Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX C
A.O. No. 2018 -__0001__

ASSESSMENT TOOL FOR LICENSING A LAND AMBULANCE AND

AMBULANCE SERVICE PROVIDER

I. GENERAL INFORMATION

Name of Ambulance Service Provider (ASP): _______________________________________________

Complete Address: _____________________________________________________________________

_____________________________________________________________________

Email
Tel./Fax Nos.: _______________________________ Address:_______________________________

Name of Owner: _______________________________________________________________________

Category:

 Type I - BLS Ambulance  Type II- ALS Ambulance

Ownership:

 Government:  Private

 National  Single Proprietorship

 Local  Corporation
Others (specify) _____________ Others (specify) ____________

Institutional Character:

 Institution-based  Non-institution-based/Free-Standing
Type of application:

 Initial  Renewal
DOH License Number (ASP):________________

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II. TECHNICAL REQUIREMENTS
Instruction: In the appropriate box, place a check mark (√) if the ambulance or ambulance service
provider is compliant or X-mark if not compliant.

STANDARDS
(AMBULANCE SERVICE Type I Type II COMPLIANT REMARKS
PROVIDER)
1. Land Transportation Office
Registration under the name of
the Ambulance Service Provider

2. For Institution-based:

Designated area that will house

the policies, files, records, etc. of
the ASP and which shall serve as
the operations control and
dispatch center of ambulance/s.

For Non-institution-based:

Operations control and dispatch

center of ambulance/s whether it
be a business office or space
3. ASP office has adequate parking
spaces for the ambulance/s they
own (when applicable).

A. 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 land ambulances, other policy guidelines
and/or related issuances.
1. Documented policies and
procedures on:
a. Administrative and technical
standard operating
procedures (SOP) for the
provision of its services
b. Establishment of its referral
system
2. For health facilities (ex.
hospitals, infirmaries and
birthing facilities) with
outsourced ambulance services:

Notarized Memorandum of
Agreement (MOA) between the
health facility and ASP

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STANDARDS
(AMBULANCE SERVICE Type I Type II COMPLIANT REMARKS
PROVIDER)
For Non-institution-based/ Free-
Standing ambulance service
providers servicing the public
independently:

Notarized Memorandum of
Agreement (MOA) with a
hospital
3. Schedule of Retention and
Disposal of Records and other
relevant information
4. Quality Assurance Program
5. Continuous Quality
Improvement
a. Client satisfaction survey
with analysis
b. Handling and resolution of
complaints
6. Copies of the clinical protocol
for each specific case
B. 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 which may include electronic communications or
otherwise allowed under R.A. 8792 known as “Electronic Commerce Act of 2000.” Moreover, management
of data or information should be in adherence to R.A. 10173 also known as the “Data Privacy Act of 2012.”
1. Hospital Referral Form- - -
completely and accurately filled
out; kept secured and
confidential
2. Logbook - completely and - - -
accurately filled out with the
following contents:

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. File of the Annual Statistical - - -
Report (for renewal) -
completely and accurately filled
out

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STANDARDS
(AMBULANCE SERVICE Type I Type II COMPLIANT REMARKS
PROVIDER)
C. 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. Written plan and program of
proper disinfection and
preventive maintenance of the
ambulance vehicles
3. Adequate personal protective
equipment (PPEs)
4. 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
D. EQUIPMENT, MEDICINES AND SUPPLIES
Every ambulance shall have available and operational prescribed equipment, medicines and supplies.
1. There shall be a program for
calibration, preventive
maintenance and repair of
equipment, including
decontamination and
disinfection.
2. There shall be a contingency
plan in case of equipment
breakdown and malfunction,
especially during patient
transport.
3. There shall be a program for the
management of temperature
sensitive medication.

