulances shall have communication devices linked to the operations

center of the ambulance service provider and the referral hospital for
recording and effective management of cases.

4. Medical direction shall be part of the ambulance service.

All patients being transported by ambulance shall have standard patient

~· record form.

Page 6 of llr«'
f. INFORMATION MANAGEMENT
Every ambulance service provider shall maintain a system of communication,
recording and reporting of the patient's condition as well as the results of
examinations.

1. Hospital Referral Form

Each form shall be kept confidential and shall contain sufficient
information to identify the patient and to justify the treatment provided,
which includes the information of transfer/referral of patient to another
physician or health facility.

2. Logbook
Ambulance service providers shall maintain a logbook which shall be
signed by the head of the DOH licensing team during inspection and/or
monitoring visits. The logbook shall contain, but not be limited to, the
following information (Refer to Annex C: Logbook of Accomplishments
for Inspection and Monitoring):
a. Name, sex and age of patient;
b. Name of attending physician, when applicable;
c. Origin and destination;
d. Date and time of dispatch and return of ambulance;
e. Reason for transfer/transport.
f. Disposition of patient.

3. Submission of Reports
Ambulance service providers shall submit an annual report utilizing the
template provided by DOH on or before 31 March. The report shall
contain, but not be limited to, the following information. (Refer to
Annex-D: DOH Annual Statistical Report for Ambulance Service
Providers)
a. Number of ambulance conductions stating Regional Office, Province,
Municipality, City, including the type of the health facility:
1. Inter-facility hospital to hospital
2. Other health facilities to hospital (e.g. Medical Out-Patient Clinics,
RHU, birthing facility, infirmary, drug abuse and treatment
centers, psychiatric custodial care facility, nursing homes)
3. Home to hospital
4. Hospital to Home
5. Other routes, specify. (i.e. Hospital to Airport/Ports or vice versa)
b. Reason for referral/transport
c. Date, time and description of Adverse Events e.g. number of deaths en
route, if any. In case of ambulance death referred by a hospital, the
referring hospital shall issue the death certificate. Otherwise, the
City/Municipal Health Officer, where the patient died, shall issue the
~death certificate.

Page 7oft~
 g. ENVIRONMENTAL MANAGEMENT
Every ambulance service provider shall ensure that the environment is safe for
its patients and staff including members of the public as necessary and that the
following measures and/or safeguards shall be observed:

1. The ambulance shall be properly ventilated, lighted, clean and safe.

2. The ambulance shall have a partition between the driver and the
compartment or body. The partition shall be air-tight bulkhead with
transparent viewing panel.

3. There shall be a written plan and program of proper disinfection and

preventive maintenance of the ambulance vehicles.

4. There shall be procedures for the proper disposal of infectious wastes and
toxic and hazardous substances in accordance with R.A. 6969 known as
"Toxic and Hazardous Substances and Nuclear Wastes Act" and other
related policy guidelines and/or issuances.

VI. PROCEDURAL GUIDELINES

A. APPLICATION FOR INITIAL DOH-LTO

1. Ambulance owners and ambulance service providers shall submit the following
relevant documents to HFSRB:
a. Duly accomplished application form. This form can be downloaded from
http:lhfsrb.doh.gov.phl.
b. Proof of ownership
1. Department of Trade and Industry (DTI);
2. Securities and Exchange Commission (SEC) Registration with Articles
of Incorporation and By-laws;
3. Enabling Act or Board Resolution for government;
4. Cooperative Development Authority Registration with Articles of
Cooperation and By-laws, whenever applicable
c. Registration of the vehicle(s) from the Land Transportation Office
d. License of the ambulance driver/s as Professional Driver, from the Land
Transportation Office

2. Pay the corresponding fee, and submit a copy of the official receipt to HFSRB.

3. Once the application has been approved, the ambulance service provider shall be
given a copy of the Official DOH Ambulance Logo and this shall be mounted
accordingly to each ambulance vehicle prior to the issuance of the DOH-LTO.
Each ambulance vehicle shall have a copy ofDOH-LTO of the ambulance service
provider.

Page 8 of 11rJ
B. APPLICATION FOR RENEWAL OF DOH-LTO

1. Ambulance owners and ambulance service providers shall prepare following

relevant documents prior to application.
a. Duly accomplished application form. This form can be downloaded from
http:/hfsrb.doh.gov.ph!.
b. DOH annual ambulance statistical report
c. other relevant records as may be required by DOH

2. Applicants shall submit the application to the following offices, which shall
receive and process the renewal application
a. HFSRB for non-institution-based ambulance service providers and level 2
and 3 hospital-based ambulance service providers.
b. Regional Offices for Infirmary and Level 1 hospital-based ambulance
service providers

3. Pay the corresponding fee, and submit a copy of the official receipt to HFSRB or
Regional Office, whichever is applicable.

