APPLICATION FOR APPROVAL TO PROVIDE AMBULANCE SERVICES IN THE ACT

Section 61 of the Emergencies Act 2004

TO BE COMPLETED BY APPLICANT

INDIVIDUAL / COMPANY NAME		

CONTACT PERSON		

POSTAL ADDRESS		

EMAIL ADDRESS		

MOBILE NUMBER		

B/H PHONE NUMBER		

FAX NUMBER		

DATE OF APPLICATION		

APPLICATION IS MADE FOR APPROVAL TO PROVIDE (SELECT THE SERVICE FOR WHICH APPROVAL IS SOUGHT):

	Provision of emergency medical treatment within a specific event precinct, not including ambulance patient transport, whether within the event precinct or outside the event precinct boundaries.  

	Provision of emergency medical treatment within a specific event precinct, including ambulance patient transport within the event precinct only.  

THIS APPLICATION MUST BE ACCOMPANIED BY THE PRESCRIBED FEE.

NOTE: The Emergency Services Agency may require an applicant to provide further information or documents to decide the application.

A.   Definitions for this application:

Ambulance Commander – means the ACTAS manager responsible for ambulance services at the scene of a major incident.

Applicant – means the person applying, under section 61 of the Emergencies Act 2004, for Approval as a Provider of the Approved Services.

Approval – means the Approval granted to the Provider by the Minister under section 62 of the Emergencies Act 2004.

Approved Services – means the ambulance services to be provided under the Approval.

ACTAS – means the ACT Ambulance Service.

clearly distinguishable – means, for clauses C13 and C14, that PPE, Official Clothing and Official Vehicles are marked, badged, labelled, coloured and presented in such a way that it is clearly evident that the PPE, Official Clothing and Official Vehicles are not those of ACTAS or any of the ACT emergency services.

equipment – includes:
a)	medical apparatus; and
b)	machinery, fit-out or device fixed to an Official Vehicle.

ESA – means the ACT Emergency Services Agency and, where the context permits or requires, includes any or all of the emergency services established under the Emergencies Act 2004.

ESA Contact Officer – is the person nominated in writing by the ESA to the Provider as the primary contact point between the ESA and the Provider.  

Event – includes any private function, public entertainment, public meeting or any other activity where the Applicant provides the services for which Approval is provided.

Event Precinct – means a specific area or zone of operations where the Event associated with the provision of the Approved Services will be conducted.

first aid – means the provision of help to an injured person before the arrival of a qualified ambulance officer or medical professional.

Medical Officer – means a doctor, registered within the Territory, who is working for the Provider.

medical treatment – may include:
a)	undertaking a medical examination and assessment;
b)	giving medical advice;
c)	giving first aid;
d)	undertaking a medical procedure; or
e)	administering a medication.

Official Clothing – includes any specifically coloured, marked or badged clothing directly utilised by the Provider in delivering the Approved Services.

Official Vehicle – includes any specifically coloured, marked or badged vehicle directly utilised by the Provider in delivering the Approved Services.

PPE – means personal protective equipment.

Provider – means the applicant for Approval, being the person or organisation that will conduct or manage the Approved Services and, where the context permits or requires, includes an employee, servant or agent of the Provider.

public entertainment – includes an exhibition, performance, lecture, game or sport to which the public has access whether or not by payment.

B.   Particulars of the Provider and its activities:

1.	The details of the Applicant are provided in Schedule A.

2.	The services for which the Applicant seeks approval are set out in Schedule B.  The Applicant must provide sufficient detail of the proposed scope and extent of ambulance services that approval is sought for within the relevant area.

3.	Details about the personnel employed or used by the Applicant, demonstrating its capability to deliver Approved Services in accordance with Australian or industry standards relevant to those services, are set out in Schedule C.

4.	Details of PPE and Official Clothing to be used by the Applicant are set out in Schedule D.

5.	Details of Official Vehicles and Equipment to be used by the Applicant are set out in Schedule E.

6.	Particulars of clinical governance structures & arrangements associated with the provision of ambulance services are set out in Attachment 1.

7.	Details of the Applicant’s arrangements for structure and communications, including chain of command, are set out in Attachment 2.

8.	The Applicant’s proposed form of record of first aid or medical treatment provided is at Attachment 3.  

9.	The Applicant’s proposed Code of Conduct is at Attachment 4.

C.   General Conditions:

1.	The Applicant acknowledges that, if an Approval is granted, it will be subject to the General Conditions specified below and any Special Conditions imposed by the Minister.

2.	The Provider may make written application to the Minister to amend an Approval for services previously approved.  The Minister may, after consulting with the Commissioner, amend the Approval.

3.	The Approval may be revoked without notice if the Provider fails to comply with any of the conditions of the Approval.

Notes: 1.	It is an offence under section 63 (1) of the Emergencies Act 2004 to provide ambulance, services without Approval.
 2.	It is an offence under section 63 (2) of the Act, if an Approval has been granted, to provide services that are not approved.

4.	The Provider must ensure that all employees, servants and agents of the Provider agree to be bound by, and comply with, the terms of the Approval.

