Paramedic training Checklist

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=80 BGCOLOR="#CCFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Roscommon Township</B></FONT><FONT SIZE="2" COLOR="#000000" FACE="Times New Roman" ><B>  </B><B>|</B><B>  </B></FONT><B>  </B> <A HREF="index.htm" TARGET="_top" TITLE="Roscommon Township">home</A>      <A HREF="id28.htm" TARGET="_top" TITLE="Ambulance">Ambulance</A>     <A HREF="houghton_lake_employee_handb.htm" TARGET="_top" TITLE="Employee Handbook">Employee Handbook</A> </div> <bR> <bR> <bR> <bR> <div> </div> </td> </tr><tr> <td valign="top" height=400 style=" border-top: 5px solid #66FFFF;" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Paramedic training Checklist</I></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="642" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 ><NOBR><div> Protocol/Equipment/Medication</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> Phase 1</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> Phase 2</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="267" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="166"><div> Introduction</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> Proven Proficiency</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="267" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="166"><div> Trainer/Trainee</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> Trainer/Trainee</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="267" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B><U>Equipment</U></B></div> </tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> LifePak 12</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -12 lead</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Defibrillator</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Pacemaker</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Capnography</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Menus/archives</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> IV pump</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Full set/Half set</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Medication Calculator</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Vent tubing</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> IV equipment</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -IV catheters, drip sets</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -IO Needles</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Intubation equipment</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Technique</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Confirmation devices</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Combitube</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Cricothyrotomy Kit</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Needle Cric/decompression Kit</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pediatric Broslow Bag</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Broslow tape/Pedi wheel</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Obstetric Kit</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div>     -Meconium aspirator</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B><U>Medications</U></B></div> </tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Adenosine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Albuterol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Amiodarone</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Aspirin</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Atropine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Calcium Chloride</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Dextrose 50%</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Diazepam</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Diphenhydramine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Dopamine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Duoneb</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Epinephrine 1:1000</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Epinephrine 1:10000</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Epipen</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Furosemide</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Glucagon</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Glucose (oral)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Lidocaine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Lidocaine infusion</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Magnesium Sulfate</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Meperidine</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Methylprednisolone</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Midazolam</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Morphine Sulfate</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Naloxone</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Nitroglycerine SL</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Nitroglycerine Infusion</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Sodium Bicarbonate</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Vasopressin</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Zofran</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B><U>Documentation</U></B></div> </tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Patient Run Reports</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Non-Transports</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> 3200 Forms</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Required reporting situations</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> PSRO requirements</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Billing requirements</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B><U>Protocols</U></B></div> </tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Airway</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Airway/oxygenation</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Allergic Rxn/Anaphylaxis</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Cricothyrotomy Procedure</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Epipen Procedure</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Nebulizer Rx protocol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Obstructed airway</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pleural decompression</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Respiratory distress protocol</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Cardiovascular</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Advanced medical directives</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Arrest/General management</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Bradycardia/Heartblock</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Cva/Stroke</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Chest Pain Protocol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> IV Nitroglycerine procedure</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> DNR policy</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Electrical Therapy Procedure</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pulseless arrest Protocol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Tachycardia with pulse</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Termination of resuscitation</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Vagal Maneuvers</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>General Medical</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Abdominal problems</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Acute Altered mental status</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> General weakness</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Hemorrhage (non-trauma)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Hypertensive emergency</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Obstetrical emergencies</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pain Management</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Patient Sedation</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Poisoning/Overdose</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Psychiatric</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Physical Pt restraint</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Seizures</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Sexual assault</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Shock</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Syncope</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Environmental</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Burns</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Drowning/Near Drowning</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Environmental Hyperthermia</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Hypothermia/Frostbite</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Trauma</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Assessment/Stabilization Protocol</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Chest injury</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Head injury</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Helmet removal</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Shock</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Soft tissue/orthopedics injuries</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Spinal immobilization</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Spinal injury protocol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Fluid and medications</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Additional procedures and medications</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Medication administration protocol</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Vascular access protocol</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Pediatrics</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> General pediatric assessment and Rx</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Altered mental status (peds)</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Anaphylaxis/allergic rxn (peds</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Bradycardia (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Bronchospasm (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Burns (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Death of a child</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Foreign body airway obstruction (peds)</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Near Drowning (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Newborn resuscitation </div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Non-traumatic cardiac arrest</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Pediatric non-traumatic shock</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pain management (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="267"><div> Respiratory distress/failure or arrest (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Seizures (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Tachycardia (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Toxic exposure (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Trauma (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Pulseless arrest (peds)</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><div> <B>Special circumstances</B></div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> Abuse and neglect (suspected) 3200</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Contaminated patient</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Dead on Scene</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Infection control</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Mass Casualty policy</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Physician on scene</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Protocol deviation procedure</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="267"><div> Refusal of care</div> </tD> <tD VALIGN=TOP WIDTH="166"><div> _____/_____</div> </tD> <tD VALIGN=TOP WIDTH="199"><div> _____/_____</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="267"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="267" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="166"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="166" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="199"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="199" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> </td> </tr></table></body>