Information
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Conducted on
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Location
Default Section
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Odometer Reading
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Hours
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Fuel Level
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Oil Level
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Misc.
Vehicle Cab
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Gas Card
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Insurance Card
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Door Openers
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Gloves
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Maps
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Notes
Mechanical Check
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Emergency Lights
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Horn/Siren
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Tail/Brake Lights
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Head Lights
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Turn Signals
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Dash Gauges
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Trans Fluid
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Brake Fluid
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Steering fluid
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Coolant
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Tires at 60 PSI
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Notes
Compartment #1 Top
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4 Restraints w/ Straps 2 Packs Posey Restraints 1 OB Kit w/head warmer 6 Cold Packs 6 Hot Packs
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Notes
Compartment #2 Bottom
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1 Pressure Infuser 4 Needle-less Locks 4 10ml Pre-filled Normal Saline Flushes 4 Start Kits 1 Container w/ 2 1ml Syringes 2 3ml Syringes 2 12ml Syringes 2 35ml Syringes 2 18g Safety Needles 2 22g Filter Needles 1 Blood Draw Kit
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Notes
Compartment #3 Bottom
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3 Lactated Ringers 1000ml Bags 3 Normal Saline 1000ml Bags
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Notes
Compartment #3 (Linen)
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8 Sheets 8 Pillowcases
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Notes
Compartment #4 Top Left
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2 Gowns 1 Box TB Masks & Face Shields 2 Safety Glasses/Goggles 1 Burette Set
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Notes
Compartmment #1 Bottom
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6 Trauma Dressings 5 Triangular Bandages 1 Silver Swaddler 2 4'' Coban 8 4" Roller Gauze 20 Alcohol Preps 5 Blankets 3 ABD PADS 2 Vaseline Gauze 1 Box 4x4 Gauze Pads 1 Box 2x2 Gauze Pads
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Notes
Compartment #2
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4 Each 16g, 18g, 20g, and 22g IV Catheters 2 24g IV Catheters 1 2'' Cloth Tape 2 1'' Cloth Tape 2 1" Coban 2 Macro Drip Tubing 2 Micro Drip Tubing
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Notes
Compartment # 4 Bottom Left
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3 Non-Rebreather Masks 3 Nasal Cannulas 1 Pediatric Mask 1 Infant Mask 1 Tracheostomy Mask 2 Yankauer Tip Suction 1 each 8, 10, 14, 18Fr. Suction Catheters 1 Replacement Tubing-Portable Suction 2 Disposable Suction Container 2 Disposable Suction Lid w/ Tubing 1 Combitube
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Notes
Compartment #4 Top Right
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1 Infant BVM 1 Child BVM 1 Adult BVM 2 Chest Seals 2 Decompression Needles 1 CPAP 1 Pertrach 1 Container w/ Oral Airways 40, 60, 80, 90, and 100 Nasal Airways 12-30Fr.
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Notes
Compartment #4 Bottom Right
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1 Pack Adult Electrodes 2 Packs Pediatric Electrodes 1 Adult Fast Patch 1 Pediatric Fast Patch 1 Zoll Monitor Paper 1 each Adult & Pediatric Transducers 5 Nail Polish Remover Pads 2 Neb Kits, w/2 Albuterol 1 BVM Neb Adapter 1 each Adult & Pediatric Aerosol Masks 4 Albuterol (extra) 1 each Adult & Pediatric ET Tube Holder 1 Pocket Mask 1 Cot Battery (spare) 1 Zoll Battery (spare)
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Notes
Compartment #8 Top
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1 Each 7.0, 7.5, 8.0 ET Tubes 1 Each Adult & Pediatric Stylet 1 Spare Monitor Cable 1 Baby Bottle w/Nipple
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Notes
Compartment #6 Bottom
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1 Region 6 Care Guidelines Extra Blankets
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Notes
Compartment #9
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1 Bottle Baby Shampoo 1 Contact Lens Case 1 Oral Thermometer w/cover 1 Nose Clamp 1 Ring Cutter 1 Hemostat 1 Box Glucometer Strips 2 "C" Batteries (spare)
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Notes
Compartment #12
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2 Sterile Water, 1000ml 4 Graduated Cylinders
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Notes
Compartment #10
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1 Box each Small Gloves Medium Gloves Large Gloves
