Standard Operating Procedures Manual For Ambulance Operations

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Standard OperatingProcedure

Contents
Introduction and Background ------------------- 29 General Standard Operating Procedures -- 3 Speci!ic Standard Operating Procedures -- 33 "ode o! "onduct ---------------------------------------- 39 Anne#ure$SOP%-&----------------------------------------'3

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Section 1: Standard Operating Procedures for Ambulance Operations

1.1. Introduction: This manual provides Standard Operating Procedures (SOPs) for operating ambulances at the Rural Hospitals (RH) / Block Primary Health entres (BPH ) in !est Bengal" Standard Operating Procedures are a set of #ritten instructions that should be follo#ed in every sphere of activity in order to achieve economy$ efficiency$ effectiveness and uniformity" %n other #ords SOPs are prescribed procedures that tell #ho #ill do #hat$ #here$ #hen$ #hy and ho#" 1.2 Background &ccessibility to emergency health services especially emergency obstetric care is still a ma'or concern in remote areas of !est Bengal despite ambulance services being operated by the Red ross Society$ St" (ohn)s &mbulance$ other *+Os and Private Bodies" Operating ambulance services in such areas #ill help to improve accessibility$ safety and security of patients because ambulance services are meant to bridge the gap bet#een the need for critical care of patients and timely care to be offered by hospitals / physicians for diagnosis and treatment of ailing patients" ,o meet this need for emergency health care +overnment of !est Bengal decided to set up emergency transportation services by involving reputed *+Os/ BOs/,rusts$ etc to take-up day to day operational management of ambulance services" &ccordingly$ .//&mbulance Services at the level of Rural Hospitals (RH)/ Block Primary Health entres (BPH )/Primary Health entres (PH ) managed by *+Os/ BOs etc under PPP have become operational in eight districts of !est Bengal from 0arch 1223" 4ncouraged by the initial success of the scheme$ 5oH6! has no# decided to replicate this scheme in the remaining Blocks of the eight districts as #ell as at the Block level in other districts of the state" 6or successful and efficient running of ambulance services by these *+Os/ BOs/,rusts$ etc it is essential to have and follo# Standard Operating Procedures that #ill direct all those involved in ambulance operations to perform and accomplish tasks #ith a greater degree of efficiency$ economy and uniformity" SOPs in the case of ambulance operations #ill be of t#o types$ general and specific" General SOPs #ill detail out the +eneral &ttributes and onduct of Personnel/*+Os involved in ambulance operations #hile specific SOPs #ill help direct people involved in ambulance operations to respond to and act upon re7uests for ambulance services in specific #ays"

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Section 2 General Standard Operating

Procedures
2.1 General Attributes & Conduct of Personnel Involved in Ambulance O erations
1"."." Respect and onsideration &mbulance Services personnel #ill treat all patients #ith respect and consideration regardless of their race$ color$ se8$ creed$ culture$ economic status and religious beliefs" ,here #ill be no discrimination on the basis of race$ se8$ se8uality and se8ual orientation" 1"."1" Professional 48ecution Both the driver and the attendant #ill ensure that the vehicle and related e7uipments are #ashed and cleaned once daily and in bet#een transportation of patients" ,he driver of the vehicle #ill check the status of fuel$ o8ygen cylinder and other necessary e7uipment as per the checklist provided (Annexure/SOP 1! every morning as #ell as before leaving for a call" Both the driver and the attendant #ill complete all paper#ork related to ambulance operations in bet#een calls and at the end of the day" ,he cleaning of vehicle$ cleaning of e7uipment$ completion of paper#ork$ and continuing maintenance of the vehicle are absolutely necessary for proper and timely functioning of ambulance services" 1"."/" &ttendance Both the driver and the attendant #ill be available for ambulance duty at any point of time to perform the duty" %t is the responsibility of the operating partner to ensure that regular attendance and punctuality is maintained at all points of time" 1"."9" :niform Standard uniform code #ill be dark gray shirts and trousers" Both the driver and the attendant #ill #ear uniforms as specified above #hile on duty to promote professionalism and facilitate identification as ambulance operations staff" 1"."3" Physical 6itness ,he 5river and the attendant #ill remain physically and mentally fit and sound so as to be able to perform their duties at all times"

