MICHIGAN STATE UNIVERSITY EMERGENCY MEDICAL RESPONSE TRAINING SITE VISIT CHECKLIST The lead instructor from Michigan State University will go through all this information with you. By completing as much of this checklist as possible ahead of time, you will be prepared to provide the information we will need to make the class specific to your location. THANKS FOR YOUR ASSISTANCE! Facility: Type Production: Mailing Address (For Fedex): City: Contact Name: Email: Class Dates: Number of Programs: State: Zip: Phone: Pager: Start/End Times: # Employees/Program: Indicate previous training provided to Emergency Response Team members: Incipient Fire Rescue from Heights Confined Space Rescue First Aid/CPR Incident Command Hazmat (Level: ) If ERT members have received pervious medical training, please complete the following: Date(s) of Training Description Training Provider
Please indicate whether the following emergency medical equipment is available for the ERT at your location. If possible, attach a copy of the inventory of the response vehicle at this workplace. Equipment Name of Equipment Yes No Airway Management, Oxygen Therapy, Ventilation: Oxygen tanks with nasal canals and masks Oropharyngeal or Nasopharyngeal Airways Suctions with flexible or rigid tips Portable suctions Bag valve masks Pocket masks Patient Assessment Equipment: Stethoscopes Blood pressure cuffs Pen lights Bleeding Control or Splinting Dressing/Bandages Pre-manufactured splints Padded board splints Traction splints Spinal Immobilization Cervical collars Back boards
Please indicate the type of medical emergencies the ERT may respond to: Type of Incident Yes No Type of Injuries Medical Trauma Environmental Entrapment Chemical Other: If your ERT will be operating at the 40-hour Emergency Medical First Responder Level, please indicate the types of activities they may have to perform by checking the appropriate boxes below: Activity Yes No Activity Yes No Oxygen delivery Cervical collars Naso & Oropharyngeal Back boarding Airways Suctioning Others (Please list): Ventilating with BVM Vital signs CPR, 1-2 person adult, 4 hours CPR, adult, child, infant, 8 hours Foreign body airway obstruction Bleeding control Rigid splinting Traction splinting
Please list any specialized equipment, other than that mentioned above, that is available to the ERT: Type of Equipment Use/Purpose Please indicate whether or not you have Standard Operating Guides for any of the following: Incident Command First Aid BBP Activation of Outside EMS Specialized Equipment Other: Please Specify: NOTE: If you do not have any SOG s, MSU can provide some generic ones that you will need to modify for your own use. Please describe any emergency medical responses that have occurred at your facility within the past 12 months: Date Incident Description
Level of Training Required (Please check one): First Aid Medical First Responder This level of training is designed specifically for the person who is often the first on the scene. This training emphasizes activating the EMS system. This training emphasizes activating the EMS system and providing immediate care for lifethreatening injuries and illnesses and for controlling the scene and preparing for the arrival of the ambulance. First Aid Refresher Medical First Responder Refresher After discussing training requirements, the lead instructor will then discuss training hours: Courses to Be Delivered # Hours # Programs/Shifts First Aid Medical First Responder First Aid Refresher Medical First Responder Refresher
CHECKLIST FOR CLASS ROOM Item Yes No Unsure Has room been scheduled for entire training program? Tables and chairs for all participants 2 tables for instructors TV and VCR with back-up Overhead projector with back-up Large screen Chart pad and easel Coffee (am/pm) and beverages (pm) Arrangements for lunch Sample protective clothing Invite Union/Management to attend last day CHECKLIST FOR MEDICAL SIMULATION Item Yes No Unsure Airway supplies Back boarding supplies Bleeding control CPR INSTRUCTOR CHECKLIST FOR FACILITY Item Yes No Have you requested copies of relevant SOG s? Have you identified an area where you can conduct hands-on activities? Have you explained the class cancellation policy? (See next page) Have you explained employee attendance policy? (See next page) Have you explained the medical clearance policy? (See next page) Have you requested information on lodging? Please indicate name, address and phone number of client -approved hotel/motel.
INSTRUCTOR CHECKLIST: POLICIES AND PROCEDURES Item Yes No, Why Not? Have you explained the following Class Cancellation Policy? If the facility needs to cancel or postpone the class, they must contact MSU 7 calendar days in advance. We need this time to advise instructors of changes in our schedule. MSU will bill for expenses incurred if classes are cancelled with less than 7 days notice. Have you explained the following Employee Attendance Policy? In order to receive a certificate, employees must attend the entire training program. Participants who miss any days will have to make the day up at a subsequent program at their facility or the nearest facility where training is scheduled. Exceptions to this policy are permitted, but they must be discussed with MSU not with the individual instructor. The instructor will hold all certificates of participants who do not complete the training unless other arrangements have been made with MSU in advance. Have you explained the policy on appropriate attire? Employees must dress accordingly to the weather. However, because of hazards present, no tank tops or shorts, and no sandals. Employees should wear long pants and avoid loose fitting clothes. Shirts suitable for work are recommended. Have you explained the medical clearance policy? The facility must provide MSU with a letter indicating that all participants have completed a medical evaluation within the past year. The medical evaluation must indicate that the participant is allowed to engage in activities associated with medical emergency response. No participants will be allowed to engage in hands-on activities unless the letter is provided. Have you requested information on hotel/motel accommodations? Is there a Ford discount? Please indicate the name, address and phone number of the hotel/motel.