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

• Daily Fluid Check

  Passed

  Failed

  Did Not Check

Tire Pressures

• Checked?

  Checked

  Not Checked

• Drivers Side Front

  Checked

  Not Checked

• PSI

• Add media

  Media

• Passenger Front

  Checked

  Not Checked

• PSI

• Add media

  Media

• Drivers Rear Tire

  Checked

  Not Checked

• PSI

• Add media

  Media

• Passenger Rear Tire

  Checked

  Not Checked

• PSI

• Add media

  Media

• 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 #

• 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 #

• Add media

  Media

Compartment A-3 1 Pedi Bag

• Tag #

• Add media

  Media

Compartment A-4 1 Trauma Bag

• Tag #'s

• Add media

  Media

Compartment A-5 1 CPAP Unit 1 CPAP Spare Circuit

• Tag #

• Add media

  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

  Yes

  No

  N/A

• Baby ASA Expiration Date

• 1 Bottle Nitro Spray

  Yes

  No

  N/A

• Nitro Spray Expiration Date

• Missing Items -

• 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

Compartment A-7 1 LP 15 Monitor

• Present and Functioning

  Yes

  No

  N/A

• Self Test Passed?

  Yes

  No

  N/A

• Add media

  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

  Full

  3/4

  1/2

  1/4

  Empty

• Battery #2

  Full

  3/4

  1/2

  1/4

  Empty

• Any missing items?

  Yes

  No

• Missing Monitor Items

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

• Tag #'s

• D-50

• Expiration Date

• Add media

  Media

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

• Tag #'s

• Add media

  Media

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

• Linen Stocked?

  Yes

  No

  N/A

• Add media

  Media

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

• Tag #'s

• Add media

  Media

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

• Gloves Stocked?

  Yes

  No

  N/A

Under Airway Seat 1 Bed Pan 1 Urinal

• Yes

  No

  N/A

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

• Dual USB car charger with 2x microUSB cables<br>

  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

• Tire Pressure Gauge

  Yes

  No

  N/A

• 2 PFD's

  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

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

• 1 MCI Kit

  Yes

  No

  N/A

• House Bag Top Tag#

• Add media

  Media

• Front Tag #

• Add media

  Media

• Right Tag #

• Add media

  Media

• Left Tag #

• Add media

  Media

• Back Tag #

• Add media

  Media

• 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

• DRUG BOX TAG #

• Add media

  Media

Under the Bench Seat

• 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 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 KED

  Yes

  No

  N/A

• Container of Rock Salt (Winter)

Exterior Front Drivers Side Compartment

• 6 Padded Board Splints (2 of each size)

  Yes

  No

  N/A

• 1 Reeves with a sheet

  Yes

  No

  N/A

• 1 PEDI Immobilizer

  Yes

  No

  N/A

• 1 PEDI Traction

  Yes

  No

  N/A

• 1 Adult Traction

  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

• 2 Long Boards with straps

  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 12 collars, 2 of each size

  Yes

  No

  N/A

Interior Shelf Area

• Main Oxygen PSI

• Add media

  Media

• Suction Working

  Yes

  No

  N/A

• 1 Sealed Yankauer

  Yes

  No

  N/A

• 10 HIPAA Forms

  Yes

  No

  N/A

• 1 ALS Protocol Book

  Yes

  No

  N/A

Interior

• 2 Spare Oxygen Tanks

  Yes

  No

  N/A

• 2 Hand Lights & Working

  Yes

  No

• PSI

• PSI

• Stretcher - Clean and operational with no defects

  Yes

  No

• Stair Chair - Clean and operational with no defects

  Yes

  No

• 1 Fire Extinguisher

  Yes

  No

  N/A

• 1 Saline Cooler

  Yes

  No

  N/A

• Temperatures of Drug Cabinet in Degrees

• Add media

  Media

• Cooler

• Add media

  Media

• Rear Patient Area

• Add media

  Media

• Crew Member #1

  Sign

• Crew Member #2

  Sign