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Appendix A
Facility Codes for EMS Region 1
Facility
Appendix A
Facility Codes for EMS Region 2
Facility
Appendix A
Facility Codes for EMS Region 3/4
Facility
Appendix A
Facility Codes for EMS Region 5
Facility
Appendix A
Facility Codes for EMS Region 6/7
Facility
Veterans Administration Medical Center Clarksburg Appendix A
Facility Codes for EMS Region 6/7 (Continued)
Facility
Appendix A
Facility Codes for EMS Region 8/9
Facility
Appendix A
Facility Codes for EMS Region 10/11
Facility
Bishop Joseph Hodges Continuous Care Ctr.
Appendix A
Codes for Out-of-State Facilities
Facility
Kentucky
Pennsylvania
Tennessee
Appendix A
Codes for Out-of-State Facilities (Continued)
Facility
Washington DC
Maryland
Virginia
North Carolina 921
General Use
Appendix B
Codes for Regional Medical Command Centers
Medical Command Center Name
West Central Medical Command Center (WESTCOM) Appendix C
Squad Codes for EMS Region 1
McDowell Co. Emergency Ambulance Authority US Dept. of Interior - National Park Service Green Sulphur District Volunteer Rescue Squad Jan Care Ambulance Service - Raleigh Co. Jan Care Ambulance Service - Wyoming Co. Appendix C
Squad Codes for EMS Region 2
Cabell Huntington Hospital Pt. Transport Service Mason County Emergency Amb. Service Authority LEASA (Logan Co. Emergency Amb. Svc. Authority) Lifeline Medical Transport - Cabell County Appendix C
Squad Codes for EMS Region 3/4
Clay County Emergency Ambulance Authority Greenbrier County Emergency Amb. Service Appendix C
Squad Codes for EMS Region 5
Pleasants Co. Emergency Ambulance Authority Tyler Co. Emergency Squad - Middlebourne Sistersville General Hospital Ambulance Service MJS Enterprises/dba St. Joseph=s Ambulance Services Blennerhassett Volunteer Fire Department General Ambulance Service - Jackson County Appendix C
Squad Codes for EMS Region 6/7
Braxton Co. Emerg. Amb. Svc. Authority - Burnsville Braxton Co. Emerg. Amb. Svc. Authority - Sutton Lewis County Emergency Amb. Svc. Authority Appendix C
Squad Codes for EMS Region 6/7 (Continued)
Lambert’s Ambulance Service - Harrison Co. Harrison Co. Emergency Squad - Shinnston STAT Ambulance Service - Harrison County Appendix C
Squad Codes for EMS Region 8/9
Berkeley Co. EAA - South Berkeley VFD & Rescue Pendleton Co. Emerg. Rescue - North Fork Pendleton Co Emerg. Rescue. - Sugar Grove Pendleton Co. Emerg. Rescue - Upper Tract Berkeley Co. Emergency Ambulance Authority Appendix C
Squad Codes for EMS Region 8/9 (Continued)
Capon Springs Volunteer Fire & Rescue Lamberts Ambulance Service - Hedgesville Appendix C
Squad Codes for EMS Region 10/11
Weirton Area Ambulance & Rescue Squad Appendix D
State Approved Drugs/Solutions
Drug/Solution
Appendix D
State Approved Drugs/Solutions
Drug/Solution
Dextrose 10% in Water (D10W) 44 Dextrose 50% in Water (D50W) 05 Dextrose 25% in Water (D25W) 68 Diastat Appendix E
WV OEMS Patient Care Record
Submission Form
Use a separate form for each month.
Directions:
Separate yellow copies by month, then Emergency ALS, Emergency BLS, Non-EmergencyTransports, and No Transports.
Please do not submit partial months. All records are to be in the TSN Field Office by the 15thof the month for the previous month. Example: January forms need to be in the office by the15th of February.
Attach this from as a cover sheet to your yellow copies.
Send to the appropriate WV EMS TSN Field Office.
****************************************************************************************************************************** Squad Name:_______________________________________________Squad Number:_________________ Month:______________________________Year:__________Date Sent to TSN:_______________________ Total Runs:____________________Emergency ALS Runs:___________Emergency BLS Runs:___________ Non-Emergency Transports:_________No Transports:_________ Prepared for Submission By:_____________________________________________________________ ************************************************************************************************************************* FOR TSN FIELD OFFICE USE ONLY
Date Entered:____________________Entered By:____________________________________________ File Date and Name:____________________________________________________________________ TSN Regional EMS Field Offices
Headquarters
Field Office for Region 1
Field Office for Region 2
Field Office for Region 3/4
Field Office for Region 5
Acting Program Director: Allisynne Dunlap Field Office for Region 6/7
Field Office for Region 8/9
Field Office for Region 10/11
Berkeley, Grant, Hampshire, Hardy, Jefferson, Barbour, Braxton, Doddridge, Gilmer, Harrison, Lewis, Marion, Monongalia, Preston, Randolph,

Source: http://www.nhtsa-tsis.net/statecatalog/states/wv/docs/PCRManualAppendixrevised100705.pdf

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