4. Once the application has been approved, the ambulance service provider shall be
given a copy of the Official DOH Ambulance Logo and this shall be mounted
accordingly to each ambulance vehicle prior to the issuance of the DOH-LTO.
Each ambulance vehicle shall have a copy ofDOH-LTO of the ambulance service
provider

5. The DOH-LTO of an ambulance shall be cancelled automatically without notice

upon failure to submit a duly accomplished application form and to pay the proper
fee beyond thirty (30) days from the date of expiration stated in its license.
Thereafter, the service provider shall apply as initial DOH-LTO

C. INSPECTION

1. The HFSRB or RO, as the case may be, shall conduct licensure inspections
utilizing the Assessment Tool for licensure of ambulances within fifteen (15)
working days upon submission of complete requirements.

2. The applicant shall ensure that all key staff, pertinent records, and ambulances are
made available to HFSRB/RO Director and/or his authorized representative(s)
during inspection visits

D. MONITORING

1. Ambulances and ambulance service providers shall be monitored regularly.

2. The HFSRB or RO Director and/or his authorized representative(s) shall conduct

periodic monitoring visits utilizing the Assessment Tool for licensure of

~
ambulances.

Page 9 of llrv/
 3. The applicant shall ensure that all key staff, records, premises and facilities are
made available to HFSRB or RO Director and/or his authorized representative(s)
during monitoring activities.

4. A Notice of Violation shall be issued immediately for non-compliance with these

rules and regulations.

VII. SCHEDULE OF FEES

A. A non-refundable fee shall be charged for the application of DOH-LTO of an

ambulance.

B. All fees/checks shall be paid to the order of DOH in person or through postal money
order [or through bank to bank payments as soon as the system becomes functional].

C. All fees, surcharges and discounts shall follow the current DOH prescribed schedule
of fees in A.O. No. 2007 - 0001 "Revised Schedule of Fees for Certain Services
Rendered by the Bureau of Health Facilities and Services and Centers for Health
Development. .. ", A.O. No. 2007 - 0023 regarding "Schedule of Fees for the One-
Stop Shop Licensure System for Hospitals", and A.O. No. 2008- 0028 "Schedule of
Fees for the One-Stop Shop Licensure System for Non-Hospital Based Facilities ... ",
other policy guidelines and/or relevant issuances.

VIII. VIOLATIONS
Ambulance service providers found violating any provision of these rules and regulations
and its related issuances and relevant policy guidelines, and/or commission/omission of acts by
personnel operating an ambulance under this Order shall be penalized and/or its DOH-LTO
suspended or revoked.

IX. INVESTIGATION OF CHARGES AND COMPLAIN TS

The Health Facilities and Services Regulatory Bureau or the Regional Office Director
and/or his authorized representative(s) shall investigate the complaint and verify if the hospital or
other health facility concerned or any of its personnel is liable for an alleged violation. The
HFSRB or RO Director may order the preventive suspension of operation of the concerned
ambulance service provider. The preventive suspension shall not be more than ninety (90) days.
Upon completion of the deficiencies noted during the investigation, the preventive suspension
can be lifted immediately, and impose the appropriate penalty for the violation.

X. SANCTIONS AND PENALTY

After a thorough investigation of charges and complaints, the following penalties shall be
imposed:

Number of Offense Penalty Fine

l 5t Offense Suspension of DOH-LTO for thirty (30) days PhP 20,000.00

p 2no Offense Su~ension ofDOH-LTO for ninety (90) days PhP 50,000.00
3ro Offense Cancellation ofDOH-LTO PhP 100,000.00

Page 10 ofl
 In case of serious injury or death of the patient, passengers, pedestrians or the general
public due to the negligence or misuse of the ambulance service, the DOH-LTO of the
ambulance service provider shall be automatically revoked. This is without prejudice to any
criminal or civil charges or both that may be filed by the aggrieved party against the ambulance
service provider.

Other imposable penalty for violations hereof shall be in accordance with A.O. No. 2007
- 0022 entitled "Violations Under the One-Stop Shop Licensure System for Hospitals" and
violation provision under A.O. 2008 - 0027 known as "One-Stop Shop Licensure System for
Non-Hospital Based Facilities ... ," its related issuances and this Order.

XI. APPEAL
The management of the ambulance service provider aggrieved by the decision of the
Director ofHFSRB or RO may, within ten (10) days after receipt of the notice of decision, file a
notice of appeal to the Office of the Secretary of Health. Thereupon, HFSRB shall promptly
certify and file a copy of the decision, including all documents and transcript of hearings on
which the decision is based, with the Office of the Secretary for review. The decision of the
Secretary of Health shall be fmal and executory.

