Information

  • Samaritan Base

  • Unit inspection Date/Time

  • Prepared by

Ambulance Physical Condition

General Vehicle Condition

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

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

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

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

  • Is the patient compartment clean and free of damage?

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

  • Protocol book on unit?

Fuel and general engine fluids check

  • 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?

  • Transmission Fluid at acceptable level?

  • Front left tire pressure

  • Front right tire pressure

  • Rear left tire

  • Rear right tire

Emergency Alert Systems and General Lights

  • 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?

General Vehicle Section Narrative

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

Patient care equipment

Stretcher/Response bags/Monitor

  • 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?

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

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

  • Monitor passed user test?

  • 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)

Patient Compartment

  • MiFi wireless network present?

  • 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

Safety Equipment

  • 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

BLS Airway Supplies

  • 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

Advanced Airway Supplies

  • Magill Forceps Large and Small

  • Endotracheal Stylets 2 of each

  • Endotracheal Tube 2.5 - 8.5

  • Laryngoscopes present and functioning.

Advanced Life Support Supplies

ALS Supplies

  • 24g IV Cath x 6

  • 22g IV Cath x 12

  • 20g IV Cath x 12

  • 18g IV Cath x 12

  • 16g IV Cath x 12

  • 14g IV Cath x 12

  • Saline Locks x 10

  • Dial-A-Flow x 2

  • Extension x 5

  • 60gtt Drip Set

  • 10gtt Drip Set x 5

  • Manual IO x 2

  • Normal Saline x5

BLS Supplies

  • Traction Splint

  • C- Collar Adult x 2 Pediatric x 1

  • KED

  • Long Spine Board x 2

  • Extremity Splint x3

  • Pulse Ox

  • Glucometer

  • Blood Pressure Kit

  • Stethoscope

  • Thermal Blankets x 2

  • OB Kit

  • Stethoscope

  • Thermometer

  • Trauma Shears

  • Rolls of Tape x 4

  • Large Trauma Dressing x 2

  • Sterile Occlusive Dressing x 4

  • Lubricant x 2

  • Burn Sheet x 2

  • Triangle Bandage x 8

  • Roller Gauze x 10

  • Sterile 6x8 x 6

  • Sterile 4x4 x 50

  • Cold Packs x 6

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