Ambulance 2

• Conducted on

  Date

• Prepared by

• Location
  Address

• How many full portable oxygen tanks?

• How many empty portable oxygen tanks?

• Pressure of main tank?

Airway

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

Trauma

• Yes

  No

  N/A

Vitals

• Is blood pressure cuff operable?

  Pass

  Fail

  N/A

• Is pulse ox operable?

  Pass

  Fail

  N/A

• Adult, pediatrics, and infant blood pressure cuffs?

  Yes

  No

  N/A

• Is glucometer working? Stocked: lancets, alcohol wipes, gauze pads and bandaids?

  Yes

  No

  N/A

Patient compartment

• How many stretcher covers?

• How many blankets?

• How many pillows?

Safety equipment

• How many biohazard bags?

• Safety goggles?

• How many face shields ?

• How many N95s?

• How many gowns?

• How many surgical masks?

• Paper towels and sanitizing spray?

• Sanitizing wipes?

Action tray

• Portable suction functional?

  Pass

  Fail

  N/A

• Protocol book present?

  Yes

  No

  N/A

• Small, medium and large gloves?

  Yes

  No

  N/A

Stretcher

• Is stretcher functional?

  Yes

  No

  N/A

• Portable oxygen tank pressure?

• Stretcher batteries charged?

  Yes

  No

  N/A

• Oxygen cylinder wrench present?

  Yes

  No

  N/A

• Surgical masks?

  Yes

  No

  N/A

• Yes

  No

  N/A