XII. TRANSITORY PROVISION

Non-institution-based ambulance service providers shall be given one (1) year from
approval of this Order to comply with the requirements. For hospital-based ambulance service
providers, these requirements shall apply immediately. Once the one year moratorium has
lapsed, all applications shall be subjected to the requirements set forth by this Order.

XIII. REPEALING CLAUSE

Provisions from previous issuances that are inconsistent or contrary to the provisions of
this Order shall be deemed impliedly or expressly amended or revoked.

XIV. SEPARABILITY CLAUSE

In the event that any provision or part of this Order is declared unauthorized or rendered
invalid by any Court of law, those provisions not affected by such declaration shall remain valid
and effective

XV. EFFECTIVITY
This Administrative Order shall take effect after fifteen (15) days following the
completion of publication in two newspapers of general circulation.

JANETTE

Page 11 ofll
 Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY

AnnexA
AO 2016- 0029

Official DOH Ambulance Logo

LICENSED BY THE DOH

Building I, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila • Trunk Line 651-7800 Direct Line: 711-9501
Fax: 743-1829; 743-1786 • URL: htUJ://www.doh.gov.ph; e-mail: osec@doh.gov.ph
 Republic ofthe Philippines
Department of Health
OFFICE OF THE SECRETARY

AnnexB
AO 2016-
Required Emergency Equipment, Supplies and Medicines

ITEM QUANTITY
A. Ambulance Compartment I Body
1. Tempered glass division (separatin_g_ the driver to the boc!Y)_
2. Air condition with control
3. Electric (internal and external) supply bulbs
4. Fire Extinguisher (rating 2A1 OBC)
5. Flash lights with extra batteries and bulbs
6. Ambulance wheeled cot with mounted cot fastening system
7. Folding Stretcher I Poles (1 set) and Canvas (2)
8. Orthopedic (scoop) stretcher
9. Overhead aluminum grabrail on the ceiling on top of the
patient/stretcher

B. Communication Equipment
1. Two-way radio communication - installed 1 unit
2. Cellular phone 1 unit
3. Intra-vehicle intercom system (between driver and body)

c. Ventilation and Airway Equipment

1. Suction Apparatus and accessories
a. Portable Suction Machine 1 unit
b. Flexible suction catheters Fr. 5- Fr. 14 1_£ieee each
2. Portable oxygen equipment I Installed
a. Portable oxygen tank - secured 1 unit
b. Flow regulator 1 unit
3. Bag valve mask resuscitator with rebreather bag
a. Adult 1 piece
b. Pediatric -pressure relief valve 1 piece
c. Infant - pressure relief bag 1_Qiece
4. Nebulizer 1 unit

D. Monitorine; and Defibrillation (trained team)

1. Automatic external defibrillator (AED) 1 unit
2. Defibrillator pads - disposable 1 pair

E. Immobilization Devices
1. Rigid cervical collars (small, medium, large) 1 piece each
2. Firm padding or commercial head immobilization device 1 piece
3. Lower extremity traction devices (supporting slings, padding, 1 piece each
traction strap)
4. Upper and Lower extremity immobilization devices
a. Joint above and joint below fracture 1 piece each
b. Rigid support appropriate material (cardboard, metal, 1 piece each
pneumatic, vacuum, wood or_Q].astic}, various size~
c. Resistant straps or cravats 3_p_ieces

Building I, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila • Trunk Line 651-7800 Direct Line: 711-9501
Fax: 743-1829; 743-1786 • URL: http ://www.doh.gov.ph; e-mail: osec@doh.gov.ph
 AnnexB
AO 2016-

5. Full body vacuum mattress - used for head, spine, and head-to- 1 piece
feet immobilization
6. Sandbags - for initial on-site immobilization only 1 piece
ITEM QUANTITY
F. Dressings and Bandages
1. Sterile burn sheets 3 pieces
2. Triangular bandages 3_IJieces
3. Sterile Dressings
a. 1O"x30" or larger 3_packs
b. ABDs, 10"x12" or larger 3_}J_acks
c. 4"x4" gauze sponges 4_Jl_acks
4. Sterile gauze rolls (various sizes) 5_}J_ieces each
5. Non-sterile elastic bandages (various sizes) 1 piece each
6. Sterile occlusive dressing 3"x8" or lar_ger 3 pieces
7. Adhesive tape roll
a. Various sizes of2" or 3" hypoallergenic 1 piece
b. Various sizes of 2" or 3" non-hypoallergeniclordinary 1_£ieee

G. Obstetrical
1. Individual disposable delivery kit- sterile 1 set
2. Wrap I blanket for newborn 1_piece

H. Infection Control
1. Eye protection (full peripheral glasses or goggles or face
shield)
2. HEPA Masks I Surgical Masks
3. Non-sterile and Sterile Gloves 1_pair each
4. Jumpsuits or Gowns 1 unit
5. Shoe covers 1_pair
6. Hand sanitizer or 70% alcohol
7. Disinfectant solution for cleaning e_!!uip_ment
8. Disposable trash bags - color-coded

