Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX F
AO No. 2016-0029
ASSESSMENT TOOL FOR LICENSING AN AMBULANCE AND
AMBULANCE SERVICE PROVIDER
I. GENERAL INFORMATION

Name of Ambulance Service Provider: ____________________________________________________

Complete Address: ____________________________________________________________________

____________________________________________________________________

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

Name of Owner:
_______________________________________________________________________

Classification:

Institution-based Non-institution based

Institutional Character:
Specify: _______________ Specify: ______________________

Ownership:

Government: Private:

National Single Proprietorship

Local Corporation

Others: (specify) ____________________ Others: (specify) ____________________

Number of Ambulance units: _______________

Type of application: Initial Renewal

DOH License Number:

_________________________________

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 1 of 10
 ANNEX F
AO No. 2016-0029
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 AND REQUIREMENTS COMPLIANT REMARKS

A. SERVICE DELIVERY
Every ambulance service provider shall ensure that the services delivered to patients comply with
the standard quality embodied in this Assessment Tool for licensure of 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

c. Contingency plans in case of vehicle and

equipment breakdown
d. Schedule of Retention and Disposal of Records
and other relevant information
e. Quality Assurance Program

f. Continuous Quality Improvement

- Client satisfaction survey with analysis
- Handling and resolution of complaints
2. Notarized Memorandum of Agreement (MOA)
with hospital facilities.
3. Linked-in communication devices between the
operations center of the ambulance service provider
and the referral hospital
4. Copies of the clinical protocol for each specific
case
5. Standard Patient Record form (10 sets)
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. Responders
Minimum of two (2) responders for each dispatch.
a. Each responder shall be trained,from a DOH-
recognized training provider, in the following:
- Basic Life Support
- AdvancedCardiac Life Support
- Standard first aid
- Emergency Medical Training
b. Valid PRC ID, if applicable
2. Driver
There shall be one (1) driver for every shift. Each
driver shall have the following:
- Valid professional driver’s license
- Certificate of proficiency from TESDA
DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 2 of 10
 ANNEX F
AO No. 2016-0029
STANDARDS AND REQUIREMENTS COMPLIANT REMARKS
3. Complete 201 files of each personnel containing:
- Certificate of Trainings attended
- Job description
- Notarized contract of employment
- Valid PRC ID, if applicable
4. Schedule of duties or shift of personnel
5. Staff development program for continuing
education and professional development of the staff
C. AMBULANCE
An ambulance vehicle shall be able to accommodate the patient, and the required number of personnel
and equipment.
1. Land Transportation Office (LTO) Registration
under the name of the ambulance service provider
2. The word AMBULANCE 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
3. The prescribed DOH logo on both sides of the
vehicle (for renewal)
4. Emergency Warning Light System and Siren-
Public Address System
5. Ambulance Body
- Tempered glass division (separating the driver
to the body)
- Air conditioning system with control
- Electric (internal and external) supply bulbs
- Fire Extinguisher (rating 2A10BC)
- Flash lights with extra batteries and bulbs
- Ambulance wheeled cot with mounted cot
fastening system
- Folding Stretcher / Poles (1 set) and Canvas (2)
- Orthopedic (scoop) stretcher
- Overhead aluminum grabrail on the ceiling on
top of the patient/stretcher
6. Communication Equipment
- One (1) unit installed two-way radio
communication
- One (1) Cellular phone
- Intra-vehicle intercom system (between driver
and body)
D. 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 is properly ventilated, lit, cleaned
and secured

