Ambulance Rig Check

• Conducted on

  Date

• Inspected by

• Location

• Ambulance

  Select Medic 20 Medic 21 Medic 22 Medic 23 Medic 24 Medic 25 Medic 26 Medic 27 Medic 28 Medic 29

  • Medic 20
  • Medic 21
  • Medic 22
  • Medic 23
  • Medic 24
  • Medic 25
  • Medic 26
  • Medic 27
  • Medic 28
  • Medic 29

• Fuel level

  Full

  3/4

  1/2

  1/4

  Empty

• DEF Level

  Select Full 3/4 1/2 1/4 Empty N/A

  • Full
  • 3/4
  • 1/2
  • 1/4
  • Empty
  • N/A

• Oil level and condition

  Select Good Low Clean Dirty

  • Good
  • Low
  • Clean
  • Dirty

• Coolant Reservoir

  Good

  Low

• Transmision level and condition

  Select Good Low Clean Dirty

  • Good
  • Low
  • Clean
  • Dirty

• Belt condition

  Pass

  Fail

• Air filter condition

  Pass

  Fail

• Windshield washer fluid

  Filled

• Map Book

  Yes

  No

• ERG

  Yes

  No

• Flashlight

  Yes

  No

• Gas Cards

  Yes

  No

• Seat belts

  Pass

  Fail

  N/A

• Brakes

  Pass

  Fail

  N/A

• Parking brakes

  Pass

  Fail

  N/A

• Headlights, Brights, Brake lights, Turn signals, Hazards

  Pass

  Fail

• Dash lights, Cab lights, Compartment Lights

  Pass

  Fail

• Backup lights, Backup alarm

  Pass

  Fail

  N/A

• Scene lights

  Pass

  Fail

  N/A

• Emergency lights

  Pass

  Fail

  N/A

• Siren

  Pass

  Fail

  N/A

• Radio check

  Pass

  Fail

  N/A

• Tire wear, Tire pressure

  Pass

  Fail

• Tire pressure

  Filled

  NA

• Tire wear

  Media

Jump bag

Left outside pocket

• Stethoscope

  Yes

  No

• Blood pressure cuff

  Yes

  No

• Portable Sp02

  Yes

  No

• Thermometer

  Yes

  No

• Penlight

  Yes

  No

• Blood glucometer

  Yes

  No

• Meter batteries

  Pass

  Fail

• Test strips

  Yes

  No

• Expiration date

• Band-Aids, Alcohol pads, Lancets

  Yes

  No

Right outside pocket

• BLS Drug box

  Yes

  No

• Ondansetron PO

  Yes

  No

• Expiration date

• Naloxone IM

  Yes

  No

• Expiration date

• Adrenaline IM

  Yes

  No

• Expiration date

• Nitroglycerin PO

  Yes

  No

• Expiration date

• Albuterol Sulfate

  Yes

  No

• Expiration date

• Ipratropium Bromide/ Albuterol sulfate DuoNeb

  Yes

  No

• Expiration date

• Oral Glucose

  Yes

  No

• Expiration date

• Aspirin

  Yes

  No

• Expiration date

• Needles, Syringes, Band-aids, Alcohol swabs, MAD device,

  Yes

  No

Center Pockets

• Iv starts

  Yes

  No

• Sam splints

  Yes

  No

• Tourniquet

  Yes

  No

• Occlusive dressing

  Yes

  No

• Tape, Cloth tape

  Yes

  No

• Koban/ Self adherent bandage

  Yes

  No

• Triangle bandage

  Yes

  No

• Elastic bandage

  Yes

  No

• Gauze rolls

  Yes

  No

• Kurlix/ Krinkle gauze

  Yes

  No

• Combine ABD pad

  Yes

  No

• 4X4 gauze

  Yes

  No

• Band-aids

  Yes

  No

• Cold packs

  Yes

  No

• Hot packs

  Yes

  No

• C-collar

  Yes

  No

• Emergency blanket

  Yes

  No

• Nose clamps

  Yes

  No

• Ring cutter

  Yes

  No

• Multi-trauma dressing

  Yes

  No

• Burn sheet

  Yes

  No

• OPA set

  Yes

  No

• NPA set

  Yes

  No

