2017 ALS LICENSURE INSPECTION PA

• WOEMS2017LIALSPA

• 2017 ALS LICENSURE INSPECTION PA

• White Oak EMS

• Conducted on

  Date

• Prepared by

• Location
  Address

• Crew 2

• Crew 1

Vehicle Information:

• License Plate:

• WOEMS UNIT #

• Affiliate #

• Exterior Markings intact:<br>

  Yes

  No

  N/A

• Current Vehicle Inspection Expiration:

• Current Vehicle Insurance Expiration:

• Current Vehicle Registration Expiration:

• Fire Extinguisher (2) 5lb ABC:

  Yes

  No

  N/A

• Extinguisher #1 Expiration Date:

• Extinguisher #2 Expiration Date:

• ALL Exterior lights Working:

  Yes

  No

  N/A

• ALL Interior Lights Working:

  Yes

  No

  N/A

Interior Requirements

• Flooring intact & Clean ?

  Yes

  No

  N/A

• General Safety concerns:

  Yes

  No

  N/A

• Patient Compartment / Cab partition ?

  Yes

  No

  N/A

• Storage Cabinets with functioning doors ?

  Yes

  No

  N/A

• All items Secured ?

  Yes

  No

  N/A

• Stretcher & Straps ?

  Yes

  No

  N/A

• Doors with Working hinges, latches & seals ?

  Yes

  No

  N/A

• "No Smoking / Oxygen Equipped" signage (2) Front & Rear ?

  Yes

  No

  N/A

• "Fasten Seat Belts" signage (2) Front & Rear ?

  Yes

  No

  N/A

• UHF Dispatch Radio ?

  Yes

  No

  N/A

• VHF Hospital Radio ?

  Yes

  No

  N/A

• Main O2 with 500psi all 3 straps secure and non sparking wrench ?

  Yes

  No

  N/A

• Main Suction functioning ?

  Yes

  No

  N/A

• Operational HVAC Front & Rear ?

  Yes

  No

  N/A

Medical Equipment:

• Current version EMS Protocols ?

  Yes

  No

  N/A

• Functional Portable Suction ?

  Yes

  No

  N/A

• Suction Catheters Sterile ?

  Yes

  No

  N/A

• Rigid (2)

• 6 French (1)

• 8 French (1)

• 10 or 12 French (2)

• 14 or 16 French (2)

• 6 sizes Oral Airways

• 5 sizes Nasal Airways

• (1) Portable O2 Cylinder 0-25 lpm Secured in vehicle 300psi

• (1) Spare Portable O2 Cylinder Secured

• (1) Adult Nasal Cannula

• (1) Pediatric Nasal Cannula

• (1) High flow mask adult

• (1) High flow mask Pedi

• (1) High flow mask infant

• (1) pocket mask with one way valve & O2 port.

• Humidifier (1)

• BVM Adult

• BVM Child

• BVM infant

• BVM Neonatal

• BP CUFF Adult

• BP CUFF Large

• BP CUFF Child

• Stethoscope Adult

• Stethoscope Pediatric

• Penlight (1)

• (4) Dressings Multi Trauma 10"x30"

• (4) Dressings Occlusive 3"x4"

• (25) Dressings Sterile 3"x3"

• (6) dressing rolls self adhering gauze

• (4) Rolls Tape (1) Hypoallergenic

• Bandage Shears (1)

• (1) Commercial Mechanical Tourniquet

• (1) Lateral Cervical Spine Device

• (1) Long Spine Board

• (1) Short Spine Board

• Collars (1) each Sm Med Lrg & Pedi

• (5) Straps 9' (3 may be speed clips)

• Folding Litter/Collapsible Device (1)

• (1) Traction Splint Adult & Pedi or Combo

• (2) Upper Extremity Splints

• (2) Lower Extremity Splints

• (1) ALS Pediatric Length bases drug dosing tape

• Sterile H2o/NSS 2 Liters

• (4) Cold Packs

• (4) Heat Packs

• (8) Triangular Bandages

• (2) Sterile O.B. Kits

• (1) Bulb Syringe

• (1) Sterile Foil/Thermal Blanket

• (2) Sterile Burn sheets 4'x4'

• (1) Pillow

• (2) Blankets

• (4) Sheets

• (2) Pillow Cases

• (4) Towels

• (1) Disposable Tissues (box)

• (1) Emesis Container

• (1) Bedpan

• (1) Urinal

• (4) Paper Drinking Cups (3oz)

• (1) Emergency BLS jump kit

• (1) Thermometer, Electronic, Digital.

