EMS SERVICE ZONE plan APPLICATION

Service Zone Name

Regional OFFICAL USE ONLY
Plan Date Received	Plan Reviewed	Plan Returned with Recommendations 	Recommended 
To OEMS	

oems OFFICAL USE ONLY
Plan Date Received	Reviewed By	Plan Approved	Plan Returned with Recommendations	Plan
Updated	

	MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
OFFICE OF EMERGENCY MEDICAL SERVICES
Service Zone Plan Application Template	

     		     	
Name of Local Jurisdiction(s)		Date	
Identify the local jurisdiction(s) in the service zone:	
     

	
	
I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury.	
Authorized Signature			     	
	Name		Title	
Location of Authorized Signatory	
     	
Street Address: Number, Name, Type, Unit # 	
     		  		     	—	    	
City/Town	State		Zip	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension	Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address	

	

Local Jurisdiction(s)’ Contact for Service Zone Plan	
     		  		     		     	
Name: First		MI		Last		Title	
     	
Street Address: Number, Name, Type, Unit # 	
     		  		     	—	    	
City/Town	State		Zip	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension	Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address	

Name of Person Completing Application	
     		  		     		     	
Name: First		MI	Last		Title	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension	Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address	

Person responsible for monitoring compliance of local jurisdiction(s) with the service zone plan:	
     		  		     		     	
Name: First		MI	Last		Title	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension	Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address	

Authorized Regional Council Signature		
Date	     			
     		  		     		     	
Print Name: First		MI		Last		Title	

EMS Region	1   	2   	3   	4   	5   	
	Western MA	Central MA	Northeast	Metro Boston	Southeast	

The chief municipal official of the local jurisdiction covered by the service zone plan must sign this application. If the service zone is comprised of multiple local jurisdictions, the chief municipal official of each local jurisdiction must sign this application.

I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury. 	
Authorized Signature		
     	
Local Jurisdiction	
     		  		     		     	
Print Name: First		MI		Last		Title	

I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury. 	
Authorized Signature		
     	
Local Jurisdiction	
     		  		     		     	
Print Name: First		MI		Last		Title	

I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury. 	
Authorized Signature		
     	
Local Jurisdiction	
     		  		     		     	
Print Name: First		MI		Last		Title	

I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury. 	
Authorized Signature		
     	
Local Jurisdiction	
     		  		     		     	
Print Name: First		MI		Last		Title	

I, the undersigned, attest that I am duly authorized to complete and sign this application, that I have read this application in its entirety and that the information contained herein is complete, accurate and true, Signed under the pains and penalties of perjury. 	
Authorized Signature		
     	
Local Jurisdiction	
     		  		     		     	
Print Name: First		MI		Last		Title	

Please copy this sheet if additional signatory pages are needed

Service Zone Planning Process

105 CMR 170.500 (B)(1)-(5): Local jurisdictions must develop service zone plans with input from the following entities, at a minimum: first responder agencies operating in the service zone; EFR agencies, if any; all ambulance services providing primary ambulance response pursuant to provider contracts in the service zone; all other ambulance services operating in the service zone; and health care facilities in the service zone, including hospitals and nursing homes. 
1)	Provide a short narrative explaining how the planning and designation process was conducted (Attach on separate document).
2)	On the following page, please complete the table indicating all parties that participated in the Service Zone Planning process.
 
					
Section	Category	Name of Entity	Contact Person Name
(First , MI, Last )	Contact Title	Contact Phone	
						
 	Example	City of Bridgeport Emergency Management     	David Jones	Emergency Mgmt. Coordinator	( 203 ) 123–4444 
Ext. 4965	
B (2) a	Elected state/local official	     	     	      	(   )    –    	
					Ext.      
	
B (2) b	Emergency management	     	     	      	(   )    –    	
					Ext.      
	
B (2) c	Law enforcement	     	     	      	(   )    –    	
					Ext.      
	
B (2) d	Designated primary ambulance service	     	     	      	(   )    –    	
					Ext.      
	
B (2) e	Other Ambulance Services Providing Primary Ambulance Service (e.g., primary Advanced Life Support (ALS); ambulance services with provider contracts)	     	     	      	(   )    –    	
					Ext.      
	
