Form Ioci 12-12 - Emergency Medical Services (Ems) Systems Equipment Waiver Request Form - Illinois Department Of Public Health
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1State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Equipment Waiver Request
DO NOT USE FOR STAFFING WAIVERS
Request to waive:
Equipment Requirements
X
Vehicle Requirements
Other
Provider Name ________________________________________________________________________________________
Address ________________________________ City _______________________ State_______ ZIP_______________
Contact Person _______________________________ Phone _________________ E-Mail _________________________
Vehicle license(s) with last four (4) Vehicle Identification Numbers ________________________________________________
Section 515.150 b) 1) - 5) Waiver Provisions
Vehicle Design Section 3.16.4, subsection A and B of the KKK-A-1822F
1. List the section of the act for which the waiver is being sought.
2. Explain why complying with this section of the act is a hardship including a description of how you have attempted to comply
with this section
a.) Many new vehicle body styles do not allow for front markings on a “curved surface above the grille” as required in subsection A, nor would
__________________________________________________________________________________________________
any lettering on the hood styles be easily visible from traffic in the front of the ambulance.
b.) Current IDPH licensed ambulances that do not meet subsection A and/or B, have markings, emblems, and paint schemes that may not
__________________________________________________________________________________________________
easily allow for the addition of the word “AMBULANCE” in 6 inch in height letters. The cost of both removal and replacing of emblems and
__________________________________________________________________________________________________
markings is not cost effective and does not impact patient care or safety.
3. Explain how the waiver will NOT reduce the quality of medical care established by the act.
__________________________________________________________________________________________________
a. Emblems, Markings, and color schemes, as identified in KKK-A-1822F, subsection A and B, will not impact the quality
of care to a patient in the prehospital setting.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
24
Requested length of time for the waiver (maximum 12 months) _________ months
Per Ambulance Compliance Section Chief
______________________________________________________________________
__________________________
Provider Signature
Date
Submit completed request to your EMS System Hospital for Signature
EMS System ONLY
EMS System Hospital Name ______________________________________________________ System Number________
Address ________________________________ City _______________________ State_______ ZIP_______________
The above request
Complies
Does NOT comply
with our EMS System Plan.
______________________________________________________________________
__________________________
EMS Medical Director Signature
Date
Submit completed request to your Regional EMS Coordinator for Signature
Regional EMS Coordinator ONLY
I recommend the waiver be
Processed
Denied
Refer to attached Waiver Explanation Form.
___________________
Initial and Date
Central Office ONLY
Waiver:
Processed
Denied
_____________________
Copies mailed
Initial and Date
IOCI 12-12
8/11
Printed by Authority of the State of Illinois
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