Appendix F1 - CMO questionnaire - Circuit Racing (excl. MotoGP, WorldSBK)

A copy of this form has to be handed over to the Medical Director before the first track inspection (art. 09.7.1 and 5.3.10 of the Medical Codes).

This questionnaire must be completed by the Chief Medical Officer (CMO) and returned to the FIM: cmi@fim.ch 2 months prior to the event

Included:

1) EVENT INFORMATION

2) CHIEF MEDICAL OFFICER (CMO)

3) MEDICAL SERVICES

Rows	YES	NO
Are all medical services under the control of the Chief Medical Officer (CMO)
Is the medical service for the general public under the control of a deputy CMO or other doctor than the CMO himself/herself?

3a) TOTAL NUMBER OF MEDICAL PERSONNEL (medical centre, track, spectators)

Rows	Thursday	Friday	Saturday	Sunday	Monday
Doctor (CMO incl.)
Nurse
Paramedic or equivalent
Other medical personnel
Stretcher bearer
Driver
Other (e.g., pilot)
Total medical personnel

4) VEHICLES TYPE A1 = MEDICAL INTERVENTION VEHICLES

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

4a) TYPE OF VEHICLE

4b)

Rows	YES	NO
Do positions conform to map of circuit/post?
Doctor as per Medical Code
Second doctor, nurses, paramedic or equivalent as per Medical Code
Driver as per Medical Code

4c) TYPE OF VEHICLE

4d)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Nurse, paramedic or equivalent as per Medical Code
Driver as per Medical Code

4e) MEDICAL EQUIPMENT

Rows	YES	NO
Portable oxygen supply
Manual ventilator
Intubation equipment
Suction equipment
Intravenous infusion equipment
Equipment to immobilise limbs and spine (incl. cervical spine)
Sterile dressings
ECG monitor and defibrillator
Drugs for resuscitation and analgesia/IV fluids
Sphygmomanometer and stethoscope

4f) OTHER EQUIPMENT

Rows	YES	NO
Protective canvas/Tarpaulins

4g) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio communication with Race Control and CMO/Medical Director
Visible and audible signals
Equipment to remove suits and helmets

5) VEHICLES TYPE B1

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

5a) TYPE OF VEHICLE

5b)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Doctor as per Medical Code
Paramedic or equivalent as per Medical Code
Driver

5c) VEHICLES TYPE B2

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

5d) TYPE OF VEHICLE

5e)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Driver
Two paramedics or equivalent as per Medical Code

5f) MEDICAL EQUIPMENT

Rows	YES	NO
Portable oxygen supply
Manual and automatic ventilator
Intubation equipment
Suction equipment
Intravenous infusion equipment
Equipment to immobilise limbs and spie (incl. cervical spine)
Sterile dressings
Thoracic drainage equipment/chest decompression equipment
Tracheostomy equipment/surgical airway equipment
Sphygmomanometer and stethoscope
Stretcher
ECG monitor and defibrillator
Pulse oximeter
Drugs for resuscitation and analgesia/IV fluids

5g) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio communication with Race Control and CMO
Visible and audible signals
Equipment to remove suits and helmets
Air conditioning and refrigerator (recommended)

6) VEHICLES TYPE C

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

6a) TYPE OF VEHICLE

6b) PERSONNEL

Rows	YES	NO
Ambulance personnel or paramedics or equivalent
Driver
First aider

6c) MEDICAL EQUIPMENT

Rows	YES	NO
Stretcher
Oxygen supply
Equipment to immobilise limbs and spie (incl. cervical spine)
First aid medicaments and materials

6d) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio communication with Race Control and CMO
Visible and audible signals

7) MEDICAL GROUND POSTS

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

7a) POSITIONS

Rows	YES	NO
Do positions conform to map of circuit/posts?

7b) MEDICAL EQUIPMENT

Rows	YES	NO
Equipment for initiating resuscitation and emergency treatment
Initial airway management
Ventilatory support
Haemorrhage control & circulatory support
Cervical collar
Extrication device - scoop stretcher or spinal board or equivalent

7c) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio communication with Race Control and CMO
Adequate shelter for staff and equipment and ground post staff

7d) OTHER EQUIPMENT

Rows	YES	NO
Protective canvas/Tarpaulins

8) PIT LANE GROUND POSTS

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

8a) POSITIONS

Rows	YES	NO
Do positions conform to map of circuit/posts?

8b) PERSONNEL

Rows	YES	NO
Doctor, paramedic or equivalent experienced in emergency care
Stretcher bearers

8c) MEDICAL EQUIPMENT

Rows	YES	NO
Airway management and intubation equipment
Drugs for resuscitation and analgesia/IV fluids
Cervical collars
Manual respiration system
Intravenous infusion equipment
First aid equipment
Scoop stretcher or spinal board or equivalent

8d) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio communication with Race Control and CMO

9) MEDICAL CENTRE

Rows	YES	NO
Is a medical centre available at this circuit as per Medical Code?
Is it a permanent structure?
Is it less than 10 mins from any part of the circuit?
Secure environment from which media and public can be excluded
Area easily accessible by first aid vehicles
Helicopter landing area nearby
One or two rooms large enough to allow resuscitation of at least two severely injured riders simultaneously (resuscitation area)
X-ray room or portable digital x-ray machine
A room large enough to treat more than one rider with minor injuries simultaneously
Temporary separation in this area, e.g., curtains or screens
Reception and waiting area
Doctor's room
Toilet and shower room with disabled access
A staff changing room with male and female toilets
Medical staff room for 12 or more persons
Radio communication with Race Control, the CMO, ambulances and ground posts
If the medical centre has normal electric power supply, it must also be permanently connected to its own U.P.S. (Uninterruptible Power Supply)
Water supply, heating, air-conditioning and sanitation appropriate to the country
Closed circuit TV
Office facilities
Dirty utility room
Equipment storage
Security fence
Telephones
Security guard
Parking for ambulances

