Ambulance Physical Condition
Is the exterior of the vehicle clean and free of damage?
Is the interior cab of the truck clean and free off damage?
Is the patient compartment clean and free of damage?
Protocol book on unit?
Fuel level at checkout? (Indicate the closest amount)
Are engine oil levels acceptable?
Are windshield wiper fluid levels acceptable?
Is there any indication of leaking fluids?
Headlights functional?
Clearance lights functional?
Emergency lights functional?
Scene lights functional?
Sirens functional?
Backup alarm functional
Brake lights functional
Tail lights functional?
Turn lights functional?
Enter additional detail as necessary for any negative findings above?
Patient care equipment
Stretcher is present, functioning normally. Batteries are charged?
Stretcher patient restraints including shoulder straps present?
Airway bag is present, stocked correctly with a charged oxygen cylinder?
Heart Monitor is present, clean, fully charged, with spare batteries on the charger?
Response bag present, clean and fully stocked with no expired items?
Narrative for Stretcher/Response bags/Monitor section. (Only required if you marked a no answer)
Linens stored and clean?
Regular Trash Can Present?
Bio Hazard Trash Can Present?
Portable Suction present and functional?
On Board Suction present and functional?
Transport Ventilator present, clean and functional?
CPAP present, clean and functional?
Safety Equipmeent
2 Hard hats with goggles?
2 Pair gauntlet gloves?
2 Safety Vests
2 Flashlights?
2 BSI Kits
Window Punch
Sharps Container
3 Road Reflectors
Hand Sanitizer
1 Fire Extinguisher Cab, 1 Fire Extinguisher Outside compartment, 1 Fire Extinguisher patient compartment?
Basic Life Support Supplies
Oropharyngeal Airway, 1 each size