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 3 of 10
 ANNEX F
AO No. 2016-0029
STANDARDS AND REQUIREMENTS COMPLIANT REMARKS
2. Written plan and program of proper disinfection
and preventive maintenance of ambulance vehicles
3. Schedule logbook of the preventive maintenance of
the ambulance vehicle
4. Procedures on proper disposal of infectious wastes,
toxic and hazardous substances in accordance with
Republic Act No. 6969 known as “Toxic and
Hazardous Substances and Nuclear Wastes Act”
and other related policy guidelines and/or issuances
5. Adequate personal protective equipment (PPEs)
E. 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 – completely and
accurately filled out; kept secured and confidential
2. Logbook - completely and accurately filled out
with the following contents:
- Name, sex and age of patient;
- Name of attending physician, when applicable;
- Origin and destination;
- Date and time of dispatch and return of
ambulance;
- Reason for transfer/transport;
- Disposition of patient
3. File of the Annual Statistical Report (for renewal) -
completely and accurately filled out with the
following contents
- Number of ambulance conductions stating
Regional Office, Province, Municipality, City,
including the type of the health facility:
o Inter-facility hospital to hospital
o 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)
o Home to hospital
o Hospital to Home
o Other routes, specify. (i.e. Hospital to
Airport/Ports or vice versa)
- Reason for referral/transport
- Date, time and description of Adverse Events,
e.g. number of deaths en route, if any.

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 4 of 10
 ANNEX F
AO No. 2016-0029
F. EQUIPMENT, MEDICINES AND SUPPLIES
Every ambulance shall have available and operational prescribed equipment, medicines and supplies.
ITEM QUANTITY COMPLIANT REMARKS
A. Ventilation and Airway Equipment
1. Suction Apparatus and accessories
a. Portable or Mounted Suction
1 unit
Machine
b. Flexible suction catheters Fr. 5,
1 piece each
8, 12 and 14
2. Portable oxygen equipment /
Installed
a. Portable oxygen tank - secured 1 unit
b. Flow regulator / flow meter 1 unit
c. Oxygen mask No. 2, 3 and 4
1 piece each
(for newborn, infant and adult)
3. Bag valve mask resuscitator with
rebreather bag for adult, pediatric 1 piece each
and infant
4. Nebulizer with nebulizer kit 1
B. Monitoring and/or Defibrillation
1. Automatic external defibrillator
1 unit
(AED)
2. Defibrillator pads – disposable 1 pair
3. Sphygmomanometer, Non-
mercurial
- Adult cuff 1
- Pediatric cuff 1
4. Stethoscope (pediatric and adult) 1 each
C. Immobilization Devices
1. Rigid cervical collars (small,
1 piece each
medium, large)
2. Firm padding or commercial head
1 piece
immobilization device
3. Lower extremity traction devices
(supporting slings, padding, traction 1 piece each
strap)
4. Upper and Lower extremity
immobilization devices
a. Joint above and joint below
1 piece each
fracture
b. Rigid support appropriate
material (cardboard, metal,
1 piece each
pneumatic, vacuum, wood or
plastic), various sizes)
c. Resistant straps or cravats 3 pieces
5. Full body vacuum mattress – used
for head, spine, and head-to-feet 1 piece
immobilization