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STANDARDS AND
REQUIREMENTS Type I Type II COMPLIANT REMARKS
(AMBULANCE VEHICLE)
LTO PLATE OR CONDUCTION STICKER NUMBER:
E. AMBULANCE BODY
An ambulance vehicle shall be able to accommodate the patient, and the required number of personnel and
equipment.
1. Safety non-porous partition
(separating the driver and the
body of the ambulance
2. Electric (internal and external)
supply bulbs
3. Overhead grab rail on the
ceiling on top of the
patient/stretcher
4. Inverter power source
5. Licensed Ambulances shall bear
the following markings:
a. Front: The reflectorized and
capitalized word
“AMBULANCE” which is
spelled out in reverse (mirror
image). The height of each
letter shall be no less than 10
centimeters and the word
shall be seen at least six (6)
meters away.
b. Side: Each side of the
ambulance body shall have
the capitalized word
“AMBULANCE” not less
than 15 cm in height.
c. Rear: The reflectorized and
capitalized word
“AMBULANCE” not less
than 15 cm in height and the
prescribed DOH ambulance
logo to be issued by the
DOH once the application
for a license is approved
No other signage or pictures
outside of what is prescribed.
(May opt to mount the blue
“Star of Life” emblem on
any part of the ambulance
vehicle)
6. Adequate and stable cabinet/s
that can appropriately store the
required equipment, medicines
and supplies
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STANDARDS AND
REQUIREMENTS Type I Type II COMPLIANT REMARKS
(AMBULANCE VEHICLE)
7. Emergency Warning Light
System and Siren-Public
Address System
F. PERSONNEL
Each ambulance shall be manned by an adequate number of qualified, trained and competent staff to ensure
efficient and effective delivery of quality ambulance services.
1. Minimum of two (2) ambulance - - -
personnel excluding the driver is
required for every ambulance
dispatched.

Each staff shall be trained from a

DOH-recognized training
provider, in the following:
a. Standard First Aid - - -
b. Basic Life Support - - -
c. Advanced Cardiac Life - - -
Support
d. Emergency Medical Starting CY 2020 Starting
- CY -
Technician (EMT) onwards: 2020 onwards:
Training- will be in EMT Training- EMT Training-
transition Basic Advanced
/Paramedic
Training
2. Driver
There shall be one (1) driver for
every shift. Each driver shall
have the following:
a. Valid professional driver’s
license
b. Certificate of Proficiency
from TESDA (NC II)
3. Complete 201 files of each
personnel containing:
a. PRC ID
b. Certificate of
Trainings attended
c. Job description
d. Notarized Contract of
Employment
4. Schedule of duties or shift of
personnel
5. Staff development and
continuing education program to
upgrade the knowledge, attitude
and skills of staff

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LIST OF EQUIPMENT, MEDICINES AND SUPPLIES

Each ambulance shall be adequately equipped with appropriate equipment, medicines and supplies.

ITEM Type I Type II COMPLIANT REMARKS

A. Ventilation and Airway Equipment

1. Suction apparatus and accessories
a. Portable or Mounted Suction
Machine
b. Flexible suction catheters
Fr. 5,8,12 and 14
2. Portable oxygen
equipment/installed
a. Portable oxygen tank with
regulator
b. Oxygen mask No. 2,3 and 4
(for newborn, infant and adult)
3. Bag valve mask resuscitator with
rebreather bag for adult, pediatric
and infant
4. Endotracheal tubes (pedia and
adult)
5. Airways (pedia and adult)
6. Nebulizer with nebulizer kit
7. Laryngoscope set (pedia and adult)
B. Monitoring and/or Defibrillation
1. Defibrillator Manual with
AED
cardiac monitor
2. Defibrillator pads – disposable
3. Sphygmomanometer, Non-
mercurial
- Pediatric cuff
- Adult cuff
4. Stethoscope (pediatric and adult)
C. Immobilization Devices
1. Rigid cervical collars (small,
medium, large)
2. Firm padding or commercial head
immobilization device
3. Lower extremity traction devices
(supporting slings, padding,
traction strap)
4. Upper and Lower extremity
immobilization devices
a. Joint above and joint below
fracture
b. Rigid-support appropriate
material (cardboard, metal, pneumatic,
vacuum, wood or plastic)-various sizes

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ITEM Type I Type II COMPLIANT REMARKS

c. Resistant straps or cravats

d. Orthopedic (scoop)
stretcher/ Long back board
D. Dressings and Bandages
1. Sterile burn sheets
2. Triangular bandages
3. Sterile Dressings
a. 10”x30” or larger
b. ABDs, 10”x12” or larger
c. 4”x4” gauze sponges
4. Sterile gauze rolls (various
sizes)
5. Non-sterile elastic bandages
(various sizes)
6. Sterile occlusive dressing
3”x8” or larger
7. Adhesive tape roll
a. Various sizes of 2” or 3”
hypoallergenic
b. Various sizes of 2” or 3”
non-
hypoallergenic/ordinary
E. Obstetrical Delivery Set
1. Sterile delivery kit
2. Wrap / blanket for newborn
F. Infection Control
1. Eye protection (full peripheral
glasses or goggles or face
shield)
2. HEPA Masks / Surgical
Masks
3. Non-sterile and Sterile Gloves
4. Jumpsuits or Gowns
5. Shoe covers
6. Hand sanitizer or 70% alcohol
7. Sharps container (puncture
proof)
G. Miscellaneous
1. Blood Glucose Meter with
strips
2. Thermometer, non-mercurial
3. Heavy bandage or paramedic
scissors for cutting clothes,
belts and boots
4. Alcohol swabs
5. Heat and Cold packs or their
equivalent

