Agency Name

Agency Code

	Service Type
	Ambulance Service
	ALS FR
	BLS FR

	Agency Type
	Paid
	Volunteer
	Combination

	Level of Care (choose highest level authorized)
	EMT
	AEMT
	AEMT-CC
	Paramedic
	Specility Care Transport

NYS County

Agency Contact Information

Name

Company

Email

Phone

Address

Address 2

City/Town

State/Province

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP/Postal Code

Alternate phone number

How many ambulances does your agency currently operate?

How many EASV's does your agency currently operate?

	Please acknowledge that this contract term is for October 1, 2021 to June 30,2022
	I acknowledge that I can commit resources for this length of time
	I acknowledge that I cannot commit resources for this of time, but will respond in case of vacancies

	Please acknowledge this contract is currently for 1 ALS Ambulance with crew (Paramedic and EMT) to be at each of the listed sites below. When responding to the survey, please answer each question related to the ask of an ALS ambulance and that the site hours are normally (subject to change) from 7AM to 8PM Monday thru Saturday and 7AM to 1PM on Sunday.
	Yes
	No

	I acknowledge that all responses are with ALS ambulances in mind
	Yes
	No

	Can your agency provide standby services for: Seven (7) sites within the Metropolitan Regional Area
	Can Support
	Cannot Support

	If the agency is not able to support all the 7 Individual sites at once, please indicate if you are able to support any of the sites individually:
	Suffolk
	Nassau
	Bronx x2
	Brooklyn
	Westchester x 2
	Queens

If the request is for additional sites to be opened, how many additional sites can the agency support (numeric response)

	Western Regional Area: Erie
	Can Support
	Cannot Support

	Western Regional Area: Monroe
	Can Support
	Cannot Support

If the request is for additional sites to be opened, how many additional sites can the agency support (numeric response)

	Central NY: Onondaga
	Can Support
	Cannot Support

If the request is for additional sites to be opened, how many additional sites can the agency support (numeric response)

	Capital Region : Albany
	Can Support
	Cannot Support

If the request is for additional sites to be opened, how many additional sites can the agency support (numeric response)

Will your agency require travel with long-term stays (permitted for any travel over 50 miles one-way) to any specific sites? If yes, please list all sites that this would apply for

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