B (2) f	Other Ambulance Services Operating in 
the Service Zone				(   )    -     	
B (2) g	Designated EMS first response (EFR) service(s), if any	     	     	      		
					Ext.      
	
B (2) h	Other First Responder Agencies	     	     	      	(   )    –    	
					Ext.      
	
B (2) i	Hospital(s)	     	     	      	(   )    –    	
					Ext.      
	
B (2) j	Other health care facilities, including nursing homes	     	     	      	(   )    –    	
					Ext.      
	
	Other	     	     	     	(   )    –    	
					Ext.      

Service Zone Provider Selection Process and Local EMS Performance Standards

105 CMR 170.510 (B): Please describe the selection process the service zone has for selection and changing of EMS service delivery or designated service zone providers. This must be an open, fair, and inclusive process.

     

Local EMS Performance Standards

105 CMR 170.510(C): Local jurisdictions must set the following EMS performance standards in their service zone plan.  These are the criteria for the selection of service zone provider(s). Potential service zone providers must be evaluated on their ability to meet these local standards. Performance standards must meet minimum standards set forth in the EMS regulations, where applicable.  Standards include:

1)	response time
2)	staffing requirements
3)	deployment of resources
4)	adequate backup
5)	level of service and level of licensure of designated service zone providers
6)	medical control
7)	appropriate health care facility destinations
8)	any other EMS performance measure on which the local jurisdiction(s) wish to set standards and use as selection criteria for EMS providers

 On the following page, please indicate your service zone’s standards.
.

Section	Type of Provider	Standard Response Time 
(Minutes)	How is Response Time Measured?	Licensure Level(s)	
			Starting Point	Ending Point		
C (I) a	Designated primary ambulance service	     	     	     		BLS	
						ALS-Intermediate	
						ALS-Paramedic	
C (I) b	Other ambulance services providing primary ambulance service (e.g. Primary ALS)	     	     	     		BLS	
						ALS-Intermediate	
						ALS-Paramedic	
C (I) c	Ambulance services providing back up to primary ambulance service	     	     	     		BLS	
						ALS-Intermediate	
						ALS-Paramedic	
C (I) d	Designated EMS first response (EFR) service(s) if any	     	     	     		BLS	
						ALS-Intermediate	
						ALS-Paramedic	
C (I) e	Other first responder agencies	     	     	     			

Please indicate what service zone standards are in place for each designated service zone provider; designated primary ambulance service, ambulance services with provider contracts, and EFR(s).  Service zone standards must meet all applicable EMR regulatory standards.  Relevant regulatory citations are indicated, where applicable, at the end of each subsection heading.

A	Staffing Requirements (170.305)	
	     	
B	Deployment of Resources	
	     	
C	Adequate Backup (170.385)	
	     	
D	Medical Control [170.300, 170.330(C)]	
	[Medical control means the clinical oversight by a qualified physician to all components of the EMS system, including, without limitation, the Statewide Treatment Protocols, medical direction, training of and authorization to practice for EMS personnel, quality assurance and continuous quality improvement.]	
	     	
E	Health Care Facility Destinations	
	     	
F	Other EMS performance standards established by the service zone	
	Please indicate any other standards are in place for performance measures on which the local jurisdiction(s) wish to set standards and use as selection criteria for EMS providers:	
	     	

EMS and Public Safety Providers
 
105 CMR 170.510 (A): Inventory of resources available in the service zone.  Please complete the following table indicating all EMS providers in the service zone.

	Category	Name of EMS Service	Number of Vehicles	Hours of Operation
(HH:mm)	Contact Person Name
(First , MI, Last )	Contact Title	Contact Phone	
1	Designated primary ambulance service (can only be 1 per service zone)	          	     	        
to
     	     	     	(   )    	–     	
							Ext.      	
2	Other ambulance services providing primary ambulance service (e.g., primary ALS; ambulance services with provider contracts)	     	     	       
to
     	     	     	(   )    	–     	
							Ext.      	
3	Ambulance services providing backup to primary ambulance service	     	     	        
to
     	     	     	(   )    	–     	
							Ext.      
	
4	Other ambulance services operating in the service zone	     	     	       
to
     	     	     	(   )    	–     	
							Ext.      
	