I. Miscellaneous Supplies
1. Sphygmomanometer (non-mercurial, with infant, pediatric and
adult cuff)
2. Stethoscope (pediatric and adult)
3. Weighing scale for pediatric equipment sizing
4. Tape measure
5. Thermometer (infrared)
6. Heavy bandage or paramedic scissors for cutting clothes, belts
and boots
7. Alcohol swabs x 20 pes 1 pack
8. Cold packs
9. IV Administration set (Macro I Micro)
10. Blankets, Sheets, Linen, or paper
11. Pillows, Pillowcase and towels
12. Disposable standard sharps containers
13. Disposable emesis bags or basins
14. Bed pan
 AnnexB
AO 2016-

15. Urinal
16. Syringes (50ml, 30ml, 10ml, 3ml1ml) 1 piece each for 50ml and 30 ml
5 pieces for 10ml, 3ml and 1ml
ITEM QUANTITY
17. Gauge needles (various sizes)
18. Incontinence pads- disposable
19. Antibacterial lubricating jelly 1 tube
20. Patient report forms (as prescribed in succeeding Annexes)

J. Medications I Fluids
1. Activated Charcoal 1 pack
2. Oral glucose, 10 ml 1 piece
3. Sterile water for irrigation, 1 liter 1 bottle
4. Intravenous fluids (various dissolution, sizes, concentration) 1 piece each
5. Normal saline water (injectable) 1 piece
6. Sterile water for injection, 1Oml 1 piece
7. Ventolin nebules 3 pieces
8. Dextrose 50%/50ml vial 1 piece

K. Controlled Medications
Sealed Drug I Code Box to be opened only under a Physician or Paramedics supervision.
This should be regularly checked for expired items by Physician-in-charge or Paramedics.
1. Atropine Sulfate 1mg/ml ampule 5 pieces
2. Isoproterenol 1mg/5ml ampule 1 piece
3. EpineiJhrine 1mg/1ml tubaxes (IM, Intracardial, IV) ampule 5 pieces
4. Diazepam 1Omg ampule/vial 1 piece
5. Dobutamine 250mg ampule 1 piece
6. Lidocaine 1gm/25ml vial 1 piece
7. Adenosine 6mg/2ml ampule 1 piece
8. Human Regular Insulin 1OOmg/ml vial 1 piece
9. Calcium Gluconate 10% 1mg/10ml ampule/vial 1 piece
10. Potassium Chloride 20mg/1 Oml vial 1 piece
11. Furosemide 1OOmg/1 Oml vial and 20mg/2ml ampule 2 pieces each
12. Magnesium Sulfate 50% 1gm/2ml ampule 1 piece
13. Bretylium 500mg/10ml vial 1 piece
14. Dopamine 400mg/5ml vial 1 piece
15. Diphenhydramine 50mg/ml ampule 1 piece
16. Sodium bicarbonate 1Oml ampule 1 piece
17. Digoxin 0.1mg/ml ampule and 0.5mg/2ml ampule 2 pieces for 0.1mg/ml ampule
1 piece for 0.5mg/2ml ampule
18. Calcium Chloride 10% ampule/vial 1 piece
19. Nitroglycerine spray I sublingual I patch 1 piece
 Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY

AnnexC
AO 2016-

TEMPLATE FORMAT FOR THE LOGBOOK OF ACCOMPLISHMENTS FOR INSPECTION AND MONITORING

Attending Reason for

Name of Patient Origin Destination Dateffime Disposition
Physician Transport

Building I, San Lazaro Compound, Rizal Avenue, Sta Cruz, 1003 Manila • Trunk Line 651-7800 Direct Line: 711-9501

\ Fax: 743-1829; 743-1786 • URL: http://www.doh.gov.ph; e-mail: osec@doh.gov.ph

 Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
AnnexD
AO 2016-

ANNUAL STATISTICAL REPORT FOR AMBULANCE SERVICE PROVIDERS

Name of Ambulance Service Provider: ----------------------------------------

License Number: -------------- Validity: _ _ _ _to _ _ __
Number of Ambulance/s licensed by the DOH: _ _ _ _ __

A. Total Ambulance Conduction (Per Vehicle)

Total number of
conductions

Total Hospital to
Hospital Conduction

Total Other Health

Facilities to Hospital
Conduction

Hospital to Home
Conduction

Home to Hospital
Conduction

Hospital to other
routes (i.e. hospital to
airport) or vice versa

B. Reasons for Referral or Transport

Building I, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila • Trunk Line 651-7800 Direct Line: 711-9501
Fax: 743-1829; 743-1786 • URL: http://www.doh.gov.ph; e-mail: osec@doh.gov.ph