A. General Base & Facility YES NO N/A 1. Uniforms - Are all personnel in applicable uniform according to policy (2 pt.)

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1 Location/Base: Base Manager: Surveyor: Date: Co-Surveyor: NOTE: This tool is has been designed to assure accountability at all AMG bases, evaluating multiple air medical-specific items. This survey shall aid the appropriate personnel in accomplishing four (4) individual inspections a year at each particular base. The surveys are to be conducted by a combination of the following personnel; Base Safety Rep, Maintenance Manager, Operations Manager, Area Manager, and/or Program Director. Not more than two (2) surveys may be conducted by one person. Once this survey is completed please file locally and send a copy to your appropriate Supervisor and Lafayette QSC Department, ATTN: Lenny Leblanc. DIRECTIONS: The tool is divided into sections, with a set number of points pre-awarded. In order to allow for a balanced scoring system, all bases will start out with an aggregate score of 100 points. When a deficiency for a specific item is noted, (as evidenced by a NO check mark or comment) the points for that item are deducted. Final scoring is based on the number of deductions from the initial score. At the completion of the audit and evaluation, the completed paperwork shall be turned in to the Program Director or their designee. A. General Base & Facility YES NO N/A 1. Uniforms - Are all personnel in applicable uniform according to policy (2 pt.) 2. Cleanliness Is the base areas clean (1 pt.) 3. Computer/Internet History Are crew members complying with the PHI computer use policy (no evidence of inappropriate internet site utilization) (2 pts.) 4. Smoke Alarms/ Carbon Monoxide Detectors Where smoke alarms are required (living quarters, kitchens, bedrooms); are they in place and functioning properly? Perform an inspection for operation. (2 pts.) 5. EEP, Emergency Evacuation/Action Plan Is an EEP Plan available and is it current? Emergency phone numbers should be posted near phones where they can be readily accessible in case of an emergency. (2 pts.) 6. Safety Board Is the safety bulletin board being updated with the latest safety information? (News & Views, Rotor Blades, Safety Alerts, etc ) (1 pt.) B. Base/ Facility Tracking and Policy Accountability YES NO N/A 1. Daily/Shift Briefings - Are daily/shift briefings noted and kept on-file, with any concerns passed on to the next shift/crew? (2 pts.) 2. Base Meetings Are base meeting minutes current, with attendees noted along with appropriate titles? (2 pts.)

2 B. Base/ Facility Tracking and Policy Accountability YES NO N/A 3. Base Meeting Tracking Is there a procedure in-place to confirm that personnel absent from meetings have reviewed and understood the meeting minutes or training? (1 pt.) 4. Management/Safety/CQI Meeting Information Pass-Down Is management, safety, and CQI meeting information being passed on to crew members, and documented in the base meeting minutes? (1 pts.) 5. Policies and Protocols - Do all base personnel know the location of programspecific policies, protocols and procedures? (1 pt.) 6. Medical Supply Par Lists Is there a complete par list for all medical equipment, and is it being followed? (1 pt.) 7. Record Security - Are applicable records secure such as CQI, and HIPAA-related material? (2 pts.) 8. CMN Copies Are there scanned copies of CMN s kept for future access? (1 pt.) 9. Ride-Along Forms Are ride-along forms complete, including HIPAA forms, and kept on-file? (1 pt.) 10. Narcotic Tracking/Security Are narcotics secure with inventory forms up to date - no missing entries and all discrepancies resolved? (3 pts.) 11. Certifications Is there a copy of all current required certifications and licenses for all personnel available at the base? (2 pt.s) 12. MSDS Sheets Are there MSDS sheets available to the crew for all chemicals being used? Does every crew member know the location of the MSDS sheets and how to access them? (1 pt.) 13. Critical Publications Are there current and updated copies of the GOM, GMM, EOC manual on-site? Do personnel know how to access the HS & E manual on the intranet? (2 pts.) TOTAL POSSIBLE POINTS 20 C. Initial and Ongoing Training YES NO N/A 1. New Hires Have newly assigned personnel received a short briefing to include base/shop specific hazards, local evacuation plans, emergency response information, emergency equipment location, job specific safety training requirements, and safety meetings? (1 pt.)