5	Designated EFR service(s), if any	     	     	       
to
     	     	     	(   )    	–     	
							Ext.      
	
6	Other first responder agencies	     	     	        
to
     	     	     	(   )    	–     	
							Ext.      

Health Care Facility Resources / Facilities with Health Care Capabilities
 
105 CMR 170.510(A)(5): As part of the inventory of EMS-related resources, please complete the following table for all health care facilities or facilities with health care capabilities on site within the service zone. 
					
	Type of Facility	Name of Entity	Address/Location
(Street, City, State, Zip)	Hours of Operation 
or Event Date	Summary of Care Capabilities	24 Hour 
Emergency Phone	
E (1)	All hospitals in service zone	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (2)	All receiving hospitals	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (3)	Affiliate hospitals for primary ambulance service	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (4)	Designated specialty care hospitals (i.e., Department-designated trauma and stroke centers) receiving patients from service zone	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (5)	Nursing homes	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (6)	Assisted living centers	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (7)	Entertainment venues	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
E (8)	Special Events	     	     	     –     
or
     	     	(   )    	-    	
						Ext.      	
 (9)	Other	     

	     	     –     
or
     	     	(   )    	-    	
						Ext.      	

Inventory of Communications Systems

105 CMR 170.510(A)(8): As part of the inventory of EMS-related resources, local jurisdictions need to identify emergency medical dispatch and public safety answering points (PSAPs).

Section I: Primary PSAP Center (the main emergency call receiving center)
	
Name and Address
	
     	
Name of Primary PSAP Center	
     	
Street Address: Number, Name, Type, Unit # 	
     		  		     	—	    	
City/Town	State		Zip	
	
PSAP Operation by:	
	Fire		Police		Other	     	
	
PSAP Contact Information	
	
     		  		     		     	
Name: First		MI		Last				Title	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension		Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address					

	
Number of Dispatcher(s) or Call Takers per Shift	     		
Dispatchers Trained In EMD?		All		Some		None	
Name of EMD System In Use at Center	     	

Section II: Secondary PSAP Center, if any (an alternate answering point for emergency calls)
	
Name and Address
	
     	
Name of Secondary PSAP Center	
     	
Street Address: Number, Name, Type, Unit # 	
     		  		     	—	    	
City/Town	State		Zip	
	
Secondary PSAP Operation by:	
	Fire		Police		Other	     	
	
Secondary PSAP Contact Information	
	
     	  		     		     	
Name: First		MI		Last		Title	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension		Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address					

	
Number of Dispatcher(s) or Call Takers per Shift	     		
Dispatchers Trained In EMD?		All		Some		None	
Name of EMD System In Use at Center	     	

Section III: Alternate PSAP Center (the backup to the primary PSAP, in case it is not available)
	
Name and Address
	
     	
Name of Alternate PSAP Center	
     	
Street Address: Number, Name, Type, Unit # 	
     		  		     	—	    	
City/Town	State		Zip	
	
Alternate PSAP Operation by:	
	Fire		Police		Other	     	
	
Alternate PSAP Contact Information	
	
     		  	     		     	
Name: First		MI		Last		Title	
(     )	   	—	    	     		(     )	   	—	    	     	
Phone: Area Code, Number, Extension		Fax: Area Code, Number, Extension	
     	@	     	
Primary Email Address					

	
Number of Dispatcher(s) or Call Takers per Shift	     		
Dispatchers Trained In EMD?		All		Some		None	
Name of EMD System In Use at Center	     	

Medical Control Plan
 
105 CMR 170.510 (G): Local jurisdiction(s) need to include a plan for medical control*. At a minimum, this will consist of tracking current affiliation agreements, consistent with 105 CMR 170.300 for each ALS level EMS service providing primary ambulance response or EFR response (if any) operating in the service zone. If there are services operating in the service zone at the BLS level only, the service zone may want to track memoranda of agreement with hospitals for medication administration oversight as well. 

On the following page, please list each affiliate hospital(s) and medical director(s) who has authority over the clinical and patient care aspect of the affiliated EMS service. 
 

*Medical control means the clinical oversight by a qualified physician to all components of the EMS system, including, without limitation, the Statewide Treatment Protocols, medical direction, training of and authorization to practice for EMS personnel, quality assurance and continuous quality improvement.