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1".";" Patient 5isposition Patients should be transported to the hospital as per the guidelines specified in the Scheme 1"."<" ommunication Protocols Proper communication protocols need to be maintained #ith the callers and patient party" Guidelines/Protocols= Simple$ direct$ professional and courteous language #ill be used at all times" !hen an ambulance is dispatched on the basis of a call the dispatcher #ill ensure that the ambulance is responding to the correct address" ontact #ith the dispatch (ambulance and driver) #ill be maintained at all times" Some commonly used &mbulance Operation terms are= >&vailable? >On call? >Out of Service? >Received? >Responding? >Status? >!elfare heck? >On Scene? >,ransporting? follo#ed = ambulance is available to respond to a call" = ambulance is picking up or transporting a patient = ambulance is not available to respond = ambulance staff has received the information" = ambulance is en route to a call = 6ind out the availability of ambulance = ,o check the physical #elfare of the ambulance staff = &mbulance has arrived at call location" = &mbulance is transporting the patient to a hospital" 0ust be by hospital name" >&rriving at Hospital? = &mbulance has arrived at the hospital (use name)

1"."@ 0obile Phone ,he *+O/ BO/,rust shall provide a mobile phone to the 5river of the &mbulance for enabling the 5river to establish timely communication link #ith the RH/BPH "

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2.2 Infection Control B! Ambulance Personnel i" :se all protective gears for handling patients at all times ii" !hen the possibility of e8posure to blood or other body fluid e8ists$ gloves are recommended" %f hands accidentally become contaminated #ith blood$ they should be #ashed thoroughly as soon as possible" iii" !hen there is a risk of eye or mouth contamination (for e8ample$ the patient is vomiting bloody material or there is arterial bleeding)$ protective eye#ear and masks are recommended" iv" 0asks should be #orn by the ambulance staff or patient for those infectious agents transmitted by airborne diseases like ,uberculosis$ hicken Po8$ 0easles and the like v" 47uipment should be thoroughly cleaned after each use" vi" &ll significant e8posures shall be reported to the Superintendent/ B0OH/0O% immediately so that necessary action can be taken" Significant exposure is defined as the following: i" &ny puncture of the skin by a needle or other sharp ob'ect that has had contact #ith patient)s blood or body fluids or #ith fluids infused into the patient" ii" Blood spattered onto mucous membranes (e"g" mouth or eyes)" iii" ontamination of open skin (cuts$ abrasions$ blisters$ open dermatitis) #ith blood$ saliva$ amniotic fluid$ etc"" 2.". Patient Care #e orts$ %ocumentation 5ocumentation is one of the most important aspects of completing an ambulance call" Both the call receiver as #ell as the driver of the ambulance must maintain and complete call reports" Patient are Reports are fre7uently referred to as all Reports" ,he documentation norm #ill be A a" omplete report on each patient for any call (Annexure/SOP 2! b" &ll call reports to be recorded in duplicate as the call occurs and the duplicate copy kept in office file" c" &ll calls to be registered in the Bog Book after the completion of the call (Annexure/SOP "!

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Section ": Specific Standard Operating Procedures