3 C. Initial and Ongoing Training YES NO N/A 2. All PHI personnel Are all personnel meeting the job specific safety training requirements and recurrent requirements specified in HS&E Manual Chapter 3? Examples would include blood borne pathogens, first-aid, and HAZ-MAT. (1 pts.) 3. Training Binders - Are training binders and paperwork complete and available for review? (1 pt.) 4. CAMTS Is there evidence of CAMTS-required training and ongoing education for all crew members, such as blood borne pathogens and HAZMAT(includes pilots and mechanics)? (2 pts.) 5. Safety Day Have all operational crew members completed hands-on safety and egress training within the past calendar year? For those that have not, has follow-up training been completed? (2 pts.) 6. Clinical Training Is clinical training up to date with forms completed and signed? (2 pts.) 7. LZ Training Is there evidence of LZ training classes, including copies of the class outline and sign-in sheets? (1 pt.) D. Maintenance Area / Hanger (2 pts. ea.) YES NO N/A 1. Compressed Gas/Air Cylinders Are protective caps in place when cylinders are not in use? Are cylinders secured (chains, etc. shall be placed around the cylinder to prevent tipping? 2. Flammable / Combustible chemicals - Are flammable and combustible liquids stored inside an approved flammable storage cabinet or an approved flammable storage safety can? The cabinet shall be properly labeled (No Smoking 50ft., Flammable) and Flammable storage lockers (inside storage) should have the vent caps installed. Chemical containers shall be properly closed at all times and adequately labeled. Large drums and containers shall be properly grounded. Are soiled towels placed in a closed holding container or placed in a well ventilated area? Stored away from electrical receptacles? 3. FOD Prevention tools and company equipment kept in good, neat working order? Are specialty tools flagged and and/or equipped with high visibility markings? 4. Lifting Devices Are slings, straps and lifting devices in acceptable working condition and are they being inspected before each use? Are hooks equipped with serviceable spring loaded safety latches?

4 D. Maintenance Area / Hanger (2 pts. ea.) YES NO N/A 5. Machine Guards Are bench grinders, saws, and similar industrial type equipment/machines equipped with properly adjusted safety guards, recommended by the manufacturer? 6. Calibrated Tools/Equipment Are special tools (torque wrenches, gauges, NDT machines, etc.) and/or equipment calibrated and tagged with next/last calibration? Are they maintained and stored properly? 7. Timed Parts and Shelf Item Expiration Dates Is the system to track timed parts and shelf item expiration dates complete and up to date? 8. Work Stands Are work stands being maintained according to PHI standards, (Non-skid on walking and working surfaces, good paint condition, no cracks, tight fitted working platforms etc )? All PHI stands shall be equipped with foam padding to prevent damage to the a/c. 9. Tool Control Is there a system in-place to monitor tools currently being used, and or an inventory list kept at the a/c when maintenance is being conducted? 10. Acft. Tow Vehicle / Maintenance Truck Is the tow vehicle or truck used by maintenance clean inside and out with no debris inside the cab? Appropriate preventative maintenance such as recent oil change, with tires, belts and hoses in serviceable condition. TOTAL POSSIBLE POINTS 20 E. Safety Issues YES NO N/A 1. JSA s - Are JSA s specific to the aircraft model and stretcher relative to patient loading and unloading available on-site? Are they being reviewed by flight crews during routine safety meetings? (2 pts.) 2. Helmets Are helmets assigned to each crew member? Are they in working order? (1 pt.) 3. Risk Matrix Is the EOC risk matrix being utilized in accordance with company policy? (1 pt.) 4. NVG Logs Are NVG logs complete with no missing or partial entries (pilot and crew)? (1 pts.) 5. EOC Procedures Are all crew members knowledgeable of the company s EOC procedures? (2 pts.)