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Notes
Compartment #11
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2 Sterile Burn Sheets
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Notes
Under Bench Seat
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2 Rescue Helmets w/ Goggles 2 Disposable Yellow Blankets 1 Pillow 1 each Bed Pan & Urinal 1 Full Oxygen Cylinder 5 Biohazard Bags 1 Body Bag 1 Child Safety Seat (inflatable)
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Notes
Entry Bag
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Drug Box 1 Dextrose 50% 2 Atropine Sulfate-1mg 2 Lidocaine-100mg 1 Glucagon 3 Epinephrine 1:10,000-1mg 1 Adenosine-6mg 1 Glucose Paste 2 Epinephrine 1:1000 1 Bottle Baby Aspirin 2 Narcan-2mg 2 3ml Syringes 12 Alcohol Preps 2 Amidodarone-150mg 1 Benedryl-50mg 1 Zofran-4mg 1 Nitro Tabs 1 Nitro Spray 1 Terbutaline-1mg 6 Lancets 2 22g Safety Needles 2 Filter Needles
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Pulse Oximetry Bag 4 "AA'' Batteries 4 Nail Polish Remover 1 Pulse Oximeter
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Trauma Pouch (Top Cover) 1 Trauma Bandage 4 ABD Pads 6 4x4's 1 1'' Cloth Tape 1 1" Coban 1 4'' Coban 1 Broselow Pediatric Emergency Tape 3 Refusal Sheets 1 Billing Sheet
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Main Compartment 1 Intubation Bag (Blue) 1 IV Bag (Red) 1 Drug Box 1 Pulse Ox 1 IO Kit 1 Oxygen Cylinder w/regulator
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IV Bag (Red) 1 1'' Coban 1 1" Cloth Tape 1 Trauma Shears 2 12ml Syringes 2 IV Start Kits 1 Blood Draw Kit 2 Saline Flushes 2 Each 16g, 18g, 20g, & 22g IV Catheters 8 4x4's 1 Micro Drip Tubing 1 Macro Drip Tubing 1 50ml D5W 1 250ml NS 2 IV Locks 1 Sharps Shuttle
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Intubation Bag 3 Miller Blades 2 Macintosh Blades 7 Oral Airways 2 12ml Syringes 1 each 2, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, & 8.0 ET Tubes 1 Meconium Aspirator 2 ''C'' Batteries 1 Viscous Lidocaine 1 Intubation Handle 1 1'' Cloth Tape 1 Adult ET TubeHolder 1 Pediatric ET TubeHolder 1 CO2 Detector
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EZ IO Kit 1 EZ IO Drill 2 Adult IO Needles 1 Pediatric IO Needle
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Narcotics Bag Sealed ? SIGNATURE REQURIED
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Right Side Compartment 1 Nebulizer w/Albuterol 1 Adult Aerosol Mask 1 Pediatric Aerosol Mask 1 CPAP
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Left Side Compartment 1 Adult Non-Rebreather Mask 1 Adult Nasal Cannula
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Left Side Rear Compartment 1 Glucometer 1 B/P Cuff 1 Stethescope
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Outside Front Compartment 1 Adult Oxygen Sensor 1 Pediatric Oxygen Sensor 1 Pediatric Oxygen Mask 1 Pediatric BVM 1 Adult BVM
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Notes
Intercept Bag
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Center 1 Dextrose 50%-50ml 1 Lidocaine 2%-100ml 1 Glucagon 1 1000ml NS 1 Micro Drop Tubing 1 Macro Drop Tubing 4 Pre-Filled 0.9 Flushes 1 Sodium Bicarbonate-50ml 1 Procainamide 1 1'' Tape
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Right Side 2 Narcan-2mg 4 Adenosine-6mg 3 Epinephrine 1:10,000-1mg 4 Furosemide or 160mg total 2 Magnesium Sulfate-2gm 1 Amiodarone-150mg 1 Ondansetron-4mg 1 Thiamine-200mg 1 Benadryl-50mg 1 Verapamil-5mg 1 Glucose Paste 1 High-Dose Atropine 1 High Does Epinephrine
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Left Side 1 500ml Hypertonic 3% Saline 1 50ml D5W 1 500ml Lidocaine-2g 1 250ml Dopamine-400mg
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Notes
Exterior Rear Compartment
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2 Backboard w/4 straps 1 Stair Chair w/straps 1 Pediatric Board w/cover 1 Rescue Seat w/cover 1 Bag w/ 2 Adult CIDS 2 Pediatric CIDS 6 Adult C-Collars 4 Pediatric C-Collars 1 Infant C-Collar 2 2" Cloth Tape
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Notes
Zoll Heart Monitor
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Left Pouch 1 Monitor Cable
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Right Pouch 20 Adult Electrodes
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Back Side Pouch 1 Pulse Ox Cable 1 12-Lead EKG Cable 1 Defibrillator Cable 1 Adult Fast Patch 1 Razor 1 Zoll Paper 1 Pediatric Fast Patch 1 Infant Fast Patch 2 packs Pediatric Electrodes 1 Power Cable 1 each Adult & Pediatric Transducers 1 Zoll Battery if not in cabinet
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Front Pouch 1 Auto B/P Cuff
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Notes
Exterior Passenger Side Rear Compartment
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1 Splint Bag w/ 1 Sam Splint 1 Kendrick Splint Set 2 Arm (short & long) 2 Leg (short & long) 1 each wrist & elbow splint 1 KED w/ cover and pillow 1 Sager Splint Set
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Notes
Exterior Driver's Side Front Compartment
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1 Oxygen Cylinder (500 PSI Minimum) 1 Open End Wrench 1 Scoop Stretcher w/three orange straps
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Notes
Repairs/Signature
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Are there any repairs needed?
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Crew Member #1 Signature
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Crew Member #2 Signature