647 Ambulance Truck Check

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Daily Fluid Check

• Checked?

  Yes

  No

  N/A

• Oil

  Full

  Low

• Antifreeze

  Full

  Low

• Transmission Fluid

  Full

  Low

• Break Fluid

  Full

  Low

• Windshield Fluid

  Full

  Low

• Steering Fluid

  Full

  Low

Tire Pressures

• Checked?

  Yes

  No

  N/A

• Drivers Side Front

  Checked

  Not Checked

• PSI

• Passenger Front

  Checked

  Not Checked

• PSI

• Drivers Rear Tire

  Checked

  Not Checked

• PSI

• Drivers Inner Tire Pressure

  Checked

  Not Checked

• PSI

• Passenger Rear Tire

  Checked

  Not Checked

• PSI

• Passenger Inner Tire Pressure

  Checked

  Not Checked

• PSI

• Treads OK?

  Safe

  At Risk

  N/A

Compartment A-1 6 Emesis Basins 1 Current OSHA Book 1 Jane Biohazard Book 6 Bottles NSS 1 ANSI Vest 2 PPE Kits 1 NIOSH Book 1 Box Particle Masks 6 Bottles Sterile Water

• Tag #'s

• Add media

  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 #'s

• Add media

  Media

Shelf A-3 2 - Blankets 2 - Sheets

• Linen Stocked?

  Yes

  No

  N/A

• Add media

  Media

Compartment A-4 Pedi Bag Trauma Bag 1 CPAP Unit 1 CPAP Spare Circuit

• Pedi Bag Tag #

• Trauma Bag Tag #

• C-PAP Tag #

• C-PAP Spare Circuit

  Yes

  No

  N/A

• Add media

  Media

Compartment A-5 6 -Pillow Cases 6 - Sheets 6 - Towels 6 - Blankets

• Tag #'s

• Add media

  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

  Media

Interior Shelf Area

• Main Oxygen PSI

• Suction Working

  Yes

  No

  N/A

• Suction Canister w/tubing

  Yes

  No

  N/A

• 1 - Yankauer

  Yes

  No

  N/A

• ALS Protocol Book

  Yes

  No

  N/A

• Add media

  Media

Compartment A-7

• 1 - Box Non-Latex Gloves

  Yes

  No

  N/A

• 1 Box Large Non-Latex Gloves

  Yes

  No

  N/A

• Add media

  Media

Compartment A-8

• Tag #

• Spare ANSI Vest

  Yes

  No

  N/A

• Add media

  Media

Compartment A 9 2 - Boxes Small Non-Latex Gloves 1 - IV Kit 3 - Each IV Caths 14,16,18,20,22,24 5 - OP Sites 1 - Bottle Baby ASA 3 - Flushes 2 - IV Start Kits 1 - 500 NSS 1 - 20 Drip 1 - Roll Tape 1 - Nitro Spray 2 - Extension Sets 5 - Alcohol Wipes

• 2 Boxes Small Non-Latex Gloves

  Yes

  No

  N/A

• 1 Bottle Baby ASA

  Yes

  No

  N/A

• Baby ASA Expiration Date

• 1 Bottle Nitro Spray

  Yes

  No

  N/A

• Nitro Spray Expiration Date

• 1 IV Kit

  Yes

  No

  N/A

• Add media

  Media

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

• Tag #

• Add media

  Media

Under Airway Seat

• 1 - Bed Pan

  Yes

  No

  N/A

• 1 - Urinal

  Yes

  No

  N/A

• Add media

  Media

Interior

• 2 - Full Oxygen Tanks (one w regulator)

• 2 - Flashlights

  Yes

  No

  N/A

• 1 - Fire Extinguisher

  Yes

  No

  N/A

• 1 - Long Board w Straps

  Yes

  No

  N/A

• 1 - Cooler with Saline

  Yes

  No

  N/A

• Drug Box Tag #

• Add media

  Media

Cockpit

• Vehicle Inspection Valid

  Yes

  No

  Near Expiration

• Mileage Reading

• Add media

  Media

• Fuel Level

  Full

  3/4

  1/2

  1/4

  Empty

• Insurance/Owners Cards

  Yes

  No

  N/A

• Garage Door Opener

  Yes

  No

  N/A

• Map Book

  Yes

  No

  N/A

• GPS Unit

  Yes

  No

  N/A

• Personal CO Detector

  Yes

  No

  N/A

• Accident Pack

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Nextel with Charger in Cab

  Yes

  No

  N/A

• Tire Pressure Gauge

  Yes

  No

  N/A

• 2 PFD's

  Yes

  No

  N/A

• MCI Kit Behind Passenger Seat

  Yes

  No

  N/A

• ALL EMERGENCY LIGHTS WORKING

  Yes

  No

  N/A

• Front Heat and AC Working?

  Yes

  No

  N/A

• Rear Vent Working?

  Yes

  No

  N/A

• Gas Cards Present?

  Yes

  No

  N/A

• UPMC East Card Present

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Morning DECON Performed

  Yes

  No

  N/A

• Vehicle Cleaned

  Yes

  No

  N/A

• Interior Rear Lights Working?

  Yes

  No

  N/A

• Any new damage to vehicle

  Yes

  No

• Drivers Sider Door ANSI Class II Vest

  Yes

  No

  N/A

• Passenger Side Door ANSI Class II Vest

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is Cockpit clean?

