Daily Fluid Check




Transmission Fluid

Break Fluid

Windshield Fluid

Steering Fluid

Daily Fluid Check

Tire Pressures


Driver's Side Front


Passenger Front


Driver's Rear Tire


Passenger Rear Tire


Treads OK?

Compartment A-1
6 emesis basins
6 bottles Sodium Chloride
3 Bags 1000 mL nSS


Compartment A-2
1 box tissues
6 bottles Sterile Water
1 humidifier kit
1 Purell


Compartment A-3
CPAP (tagged)
2 adult BVM
1 ANSII Class II Vest

CPAP Tag #

Compartment Tag#

Compartment A-4
1 spare CPAP Circuit
1 pocket mask
6 oral airways
5 nasal airways
4 adult NRB
4 adult Nasal Cannula
4 nebulizers
1 spare suction canister with tubing
2 adult simple mask
2 adult trach mask
2 O2 tubing
4 yankauer
1 each French 6,8,10,12,14,16,18 catheters
6 surgilube


Under Airway Seat

1 bedpan

1 urinal

1 traffic hazard kit

Compartment A-5
2 PPE Kits
1 box of N95 masks
3 burn sheets


Compartment A-6
5 trauma dressings
2 OB kits


Compartment A-7
5 hot packs
5 cold packs
1 Sam splint
10 triangular bandages
10 non-adhering dressing
1 roll sterile aluminum foil
5 brown paper bags
3 oral glucose
1 pen light
1 Thermometer with Covers
4 rolls assorted tape
1 roll hypoallergenic tape
1 razor
1 ring cutter
1 bulb syringe
10 drink cups
1 NIOSH book
1 Jane biohazard book
1 current emergency response guidebook


Compartment A-8
10 combine dressings
4 large Kling
4 small Kling
1 box 4x4
1 box 2x2
1 box bandaids
1 crash sheers
1 bandage sheers
1 spare monitor battery
1 roll monitor paper
1 D50 with expiration
5 9' straps


Compartment A-9
Spare linen full

Compartment A-10
1 can Lysol
10 bio bags
1 roll disinfectant wipes

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 Aspirin

Baby ASA expiration date

1 bottle Nitro Spray

Nitro Spray expiration date

Missing items

House Bag/Oxygen/Portable Suction Cabinet

Portable suction working

Spare battery

Canister with tubing

2 Yankauer's

8 French

10 French

12 French

BLS/ALS Protocol Book

House bag top Tag #

House Bag Red Medication Tag #

House Bag Oxygen PSI

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

All Equipment Present?

Missing Equipment?

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

All Equipment Present?

Equipment Missing?

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

All Equipment Present?

Equipment Missing?

Drug Box

Drug box tag #

Under bench seat
2 CID Blocks with straps
1 reeves with sheet
1 Pedi immobilizer
1 Pedi traction splint
1 adult traction splint
1 full arm splint
1 half arm splint
1 foot/ankle splint
1 full leg splint
1 1/2 leg splint
1 hand/wrist splint
6 padded board splints

Pediatric bag seal #

1 spare oxygen cylinder PSI

12 cervical collars (6 various adult & 6 various pedi)

LP 15 Monitor

Present and functioning

Self test passed (tap white border and take photo of self test receipt)

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 cellular transmitter

Battery 1

Battery 2

Any missing items

Missing items

Above side door

Medium gloves

Large gloves

Sharps container

Interior shelf area

Main oxygen PSI

Suction working

1 sealed yankauer

Below bench

2 long boards with straps

1 scoop stretcher

Compartment A-11

1 stair chair


Vehicle inspection valid

Mileage reading

Fuel level

Insurance/owners cards

Garage door opener

Map book

GPS unit

EZ-PASS Present

Personal CO detector

Accident pack

Non-latex gloves S,M,L,Xl

Tire pressure gauge

2 Ballistic Vests

2 PFD's

All emergency lights working

Front heat and A/C working

Rear vent working

Gas cards present

Marathon Card Present

UPMC East card present

Entry keys (the oaks, 152 royal oak dr

Morning DECON performed

Vehicle cleaned

Interior rear lights working

Any new damage to vehicle

Driver's side door ANSI class II vest

Passenger side door ANSI class II vest

Exterior vehicle lights working (head lights, turn signals)

Is cockpit clean


MDT with Jetpack Present and Functioning


15 patient forms

5 DOA forms

5 refusal forms

2 pens

2 White Oak EMS Quick registration forms

10 HIPAA forms


2 spare oxygen tanks

CPAP Cylinder PSI


1 Fire Extinguisher

Temperature of drug cabinet in degrees

Rear patient area temperature

Medication tag log book

Crew member #1
Crew member #2