Title Page
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Conducted on
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Prepared by
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Available for inspection
General Condition
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Overall cleanliness inside and out
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Any leaks or damages
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Belts - condition, tension
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Hoses
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Tires and rims in good condition (All tires inflated to 110 PSI)
Fluids
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Miles
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Hours
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Engine oil (15W40)
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Transmission
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Power steering
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Coolant
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Batteries
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Diesel exhaust fluid
Cab Interior
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Gauges
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Warning lights buzzers
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Controls
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Mirrors
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Interior lights
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Back up camera
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Radios
Chassis
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Suspension
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Steering
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Fuel tank
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Exhaust
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Drive train
Stretcher
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No leaking hydraulic fluid
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No hanging wires
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Manual backup handle working properly
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Frame intact (No cracks, bent bars, etc)
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Wheels free of debris and moving freely
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All hardware secured
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X-frame expands and retracts
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IV pole secured and extends
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Head section extends and retracts
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O2 tank present and secured
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No tears in mattress
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All straps present and free from tears
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Battery is free of debris and cracks
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Spare battery changed, free of debris and cracks
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Charger is not damaged and is clean
Power Load
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No loose bolts or cracks
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Lights all working
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All buttons intact
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Lift arms present and working
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Tested and working properly
Stairchair
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Frame intact, no cracks or bent bars, all hardware secured
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Seat intact, no cracks, debris or fluids, opens and closes
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All handles intact and bottom extends, All straps intact and functional
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Tracks move freely
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Cleaned entire stairchair
Portable Suction
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Turns on with power cord
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Unplugged and works on battery power
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Container, suction tube and yankauer present
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French catheter, gloves and face shield present
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Turn on and pinch line to 300 mmhq in under 5 seconds
Main Suction
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Turn on and pinch line to 300 mmhq in under 5 seconds
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Container, suction tube and yankauer present
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Sanitization completed
