Loading...
HomeMy WebLinkAbout065278 - General - Contract - City of Haltom CityCity Secretary Contract No. 65278 CITY OF FORT WORTH AND CITY OF HALTOM CITY FIRST RESPONDER AND PROVIDER AGREEMENT This First Responder and Provider Agreement ("Agreement") is made between the City of Fort Worth ("Provider") and the City of Haltom City ("FRO"), both units of local government organized under the laws of the State of Texas. Provider and FRO may be referred to individually as a "Party," and collectively as the "Parties" in this Agreement. WHEREAS, the relationship between the Provider and FRO is established by the EMS Interlocal Agreement, executed by the Parties; WHEREAS, FRO, Provider, and each jurisdiction that receives EMS System services from Provider, adopted a Uniform EMS Ordinance that obligates each jurisdiction to comply with the terms of their respective EMS Interlocal Agreements and to operate under the direction of Provider's Medical Director and the department of the Office of the Medical Director ("OMD"); WHEREAS, FRO, and other jurisdictions that receive EMS System services from Provider, and as required by its EMS Interlocal Agreement, must establish, operate, and fund a First Responder Program, as contemplated by Texas Administrative Code (TAC) 157.14, within their respective jurisdictions; WHEREAS, Provider, by and through its Medical Director and OMD, publishes protocols, procedures, and policies in documents entitled the Fort Worth Regional EMS System Out -of -Hospital & Mobile Integrated Healthcare Protocols ("OMD Protocols"); WHEREAS, Provider and its Medical Director are responsible for, among other things, credentialing and re-credentialing of personnel, establishing minimum equipment and medication requirements for first responder vehicles, and monitoring the quality of patient care provided within Provider's EMS System; and WHEREAS, Provider and FRO desire to formalize an agreement to comply with Texas Administrative Code § 157.14, entitled "Requirements for First Responder Organization License_" NOW THEREFORE, known by all these present, Provider and FRO, acting herein by and through their duty authorized representatives, agree to the following terms: I. LEVEL OF CERTIFICATION 1.1 Provider recognizes FRO as a ❑ Basic Life Support / ® Advanced Life Support First Responder Organization. As such, FRO is to meet all requirements listed in the OMD Protocols associated with the designated level of support. First Responder and Provider Agreement Page 1 of 9 OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX 1.2 When deemed necessary by Provider personnel to aid with patient care at a scene or during patient transport, any of FRO's members or employees who are credentialed by OMD may provide care within their credentialed scope. In such cases, equipment, supplies, and medications from a Provider ambulance may be used as needed. 1.3 FRO shall ensure it maintains compliance with Texas Administrative Code § 157.14(e), including, but not limited to its obligations relating to medical oversight, staffing, reeordkeeping, infection control, data reporting, vehicle condition, and other responsibilities required for licensure as a First Responder Organization. FRO further agrees to cooperate with Provider and the Medical Director to the extent necessary to ensure such compliance. 1.4 The above notwithstanding, Provider acknowledges that the Texas Department of State Health Services (DSHS) recognizes the Emergency Care Attendant (ECA) as a certified level of EMS provider under Texas law. The ECA level is not a credentialed level under the OMD protocols and, therefore, ECAs are not subject to medical director eredentialing requirements applicable to credentialed positions. ECAs may, however, provide services consistent with their DSHS certification level and within the scope of Basic Life Support (BLS) functions as defined by state law and DSHS. FRO ECAs operating under this Agreement may receive appropriate training as determined by Provider but such training shall not constitute or imply credentialing under the Medical Director's protocols. Nothing in this Agreement shall be construed to expand or restrict the statutory or regulatory scope of practice of ECAs under state law, nor to require the Medical Director to credential or supervise ECAs beyond that scope. II. PROTOCOLS AND MEDICAL EQUIPMENT 2.1 FRO is required to adhere to the OMD Protocols, attached hereto as Exhibit "A." 2.2 FRO must equip first response apparatus with the approved supplies, medications and equipment as referenced in the OMD Protocols consistent with FRO's level of care. A minimum equipment and medication list is provided in the attached Exhibit `B." III. FRO OPERATION 3.1 FRO must provide EMS first responder EMS System services twenty-four (24) hours per day and seven (7) days per week. 3.2 In the event that such EMS System services are interrupted, FRO must notify Provider and the Medical Director as soon as possible. IV. PATIENT CARE REPORTING 4.1 Provider and FRO recognize documentation of patient care is essential for effective communication and continuity of care. FRO must adopt or develop a method by which patient care provided prior to Provider's arrival can be documented and shared with Provider before the patient is transported. Such documentation method must be submitted to Provider and the Medical Director for approval. First Responder and Provider Agreement Page 2 of 9 4.2 Exhibit "C," attached hereto, contains a copy of the FRO Patient Care Report that has been approved by the Medical Director. It is agreed that the original copy (Copy 1) will be retained by FRO and the second copy (Copy 2) will be given to Provider before the patient is transported to the hospital unless Electronic Patient Care Reports (EPCR) are utilized. If approved by the Medical Director, EPCRs may be used in place of paper copies. EPCRs shall be compliant with Chapter 157.14 of