,he primary function of an ambulance is emergency transportation of obstetric care$ accident and other emergency health cases from the villages/places of residence to the RH/BPH s or to the Sub-5ivisional/5istrict/tertiary hospital or to a nearest private hospital" Re7uest for ambulance services #ill therefore come to the RH/BPH through telephone or in the form of a personal caller for transporting accident or obstetric care and other emergency health cases (termed hereunder as normal emergency cases) as per guidelines mentioned belo#" ".1A. #e&uest 'or Ambulance (ervices Over )ele *one 'or )rans orting +mergenc! Cases /".&." &n employee of RH/BPH authoriCed by the Superintendent/B0OH/0O% #ill receive a phone call re7uesting for ambulance services" /".&"1 5etails of re7uest #ill be noted in the DRe7uest for &mbulance) / all Record form (&nne8ure 1) in duplicate" 6ull address and clear direction for location of the patient supported by important landmarks #ill also be noted do#n" ,he employee of RH/BPH #ill in turn inform about user charges and mode of payment to the caller" /".&"/ ,he filled-in form should be signed by Superintendent/B0OH or 0edical Officer on duty or any other person authoriCed by Superintendent/B0OH/0O% before dispatch of the ambulance" /".&"9 ,hereafter$ the original of the form is to be handed over to the driver of the ambulance immediately" ,he copy of the form should be kept in office file" /".&3" ,he concerned employee #ill immediately try to establish contact #ith the driver of the ambulance and pass on the necessary information" %f contact cannot be established #ith the driver of the ambulance #ithin /2 minutes$ the same should be informed to the telephone caller so that the patient party can make alternate transportation arrangements" /".&;" %n case$ the patient is to be transported to any center other than the RH/BPH $ the concerned employee #ill intimate and obtain prior permission for the same from the Superintendent/B0OH/0O% and then pass on the necessary information to such center

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".1B #e&uest 'or Ambulance (ervices In Person ,B! Patient-s #elatives or .eig*bour/ 'or )rans orting +mergenc! Cases /".B"."5etails of re7uest #ill be noted in the DRe7uest for &mbulance) form (&nne8ure 1) in duplicate" 6ull address and clear direction for location of the patient supported by important landmarks #ill also be noted do#n" ,he employee of Superintendent/BPH #ill in turn inform about user charges and mode of payment to the caller" /".B"1 ,he filled-in form should be signed by Superintendent/B0OH or 0edical Officer on duty or any other person authoriCed by Superintendent/B0OH/0O% before dispatch of the ambulance" /".B"/",hereafter the original of the form is to be handed over to the driver of the ambulance immediately" ,he copy of the form should be kept in office file" /".B"9"%n case the &mbulance is out on duty$ the concerned employee of Superintendent/BPH #ill inform the same to the person and re7uest him/her to #ait up to a ma8imum of half an hour /".B"3",he concerned employee #ill immediately try to establish contact #ith the driver of the ambulance in the 5river)s mobile phone and pass on the necessary information" %f contact cannot be established #ith the ambulance #ithin /2 minutes$ the same should be informed to the personal caller so that the patient party can make alternate transportation arrangements /".B";" %n case of ambulance being available the concerned employee of RH/BPH #ill inform about its availability and details of user charges and mode of payment to the personal caller$ re7uesting for ambulance" /".B"<" %n case$ the patient is to be transported to any center other than the RH/BPH $ the concerned employee #ill intimate and obtain prior permission for the same from the Superintendent/B0OH/0O% and then pass on the necessary information to such center"

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".2. Pick0u and trans ortation of atient

".2A. If t*e ambulance is available at t*e #1$BP1C at t*e time of recei t of call$ ersonal caller /"1&"." Before movement$ the driver #ill check the status of fuel$ o8ygen cylinder and other necessary e7uipment as per the D heck Bist) provided to him (Annexure/SOP 1! /"1&"1" ,he driver / attendant #ill take #ith him the DRe7uest for &mbulance) and blank >0oney Receipt? form in duplicate (#one$ %eceipt form: Annexure/SOP &! /"1&"/" On reaching the pick-up point$ the driver #ill produce DRe7uest for &mbulance) form and get the same signed #ith the time of arrival for pick-up mentioned at the column provided$ by the patient)s relative" /"1&"9" ,he driver / attendant #ill also tell the patient)s family members to take #ith them the prescription of the 5octor and other important reports" /"1&"3" ,he driver and attendant #ill ensure safe shifting of the patient to the ambulance on a stretcher$ #herever re7uired$ #ith the help of the accompanying attendant and family members of the patient" /"1&";" Only t#o persons from the patient)s family #ill be allo#ed to accompany the patient in the ambulance" /"1&"<" ,he driver/attendant #ill ensure use of o8ygen cylinder/other life saving e7uipment by the patient$ if re7uired"