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ITEM Type I Type II COMPLIANT REMARKS

6. Flash lights with extra batteries

and bulbs
7. Blankets, sheets, linen or paper
8. Pillows, pillow case and towels
9. Disposable emesis bags or
basins
10. Bed pan
11. Urinal
12. Incontinence pads – disposable
13. Lubricating jelly
H. Communication Equipment
Communication devices exclusive for
ambulance use between the OPCEN,
ambulance vehicles and referral
facilities which may be any of the
following:
1. Radio Licensed hand-
held radio with
base station
2. Cellular Phone
I. Patient Transport
1. Ambulance wheeled cot with
mounted cot fastening system
J. Injury Prevention Equipment
1. Fire Extinguisher
K. IV Therapy Supplies
1. IV Administration set
(Macro/Micro)
2. IV cannula (G19, 20, 21, 23, 25, 26)
3. Syringes (50ml, 30ml, 10ml, 3ml 1ml)
L. Medicines / Fluids
1. Activated Charcoal
2. Salbutamol nebules
3. Sterile water for irrigation, 1
liter
4. Sterile water for injection,
10ml
5. Intravenous fluids
- D5 LRS 1 Liter
- D5 NSS 1 Liter
- D5 Water 1 Liter
- D5 0.3NaCl 500ml
- Plain LRS
- Plain NSS
6. Normal saline water
(injectable)
7. Dextrose 50%/50ml vial
8. Plasma Expander

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ITEM Type I Type II COMPLIANT REMARKS

M. Controlled Medications
Sealed Drug / 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
2. Epinephrine 1mg/1ml tubaxes
(IM, Intracardial, IV) ampule
3. Diazepam 10mg ampule/vial
4. Dobutamine 250mg ampule
5. Lidocaine 1gm/25ml vial
6. Adenosine 6mg/2ml ampule
7. Human Regular Insulin
100mg/ml vial
8. Calcium Gluconate 10%
1mg/10ml ampule/vial
9. Potassium Chloride
20mg/10ml vial
10. Furosemide 100mg/10ml vial
and 20mg/2ml ampule
11. Magnesium Sulfate 50%
1gm/2ml ampule
12. Dopamine 400mg/5ml vial
13. Diphenhydramine 50mg/ml
ampule
14. Sodium bicarbonate 10ml
ampule
15. Digoxin 0.1mg/ml ampule and
0.5mg/2ml ampule
16. Nitroglycerine spray /
sublingual / patch
17. Verapamil 5mg/2ml ampule

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Name of Ambulance
Service Provider: _________________________________________________________________
Date of Inspection: __________________________________________________________________

RECOMMENDATIONS:
For Licensing
[ ] For Issuance of License To Operate as AMBULANCE SERVICE PROVIDER
Validity from ____________________ to _______________________
LTO Plate or Conduction Sticker Number (Vehicle/s):
1. ___________________________________ 4. ______________________________________
2. ___________________________________ 5. ______________________________________
3. ___________________________________ 6. ______________________________________
*Use additional sheet/s if needed
[ ] Issuance depends upon compliance to the recommendations given and submission of the following
within ____________________ days from the date of inspection
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
[ ] Non-issuance. Specify reason/s: ____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Inspected by:
Printed name Signature Position/Designation
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Received by:
Signature: ___________________________________
Printed Name: ___________________________________
Position/Designation: ___________________________________
Date: ___________________________________

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Name of Ambulance
________________________________________________________________
Service Provider:
Date of Monitoring: ________________________________________________________________
DOH License Number
________________________________________________________________
(ASP):
LTO Plate or Conduction Sticker Number (Vehicle/s):
1. ___________________________________ 4. ______________________________________
2. ___________________________________ 5. ______________________________________
3. ___________________________________ 6. ______________________________________
*Use additional sheet/s if needed
RECOMMENDATIONS:
For Monitoring
[ ] Issuance of Notice of Violation
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
[ ] Non-issuance of Notice of Violation
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
[ ] Others. Specify ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Monitored by:
Printed name Signature Position/Designation
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Received by:
Signature: _________________________________
Printed Name: _________________________________
Position/Designation: _________________________________
Date: _________________________________

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