the TAC. V. CERTIFICATION OF FRO PERSONNEL WHO RENDER PATIENT CARE 5.1 The Medical Director has established a process requiring personnel to be credentialed to provide patient care within the Provider's EMS System. FRO personnel must meet and maintain the OMD requirements of credentialing. The Medical Director and Provider require ongoing testing of personnel within the EMS System. VI. ASSESSMENT OF CARE PROVIDED BY FRO 6.1 The OMD will assess care provided by the FRO based on factors including but not limited to: a. Contribution to the development and alignment of clinical quality goals and strategies within the EMS System; b. Access to relevant clinical data supporting quality assurance, performance measurement, and improvement initiatives within the EMS System; c. Ensuring documentation supports the accurate measurement of clinical quality goals based on nationally endorsed clinical quality measures and benchmarks; d. Engagement in identified quality improvement initiatives, including the development, testing, and implementation of changes aimed at improving clinical performance; e. Compliance and participation with the OMD Quality Assurance Policy, including clinical case reviews, implementation of clinical restrictions if necessary, and Clinical Improvement Plans ("CIPs") to address any identified performance gaps or deficiencies; and f. Participation in clinical registries and research initiatives as guided by the OMD, supporting studies aimed at improving patient care and clinical outcomes within the EMS System. VII. FRO RESPONSE CODE POLICIES 7.1 FRO agrees to respond to requests for service when deemed necessary by the Provider's Emergency Medical Dispatch protocols and policies approved by the Medical Director. 7.2 FRO may adopt other response policies that may be necessary to assure the safety and wellbeing of their personnel and community. When such additional policies affect responses to high -acuity medical situations, approval from the Medical Director is required. First Responder and Provider Agreement Page 3 of 9 VIII. ON -SCENE CHAIN OF COMMAND POLICIES 8.1 In addition to FRO's standard operating procedures related to the chain of command, FRO must recognize the Provider's EMS Supervisor as the highest ranking medically trained EMS person on scene. 8.2 FRO shall comply with the OMD Protocols, including training of supervisory personnel. While FRO may be responsible for incident command, the Provider is responsible for patient care and transport decisions in accordance with the OMD Protocols. IX. MISCELLANEOUS 9.1 Cancellation of Ambulances. FRO may cancel ambulance responses in accordance with the OMD Protocols. 9.2 First Responder Personnel Accompanying Patients on Ambulances. When deemed necessary by Provider and FRO, FRO and Provider agree to allow at least one OMD credentialed person to assist with patient care on -board an ambulance during transport. 9.3 First Responder Personnel Driving or Operating Provider's Vehicles. When deemed necessary by Provider and FRO, FRO personnel, that are appropriately framed in the operation and usage of Provider's vehicles, are authorized to drive and/or operate Provider's vehicles in situations deemed necessary to care for a patient or to secure the Provider's vehicle(s). (Example: from time -to -time, it may be necessary for the FRO to drive the Provider's vehicle to a fire station, or another appropriate facility, to secure it until Provider can reclaim.) Provider shall maintain adequate insurance coverage for such vehicles whether by separate policy or self -insured status. Provider agrees that in the event FRO operates and/or drives Provider's vehicle for this limited purpose, FRO shall be an authorized operator of the vehicle for insurance purposes. FRO, and its personnel, are not authorized to operate or drive Provider's vehicle for any deviation or detour from the purpose specified herein. 9.4 Confidentiality. FRO agrees to comply with all relevant confidentiality laws of the State of Texas and the Health Insurance Portability and Accountability Act of 1996. 9.5 Business Associate Agreement. FRO must execute a separate Business Associate Agreement ("BAA") in the form, or substantial form, of the BAA attached hereto as Exhibit "D." 9.6 Ori ig.nal Agreement Unaltered. This Agreement is intended to supplement the existing Emergency Medical Services Interlocal Agreement ("ILA") between the Parties. The terms and conditions of the ILA shall remain the same, in full force and effect, and are not altered by the execution of this Agreement. [Signature Page Follows] First Responder and Provider Agreement Page 4 of 9 ACCEPTED AND AGREED: PROVIDER: j By: ZjL' Name: William Johnson i Title: Assistant City Manager Date: 05/31 /2026 APPROVAL RECOMMENDED: By: 1 Name: Raymond Hill Title: Interim Fire Chief CONTRACT COMPLIANCE MANAGER: By signing I acknowledge that I am the person responsible for the monitoring and administration of this Agreement, including ensuring all performance and reporting requirements. I By: 4�� Name: Ryan Zelazny Title: Fire Deputy Chief -Operations II Date: 05/27/2026 Date: 05/27/2026 I o�aoan FORt Dd ATTEST: p>APPROVED AS TO FORM o_o 1 LEGALITY: W. C WBy: I I By: Name: Jannette Goodall I Name: Taylor Paris Title: City Secretary Title: Assistant City Attorney Date: 06/01 /2026 Date: 05/30/2026 FRO: By: Name: Rex Phelps Title: City Manager Date: /-7-26 AS TO FORM AND LEGALITY: By: W Ica(— Name: Wayne Olson Title: City Attorney Date: 1- 7 - 24 First Responder and Provider Agreement Page 5 of 9 OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX EXHIBIT "A" OMD PROTOCOLS Page 6 of 9 First Responder and Provider Agreement EXHIBIT "B" MINIMUM EQUIPMENT AND MEDICATION LIST First Responder and Provider Agreement Page 7 of 9 FORT WORTH® Office of the Medical Director Basic First Responder Minimum Equipment and Medication List Oxygen Accessories Qty Medication Delivery Items