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".2B. In case t*e ambulance is not available at #1$BP1C during time of tele *one call $ ersonal caller /"1B"." %n case the ambulance is not posted at the RH/ BPH at the time of receipt of re7uest for ambulance$ the driver$ on receiving a call from the RH/BPH $ needs to go to the place of the patient directly from another location" /"1B"1" He #ill use a blank )Re7uest for &mbulance) form available #ith him and arrange to fill in all relevant details in the form /"1B"/" ,hereafter$ the procedures from /"1&"." to /"1&"<" as mentioned above #ill be follo#ed /"1B"9" ,he 5river shall obtain a post facto approval in the Superintendent/B0OH/0O% " all Record from the

".". %ro 0in of t*e atient at #1$BP1C or ot*er referral oint$*os ital
/"/"." ,he driver / attendant #ill take the relatives accompanying the patient to the 0edical Officer of RH/BPH Referral Hospital on duty for ne8t course of action /"/"1" ,he driver / attendant #ill then get the > Re7uest for &mbulance) form signed along #ith mention of D,ime of release) in the column provided by the family member of the patient$ collect user charges and hand over the properly filled money receipt" /"/"/" ,he driver #ill fill the >Bog Book? (Annexure/SOP "! kept in the &mbulance in the custody of the driver and be produced to the Superintendent/ B0OH/0O% #henever asked for" /"/"9" ,he driver #ill inform of his arrival to the receiver of re7uests for ambulance at the RH/BPH "

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".2. )rans ortation of Accident +mergenc! Patients ".2A. #e&uest 'or Ambulance (ervices Over )ele *one 'or )rans orting Accident +mergenc! Cases /"9&"." &n employee of RH/BPH authoriCed by Superintendent/B0OH #ill receive a phone call re7uesting ambulance services for transporting accident cases" /"9&"1 5etails of re7uest #ill be noted in the D all Record ) form (Annexure/SOP 2! in duplicate" lear directions for locations of the accident victims supported by landmarks #ill also be noted do#n" /"9&"/" ,he filled-in form should be signed by the RH/B0OH/0O% on duty before dispatch of the &mbulance" /"9&"9" ,hereafter$ the original of the form is to be handed over to the driver of the &mbulance immediately" & copy of the form should be kept in the office file" /"9&"3" %n case the patient is to be transported to any centre other than the RH/BPH $ the concerned employee #ill pass on the necessary information to such centre" /"9&";" %n case the &mbulance is out on duty$ at the time of the telephone call$ the same should be intimated to the telephone caller #ith a re7uest to make an alternative arrangement in case of an e8treme emergency" Ho#ever$ the caller #ould also be re7uested to call back after .2 minutes in case no alternative arrangement could be made by the caller for transportation of the patient"" %n bet#een$ contact #ould be established #ith the driver through phone and depending on the status$ necessary actions #ould be taken"

".2B. #e&uest 'or Ambulance (ervices B! A Personal Caller 'or )rans orting Accident +mergenc! Cases /"9B"." 5etails of re7uest #ill be noted in the D all Record) form (Annexure/SOP 2! in duplicate and the same should be signed by the personal caller" lear directions for locations of the accident victims supported by landmarks #ill also be noted do#n" /"9B"1" ,he filled-in form should be signed by the Superintendent/B0OH/0O% on duty before dispatch of the &mbulance" /"9B"/" ,hereafter$ the original of the form is to be handed over to the driver of the &mbulance immediately" & copy of the form should be kept in the office file" /"9B"9" %n case$ the patient/s are to be transported to any center other than the RH/BPH $ the concerned employee #ill pass on the necessary information to such center" /"9B"3" %n case the &mbulance is out on duty$ the same #ill be intimated to the personal caller" Ho#ever$ contact #ould be established #ith the driver through phone and depending on the status$ necessary actions #ould be taken"

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".3. Pick0u and trans ortation of in4ured atient$s

".3.A. If t*e ambulance is osted at t*e #1$BP1C at t*e time of recei t of tele *one call$ ersonal call /"3"&"." Before movement$ the driver #ill check the status of fuel$ o8ygen cylinder and other necessary e7uipment as per the D heck Bist) provided to him (c'ec( list details: Annexure/SOP )1!* /"3"&"1" ,he driver #ill take #ith him the D all Record) form" (Annexure/SOP 2! /"3"&"/" On reaching the pick-up point$ the driver #ill ensure safe shifting of the patient/s to the ambulance on a stretcher$ #herever re7uired$ #ith the help of the accompanying attendant" /"3"&"9" ,he driver/attendant #ill ensure use of o8ygen cylinder/other lifesaving e7uipment by the patients if re7uired"

