Information

  • Conducted on

  • Location

Default Section

  • Odometer Reading

  • Hours

  • Fuel Level

  • Oil Level

  • Misc.

Vehicle Cab

  • Gas Card

  • Insurance Card

  • Door Openers

  • Gloves

  • Maps

  • Notes

Mechanical Check

  • Emergency Lights

  • Horn/Siren

  • Tail/Brake Lights

  • Head Lights

  • Turn Signals

  • Dash Gauges

  • Trans Fluid

  • Brake Fluid

  • Steering fluid

  • Coolant

  • Tires at 60 PSI

  • Notes

Compartment #1 Top

  • 4 Restraints w/ Straps 2 Packs Posey Restraints 1 OB Kit w/head warmer 6 Cold Packs 6 Hot Packs

  • Notes

Compartment #2 Bottom

  • 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

  • Notes

Compartment #3 Bottom

  • 3 Lactated Ringers 1000ml Bags 3 Normal Saline 1000ml Bags

  • Notes

Compartment #3 (Linen)

  • 8 Sheets 8 Pillowcases

  • Notes

Compartment #4 Top Left

  • 2 Gowns 1 Box TB Masks & Face Shields 2 Safety Glasses/Goggles 1 Burette Set

  • Notes

Compartmment #1 Bottom

  • 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

  • Notes

Compartment #2

  • 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

  • Notes

Compartment # 4 Bottom Left

  • 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

  • Notes

Compartment #4 Top Right

  • 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.

  • Notes

Compartment #4 Bottom Right

  • 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)

  • Notes

Compartment #8 Top

  • 1 Each 7.0, 7.5, 8.0 ET Tubes 1 Each Adult & Pediatric Stylet 1 Spare Monitor Cable 1 Baby Bottle w/Nipple

  • Notes

Compartment #6 Bottom

  • 1 Region 6 Care Guidelines Extra Blankets

  • Notes

Compartment #9

  • 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)

  • Notes

Compartment #12

  • 2 Sterile Water, 1000ml 4 Graduated Cylinders

  • Notes

Compartment #10

  • 1 Box each Small Gloves Medium Gloves Large Gloves

  • Notes

Compartment #11

  • 2 Sterile Burn Sheets

  • Notes

Under Bench Seat

  • 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)

  • Notes

Entry Bag

  • 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

  • Pulse Oximetry Bag 4 "AA'' Batteries 4 Nail Polish Remover 1 Pulse Oximeter

  • 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

  • Main Compartment 1 Intubation Bag (Blue) 1 IV Bag (Red) 1 Drug Box 1 Pulse Ox 1 IO Kit 1 Oxygen Cylinder w/regulator

  • 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

  • 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

  • EZ IO Kit 1 EZ IO Drill 2 Adult IO Needles 1 Pediatric IO Needle

  • Narcotics Bag Sealed ? SIGNATURE REQURIED

  • Right Side Compartment 1 Nebulizer w/Albuterol 1 Adult Aerosol Mask 1 Pediatric Aerosol Mask 1 CPAP

  • Left Side Compartment 1 Adult Non-Rebreather Mask 1 Adult Nasal Cannula

  • Left Side Rear Compartment 1 Glucometer 1 B/P Cuff 1 Stethescope

  • Outside Front Compartment 1 Adult Oxygen Sensor 1 Pediatric Oxygen Sensor 1 Pediatric Oxygen Mask 1 Pediatric BVM 1 Adult BVM

  • Notes

Intercept Bag

  • 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

  • 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

  • Left Side 1 500ml Hypertonic 3% Saline 1 50ml D5W 1 500ml Lidocaine-2g 1 250ml Dopamine-400mg

  • Notes

Exterior Rear Compartment

  • 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

  • Notes

Zoll Heart Monitor

  • Left Pouch 1 Monitor Cable

  • Right Pouch 20 Adult Electrodes

  • 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

  • Front Pouch 1 Auto B/P Cuff

  • Notes

Exterior Passenger Side Rear Compartment

  • 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

  • Notes

Exterior Driver's Side Front Compartment

  • 1 Oxygen Cylinder (500 PSI Minimum) 1 Open End Wrench 1 Scoop Stretcher w/three orange straps

  • Notes

Repairs/Signature

  • Are there any repairs needed?

  • Crew Member #1 Signature

  • Crew Member #2 Signature

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.