Qty 02 - Cylinder with Regulator (>700 psi) 1 Syringe 1 ml 2 02 - Key 1 Blunt Needle 2 Airway & Oxygen Delivery Hyperdermic Needle 1 1/2" (21g or 25g or 27g) 2 Oral Airway - (50 / 60 / 80 / 90 / 100 / 110) 1 ca Nasal Atomizer Device 2 Nasal Airway - (22 / 24 / 26 / 28 / 30) 1 ea Nebulizer 1 Water-Soluable Lubricant 2 Manual Vital Sign Tools Qry Bag Valve Mask - Adult / Pedi / Infant 1 ea BP Cuff Adult / Pedi / Infant 1 ea Neonate Size 0 BVM mask 1 BP Cuff Thigh or Adult XL 1 Nasal Cannula - Adult 1 Stethoscope 1 Non-Rebreather - Adult 1 Glucometer 1 Non-Rebreather - Pedi 1 Glucometer Test Strips 3 BiPap System 1 Disposable Lancets 3 Airway E to ment (Optional) Qty Sharps Shuttle 1 AirQ-SP-3g supraglottic airway - Neonate through Adult Sizes 1 ea Alcohol Preps 10 ETCO2 Nasal* 1 Thermometer 1 ETCO2 In -line* 1 Pedi - Len th/A e-based Resuscitation Tape 1 Suction & Accessories Qty Electrical Therapy Qry Suction - Portable w/Canister & Lid 1 AED 1 Suction - Rigid Tip 1 Quick Combo Pads Adult/Pedi I ea Suction - Tubing 1 PPE / Cleaning / Biohazard Qry Suction - Cath 5 / 14 / 18 Fr 1 ea Hand Sanitizer 1 bottle Suction- Gastric Sump Tube 10 & 16 Fr 1 ea Medical Exam Gloves 1 Box Hemmorhage Control / Bandaging / Splinting ry Gown 3 Bandaids 5 Goggles/Face Shield 3 Burn Sheet 2 Masks 3 Multi Trauma Dressing 1 Safety Vest 2 Roller Gauze 2 EMS Scissors 1 Sterile 5X9 Gauze Pad 4 Penlight 1 Sterile 4X4 Gauze Pad 4 Ringcuttcr 1 Occlusive Dressing 2 Bio Hazard Bags 2 Triangular Bandages 4 MCI Qty Ridged Splints 2 Triagc Tape / Tags 25 Pelvic Fracture Sling 1 Monitoring Equipment 1" Tape 1 *Waveform Capnography Device - must be available if carrying optional airway equipment 1 2" Tape I FRO - Basic Medication List Qty Saline or Sterile Water for Irrigation 1 Acetaminophen 500 mg Tablets (may substitute liquid) 2 Hot Pack 4 Acetaminophen Liquid 160mg / 5mL 35m1 Cold Pack 4 Aspirin 81 mg Tablets 4 Commercial Windless Tourniquet 1 DuoNeb Albuterol 2.5mg/ipratropium 500mcg** 3 Hemostatic Dressing / Packing 2 Epinephrine 1:1000 1mg / lml*** 3 Traction Splint (optional) 1 Ibuprofen 200 mg Tablets (may substitue liquid) 3 Pedi Immobilizer (optional) 1 Ibuprofen Liquid 100mg / 5mL 30 mL Immobilization / Patient Movement Qty Isopropyl Alcohol Pads 3 Backboard w/ 3 straps (optional) 1 Naloxone 2 mg / 2 ml 2 Extrication Device w/Straps & Pads 1 Nitroglycerin 0.4 mg SL Spray or Tablet 1 btl C-Collars - Adult & Pedi 1 ea Odansentron 4 mg ODT 2 Head Immobilizer (optional) 1 Oral glucose 15 g 1 Obstetrics/Labor & Deliver Items Qty ** If not carrying DuoNeb: OB - Kit I Albuterol 2.5 mg / 3 ml 3 OB - Suction Bulb 1 Ipratropium 500 mcg / 3 ml 3 OB - Foil Blanket 1 ***If not carrying Epi 1:1000 Effective: 07/01/2025 jEpi Pen Adult and Pediactric 1 ea 7c-1 L. Jarvis, MD, MS, E T P, System Medical Director / Chief Medical Officer Fort Worth Office of the Medical Director 2900 Alta Mere Dr. Fort Worth, TX 76116 FORT WORTH® Office of the Medical Director ECA First Responder Minimum Equipment and Medication List Oxygen Accessories Qty Medication Delivery Items Qty 02 - Cylinder with Regulator (>700 psi) 1 Syringe I ml 2 02 - Key 1 Blunt Needle 2 Airway & Oxygen Delivery Qty Hyperdcrmic Needle 1 1/2" (21g or 25g or 27g) 2 Oral Airway - (50 / 60 / 80 / 90 / 100 / 110) 1 ca Manual Vital Sign Tools Qry Nasal Airway - (22 / 24 / 26 / 28 / 30) 1 ca BP Cuff Adult / Pcdi / Infant 1 ca Water-Soluable Lubricant 2 BP Cuff Thigh or Adult XL 1 Bag Valve Mask - Adult / Pcdi / Infant 1 ca Stethoscope 1 Neonate Size 0 BVM mask 1 Glucometer 1 Nasal Cannula - Adult 1 Glucomctcr Test Strips 3 Non-Rebrcathcr - Adult 1 Disposable Lancets 3 Non-Rebrcathcr - Pedi 1 Sharps Shuttle 1 Suction & Accessories Qry Alcohol Preps 6 V-vac manual suction 1 Thermometer 1 Hernmofhage Control / Bandaging/ Splinting Electrical Therapy Qty Bandaids 5 AED 1 Burn Sheet 2 Quick Combo Pads Adult/Pedi 1 ca Multi Trauma Dressing 1 Personal Protective Equipment / Cleaning / Biohazard Qry Roller Gauze 2 Hand Sanitizcr 1 bottle Sterile 5X9 Gauze Pad 4 Medical Exam Gloves 1 Box Sterile 4X4 Gauze Pad 4 Gown 3 Occlusive Dressing 2 Goggles/Face Shield 3 Triangular Bandages 4 Masks 3 SAM Splints 2 Safety Vest 2 Pelvic Fracture Sling 1 EMS Scissors 1 1" Tape 1 Penlight 1 2" Tape 1 Ringcutter 1 Saline or Sterile Water for Irrigation 1 Bio Hazard Bags 2 Cold Pack 4 FRO - ECA Medication List Qty Commercial Windless Tourniquet 1 Aspirin 81 mg Tablets 4 Hemostatic Dressing / Packing 2 Epinephrine 1:1000 lmg / 1mL*** 1 Obstetrics/Labor & Deliver Items Qty Isopropyl Alcohol Pads 3 OB - Kit 1 Oral glucose 15 g 1 OB - Suction Bulb 1 Naloxone 2mg / 2ml or 0.4 mg auto injector or 4 mg nasal spray 1 OB - Foil Blanket 1 *42*If not carrying Epi 1:1,000 MCI Qty Epi Pcn Adult and Pcdiactric 1 ca Triagc Tape / Tags 25 effery L. Jarvis, MD MS, EMT-P System Medical Director / Chief Medical Officer Effective: 07/01/2025 Office of the Medical Director 2900 Alta Mere Dr. Fort Worth, TX 76116 FORT WORTH I Office of the Medical Director Paramedic First Responder Minimum Equipment and Medication List Oxygen Accessories Qtv Hemmorha a Control / Boriclaging/ Splinting tv 02 - Cylinder with Regulator (>700 psi) 1 Bandaids 5 02 - Key I Burn Sheet 1 Aires sy & Oxygen Delivery Mulri Trauma Dressing 1 Oral Airway - (50 / 60 / 80 / 90 1100 / 110) 1 ca Roller Gauze 4 Nasal Airway - (22 / 24 126 / 28 / 30) 1.2 Sterile 530 Gauze Pad 4 Water-Soluable Lubricant 2 Sterile 4X4. Gauze Pad 4 Bag Valve Mask - Adult / Pedi / Infant 1 ca Occlusive Dressing 2 Neonate Size 0 BVM mask 1 Triangular Bandages 4 Nasal Cannula - Adult 1 Rigid Splints 2 Non-Rebmather - Adult 1 Pelvic Fracture Sling 1 Non-Rebreather - Pedi 1 1" Tape 1 Bi-PAPSystem 1 2" Tape 1 Airway Equipment Saline or Sterile Water for Irrigation 1 ETC - Size 6.0, 6.5. 7.0, 7.5, 8.0 1 ea Hot Pack 4 UESeope Video Laryngoscope (VL) Camera/Monitor 1 Cold Pack 4 UEScope VL Disposable Blades - size 0, 1. 