".5. Pick0u and trans ortation of 1os itals$.ursing 1ome

atient$s from #esidence to Private

/";". ,he 5river shall obtain a post facto approval in the all Record 6orm from the Superintendent/B0OH #ho #ould approve such movement after being satisfied about the same"

".6 )rans ortation of atient$s to t*e Bordering (tates

/"<". %f the patients$ residing in the blocks closer to the bordering states$ prefer to be transported to some specific hospitals/nursing homes of those states for treatment$ such transportations #ill be allo#ed for the benefit of the patients #ith the prior intimation to the Superintendent/B0OH / 0O% "

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Section &: Code of Conduct

2.1. #oles7 #es onsibilities .GOs$CBO$)rust$etc:
2.1.1. Ambulance O erations a" ,he *+Os/ BO/,rust/etc" partner #ill e8clusively use the ambulance for carrying the emergency and referral patients #ithin the district and from the villages to the RH/BPH and to the Sub- 5ivisional/5istrict/,ertiary and nearest private sector hospital" b" ,he driver of the ambulance #ill obtain #ritten instruction for each movement of the ambulance from the Superintendent/B0OH or any other employees authoriCed by the Superintendent/B0OH/0O% in this regard c" ,he *+Os/ BO/,rust/etc partner #ill be responsible for providing ambulance services to patients #ho are in need of the same on a round the clock basis" d" %f re7uired by the condition of the patient$ the ambulance #ill pick up patients from their place of residence" e" %n case a patient does not #ish to use the services of a RH/BPH but #ishes to go directly to a higher end facility or a nearest private hospital$ the *+Os/ BO/,rust/etc" can transport such patients to their desired destination in consultation #ith the RH/B0OH/0O% to determine that there is no higher priority emergency case a#aiting transportation at the RH/BPH "%f during an emergency$ the patients are picked up from their residences and transported directly to the Private Hospitals/*ursing Homes$ the Superintendent/B0OH/0O% shall post facto approve such movements in the all Record after being satisfied about the same" f" ,he *+Os/ BO/,rust/etc #ill ensure that there are no lapses or negligence in providing such services to needy patients" g" ,he *+Os/ BO/,rust/etc #ill ensure that the vehicle >do#ntime? is not more than one day a month h" ,he *+Os/ BO/,rust/etc #ill abide by the Standard Operating Procedures for &mbulance Operations provided to them at the time of handing over of the vehicles" 2.1.2. Allo8ances ,he *+Os/ BO/,rust/etc #ill recruit and bear the allo#ances of the ambulance driver as #ell as the attendant"

&

Obligations

Of

)*e

O erating

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,he *+Os/ BO/,rust/etc #ill also bear all clerical e8penses incurred in relation to the ambulance operations and reporting re7uirements

2.1." Parking ,he *+Os/ BO/,rust/etc #ill park the ambulance in the RH/BPH compound" %n case of parking space not available in the RH/BPH $ the *+Os/ BO/,rust/etc can park the vehicle at a place arranged by it near the RH/BPH after obtaining permission from the Superintendent/B0OH/0O% " ,he *+Os/ BO/,rust/etc" can if re7uired construct a temporary shed #ithin the BPH / PH campus for parking of the vehicle" 2.1.2 9ovement #egister$:og Book ,he *+Os/ BO/,rust/etc #ill maintain a movement register/logbook$ (Annexure/SOP "! #hich #ill be kept and regularly updated by the driver of the ambulance$ indicating therein the distance covered and user charges realiCed from the patient or his/her representative" ,he logbook #ill be regularly checked and signed by the Superintendent/B0OH/0O% " 2.1.3 ;ser C*arges a" ,he *+Os/ BO/,rust/etc #ill be entitled to collect and retain user charges as per the rates fi8ed by the 5H6!S" ,hese charges can be used to meet e8penditures related to operation$ maintenance and management of the ambulance" 0oney Receipt (Annexure/SOP &! must be issued against receipt of user charges" b" %f t#o patients are transported at the same time to the referral centers$ the total user charges #ould be e7ually apportioned amongst the patients" c" *+Os/ BO/,rust/etc #ill not offer free services to any patient"

