Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Daily Fluid Check

  • Checked?

  • Oil

  • Antifreeze

  • Transmission Fluid

  • Break Fluid

  • Windshield Fluid

  • Steering Fluid

  • Daily Fluid Check

Tire Pressures

  • Checked?

  • Drivers Side Front

  • PSI

  • Add media

  • Passenger Front

  • PSI

  • Add media

  • Passenger Rear Outer Tire

  • PSI

  • Add media

  • Passenger Rear Inner Tire

  • PSI

  • Add media

  • Drivers Rear Outer Tire

  • PSI

  • Add media

  • Drivers Rear Inner Tire

  • PSI

  • Add media

  • Treads OK?

Compartment A-1 6 Emesis Basins 6 Bottles NSS 1 ANSI Vest 2 PPE Kits 1 Box Particle Masks 6 Bottles Sterile Water 3 Bags 1000 mL nSS

  • Tag #

  • Add media

Compartment A-2 4 Adult NRB 4 Adult Nasal Cannula 4 Nebulizers 1 Pocket Mask 2 Adult BVM 1 Spare Suction Canister w/tubing 1 Each French 6,8,10,12,14,16,18 Catheters 6 Oral Airways 2 Adult Simple 2 Adult Trach Masks 2 Oxygen Tubing 1 Humidifier Kit 4 Yankauer 6 Surgilube 5 Nasal Airways

  • Tag #

  • Add media

Compartment A-3 1 Pedi Bag

  • Tag #

  • Add media

Compartment A-4 Region 13 MCI Kit 1 NIOSH Book 1 Jane Biohazard Book 1 Current OSHA Book 1 ALS/BLS Protocol Book

  • MCI Bag Tag #

  • Add media

Compartment A-5 1 CPAP Unit 1 CPAP Spare Circuit

  • Tag #

  • Add media

IV Drawer 2 each IV Caths 14,16,18,20,22,24 5 Opsites 1 Bottle Baby Aspirin 2 IV Caps 2 IV Start Kits 1 MAD Device 1 1,000 NSS 1 20 Drip 1 Roll Tape 1 Nitro Spray 2 Flushes 5 Alcohol Wipes 5 2x2's 2 Extension Sets

  • 1 Bottle Baby ASA

  • Baby ASA Expiration Date

  • 1 Bottle Nitro Spray

  • Nitro Spray Expiration Date

  • Missing Items -

  • Add media

Compartment A-6 5 Hot Packs 10 Triangle Bandages 3 Burn Sheets 10 Combine Dressings 1 Box 4x4's 1 Roll Hypo Tape 1 Box Tissues 5 Brown Paper Bags 4 Small Kling 1 Bulb Syringe 10 Non Adhering Dressings 2 OB Kits 3 Oral Glucose 1 Crash Shears 1 Foil Baby Bunting 5 Cold Packs 1 SAM Splint 5 Trauma Dressings 1 Box 2x2's 4 Rolls of Various Tape 10 Drinking Cups 1 Thermometer w Covers 1 Box Band Aids 4 Large Kling 1 Ring Cutter 1 Razor 1 Roll Sterile Aluminum Foil 1 Pen Light 1 Bandage Scissors

  • Tag #'s

  • Add media

Compartment A-7 1 LP 15 Monitor

  • Present and Functioning

  • Self Test Passed?

  • Add media

Monitor Top Pocket - 4 misc cuff sizes (infant,pedi,small,large) Left Pocket - Pulse Ox Cable, Leads, Adult Cuff Right Pocket - Therapy Cables, Pedi Combo Pads, 12 Pedi Electrodes, Roll Paper, 2 ET CO2 Circuits, 1 Nasal ET CO2 Circuit Rear Pocket - 2 Adult Quick Combo Pads, Razor, 12 lead cables, 6 packages adult electrodes, 1 Blue Tooth

  • Battery #1

  • Battery #2

  • Any missing items?

  • Missing Monitor Items

Compartment A-8 1 Spare Monitor Battery 5- 9" Straps 1 Spare Roll Monitor Paper

  • Tag #'s

  • Add media

Compartment A 9 6 Pillow Cases 6 Sheets 6 Towels 6 Blankets

  • Tag #'s

  • Add media

Compartment A-10 Spare Linen 4 Towels 4 Blankets 4 Sheets 4 Pillow Cases

  • Linen Stocked?