2, 3.4 1 ca Commercial Windless Tourniquet 1 Invasive Airway Scrumment Device - Adult and Pedi 1 ea Hemostatic D—mg/packing 2 ETT Introducer- Adult 1 Traction Splint (otiona l 1 Magill Forceps - Adult and Pedi 1 ca Manual Vital Sign Tools Qry AirQ-SP-3g supmglottic airway - Neonate through Adult Sizes 1 ca BP CuffAdule / Pedi / Infant 1 ea ETCO2 Nasal 2 BP Cuff Thigh or Adult XL 1 ETCO2 In -Gar 2 Stethoscope 1 Crvcothvroidoromv Me / Tmnstmcheal Needle Kit 1 ea Glucomemr 1 Suction & Accessories Qry Glucomemr Test Strips 3 Suction - Porrablc w/Canisrer &Lid 1 Disposable Lancets 3 Suction - Rigid Tip 1 Sharps Shuttle 1 Suction - Tubing 1 Alcohol Preps 10 Suction - Cad, 5 / 14 / 18 Fr 1 ea Thermometer 1 Suction- Gastric Sump Tube 10 & 16 Fr 1 ea Pedi - Len th/A a -based Resuscitation Tape 1 Vascular Prep. Access, & Medication Delivery tv PPE / Cleaning / Biohazard Qtv Syringe Icc 2 Hand Sanitize, 1 botde Syringe 3cc 2 Medical Exam Gloves 1 Box Syringe l0cc 2 Gown 3 Normal Saline Flush 10cc (optional) 2 Goggles/Face Shield 3 Hyperdem is Needle 1 1/2" (21g or 25g or 27g) 2 Masks 3 18g Needle 1 1/2" 2 Safety Vest 3 IV Tourniquets 2 EMSScissors 1 IV Cath. 24G 3/4" 2 Penlight 1 IV Cad,. 22G I" 2 Ringcurmr 1 IV Cash. 20G 1 1/4" 2 Bio Hazard Bags 2 IV Cadh. ISG 1 1/4" 2 FRO - ALS Assist Medication List Qty IV Catb. 16G 1 114" 2 Acemmino hen 500 mg Tablet (may substitute liquid) 2 IV Cach. 14G 3 1/4" 2 Accmminophcn Liquid 160mg / 5mL 35 mL Inmosseous Needle - Pedi, Adult, Bari (If EZIO, then 25 & 45 mm) I ea Adenosine 12 m / 2 onl (optional) 2 IV Tubing 2 Amiodarone 150mg / 3 mL 3 Vcniguard 2 Aspirin 81 mg Tablet 4 Nasal Atomizer Device 2 Arropine lmg/I0mL 4 Nebulizer 1 Calcium Chloride 10% 1 gm / 10 mL (optional) 1 Obstetrics/Labor & Deliver Items Qry Dexerose 105f. (25g / 250mL) 2 OB - Kc 1 Diphenhydramine, 50 mg / 2 mL 1 OB - Suction Bulb 1 DuoNeb Abutcm12.5mg / ipmtropium 500mcg* 3 OB - Foil Blanket 1 Epinephrine 1: 10,000 long / LOmL 3 Immobilization / Patient Movement Qry Epinephrine 1: 1000 long / mL 6 or. 2 with Racemic Epi Backboards w/ 3 strops (Optional) 1 Fentanyl 100mcg / 2mL (optional) 3 Extrication Device 1 Ibuprofen 200 mg Tablets (may substimre liquid) 3 C-Collars - Adult & Pedi 1 ca libuprofen 100mg / 5 mL 30 mL Head Immobilizer (optional) 1 Isopropyl Alcohol Pads 3 Pedi Immobilizer (optional) I Kecamine 200 mg / 20 ml (optional) 1 Monitoring Equipment Kemmlac 30 rng / 2 mL 1 Cardiac Monitor 1 L(docaine 2% 100 mg / 5 mL 2 Waveform Capnography Device 1 Midazolam 5 mg / 1 ml (optional) 4 Quick Combo Pads Adult! Pedi 1 ea Nalozone 2 mg / 2 mL 2 ECG Electrodes 1 set Nitroglycerin 0.4 mg SL Spray or Tablet 1 bd ECG Paper I roll Normal Saline 1000 mL 2 MCI Ory Normal Saline 250 mL 1 Triage Tape / Tags 25 Ondansetron 4 mg ODT 2 Ondansetron 4mg / 1mL 2 Oral glucose 15 g 1 Racemic Epinephrine 2.25% 11.25 mg / 0.5 mL (optional) 2 Sodium Bicarb 8.4%% 50 ml (1 mEq / mL) 2 *Albuterol 23 mg / 3 mL 6 or. 3 with DuoNeb •Ipmtropium 500 to/ 3 mL If not carrying DuoNeb 3 effery L. jArvii, MD, MS, EMT-P, System Medical Director / Cluef Medical Officer Effective: 07101/2025 Fort Worth Office of the Medical Director 2900 Alta Mere Dr. Fort Worth, TX 76116 EXHIBIT "C" FRO PATIENT CARE REPORT Pa First Responder and Provider Agreement Page 8 of 9 Front of First (White) and Second (Yellow) Page FIRST RESPONDER ORGANIZATION EMS INCIDENT REPORT FRO: Company: FD Inc #: Date: / / FD Alarm Time: Inc. Location: Pt Name: Address: SSN: DOB: / / Age: (M/F) SKIN / Capillary Refill ❑Absent ❑Delayed ❑Normal Parent/ Guardian TIME PULSE BLOOD PRESSURE RESP SP02 GLUCOSE PULSE QUALITY ❑Regular ❑Irregular []Strong ❑Weak -[]Absent SKIN CONDITION ❑Moist ❑Dry ❑Warm ❑Cool ❑Pale ❑Blue ❑Red []Normal INITIAL GLASGOW COMA SCALE: INITIAL TRAUMA SCORE: Chief Complaint: Past History: Medications: Allergies:_ Narrative: ■1 79_ Front of First (White) and Second (Yellow) Page FRO. - FIRST RESPONDER ORGANIZATION EMS INCIDENT REPORT Company: FD Inc #: Date: / / FD Alarm Time: Inc. Location: Pt Name: Address: SSN: / / DOB: / / Age: (M/F) SKIN / Capillary Refill ❑Absent ❑Delayed ❑Normal Parent/ Guardian TIME PULSE BLOOD PRESSURE RESP SP02 GLUCOSE PULSE QUALITY ElRegular ❑Irregular ❑Strong []Weak ❑Absent SKIN CONDITION ❑Moist ❑Dry ❑Warm ❑Cool ❑Pale ❑Blue ❑Red ONormal INITIAL GLASGOW COMA SCALE: INITIAL TRAUMA SCORE: Chief Complaint: Past History: Medications: Allergies: ❑NKDA Narrative: ❑AMA ❑RAS F.D. Sign Off FWFD EMS Sign Off Back of First (White) Page AMA FORM REFUSAL OF TREATMENT / RECHASO DE TRATAMIENTO (PARAMEDIC USE ONLY) This is to certify that I release (FRO) and its employees from liability for any claim arising from or associated with my injuries or condition; and I refuse further treatment even though I am informed and I am aware that my injuries may be serious and may require further treatment. Esto es para certificar que renuncio de cargos al (FRO) y sus empleados de toda culpabilidad si algun resultado apareciera asociado con mis lastimaduras o condiciones y rehuso todo tratamiento despues qua se me ha informado y me consta qua mis lastimaduras pueden ser mas serias y despues requieren mas serios tratamientos. Legal Representative Witness Paramedic RELEASE AT SCENE FORM Did patient or LEO activate 911 for EMS? DYes ❑No Patient disoriented or confused? DYes []No Any loss of consciousness? DYes ❑No Any evidence of alcohol and/or drug use? DYes ❑No Any complaints of pain, illness, or psychological complaint/concem? DYes ❑No Any significant mechanism of injury? DYes ❑No Same vehicle DOS? DYes []No Family voicing concerns over patient's refusal? DYes ❑No If YES is answered to any of the above questions, you MUST complete a Patient Record Form AMA and a Release At Scene cannot be used. refuse any medical assessment, evaluation or treatment and refuse to be transported to a medical facility. I hereby release MedStar, the AMAA and the EPAB, their officials, officers, agents, and employees from all liability, claims and