JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
WYRESTRAIN Initial Questionaire
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Please provide the name of the Service
*
Your answer
Please provide the name of the Service Director
*
Your answer
Please provide the service director's preferred EMAIL
*
Your answer
Please provide the name of the Service Medical Director
*
Your answer
Please provide the service Medical Director's preferred EMAIL
*
Your answer
Have you reviewed the NHTSA Document "Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances" ?
*
YES
NO
Do you intend to adopt the WYRESTRAIN Guidelines into your protocol?
*
There will be a document to sign in the near future by the service director and the PMD.
Yes
No
I need more information
Would you be willing to host training for this project?
*
Yes
No
Maybe
My service will participate in the training provided by the Wyoming EMSC Program.
*
Yes
No
Do you currently have any equipment needs to be able to implement the WYRESTRAIN Guidelines?
*
Yes
No
If Yes to above, please describe your needs here.
Your answer
How many front line ambulances do you have? (Please do not include back-up units in this count. We need to establish how many trucks that are in-service and ready to respond to pick up a pediatric patient without having to move equipment between vehicles.)
*
Your answer
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s). Please put MS # in the other block at the end of the check-list.
Unit 1 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 2 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 3 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 4 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 5 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 6 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 7 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 8 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 9 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Please Check all pediatric equipment you currently have on your FRONT-LINE Ambulance(s)
Unit 10 Please put MS # in the other block at the end of the check-list.
Ferno Pedi-Mate
Safeguard Transport System
Integrated child seat in a Captains Chair that can be forward facing
Integrated Child seat in a Rear facing Captains Chair only
Front passenger air-bags that can be turned off
Inflatable Car seat
Quantum ACR
Rigid Car seat (the kind you would use in a car)
Some other pediatric restraint device (DO NOT INCLUDE: LSB, Papoose, etc)
Other:
Would someone at your service be willing to become a trainer for WYRESTRAIN?
*
Yes
No
I will get back to you on that!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of Wyoming.
Report Abuse
Forms