  • Add media

Compartment A-11 1 Can Lysol 10+ Biohazard Bags 1 Container Disinfectant Wipes 1 Purrell

  • Tag #'s

  • Add media

Compartment A-12 1 Box Small Non Latex Gloves 1 Box Medium Non Latex Gloves 1 Box Large Non Latex Gloves

  • Gloves Stocked?

Under Airway Seat 1 Bed Pan 1 Urinal

Cockpit

  • Vehicle Inspection Valid

  • Mileage Reading

  • Add media

  • Fuel Level

  • Insurance/Owners Cards

  • Garage Door Opener

  • Map Book

  • GPS Unit

  • Personal CO Detector

  • Accident Pack

  • Non-Latex Gloves Sm,Med,Large,X-Large

  • Dual USB car charger with 2x microUSB cables

  • Tire Pressure Gauge

  • 2 PFD's

  • ALL EMERGENCY LIGHTS WORKING

  • Front Heat and AC Working?

  • Rear Vent Working?

  • Gas Cards Present?

  • Marathon Card Present?

  • UPMC East Card Present

  • Entry Keys/The Oaks/152 Royal Oak Drive?

  • Morning DECON Performed

  • Vehicle Cleaned

  • Interior Rear Lights Working?

  • Any new damage to vehicle

  • Drivers Sider Door ANSI Class II Vest

  • Passenger Side Door ANSI Class II Vest

  • Exterior Vehicle Lights Working? (Head lights,turn signals, etc)

  • MDT with JetPack Present and Functioning?

  • Is Cockpit clean?

Clip Board

  • 15 Patient Forms

  • 5 DOA Forms

  • 5 Refusal Forms

  • 2 Pens

  • 2 White Oak EMS Quick Registration Forms

House Bag/Oxygen/Portable Suction Cabinet

  • Portable Suction Working

  • Spare Battery

  • Canister with Tubing

  • 2 Yankauer's

  • 8 French

  • 10 French

  • 12 French

  • House Bag Top Tag #

  • House Bag Red Medication Seal #

  • House Bag Oxygen PSI

House Bag Front Compartment 1 Nasal Cannula 1 Nonrebreather 1 Nebulizer 1 Stethoscope 1 Adult BP Cuff 1 Pulse Oximeter 1 Glucometer w/ Strips and Lancets

  • All Equipment Present?

  • Missing Equipment?

Left Side Compartment 1 500 mL Bag nSS 1 Macrodrip Set 1 Pressure Infuser

  • All Equipment Present?

  • Missing Equipment?

Right Side Compartment 1 Small Sharps Container 1 Large Adult BP Cuff 1 CO Detector

  • All Equipment Present?

  • Missing Equipment?

Drug Box

  • DRUG BOX TAG #

  • Add media

Under the Bench Seat

  • 1 Spare Pillow

  • 1 Full Arm Splint

  • Half Arm Splint

  • Foot/Ankle Splint

  • Full Leg Splint

  • Half Leg Splint

  • Hand/Wrist Splint

  • 1 Full E Cylinder with CPAP Connection

  • PSI

  • 1 Bottle of Cleaning Wipes

Exterior Rear Passenger Side Compartment

  • Smart Triage/Red Duffle Bag Tag #

  • Add media

  • 1 KED

  • 1 Container Rock Salt (Winter)

Exterior Front Drivers Side Compartment

  • 6 Padded Board Splints (2 of each size)

  • 1 Reeves with a sheet

  • 1 PEDI Immobilizer

  • 1 ADULT/PEDI Traction Splint

Exterior Middle Drivers Side Compartment

  • 2 Hand Lights

  • 2 Helmets

  • 2 sets of turn out gear

Exterior Rear Drivers Side Compartment

  • 1 Scoop Stretcher

  • 2 Long Boards with straps

  • 2 sets of CID's with straps

  • 1 Collar Bag containing 12 collars, 2 of each size

Interior Shelf Area

  • Main Oxygen PSI

  • Add media

  • Suction Working

  • 1 Sealed Yankauer

  • 10 HIPAA Forms

Interior

  • 2 Spare Oxygen Tanks

  • PSI

  • PSI

  • 1 Fire Extinguisher

  • Temperatures of Drug Cabinet in Degrees

  • Add media

  • Rear Patient Area in Degrees

  • Add media

  • Medication Tag Log Book?

  • Crew Member #1

  • Crew Member #2

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.