causes of action arising from or relating to my decision to refuse medical assessment, evaluation or treatment. U Signature Phone Parent/Guardian Signature Relationship Home Address Date I performed a scene assessment and observed that there appears to be no significant mechanism of injury at the scene and it appears has no obvious injury, illness, medical or physical complaints or symptoms. EMS Personnel Signature EMS Personnel Printed Name Date Incident Number Unit Number Witness Signature Witness Printed Name REFUSAL TO SIGN The person named above refused to sign this form. EMS Personnel Signature EMS Personnel Printed Name Date Incident Number Unit Number Witness Signature Witness Printed Name Incident Address City EXHIBIT "D" BUSINESS ASSOCLATE AGREEMENT First Responder and Provider Agreement Page 9 of 9 FORT WORTH.;. CITY OF FORT WORTH BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (the `BAA") is made and entered into by and between the City of Fort Worth Texas, a home -rule municipality organized under the laws of the state of Texas ("Covered Entity") and the City of Haltom City Texas, a home -rule municipality organized under the laws of the state of Texas [corporation, limited liability company, etc.](`Business Associate", in accordance with the meaning given to those terms at 45 CFR § 164.501). In this BAA. Covered Entity and Business Associate are each a "Party" and, collectively, are the "Parties." WHEREAS, Covered Entity is a "covered entity" as defined under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended by the HITECH Act (as defined below) and the related regulations promulgated by HHS (as defined below) (collectively, "HIPAA") and, as such, is required to comply with HIPAA's provisions regarding the confidentiality and privacy of Protected Health Information ("PHI"); WHEREAS, the Parties have entered into or will enter into one or more agreements under which Business Associate provides or will provide certain specified services to Covered Entity (collectively, the "Agreement"); WHEREAS, in providing services pursuant to the Agreement, Business Associate will have access to PHI; WHEREAS, by providing the services pursuant to the Agreement, Business Associate will become a "business associate" of the Covered Entity as such teen is defined under HIPAA; WHEREAS, both Parties are committed to complying with all federal and state laws governing the confidentiality and privacy of health information. including_ but not limited to, the Standards for Privacy of Individually Identifiable Health Information found at 45 CFR Part 160 and Part 164, Subparts A and E (collectively, the "Privacy Rule"); and WHEREAS, both Parties intend to protect the privacy and provide for the security of Protected Health Information disclosed to Business Associate pursuant to the terms of this Agreement, HIPAA and other applicable laws. NOW, THEREFORE, in consideration of the mutual covenants and conditions contained herein and the continued provision of PHI by Covered Entity to Business Associate under the Agreement in reliance on this BAA, the Parties agree as follows: FORT WORTH,.,. 1. Definitions For purposes of this BAA, the Parties give the following meaning to each of the terms in this Section 1 below. Any capitalized term used in this BAA, but not otherwise defined, has the meaning given to that term in the Privacy Rule or pertinent law. A. "Affiliate" means a subsidiary or affiliate of Covered Entity that is, or has been, considered a covered entity, as defined by HIPAA. B. "Breach" means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the Privacy Rule which compromises the security or privacy of the PHI, as defined in 45 CFR § 164.402. C. "Breach Notification Rule" means the portion of HIPAA set forth in Subpart D of 45 CFR Part 164. D. "Data Aggregation" means, with respect to PHI created or received by Business Associate in its capacity as the "business associate" under HIPAA of Covered Entity, the combining of such PHI by Business Associate with the PHI received by Business Associate in its capacity as a business associate of one or more other "covered entity" under HIPAA, to permit data analyses that relate to the Health Care Operations (defined below) of the respective covered entities. The meaning of"data aggregation" in this BAA shall be consistent with the meaning given to that term in the Privacy Rule, E. "Designated Record Set" has the meaning given to such term under the Privacy Rule, including 45 CFR § 164.501.B. F. "De -Identify" means to alter the PHI such that the resulting information meets the requirements described in 45 CFR § § 164.514(a) and (b). G. "Electronic PHI" means any PHI maintained in or transmitted by electronic media as defined in 45 CFR § 160.103. H. "Health Care Operations" has the meaning given to that term in 45 CFR § 164.501. I. "HHS" means the U.S. Department of Health and Human Services. J. "HITECH Act" means the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, Public Law 111-005. FORTWORTH. K. "Individual" has the same meaning given to that term i in 45 CFR §§164.501 and 160.130 and includes a person who qualifies as a personal representative in accordance with 45 CFR §164.502(g). L. "Privacy Rule" means that portion of HIPAA set forth in 45 CFR Part 166 and Part 164, Subparts A and E. M. "Protected Health Information" or "PHI" has the meaning given to the term "protected health information" in 45 CFR §§164.501 and 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity. N. "Security Incident" means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system. O. "Security Rule" means the Security Standards for the Protection of Electronic Health Information provided in 45 CFR Part 160 & Part 164, Subparts A and C. P. "Unsecured Protected Health Information" or "Unsecured PHI" means any "protected health information" as defined in 45 CFR § § 164.501 and 160.103 that is not rendered unusable, unreadable or indecipherable to unauthorized individuals through the use of a technology or methodology specified by the HHS Secretary in the guidance issued pursuant to the HITECH Act and codified at 42 USC § 17932(h). 