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 5 of 10
 ANNEX F
AO No. 2016-0029
ITEM QUANTITY COMPLIANT REMARKS
6. Sandbags – for initial on-site
1 piece
immobilization only
D. Dressings and Bandages
1. Sterile burn sheets 3 pieces
2. Triangular bandages 3 pieces
3. Sterile Dressings
a. 10”x30” or larger 3 packs
b. ABDs, 10”x12” or larger 3 packs
c. 4”x4” gauze sponges 4 packs
4. Sterile gauze rolls (various sizes) 5 pieces each
5. Non-sterile elastic bandages
1 piece each
(various sizes)
6. Sterile occlusive dressing 3”x8” or
3 pieces
larger
7. Adhesive tape roll
a. Various sizes of 2” or 3”
1 piece
hypoallergenic
b. Various sizes of 2” or 3” non-
1 piece
hypoallergenic/ordinary
E. Obstetrical Delivery Set
1. Individual disposable delivery kit –
1 set
sterile
2. Wrap / blanket for newborn 1 piece
F. Infection Control
1. Eye protection (full peripheral
3 pieces
glasses or goggles or face shield)
2. HEPA Masks / Surgical Masks 3 pieces
3. Non-sterile and Sterile Gloves 6 pairs sterile
and 1 box
unsterile
4. Jumpsuits or Gowns 3 units
5. Shoe covers 3 pairs
6. Hand sanitizer or 70% alcohol 2
7. Disinfectant solution for cleaning
1 gallon
equipment
8. Disposable trash bags
- Black for General wastes 2 pieces of
- Green for Biodegradable wastes each color
- Yellow for Infectious wastes
G. Miscellaneous Supplies
1. Weighing scale 1
2. Tape measure 1
3. Thermometer, non-mercurial 1
4. Heavy bandage or paramedic
scissors for cutting clothes, belts 1 pair
and boots
5. Alcohol swabs x 20 pcs 1 pack
6. Cold packs 1
DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 6 of 10
 ANNEX F
AO No. 2016-0029
ITEM QUANTITY COMPLIANT REMARKS
7. IV Administration set (Macro /
1 piece each
Micro)
8. Blankets, Sheets, Linen, or paper 1 piece each
9. Pillows, Pillowcase and towels 1 piece each
10. Disposable standard sharps
1
containers
11. Disposable emesis bags or basins 1
12. Bed pan 1
13. Urinal 1
14. Syringes (50ml, 30ml, 10ml, 3ml 1 piece each
1ml) for 50ml and
30 ml
5 pieces for
10ml, 3ml
and 1ml
15. Gauge needles (G19, 20, 21, 23, 25, 6 pieces for
26) each size
16. Incontinence pads – disposable 1
17. Antibacterial lubricating jelly 1 tube
H. Medicines / Fluids
1. Activated Charcoal 1 pack
2. Oral glucose, 10 ml 1 piece
3. Sterile water for irrigation, 1 liter 1 bottle
4. Sterile water for injection, 10ml 1 piece
5. Intravenous fluids
- D5 LR 1 Liter
- D5 NSS 1 Liter 1 piece each
- D5 Water 1 Liter
- D5 0.3NaCl 500ml
6. Normal salinte water, 1liter 1 piece
7. Normal saline water (injectable) 1 piece
8. Salbutamol nebules 3 pieces
9. Dextrose 50%/50ml vial 1 piece
I. 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 5 pieces
2. Isoproterenol 1mg/5ml ampule 1 piece
3. Epinephrine 1mg/1ml tubaxes (IM,
5 pieces
Intracardial, IV) ampule
4. Diazepam 10mg 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 100mg/ml
1 piece
vial
9. Calcium Gluconate 10% 1mg/10ml
1 piece
ampule/vial
DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 7 of 10
 ANNEX F
AO No. 2016-0029
ITEM QUANTITY COMPLIANT REMARKS
10. Potassium Chloride 20mg/10ml vial 1 piece
11. Furosemide 100mg/10ml vial and
2 pieces each
20mg/2ml ampule
12. Magnesium Sulfate 50% 1gm/2ml
1 piece
ampule
13. Bretylium 500mg/10ml vial 1 piece
14. Dopamine 400mg/5ml vial 1 piece
15. Diphenhydramine 50mg/ml ampule 1 piece
16. Sodium bicarbonate 10ml ampule 1 piece
17. Digoxin 0.1mg/ml ampule and - 2 pcs for
0.5mg/2ml ampule 0.1mg/ml
ampule
- 1 piece for
0.5mg/2ml
ampule
18. Calcium Chloride 10% ampule/vial 1 piece
19. Nitroglycerine spray / sublingual /
1 piece
patch
20. Verapamil 5mg/2ml ampule 1 piece
21. Propanolol 1mg/ml ampule 1 piece

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 8 of 10
 ANNEX F
AO No. 2016-0029
Name of Ambulance
__________________________________________________________________
Service Provider:
Date of Inspection: __________________________________________________________________

RECOMMENDATIONS:
A. For Licensing Process
[ ] For Issuance of License To Operate as AMBULANCE SERVICE PROVIDER
Validity from _____________________ to _______________________
Number of authorized ambulance units: _____________________

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: ___________________________________
DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 9 of 10
 ANNEX F
AO No. 2016-0029

Name of Ambulance
________________________________________________________________
Service Provider:
Date of Monitoring: ________________________________________________________________

RECOMMENDATIONS:
A. For Monitoring Process
[ ] 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: _________________________________

DOH- A ASP-LTO-AT
Rev ision:00
08/15/2016
Page 10 of 10