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2. Organizational Information
4. Name of Organization*
6. Mailing Address*
8. General Organization Email (If Applicable)*

   Only fill out if the team has a designated email address. Emails for contact filling out this form are requested below.

10. Areas Served*

    Cities, Townships, Etc.

12. Audit Contact Name*
14. Audit Contact Title*
15. Audit Contact Phone Number*
16. Audit Contact Email Address*
20. Medical Director Information
22. Medical Director Name*
23. Medical Director Phone Number*
24. Medical Director Email Address*
26. Acknowledgement of Medical Director Approval *

    Check box below in acknowledgement of Medical Director Approval of team's By-Laws/Constitution, SOP, Blood Borne Pathogen Plan, other documents as necessary

    1. I acknowledge that the team Medical Director has approved of necessary documents
28. Date of Last Approval by Medical Director*
    Date of Last Approval by Medical Director

    Annual approval required of By-Laws/Constitution, SOP, Blood Borne Pathogen Plan, other documents team deems necessary.

32. Communication System Information
34. What system(s) of communication does your team utilize? *

    Check all that apply.

    1. 800 MHz Radios
    2. Active 911
    3. Pagers
    4. Other
35. If Other, please describe*
39. Equipment Information
41. Please list all specialized equipment team members carry or that team has access to.*
45. By-Laws or Constitution
47. Date of Last Review*
    Date of Last Review

    Annual review required. 

49. By-Laws or Constitution Upload*

    Upload a copy of team By-Laws or Constitution here.

53. Standard Operating Procedure
55. Date of Last Review*
    Date of Last Review

    Annual review required. 

57. Standard Operating Procedure Upload*

    Upload a copy of team Standard Operating Procedure here.

61. Blood Borne Pathogen Plan
63. Date of Last Review*
    Date of Last Review

    Annual review required. 

65. Blood Borne Pathogen Plan Upload*

    Upload a copy of team Blood Borne Pathogen Plan here.

69. Other Plans or Protocols

    A place to assess and upload all other plans or protocols that don't fit in categories above if deemed required by team

71. Date of Last Review
    Date of Last Review
73. Other Plans or Protocols Upload
77. Training Documentation
79. Member List Upload*

    Upload a copy of team Member List here. Can use roster form used for annual applications or other document team uses to track members. 

81. Member Certification Acknowledgement*

    By checking this box, you are acknowledging that all team members have required training and certifications 

    1. I acknowledge that all team members have appropriate training and certifications
83. Proof of Member Certification

    Upload copies of team member's certifications here.

85. In-Service Documentation*

    By checking this box, you are acknowledging that in-service training has been offered to all members

    1. I acknowledge the team has completed in-service trainings
87. In-Service Training Documentation*

    Upload a list of in-service trainings the team has completed since last audit here.

91. Acknowledgement of Completion*

    By checking the box below you are acknowledging that all above information has been completed to the best of your abilities and with the understanding that if sections are not up-to-date there will be a requirement to complete within 1 month of submission. 

    1. I acknowledge that all above information has been completed to the best of my abilities and with the understanding that if sections are not up-to-date there will be a requirement to complete within 1 month of submission
93. Type Signature Below*
97. Follow Up

    After this form is submitted County Staff will review and follow up in one of two ways:

    1. Form and uploads are complete and up-to-date and no action is needed. County Staff will send by email a signed copy of Audit for your records.

    2. Form and uploads are incomplete or out of date and action is needed. County staff will send by an outline of action steps needed and required date of completion. At that time you may schedule a time to meet with County Staff if additional assistance or clarification is needed.

Leave This Blank:


101. 1. Receive an email copy of this form.
102. Email address

     This field is not part of the form submission.

103. Submit

* indicates a required field