2.1.5 O eration Costs ,he *+Os/ BO/,rust/etc #ill bear all operation costs and e8penses for plying the vehicle including the cost of fuel$ lubricants$ spare parts and repairing$ regular servicing as #ell as the &0 " 2.1.6 #e orts ,he *+Os/ BO/,rust/etc #ill be responsible for preparing and submitting the necessary ambulance utiliCation reports (Annexure/SOP ) +! in prescribed 0onthly Report 6ormat and other relevant paper #ork to the Superintendent/B0OH/0O% and the BH6!S #ithin the stipulated time" opy of 0onthly Report needs to be submitted to the 0OH of the 5istrict and Special Secretary$ 5epartment of Health E 6amily !elfare$ S#asthya Bha#an$ 9th floor$ !ingB$ +*-1F$ Sec-G$ Bidhannagar$ Holkata A<222F.",he Superintendent/B0OH/0O% #ill

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provide information relating to point nos" .1-&$ .1-B$ ./-& and ./-B of the 0onthly Report" ,he *+Os/ BOs/,rusts/etc #ill be re7uired to ensure that all information are properly filled in the 0onthly Report and the report is sent to all concerned so as to reach by <th of every month" 2.1.< 1andover ,he *+Os/ BO/,rust/etc #ill handover the ambulance to 5H6!S >in good condition sub'ect to normal #ear and tear? in case of termination of the agreement or on e8piry of the agreement #ithout claiming any o#nership or right #hatsoever"

2.2. Code Of Conduct Of )*e Person #eceiving )*e Call

!ill be polite !ill listen attentively !ill be sympathetic !ill record all details as per format !ill give feedback and act as per feedback !ill not initiate dialogue not relevant to ambulance operations !ill give correct information regarding availability of ambulances !ill give correct information on user charges !ill be cordial #ith the driver and attendant !ill not use aggressive and abusive language !ill not shout or scold !ill note do#n full details and not take incomplete information

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2.". Code Of Conduct Of )*e %river$Attendant

!ill be cleanly dressed in uniform !ill be polite !ill be sympathetic !ill be punctual and on time !ill complete paper#ork !ill check all operational details of the ambulance every morning and before leaving for an assignment as per checklist (&nne8ure .) &t all times #ill drive the ambulance #ithin permissible speed limits" &t .2kms to 12 kms per hour in busy/cro#ded areas and /2 kms per hour in less cro#ded areas/intersections !ill not use the hooter indiscriminately" !ill use the hooter only #hile transporting patients" !ill not che# or smoke in front of patients and during transportation and inside the ambulance #hen the ambulance is not running" !ill not consume alcohol during duty hours or should not have consumed alcohol 9 hours prior to departure !ill not shout or use abusive language !ill not charge e8tra money from the relatives of the patients !ill not harass patients

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hecklist Driving and Vehicle Operations

Anne=ur$(OP01

Before driving any ambulance a driver must have the follo#ing documentation= urrent$ valid 5riving Bicense

> lean? 5riving Record from the 5epartment of 0otor Gehicles (*o Record of Reckless 5riving$ not more than t#o moving violations in the past one year)"

Vehicle
,e'icle documents re-uired: ertificate of Registration$ ertificate of Road !orthiness/6itness$

,a8 Receipt %nsurance ertificate Pollution ertificate

Operational Checklist 6uel Brake Oil +ear Oil oolant Bife saving e7uipment Stretcher in place Gehicle is clean Hooter is #orking 0oney Receipt Blank &mbulance Re7uest 6orm Battery for the 0obile Phone is fully charged"