2. Use and Disclosure of PHI A. Except as otherwise provided in this BAA, Business Associate may use or disclose PHI as reasonably necessary to provide the services described in the Agreement to Covered Entity, and to undertake other activities of Business Associate permitted or required of Business Associate by this BAA or as required by law. B. Except as otherwise limited by this BAA or federal or state law, Covered Entity authorizes Business Associate to use the PHI in its possession for the proper management and administration of Business Associate's business and to carry out its legal responsibilities. Business Associate may disclose PHI for its proper management and administration, provided that (i) the disclosures are required by law; or (ii) Business Associate obtains, in writing, prior to making any disclosure to a third party (a) reasonable assurances from this third party that the PHI will be held confidential as provided under this BAA and used or further disclosed only as required by law or for the purpose for which it was disclosed to this third party and (b) an agreement from this third party to notify Business Associate immediately of any breaches of the confidentiality of the PHI, to the extent it has knowledge of the breach. FORTWORTH- C. Business Associate will not use or disclose PHI in a manner other than as provided in this BAA, as permitted under the Privacy Rule, or as required by law. Business Associate will use or disclose PHI, to the extent practicable, as a limited data set or limited to the minimum necessary amount of PHI to carry out the intended purpose of the use or disclosure, in accordance with Section 13405(b) of the HITECH Act (codified at 42 USC §17935(b)) and any of the act's implementing regulations adopted by HHS, for each use or disclosure of PHI. D. Upon request, Business Associate will make available to Covered Entity any of Covered Entity's PHI that Business Associate or any of its agents or subcontractors have in their possession. E. Business Associate may use PHI to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR §164.5020)(1). 3. Safeguards Against Misuse of PHI Business Associate will use appropriate safeguards to prevent the use or disclosure of PHI other than as provided by the Agreement or this BAA and Business Associate agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Electronic PHI that it creates, receives, maintains or transmits on behalf of Covered Entity. Business Associate agrees to take reasonable steps, including providing adequate training to its employees to ensure compliance with this BAA and to ensure that the actions or omissions of its employees or agents do not cause Business Associate to breach the terms of this BAA. 4. Reporting Disclosure of PHI and Security Incidents Business Associate will report to Covered Entity in writing any use or disclosure of PHI not provided for by this BAA of which it becomes aware and Business Associate agrees to report to Covered Entity any Security Incident affecting Electronic PHI of Covered Entity of which it becomes aware. Business Associate agrees to report any such event within five business days of becoming aware of the event. 5. Reporting Breaches of Unsecured PHI Business Associate will notify Covered Entity in writing promptly upon the discovery of any Breach of Unsecured PHI in accordance with the requirements set forth in 45 CFR § 164.410, but in no case later than 30 calendar days after discovery of a Breach. Business Associate will reimburse Covered Entity for any costs incurred by it in complying with the requirements of Subpart D of 45 CFR § 164 that are imposed on Covered Entity as a result of a Breach committed by Business Associate. FORTWORM, 6. Mitigation of Disclosures of PHI Business Associate will take reasonable measures to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of any use or disclosure of PHI by Business Associate or its agents or subcontractors in violation of the requirements of this BAA. 7. Agreements with Agents or Subcontractors Business Associate will ensure that any of its agents or subcontractors that have access to, or to which Business Associate provides, PHI agree in writing to the restrictions and conditions concerning uses and disclosures of PHI contained in this BAA and agree to implement reasonable and appropriate safeguards to protect any Electronic PHI that it creates, receives, maintains or transmits on behalf of Business Associate or, through the Business Associate, Covered Entity. Business Associate shall notify Covered Entity, or upstream Business Associate, of all subcontracts and agreements relating to the Agreement, where the subcontractor or agent receives PHI as described in section I.M. of this BAA. Such notification shall occur within 30 (thirty) calendar days of the execution of the subcontract by placement of such notice on the Business Associate's primary website. Business Associate shall ensure that all subcontracts and agreements provide the same level of privacy and security as this BAA. 8. Audit Upon request, Business Associate will provide Covered Entity, or upstream Business Associate, with a copy of its most recent independent HIPAA compliance report (AT-C 315), HITRUST certification or other mutually agreed upon independent standards based third party audit report. Covered entity agrees not to re -disclose Business Associate's audit report. 