• (3) Instant Glucose Gel 15g (45gram Total)

• (2) Lubrication Water Soluble (2cc)

• (1) CPAP Ventilation Portable Equipment

• (2) CPAP Circuits

• Pulse Oximetry

ALS Equipment

• (2) 2.5 or 3.0 Tube (uncuffed)

• (2) 3.5 or 4.0 Tube (uncuffed)

• (2) 4.5 or 5.0 Tube

• (2) 5.5 or 6.0 Tube

• (2) 6.5 or 7.0 Tube

• (2) 7.5 or 8.0 Tube

• (2) 8.5 or 9.0 Tube

• Laryngoscopes Handle with batteries

• Spare Batteries & Bulbs

• Straight Blade #1

• Straight Blade #2

• Straight Blade #3

• Curved Blade #3

• Curved Blade #4

• (1) Adult Stylette Malleable

• (2) Pediatric Stylettes Malleable

• (1) Forceps, Magill, Adult

• (1) Forceps, Magill, Pediatric

• (1) King #3

• (1) King #4

• (1) King #5

• (1) Cric Set Sterile

• (1) Meconium Aspirator

• (1) Nebulizer

• Phlebotomy Equipment per Protocol

• (10) Alcohol Wipes

• Glucose Meter

• (4) 14ga IV

• (4) 16ga IV

• (4) 18ga IV

• (4) 20ga IV

• (4) 22ga IV

• (4) 24ga IV

• (2) Micro Drip

• (2) Macro Drip

• (2) Tourniquets ( for IV use)

• Adenosine

• ASA

• Atropine

• Diazepam

• Midazolam

• Albuterol

• Ipratropium Bromide

• Dextrose

• Diphenhydramine

• Epi 1:1,000

• Epi 1:10,000

• Lidocaine hcl

• Naloxone

• Fentanyl

• Mso4

• Nitro

• IV Solution 2,000 total

• Sodium Bicarbonate

• (4) Needles 16-18ga

• (4) Neddles 20-22ga

• (4) Neddles 23-25ga

• (2) IO NEEDLES (14-18ga)

• (2) Syringes (at least 1 being 1ml)

• (1) Monitor/Defibrillator w/ 12 Lead, Pacing & Transmit Capabilities.

• Adult Defibrillator Pads

• Pedi Defibrillator Pads

• Spare Paper

• (6) Electrodes Adult

• (6) Electrodes Pedi

• Capnography

P.P.E.

• (2) Hand Lights

• (3) Hazard Warning Device

• (3) Hi Vis Vest

• (2) Helmets

• (2)pr Gloves, Leather, Work.

• (3) Eye Protection

• (20) Triage Tags

• (1) DOT ERG current

• (2) eye protection

• (2) face masks

• (2) gown

• (2) surgical cap/footies

• (2)pr exam gloves

• (1) Biological Waste Container

• (6) red bags for container

• (1) Sharps Container

• (6) N-95 Masks

• (1) Hand Disinfectant/ Cleaner, Non Water

Ensure ALL dates are current, not just on the minimum required amount but all items. Everything in the Ambulance is subject to Inspection. Sign Below When Complete. Export to bknight@whiteoakems.com 640C2

• Crew 2

  Sign

• Crew 1

  Sign

• Date & Time Complete

  Date

• Deficiencies Found

  Media

• Deficiencies Found

  Media

• Deficiencies Found

  Media

• Deficiencies Found

  Media