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Anne=ure$(OP0 2 Re7uest for &mbulance 6orm/ all Record 5ate= Patient *ame= aller *ame= Relationship #ith Patient= &ge of Patient= &ddress= Place of Pick :p= (%ncluding clear directions) %mportant Bandmarks= 5estination= omplaint= Signature of all Receiver/5river= &uthoriCation by Superintendent/B0OH or his/her representative= Referral 5octor= Se8 of Patient= ,el/Person/Referred by B/PH = ,ime=

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Anne=ure$(OP0 " Sample of &mbulance Bogbook/&mbulance 0ovement Register 5ate Start kms" Patie Place nt)s of *ame Pick :p ,im e I%n Place of 5rop ,ime ,ime of Out Return to RH/BPH 4nd kms" Signature of the driver of the ambulance hecked E signed by Superinten dent/B0O H

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Anne=ure$(OP02

#one$ %eceipt
.ame of Patient: Se8= 5ate= Start kms= 5rop (kms)= ,otal 5istance ,ravelled (kms")= Rate Per Hilometre= &mount ollected in Rupees= Signature of recipient= Signature of Patient/Patient Party= &ge= ,ime= Pick :p (kms)=

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Anne=ure$(OP0 3
MO()*+, -.PO-) OF )*. (GOS FO- )*. AMB/+A(". S"*.M. /(0.- PPP ." *ame of the RH/BPH /PH = JJJJJJJJJJJJJJJJJ 1" 5istrict JJJJJJJJJJJJJJ /" *ame of the *+O= JJJJJJJJJJJJJJJJJJJJJJJJJ 3" Reporting 0onth= JJJJJJJJJJJJJJJJJJJJJJJJJ 9" Gehicle *o" JJJJJJJJJJJJJJJJJ ;" 5ate of Submission JJJJJJJJJJJ

/* TOTA0 .1#23% O4 PAT53.TS T%A.SPO%T36 61%5.G T73 #O.T7 / A* T$pe of patients transported &ccident emergency cases 5elivery related cases hild related cases Other 4mergency cases Others (specify) ) otal Patients / 2* 6etails of transportation Referred from RH/BPH /PH Residence to RH/ BPH /PH Residence to other govt" hospitals Residence to private hospitals Others (specify) )otal Patients
)otal Patients

/ C* Categor$ of patients transported BPB *O*-BPB

@-&) Opening Hilometer on the first day of the month @-B) losing kilometer on the last day of the month @- ) ,otal kilometer travelled during the month F-&) *umber of days the ambulance did not carry any patient F-B) Reasons= .2-&) *umber of times the ambulance used for some other purposes= .2-B) Reasons= .." Problems encountered / %mportant case studies/ +eneral comments=

Information under 120A7 120B7 1"0A and 1"0B to be rovided b! t*e (u erintendent$B9O1 .1-&) ,otal number of patients referred from the RH/BPH /PH (OP5K4mK%P5) during the month .1-B) *umber patients availed this (PPP) ambulance out of the total referrals from the RH/BPH /PH during the month ./-&) ,otal number of beneficiaries under the Referral ,ransport Scheme from the RH/BPH /PH during the month ./-B) *umber of the beneficiaries availed this (PPP) ambulance out of the total beneficiaries under the Referral ,ransport Scheme from the RH/BPH /PH during this month

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Full Signature and Designation of the Reporting Person of the N O with seal and date

Abbreviations:

2P7C 2748S 2#O7 2P0 C2O C#O7 6748S 6o748 Go82 #O5C .GO O.GOs P7C PO0 PPP P:t* %7 SOP

2loc( Primar$ 7ealt' Centre 2loc( 7ealt' and 4amil$ 8elfare Samiti 2loc( #edical Officer of 7ealt' 2elo9 Po:ert$ 0ine Communit$ 2ased Organisation C'ief #edical Officer of 7ealt' 6istrict 7ealt' and 4amil$ 8elfare Samiti 6epartment of 7ealt' and 4amil$ 9elfare Go:ernment of 8est 2engal #edical Officer 5n C'arge .on Go:ernmental Organisation Operating .GOs Primar$ 7ealt' Centre Petrol; Oil; 0ubricant Public Pri:ate Partners'ip Pri:ate %ural 7ospital Standard Operating Procedure