9a) ROOM REQUIREMENTS

Rows	YES	NO
1 resuscitation room
2 resuscitation rooms
Entrance separate to entrance for general public
Minor treatment room
X-ray room
Medical saff room
Wide corridors and doors to move patients on trolleys

9b) EQUIPMENT FOR RESUSCITATION AREAS

Rows	YES	NO
Equipment for endotracheal intubation, tracheostomy and ventilation support including suction, oxygen and anaesthetic agents
Equipment for intravenous access including cut down and central venous cannulation and fluids including colloid plasma expanders and crystalloid solutions
Intercostal drainage equipment
Equipment for cardiac monitoring and resuscitation, including ECG monitoring, defibrillation and blood pressure measurement
Equipment for immobilising the spine at all levels
Equipment for the splinting of limb fractures
Drugs/IV fluids including analgesia, sedating agents, anticonvulsants, paralysing and anaesthetic agents, cardiac resuscitation drugs/IV fluids
Tetanus toxoid and broad spectrum antibiotics (recommended)
Equipment for diagnostic ultrasound
Digital X-ray (compulsory)

9c) EQUIPMENT FOR MINOR INJURIES AREA

Rows	YES	NO
The area must have beds, dressings, suture, equipment and fluids to treat up to three riders with minor injuries simultaneously.
Sufficient stocks to replenish the area during the event (compulsory)
Sufficient doctors, nurses, and paramedics or equivalent experienced in treating trauma

9d) OTHER FACILITY FOR TREATMENT

Rows	YES	NO
Is there another facility (e.g., room, container or tent, etc.) for treatment of injured riders?

9e) PLEASE DESCRIBE/SPECIFY - only if there is no medical centre

10) NUMBER OF MEDICAL CENTRE PERSONNEL

Rows	Thursday	Friday	Saturday	Sunday	Monday
Doctor
Nurse
Paramedic or equivalent
First aider
Other medical personnel
Stretcher bearer
Driver
Total medical centre personnel

10a) SPECIALISTS AT MEDICAL CENTRE

Rows	YES	NO
1. Surgeon experienced in trauma
2. Trauma resuscitation specialist

10b) OTHER SPECIALISTS

Rows	SPECIALTY
3.
4.
5.
6.
7.

11) RACES WITH CHILDREN (15 years and under) - Art. 09.8

Rows	YES	NO
Doctor expert in paediatric trauma
Equipment, monitoring devices and medications suitable for children

12) VEHICLES FOR TRANSPORT TO HOSPITAL

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

13) HELICOPTERS WITH MEDICAL EQUIPMENT

Rows	Thursday	Friday	Saturday	Sunday	Monday
Number

13a) MEDICAL EQUIPMENT

Rows	YES	NO
Fluids and drugs
Respirator
Oxygen
ECG/defibrillator

13b) NUMBER OF PERSONNEL

Rows	Thursday	Friday	Saturday	Sunday	Monday
Doctor
Paramedic or equivalent
Pilot

14) CLOTHING OF MEDICAL PERSONNEL AS PER MEDICAL CODE

Rows	YES	NO
Doctor
Nurses, paramedics or equivalent

15) MEDICAL PERSONNEL FOR SPECTATORS

Rows	YES	NO
Is there separate medical personnel for spectators?

15a) PERSONNEL

Rows	Thursday	Friday	Saturday	Sunday	Monday
Doctor
Nurse
Paramedic or equivalent
Other medical personnel
First aider
Stretcher bearer
Driver
Total medical personnel

16) ANTI-DOPING

Rows	YES	NO
Are there anti-doping facilities?

16a) PLEASE DESCRIBE THE LOCATION OF THE DOPING CONTROL STATION

16b)

Rows	YES	NO
Are chaperones available on site for the doping control officers?
Is a waiting area with seating available for the riders?
Are sealed bottles of still water available for the riders?

17a) HOSPITALS

Rows	Name
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoracic surgery
Burns/plastic surgery
Vascular surgery
Micro surgery
Paediatric trauma

17b) HOSPITALS

Rows	Address-GPS Coord./Google map link & Telephone N°
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoracic surgery
Burns/plastic surgery
Vascular surgery
Micro surgery
Paediatric trauma

17c) HOSPITALS

Rows	Distance (km)	Time to hospital by road (min)	Time to hospital by air (min)	Contact person
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoracic surgery
Burns/plastic surgery
Vascular surgery
Micro surgery
Paediatric trauma

17d)

Rows	YES	NO
CTI scan
MRI

18) MAPS

Rows	YES	NO
A route map is enclosed

19) CIRCUIT CMO QUESIONNAIRE

Rows	YES	NO
This questionnaire has been completed by the CMO

20) REMARKS

21) FILE UPOLAD (maps, etc.)

22) DATE

Date

23) SIGNATURE OF CMO

CIRCUIT CMO QUESTIONNAIRE

This questionnaire must be completed by the Chief Medical Officer (CMO) and returned to the FIM: cmi@fim.ch 2 months prior to the event