9. Access to PHI by Individuals A. Upon request, Business Associate agrees to furnish Covered Entity with copies of the PHI maintained by Business Associate in a Designated Record Set in the time and manner designated by Covered Entity to enable Covered Entity to respond to an Individual's request for access to PHI under 45 CFR § 164.524. B. In the event any Individual or personal representative requests access to the Individual's PHI directly from Business Associate, Business Associate within ten business days, will forward that request to Covered Entity. Any disclosure of, or decision not to disclose, the PHI requested by an Individual or a personal representative and compliance with the requirements applicable to an Individual's right to obtain access to PHI shall be the sole responsibility of Covered Entity. 10. Amendment of PHI A. Upon request and instruction from Covered Entity, Business Associate will amend PHI or a record about an Individual in a Designated Record Set that is maintained by, or otherwise within the possession of, Business Associate as directed by Covered Entity in accordance with procedures established by 45 CFR §164.526. Any request by Covered Entity to amend such information will be completed by Business Associate within 15 business days of Covered Entity's request. B. In the event that any Individual requests that Business Associate amend such Individual's PHI or record in a Designated Record Set, Business Associate within ten business days will forward this request to Covered Entity. Any amendment of, or decision not to amend. the PHI or record as requested by an Individual and compliance with the requirements applicable to an Individual's right to request an amendment of PHI will be the sole responsibility of Covered Entity. 11. Accounting of Disclosures A. Business Associate will document any disclosures of PHI made by it to account for such disclosures as required by 45 CFR § 164.528(a). Business Associate also will make available information related to such disclosures as would be required for Covered Entity to respond to a request for an accounting of disclosures in accordance with 45 CFR § 164.528. At a minimum, Business Associate will furnish Covered Entity the following with respect to any covered disclosures by Business Associate: (i) the date of disclosure of PHI; (ii) the name of the entity or person who received PHI, and, if known, the address of such entity or person; (iii) a brief description of the PHI disclosed, and (iv) a brief statement of the purpose of the disclosure which includes the basis for such disclosure. B. Business Associate will furnish to Covered Entity information collected in accordance with this Section 10, within ten business days after written request by Covered Entity, to permit Covered Entity to make an accounting of disclosures as required by 45 CFR §164.528, or in the event that Covered Entity elects to provide an Individual with a list of its business associates, Business Associate will provide an accounting of its disclosures of PHI upon request of the Individual, if and to the extent that such accounting is required under the HITECH Act or under HHS regulations adopted in connection with the HITECH Act. C. In the event an Individual delivers the initial request for an accounting directly to Business Associate, Business Associate will within ten business days forward such request to Covered Entity. 12. Availability of Books and Records FORTWORTH. Business Associate will make available its internal practices, books, agreements, records, and policies and procedures relating to the use and disclosure of PHI, upon request, to the Secretary of HHS for purposes of determining Covered Entity's and Business Associate's compliance with HIPAA, and this BAA. 13. Responsibilities of Covered Entity With regard to the use and/or disclosure of PHI by Business Associate, Covered Entity agrees to: A. Notify Business Associate of any limitation(s) in its notice of privacy practices in accordance with 45 CFR §164.520, to the extent that such limitation may affect Business Associate's use or disclosure of PHI. B. Notify Business Associate of any changes in, or revocation of, permission by an Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate's use or disclosure of PHI. C. Notify Business Associate of any restriction to the use or disclosure of PHI that Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the extent that such restriction may affect Business Associate's use or disclosure of PHI. D. Except for data aggregation or management and administrative activities of Business Associate, Covered Entity shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under HIPAA if done by Covered Entity. 14. Data Ownership Business Associate's data stewardship does not confer data ownership rights on Business Associate with respect to any data shared with it under the Agreement, including any and all forms thereof. 15. Term and Termination A. This BAA will become effective upon execution by the Covered Entity's City Manager, Deputy City Manager, or Assistant City Manager, and will continue in effect until all obligations of the Parties have been met under the Agreement and under this BAA, unless earlier terminated in accordance with the terms of this BAA. B. Covered Entity may terminate immediately this BAA, the Agreement, and any other related agreements if Covered Entity determines that Business Associate has breached a material term of this BAA and Business Associate has failed to cure that material breach, to Covered Entity's reasonable satisfaction, within 30 days after written notice from Covered Entity. FORT WORTH.. Covered Entity may report the problem to the Secretary of HHS if termination is not feasible. Notwithstanding the foregoing, Covered Entity may also terminate the Agreement any other related agreements as provided by the terms of such agreements. Additionally, Covered Entity may terminate this BAA for convenience upon 30 days' prior written notice to Business Associate. C. If Business Associate determines that Covered Entity has breached a material term of this BAA, then Business Associate will provide Covered Entity with written notice of the existence of the breach and shall provide