  Yes

  No

  N/A

Clip Board

• 15 Patient Forms

  Yes

  No

  N/A

• 5 DOA Forms

  Yes

  No

  N/A

• 5 Refusal Forms

  Yes

  No

  N/A

• 2 Pens

  Yes

  No

  N/A

• 2 White Oak EMS Quick Registration Forms

  Yes

  No

  N/A

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

  Full

  3/4

  1/2

  1/4

  Empty

• Battery #2

  Full

  3/4

  1/2

  1/4

  Empty

• Self Test Passed

  Yes

  No

  N/A

House Bag/Oxygen/Portable Suction Cabinet

• Portable Suction Working

  Yes

  No

  N/A

• Spare Battery

  Yes

  No

  N/A

• Canister with Tubing

  Yes

  No

  N/A

• 2 Yankauer's

  Yes

  No

  N/A

• 8 French

  Yes

  No

  N/A

• 10 French

  Yes

  No

  N/A

• 12 French

  Yes

  No

  N/A

• House Bag Top Tag #

• Front Tag #

• Right Tag #

• Left Tag #

• Back Tag #

• Red Seal in Tact

  Yes

  No

  N/A

Oxygen Bag 1 NRB 1 Nasal Cannula 1 Nebulizer 1 Glucometer w Supplies 2 Albuterol's 2 Atrovent

• Oxygen PSI

• Add media

  Media

• Pulse Ox Present and Working

  Yes

  No

  N/A

• Stethoscope

  Yes

  No

  N/A

• BP Cuff

  Yes

  No

  N/A

• Personal CO Detector Present & Working

  Yes

  No

  N/A

• Any items missing?

  Yes

  No

• Missing Items

• DRUG BOX TAG #

• Add media

  Media

Under the Bench Seat

• 1 - Hare Traction Splint

  Yes

  No

  N/A

• 1 - Pedi Hare Traction Splint

  Yes

  No

  N/A

• 1 - Pedi Immobilizer

  Yes

  No

  N/A

• 1 Spare Pillow

  Yes

  No

  N/A

• 1 Full Arm Splint

  Yes

  No

  N/A

• Half Arm Splint

  Yes

  No

  N/A

• Foot/Ankle Splint

  Yes

  No

  N/A

• Full Leg Splint

  Yes

  No

  N/A

• Half Leg Splint

  Yes

  No

  N/A

• Hand/Wrist Splint

  Yes

  No

  N/A

• 1 Full E Cylinder with CPAP Connection

  Yes

  No

  N/A

• PSI

• 1 - Case Bottled Water

  Yes

  No

  N/A

• 1 Bottle of Cleaning Wipes

  Yes

  No

  N/A

Exterior Rear Passenger Side Compartment

• Tool Box Tag #

• Add media

  Media

• Smart Triage/Red Duffle Bag Tag #

• Add media

  Media

• 1 Chemical Approach Duffle Kit

  Yes

  No

  N/A

• 1 Case Bottled Water

  Yes

  No

  N/A

Exterior Front Drivers Side Compartment

• 6 Padded Board Splints (2 of each size)

  Yes

  No

  N/A

• 1 Reeves Stretcher

  Yes

  No

  N/A

• 1 - KED

  Yes

  No

  N/A

Exterior Middle Drivers Side Compartment

• 2 Helmets

  Yes

  No

  N/A

• 2 sets of turn out gear

  Yes

  No

  N/A

Exterior Rear Drivers Side Compartment

• 1 Long Board with straps

  Yes

  No

  N/A

• 1 - Stairchair

  Yes

  No

  N/A

• 1 Scoop Stretcher

  Yes

  No

  N/A

• 2 sets of CID's with straps

  Yes

  No

  N/A

• 1 Collar Bag containing 6 collars, 1 of each size

  Yes

  No

  N/A

• 5 - 9ft straps on door

  Yes

  No

  N/A

Collars on Door

• Infant

  Yes

  No

  N/A

• Pedi

  Yes

  No

  N/A

• No Neck

  Yes

  No

  N/A

• Short

  Yes

  No

  N/A

• Regular

  Yes

  No

  N/A

• Tall

  Yes

  No

  N/A

ALS Drawer

• Monitor Battery

  Yes

  No

  N/A

• Monitor Paper

  Yes

  No

  N/A

• MAD Device

  Yes

  No

  N/A

• 1000 NSS

  Yes

  No

  N/A

• 20 Drip

  Yes

  No

  N/A

• 2 - Flushes

  Yes

  No

  N/A

• 2 - IV Caps

  Yes

  No

  N/A

• D-50

  Yes

  No

  N/A

• D-50 Expiration Date

• Alcohol Wipes

  Yes

  No

  N/A

• 2 - Nebulizers

  Yes

  No

  N/A

• 2 - NRB

  Yes

  No

  N/A

• 2 - Nasals

  Yes

  No

  N/A

IV Caths

• 2 - 20ga

  Yes

  No

  N/A

• 2 - 18ga

  Yes

  No

  N/A

• Lancets

  Yes

  No

  N/A

• Arm Board

  Yes

  No

  N/A

• Electrodes

  Yes

  No

  N/A

• Tape

  Yes

  No

  N/A

• OpSites

  Yes

  No

  N/A

• 4 - Albuterol

  Yes

  No

  N/A

• IV Start Kit

  Yes

  No

  N/A

• IV Extension Set

  Yes

  No

  N/A

• 1 - Cold Pack

  Yes

  No

  N/A

MORNING DECON

• Morning DECON Performed

  Yes

  No

  N/A

• Truck Clean

  Yes

  No

  N/A

• New Damage

  Yes

  No

• Exterior Lights Working

  Yes

  No

  N/A

Temperatures

• Drug Cabinet Degrees

• Cooler Degrees

  Yes

  No

  N/A

• Rear Patient Area Degrees

  Yes

  No

  N/A

• Comments/Deficiencies/Suggestions

• Crew Member #1

  Sign

• Crew Member #2

  Sign