Ambulance Daily Inspection Form

• Samaritan Base

  TAFB

  Stroud

  Stillwell

• Unit inspection Date/Time

  Date

• Prepared by

General Vehicle Condition

• Is the exterior of the vehicle clean and free of damage?

  Yes

  No

  N/A

• If damage is noted please take a photo of the damaged area?

  Media

• Is the interior cab of the truck clean and free off damage?

  Yes

  No

  N/A

• If there is damage noted in the cab of the truck please take a picture.

  Media

• Is the patient compartment clean and free of damage?

  Yes

  No

  N/A

• If damage is noted in the patient compartment please take a picture.

  Media

• Protocol book on unit?

  Yes

  No

  N/A

Fuel and general engine fluids check

• Fuel level at checkout? (Indicate the closest amount)

  1/8

  1/4

  1/2

  3/4

  Full

• Are engine oil levels acceptable?

• Are windshield wiper fluid levels acceptable?

• Is there any indication of leaking fluids?

Emergency Alert Systems and General Lights

• Headlights functional?

  Yes

  No

  N/A

• Clearance lights functional?

  Yes

  No

  N/A

• Emergency lights functional?

  Yes

  No

  N/A

• Scene lights functional?

  Yes

  No

  N/A

• Sirens functional?

  Yes

  No

  N/A

• Backup alarm functional

  Yes

  No

  N/A

• Brake lights functional

  Yes

  No

  N/A

• Tail lights functional?

  Yes

  No

  N/A

• Turn lights functional?

  Yes

  No

  N/A

General Vehicle Section Narrative

• Enter additional detail as necessary for any negative findings above?

Stretcher/Response bags/Monitor

• Stretcher is present, functioning normally. Batteries are charged?

  Yes

  No

  N/A

• Stretcher patient restraints including shoulder straps present?

  Yes

  No

  N/A

• Airway bag is present, stocked correctly with a charged oxygen cylinder?

  Yes

  No

  N/A

• Portable oxygen pressure level? (Indicate to the nearest hundred)

• Yes

  No

  N/A

• Heart Monitor is present, clean, fully charged, with spare batteries on the charger?

  Yes

  No

  N/A

• Monitor passed user test?

  Media

• Response bag present, clean and fully stocked with no expired items?

  Yes

  No

  N/A

• Narrative for Stretcher/Response bags/Monitor section. (Only required if you marked a no answer)

Patient Compartment

• Linens stored and clean?

  Yes

  No

  N/A

• Regular Trash Can Present?

  Yes

  No

  N/A

• Bio Hazard Trash Can Present?

  Yes

  No

  N/A

• Portable Suction present and functional?

  Yes

  No

  N/A

• On Board Suction present and functional?

  Yes

  No

  N/A

• Transport Ventilator present, clean and functional?

  Yes

  No

  N/A

• CPAP present, clean and functional?

  Yes

  No

  N/A

Safety Equipment

• 2 Hard hats with goggles?

  Yes

  No

  N/A

• 2 Pair gauntlet gloves?

  Yes

  No

  N/A

• 2 Safety Vests

  Yes

  No

  N/A

• 2 Flashlights?

  Yes

  No

  N/A

• 2 BSI Kits

  Yes

  No

  N/A

• Window Punch

  Yes

  No

  N/A

• Sharps Container

  Yes

  No

  N/A

• 3 Road Reflectors

  Yes

  No

  N/A

• Hand Sanitizer

  Yes

  No

  N/A

• 1 Fire Extinguisher Cab, 1 Fire Extinguisher Outside compartment, 1 Fire Extinguisher patient compartment?

  Yes

  No

  N/A

• Adult Nasal Cannula Count

• Pediatric Nasal Cannula Count

• Adult Non-Rebreather Count

• Pediatric Non-Rebreather Count

• Adult Nebulizer Count

• Pediatric Nebulizer Count

• Oropharyngeal Airway, 1 each size

  Yes

  No

  N/A

Advanced Airway Supplies