5.	The Provider must at all times conduct any Approved Services in accordance with the Approval.

6.	The Provider must cooperate with ACTAS in the provision of the Approved Services, including cooperative patient care, patient handover and other activities that may be related to the services being provided.

7.	Should an incident occur that involves multiple casualties, the Provider must comply with the directions of ACTAS Ambulance Commander, both in providing the Approved Services and in assisting ACTAS crews in medical treatment and patient care.

8.	All Medical Officers and other representatives of the Provider present at an incident must make their presence known to ACTAS Officers.  Although Medical Officers are ultimately responsible for medical care, Medical Officers must consult with ACTAS Paramedics regarding issues of medical treatment and transport, particularly in relation to criticality of injuries and transport of patients.

9.	The Provider must appoint, and submit to ACTAS details of, a person in the employment of the Provider to be its Clinical Quality Assurance Contact.  Any dispute about patient care or clinical governance arising from an incident involving ACTAS and the Provider must be forwarded to the ESA Contact Officer for review and resolution.  A meeting between ACTAS and the Clinical Quality Assurance Contact will be organised to discuss issues under dispute, and to resolve any disagreement relating to patient care.

10.	The Provider must at all times comply with all Australian and industry standards relevant to the provision of the Approved Services.  This includes the requirements that:

a)	all persons performing functions on behalf of the Provider must be appropriately qualified and experienced to provide the Approved Services.  Any Medical Officer contracted to the Provider must be registered within the Territory; and
b)	the Provider must ensure that its employees, servants and agents comply with all legislation relevant to the services to be provided.

11.	The Provider must furnish details of relevant training or education, certifications and levels of clinical practice and experience at that level of practice, for all people engaged as employees, servants or agents of the Provider.  The list must be in the form set out in Schedule C.

12.	The Provider must ensure that the PPE and Official Clothing specified in Schedule D, or as otherwise required by the Approval, are available, and used, at all times by persons performing the Approved Services.

13.	Only the PPE, Official Clothing, Official Vehicles and Equipment specified in Schedule D and Schedule E, or otherwise required by the Approval, may be used in the performance of the Approved Services.  Any Official Clothing or PPE worn by an employee, servant or agent of the Provider must clearly identify the wearer as an employee, servant or agent of the Provider and must be clearly distinguishable from Official Clothing or PPE worn by employees of ACTAS and the ESA.

14.	Any Official Vehicle used by the Provider must be clearly marked to identify the vehicle as belonging to the Provider and must be clearly distinguishable from Official Vehicles used by ACTAS and the ESA.  If approved, audible or visual warning devices fitted to an Official Vehicle may only be operated in accordance with the Australian Road Rules and any other conditions imposed by the Minister.  Visual warning devices fitted to an Official Vehicle must not be of a red, green or blue colour.

15.	The Provider acknowledges that it is not an “emergency service” for the purposes of the Emergencies Act 2004.  Therefore, the Provider:

a)	must not represent to any person that it is an emergency service for the purposes of that Act, or that it is empowered to do any thing that is not expressly permitted by the Approval; and
b)	must not perform, in an emergency or otherwise, the functions of an emergency service, except as expressly permitted by the Approval, or as directed by the ESA or a member of any of its emergency services.

16.	The Provider must not display details, logos or symbols of any sponsor of the Provider, which would bring into disrepute the good name of either the ESA or the Provider.  There should be no association with the following products or services unless a positive, socially responsible theme or health message is to be promoted:

a)	tobacco;
b)	alcohol;
c)	the sex industry; or
d)	sponsors who could involve the ESA or the Provider in controversy or expose either party to adverse criticism.

17.	The Provider must at all times maintain the clinical governance arrangements as approved and set out in Attachment 1.

18.	The Provider must, maintain an accurate record of any first aid or medical treatment provided to any person by the Provider.  Any record created in the provision of the Approved Services is to be maintained by the Provider in accordance with the Health Records (Privacy and Access) Act 1997.  The Provider must supply a copy of the proposed form of record with this application at Attachment 3.

19.	The Provider must develop a Provider’s Code of Conduct, which is agreed to by all of its employees, servants and agents, and is complied with at all times.  The Provider’s Code of Conduct is to be provided in Attachment 4 and must meet the minimum requirements set out in that schedule.

20.	
The Provider hereby releases and indemnifies the ESA, its employees, servants and agents from and against all damages, costs, expenses, loss or damage which they may incur or sustain and all actions, proceedings, claims and demands whatsoever which may be brought or made against them by any person, in respect of or by reason of or arising from:

a)	the provision, by or on behalf of the Provider, of the Approved Services;
b)	any negligence or other wrongful act or omission of the Provider or its employees, servants or agents, or of any other persons for whose acts or omissions the Provider is vicariously liable;
c)	any negligence or other wrongful act or omission of the Provider’s visitors, invitees or licensees;
d)	death, injury, loss of or damage to the Provider or its other employees, agents, sub-contractors, invitees, licensees or visitors; or
e)	any breach by the Provider of the Approval.

