Ambulance 1 Weekly Check

• Conducted on

  Date

• Prepared by

• Available for inspection

  Yes

  No

  N/A

General Condition

• Overall cleanliness inside and out

  Good

  Fair

  Poor

  N/A

• Any leaks or damages

  Yes

  No

  N/A

• Belts - condition, tension

  Yes

  No

  N/A

• Hoses

  Yes

  No

  N/A

• Tires and rims in good condition (All tires inflated to 110 PSI)

  Yes

  No

  N/A

Fluids

• Miles

  Yes

  No

  N/A

• Hours

  Yes

  No

  N/A

• Engine oil (15W40)

  Yes

  No

  N/A

• Transmission

  Yes

  No

  N/A

• Power steering

  Yes

  No

  N/A

• Coolant

  Yes

  No

  N/A

• Batteries

  Yes

  No

  N/A

• Diesel exhaust fluid

  Yes

  No

  N/A

Cab Interior

• Gauges

  Yes

  No

  N/A

• Warning lights buzzers

  Yes

  No

  N/A

• Controls

  Yes

  No

  N/A

• Fuel level

• Mirrors

  Yes

  No

  N/A

• Interior lights

  Yes

  No

  N/A

• Back up camera

  Yes

  No

  N/A

• Radios

  Yes

  No

  N/A

Chassis

• Suspension

  Yes

  No

  N/A

• Steering

  Yes

  No

  N/A

• Fuel tank

  Yes

  No

  N/A

• Exhaust

  Yes

  No

  N/A

• Drive train

  Yes

  No

  N/A

Stretcher

• No leaking hydraulic fluid

  Yes

  No

  N/A

• No hanging wires

  Yes

  No

  N/A

• Manual backup handle working properly

  Yes

  No

  N/A

• Frame intact (No cracks, bent bars, etc)

  Yes

  No

  N/A

• Wheels free of debris and moving freely

  Yes

  No

  N/A

• All hardware secured

  Yes

  No

  N/A

• X-frame expands and retracts

  Yes

  No

  N/A

• IV pole secured and extends

  Yes

  No

  N/A

• Head section extends and retracts

  Yes

  No

  N/A

• O2 tank present and secured

  Yes

  No

  N/A

• No tears in mattress

  Yes

  No

  N/A

• All straps present and free from tears

  Yes

  No

  N/A

• Battery is free of debris and cracks

  Yes

  No

  N/A

• Spare battery changed, free of debris and cracks

  Yes

  No

  N/A

• Charger is not damaged and is clean

  Yes

  No

  N/A

Power Load

• No loose bolts or cracks

  Yes

  No

  N/A

• Lights all working

  Yes

  No

  N/A

• All buttons intact

  Yes

  No

  N/A

• Lift arms present and working

  Yes

  No

  N/A

• Tested and working properly

  Yes

  No

  N/A

Stairchair

• Frame intact, no cracks or bent bars, all hardware secured

  Yes

  No

  N/A

• Seat intact, no cracks, debris or fluids, opens and closes

  Yes

  No

  N/A

• All handles intact and bottom extends, All straps intact and functional

  Yes

  No

  N/A

• Tracks move freely

  Yes

  No

  N/A

• Cleaned entire stairchair

  Yes

  No

  N/A

Portable Suction

• Turns on with power cord

  Yes

  No

  N/A

• Unplugged and works on battery power

  Yes

  No

  N/A

• Container, suction tube and yankauer present

  Yes

  No

  N/A

• French catheter, gloves and face shield present

  Yes

  No

  N/A

• Turn on and pinch line to 300 mmhq in under 5 seconds

  Pass

  Fail

  N/A

Main Suction

• Turn on and pinch line to 300 mmhq in under 5 seconds

  Pass

  Fail

  N/A

• Container, suction tube and yankauer present

  Yes

  No

  N/A

• Sanitization completed

  Yes

  No

  N/A