5 E. Safety Issues YES NO N/A 6. Safety Communication Are all crew members aware of the procedures in-place to report an issue or occurrence? Are they aware of the process when there is an onthe-job injury? (2 pts.) 7. AMRM Training Is there evidence that all crew members have completed PHI AMRM training? (1 pt.) F. Fuel YES NO N/A 1. Fuel Storage Is the system free from leaks and significant rust? Are the required filter changes up to date? Is adequate fall protection (guard rails) in place and in good repair? (PHI FUEL MANAGEMENT MANUAL). (2 pts.) 2. Flight Line Fuel Nozzles Is the fuel nozzle equipped with a serviceable nozzle screen? Is the fuel nozzle free from leaks and any other defects? Is the final GONO- GO filter in place and up to date? (1 pts.) 3. Fuel Sump/Sampling Are fuel tanks and fuel filters being sumped daily? Are records of daily fuel samples being kept on file, or readily accessible? (2 pts.) TOTAL POSSIBLE POINTS 5 G. Aircraft & Ramp Area YES NO N/A 1. Helipads/Ramp Are all tie down points in good condition? Is the area free of any loose objects and/or FOD? Are the ramp lights or helipad landing lights working properly? Is public access to the heliport restricted? (3 pts.) 2. Fire Extinguishers -Are fire extinguishers accessible without obstructions, mounted at proper heights, and inspected according to PHI policy? (1 pt.) 3. Aircraft Towing Is tow vehicle, tow bar, and ground handling wheels in good general condition? Are the appropriate wheel chocks available and being utilized on the main wheels for parking? (1 pt)

6 G. Aircraft & Ramp Area YES NO N/A 4. Aircraft Inspect exterior a/c paint, windows, float covers, cowling latches, seat covers, trim panels, and instrument panel for general condition. Reference cosmetic reports found for each specific model a/c on the PHI Intranet (EX. PHI983-ACR-001). Has an aircraft cosmetic report been completed within the last six months? (3 pts.) 5. Flyways - Are rejected take off areas adequate and are they being used? Are they marked on the heliport diagram? (1 pt.) 6. Wind Indicators Are wind indicators visible from the heliport, free to turn, and are they unobstructed by buildings or other obstacles? (1 pt.) H. Medical Cabin YES NO N/A 1. Medical Compartment Cleanliness Is the medical compartment of the aircraft clean with no dirt, blood, or other substances noted on the floor, walls, litter, or seats? (2 pts.) 2. Mounted Biomedical Equipment Is equipment properly mounted with loose cords bundled together? (1 pts.) 3. Biomedical Equipment PM Are all (applicable) biomedical devices affixed with a current preventative maintenance sticker? Is there a log available on-site to track past PM servicing and/or issues? (2 pts.) 4. Cardiac Monitor Batteries Are cardiac monitor batteries being rotated and tracked according to the operator s manual? (1 pt.) 5. Medical Inventory Has an accurate inventory of the aircraft been completed with any inventory discrepancies resolved? (1 pt) 6. Narcotics Storage Are narcotics appropriately stored with keys carried by separate crew members? (2 pts.) 7. Outdates Are medical supplies and limited shelf-life items within specified outdates, with no expired equipment or medications noted? (2 pts.) 8. ELT/Fire Extinguisher Location and Operation Do all crew members know the location of the ELT and fire extinguisher, and how to activate it? (2 pts.)

7 H. Medical Cabin YES NO N/A 9. Medical Weight and Balance Is there a current medical equipment weight and balance? Does it reflect current position and weight of medical equipment being kept in the medical (aft) cabin? Is there an ability of the pilot to add/subtract weights based on mission profile, i.e. normal vs. isolette transport? (2 pts.) TOTAL POSSIBLE POINTS 15 TOTAL SCORE FOR: Excellent Points Section A. Average Points Section B. Poor Below 80 points Section C. Section D. Section E. Section F. Section G. Section H. Total