21.	The Provider will maintain a Public Liability policy of insurance of not less than $10,000,000 that notes the ACT Government as an interested party, and covers the Provider and the ACT Government in respect of any claim arising from or related to the provision of the Approved Services.

22.	If the Provider is providing first aid or medical treatment, the Provider will maintain a Medical Liability and Indemnity policy of insurance of not less than $20,000,000, which notes the ACT Government as an interested party and covers the Provider and the ACT Government in respect of any claim arising from or related to the provision of the Approved Services.

23.	The ESA may require the Provider to provide proof that the policies of insurance required by the Approval have been effected and maintained.  The Minister may terminate the Approval if the Provider does not comply with this clause.

24.	In the event of any dispute between the Provider and the ESA in relation to the administration of the Approval, the Provider must initially contact the ESA Contact Officer.

_______________________

The Provider declares that the information given in this application and its schedules and attachments is true and complete.

Signature/s			…………………………………………………………………………

If a company or delegate
of a body corporate,
capacity/authority		………………………………………………………………………….

Date:				………………………………….

SCHEDULE A

DETAILS OF APPLICANT (complete as applicable)

Name of Applicant:	

Trading as:	

Registered Trading Name and Address:	

Address for
correspondence/service:	

Places registered:
(States, Territories)	

Contact person:	

Address:	

Phone: (w):	(mob):	

Email: 		

SCHEDULE B

SERVICES TO BE PROVIDED 

(Note: The Applicant must provide sufficient detail of the nature and scope of services under each sub heading for which Approval is sought, including all dates when the services would be provided)

	Provision of emergency medical treatment within a specific event precinct, not including ambulance patient transport, whether within the event precinct or outside the event precinct boundaries.  

	

	

	

	

	

	

	

	

SERVICES TO BE PROVIDED (cont)

(Note: The Applicant must provide sufficient detail of the nature and scope of services under each sub heading for which Approval is sought, including all dates when the services would be provided)

	Provision of emergency medical treatment within a specific event precinct, including ambulance patient transport within the event precinct only

	

	

	

	

	

	

	

	

	

SCHEDULE C

PERSONNEL AND SKILLS / QUALIFICATIONS

(Note: This table should include details of relevant training or education, certifications and levels of clinical practice and experience at that level of practice for all personnel)

NAME	SKILLS AND QUALIFICATIONS	

	

	

	

	

	

	

	

	

	

	

	

SCHEDULE D

PPE AND OFFICIAL CLOTHING TO BE USED

TYPE OF PPE	Aust. / NZ STANDARD	

		

		

		

		

SCHEDULE E

OFFICIAL VEHICLES AND EQUIPMENT TO BE USED

Note: The Applicant must provide details of all Official Vehicles or Equipment used in the provision of the Approved Services.

TYPE OF VEHICLE (including registration no) OR
EQUIPMENT 	RELEVANT STANDARD COMPLIED WITH	

		

		

		

		

ATTACHMENT 1

CLINICAL GOVERNANCE (CLAUSE B6)

Note: The Applicant must attach documented evidence of the clinical governance structures and arrangements for the provision of the services for which Approval is sought including:

•	Currency of clinical practice for all personnel;

•	Details of Medical Advisor or Supervisor;

•	Details of Clinical Quality Assurance Contact

•	Authority for clinical practice, outlining levels of clinical practice;

•	Clinical Practice Protocols and Guidelines including any pharmacology;

•	Clinical quality management processes, clinical review program and contact point for clinical review.

ATTACHMENT 2

DETAILS OF THE PROVIDER’S STRUCTURE FOR COMMUNICATIONS, COORDINATION AND CHAIN OF COMMAND (CLAUSE B7)

To be completed by the Provider – include communication strategy and contact numbers.

ATTACHMENT 3

PROPOSED FORM OF RECORD OF FIRST AID OR MEDICAL TREATMENT PROVIDED (CLAUSE C18)

ATTACHMENT 4

PROVIDER’S CODE OF CONDUCT (CLAUSE C19)

(The following minimum standards are provided to enable Applicants to develop their own Code of Conduct applicable to the Approved Services.  A copy of the Provider’s proposed Code of Conduct is to be furnished with the completed application)

MINIMUM STANDARDS FOR PROVIDER’S CODE OF CONDUCT

The Provider’s Code of Conduct should include the following obligations for the employees, servants and agents of the Provider.

•	no person acting on behalf of the Provider at an event is to operate on public roads other than in accordance with the Provider’s Approval;

•	employees, servants and agents acting on behalf of the Provider must maintain a courteous and professional approach at all times, whether or not attending at an incident;

•	employees, servants and agents acting on behalf of the Provider must not consume, or be under the influence of, alcohol or other intoxicating substance whilst on duty or wearing Official Clothing or PPE;

•	employees, servants and agents acting on behalf of the Provider must follow the directions of any ACT Emergency Services Authority or ACT Ambulance Service officer whilst attending at an event for the Provider;

•	employees, servants and agents acting on behalf of the Provider must strive to cooperate with all civil authorities at all times;

•	employees, servants and agents acting on behalf of the Provider must perform their duties with diligence and care, having regard to public safety and morality; and