Covered Entity with 30 days to cure the breach. Covered Entity's failure to cure the breach within the 30-day period will be grounds for immediate termination of the Agreement and this BAA by Business Associate. Business Associate may report the breach to HHS. D. Upon termination of the Agreement or this BAA for any reason, all PHI maintained by Business Associate will be returned to Covered Entity or destroyed by Business Associate. Business Associate will not retain any copies of such information. This provision will apply to PHI in the possession of Business Associate's agents and subcontractors. If return or destruction of the PHI is not feasible, in Business Associate's reasonable judgment, Business Associate will furnish Covered Entity with notification, in writing, of the conditions that make return or destruction infeasible. Upon mutual agreement of the Parties that return or destruction of the PHI is infeasible, Business Associate will extend the protections of this BAA to such information for as long as Business Associate retains such information and will limit further uses and disclosures to those purposes that make the return or destruction of the information not feasible. The Parties understand that this Section 14.D. will survive any termination of this BAA. 16. Effect of BAA A. This BAA is a part of and subject to the terms of the Agreement, except that to the extent any terms of this BAA conflict with any term of the Agreement, the terms of this BAA will govern. B. Except as expressly stated in this BAA or as provided by law, this BAA will not create any rights in favor of any third party. 17. Regulatory References Regulatory References. A reference in this BAA to a section in HIPAA means the section as in effect or as amended at the time. 18. Notices Notices required pursuant to the provisions of this BAA will be conclusively determined to have been delivered when (1) hand -delivered to the other party, its agents, employees, servants or representatives, (2) delivered by facsimile with electronic confirmation of the transmission, or (3) received by the other parry by United States Mail, registered, return receipt requested, addressed as follows: To Covered Entity: City of Fort Worth Attn: Assistant City Manager 100 Fort Worth Trail Fort Worth, TX 76102-6314 Facsimile: (817) 392-8654 To Business Associate: City of Haltom City Attn: City Manager 4801 Haltom Road Haltom City, TX 76117 Facsimile: (817) 759-8656 With copy to Fort Worth City Attorney's With copy to Haltom City Fire Department Office at same address Attn- Fire Chief 5525 Broadway Ave Haltom City, TX 76117 19. Amendments and Waiver This BAA may not be modified, nor will any provision be waived or amended, except in writing duly signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as continuing, or as a bar to or waiver of any right or remedy as to subsequent events. 20. HITECH Act Compliance The Parties acknowledge that the HITECH Act includes significant changes to the Privacy Rule and the Security Rule. The privacy subtitle of the HITECH Act sets forth provisions that significantly change the requirements for business associates and the agreements between business associates and covered entities under HIPAA and these changes may be further clarified in forthcoming regulations and guidance. Each Party agrees to comply with the applicable provisions of the HITECH Act and any HHS regulations issued with respect to the HITECH Act. The Parties also agree to negotiate in good faith to modify this BAA as reasonably necessary to comply with the HITECH Act and its regulations as they become effective but, in the event that the Parties are unable to reach agreement on such a modification, either Party will have the right to terminate this BAA upon 30- days' prior written notice to the other Party. FORT WORTH [Executed effective as of the date signed by the Assistant City Manager below.] / [ACCEPTED AND AGREED:] Covered Entity: ► ZJI-L By: Name: William Johnson_ Title: Assistant City Manager Date: 05/31 /2026 Business Associate By: Name: Rey Phelps Title: City Manager Date: /-%' 2w CITY OF FORT WORTH INTERNAL ROUTING PROCESS: Approval Recommended: By: Name: _Raymond Hill Title: Interim Fire Chief Approved as to Form and Legality By: Name: Taylor C. Paris Title: Assistant City Attorney Contract Compliance Manager: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. By: Name: Ryan Zelazny Title: Fire Deputy Chief - Operations City Secretary: By: Name: Jannette S. Goodall Title: City Secretary FORT WORTH. I City Secretary's Office Contract Routing & Transmittal Slip Contractor's Name: City of Haltom City First Responder and Provider Agreement Subject of the Agreement: Obligates each jurisdiction to comply with the terms of their respective EMS Interlocal Agreement. M&C Approved by the Council? * Yes ❑ No M If so, the M&C must be attached to the contract. Is this an Amendment to an Existing contract? Yes ❑ No 0 If so, provide the original contract number and the amendment number. Is the Contract "Permanent"? *Yes 0 No ❑ If unsure, see backpage for permanent contract listing. Is this entire contract Confidential? *Yes ❑ No 0 If only specific information is Confidential, please list what information is Confidential and the page it is located. Effective Date: If different from the approval date. Expiration Date: If applicable. Is a 1295 Form required? * Yes ❑ No ED *If so, please ensure it is attached to the approving M&C or attached to the contract. Project Number: If applicable. *Did you include a Text field on the contract to add the City Secretary Contract (CSC) number? Yes 0 No ❑ Contracts need to be routed for CSO processing in the followingorder: rder: 1. Katherine Cenicola (Approver) 2. Jannette S. Goodall (Signer) 3. Allison Tidwell (Form Filler) *Indicates the information is required and if the information is not provided, the contract will be returned to the department.