	Name of Provider	Name of Affiliate Hospital Providing Medical Control in the Service Zone	Name of Affiliate Hospital Medical Director	Contact Phone	
1	     	     	      	(   )    	-     	
				Ext.      	
2	     	     	     	(   )    	-     	
				Ext.      	
3	     	     	     	(   )    	-     	
				Ext.      	
4	     	     	     	(   )    	-     	
				Ext.      	
6	     	     	     	(   )    	-     	
				Ext.      	
7	     	     	     	(   )    	-     	
				Ext.      	
8	     	     	     	(   )    	-     	
				Ext.      	
9	     	     	     	(   )    	-     	
				Ext.      	
10	     	     	     	(   )    	-     	
				Ext.      	

Operational Plan for EMS Response
 
105 CMR 170.510 (H): Please explain your operational plan for coordinating the use of all EMS resources
•	Primary ambulance service 
•	Designated EMS first response (EFR) services, if any 
•	First responder agencies Ambulance services with private provider contracts 
•	Primary ALS service, if any -- in the service zone 

This can be done by diagram or text or both. 

The operational plan must:
a)	Explain how all EMS resources are to be used, and 
b)	How the service zone shall ensure the response of the closest appropriate available EMS resources. 

Pursuant to 170.510, the Operational Plan may not include criteria for notification and dispatch of a designated EFR service to health care facilities licensed by the Department: 

a)	Where there is a licensed health care professional 24 hours per day, seven days per week, 

AND
 
b)	Where there is a provider contract in place to provide primary ambulance response.

 Diagram attached

Enter operational plan on following page(s):

     

Procedures for Delivery of Trip Records and Unprotected Exposure Forms
 
105 CMR 170.510 (J): Explain the procedures the service zone will require for coordinate getting required EMS call documentation – Trip records and, when applicable, unprotected exposure forms – to receiving health care facilities. 
 
Under 105 CMR 170.345(C) of the EMS regulations, EMTs who transport the patient to the hospital deliver the trip record and any unprotected exposure forms directly to the hospital with the patient or as soon as practicable thereafter. 

However, those EMS personnel who are at the scene but do not transport the patients still need to prepare trip records and, when the circumstances apply, unprotected exposure form(s), and get these to the hospital timely. 

How they do that – how submission of all EMS responders’ paperwork to the receiving hospital gets coordinated – is in accordance with procedures set out in the service zone plan.

NOTES:
1)	Please submit with this application, the service zone agreements, if any, for ambulance services with provider contracts that include providing primary ambulance response in the service zone. Under the regulations, 105 CMR 170.249, the local jurisdiction(s) must ensure that service zone agreements are signed between the designated primary ambulance service for the service zone, and any ambulance service providing primary ambulance response in the service zone pursuant to a provider contract.

2)	Please remember that once this application has been completed, you must submit it to your EMS regional council for evaluation.  A contact list for EMS regional councils is found on our website at www.mass.gov/dph/oems/region/region.htm.You will find there a map of the Commonwealth, divided by regions, as well as contact information for each of the regional directors.

3)	If the service zone has an existing plan that satisfies the information requested in this section regarding how EMS is provided in the service zone, please attach to this application.

For updates on this application, please login to the OEMS website at www.state.ma.us/dph/oems.

 Ambulance service zone agreements attached.

 Existing plan attached.

Enter procedures on following page(s):

NOTES:

1.	Please submit with this application, the service zone agreements, if any, for ambulance services with provider contracts that include providing primary ambulance response in the service zone. Under the regulations, 105 CMR 170.249, the local jurisdiction(s) must ensure that service zone agreements are signed between the designated primary ambulance service for the service zone, and any ambulance service providing primary ambulance response in the service zone pursuant to a provider contract.

2.	Please remember that once this application has been completed, you must submit it to your EMS regional council for evaluation.  A contact list for EMS regional councils is found on our website at www.mass.gov/dph/oems/region/region.htm.You will find there a map of the Commonwealth, divided by regions, as well as contact information for each of the regional directors.

3.	If the service zone has an existing plan that satisfies the information requested in this section regarding how EMS is provided in the service zone, please attach to this application.

For updates on this application, please login to the OEMS website at: http://www.state.ma.us/dph/oems.