• Adult BVM set

  Yes

  No

• Adult bag

  Yes

  No

• Adult mask

  Yes

  No

• PEEP valve

  Yes

  No

• Oxygen tubing

  Yes

  No

• Other

  Yes

  No

Airway bag

Left back pocket

• Portable O2 tank

  Yes

  No

• PSI

• Regulator

  Yes

  No

• CPAP compatible

  Yes

  No

• O2 wrench

  Yes

  No

  N/A

Left front pocket

• OPA kit

  Yes

  No

• Water soluble lube

  Yes

  No

Center pocket rear

• NPA kit

  Yes

  No

• Water soluble lube

  Yes

  No

• I-gels

  Select 5 4 3 2.5 2 1.5 1

  • 5
  • 4
  • 3
  • 2.5
  • 2
  • 1.5
  • 1

Center pocket left

• CPAP kit

  Yes

  No

• Nebulizer kit

  Yes

  No

• Adult NRB

  Yes

  No

• PED NRB

  Yes

  No

• Nasal cannula

  Yes

  No

• Nasal cannula W/ETCO2

  Yes

  No

Center pocket right

• Adult BVM set

  Yes

  No

• Adult mask

  Yes

  No

• Adult Bag

  Yes

  No

• PEEP valve

  Yes

  No

• Oxygen tubing

  Yes

  No

• PED BVM set

  Yes

  No

• PED mask

  Yes

  No

• PED bag

  Yes

  No

• PEEP valve

  Yes

  No

• Oxygen tubing

  Yes

  No

• PED I-gels

  Select 1.5 1

  • 1.5
  • 1

• Water soluble lube

  Yes

  No

• Adolescent BVM set

  Yes

  No

• Adolescent mask

  Yes

  No

• Adolescent bag

  Yes

  No

• PEEP valve

  Yes

  No

• Oxygen tubing

  Yes

  No

• Adolescent I-gels

  Select 2.5 2

  • 2.5
  • 2

• Water soluble lube

  Yes

  No

Ambulance interior

• Portable O2 bottle

  Yes

  No

• Quantity (Min 4, Max 5)

• PSI above 300

  Yes

  No

• Regulator

  Yes

  No

• Quantity (Min 1, Max 2)

• Oxygen wrench

  Yes

  No

• Nitros oxide

  Yes

  No

  N/A

• Complete kit

  Select Nitros oxide bottle regulator and hosing Mixing unit Mouth piece (Min 5, Max 7)

  • Nitros oxide bottle
  • regulator and hosing
  • Mixing unit
  • Mouth piece (Min 5, Max 7)

• Portable Suction

  Yes

  No

• Charged

  Yes

  No

• Operational off charger

  Yes

  No

• Suction canister

  Yes

  No

• Suction hosing

  Yes

  No

• Yankeur

  Yes

  No

• GTAC

  Yes

  No

• Charger

  Yes

  No

• House oxygen bottle

  Yes

  No

• PSI

• Stretcher

  Yes

  No

• Fitted sheet, blanket, plastic sheet, chuck, pillow w/pillow case

  Yes

  No

Trauma cabinet

• 4X4 gauze

  Yes

  No

• Quantity (Min 1 box, Max 1 box)

• 5X9 gauze

  Yes

  No

• Quantity (Min 5, Max 7)

• 8X10 gauze

  Yes

  No

• Quantity (Min 5, Max 7)

• Tourniquet

  Yes

  No

• Quantity (Min 1, Max 2)

• Rolled gauze

  Yes

  No

• Quantity (Min 5, Max 7)

• Kurlix/Bulky gauze

  Yes

  No

• Quantity (Min 5, Max 7)

• Coban

  Yes

  No

• Quantity (Min 2, Max 4)

• Bandaids

  Yes

  No

• Quantity (Min 1 box, Max 1 box)

• Sam splint

  Yes

  No

• Quantity (Min 4, Max 5)

• Triangle bandage

  Yes

  No

• Quantity (Min 2, Max 4)

• Tape

  Yes

  No

• Quantity (Min 2, Max 6)

• Instant cold pack

  Yes

  No

• Quantity (Min 5, Max 7)

• Instant hot pack

  Yes

  No

• Quantity (Min 5, Max 7)

• Burn sheets

  Yes

  No

• Quantity (Min 2, Max 3)

• Occlusive dressing

  Yes

  No

• Quantity (Min 2, Max 4)

• Adult C-collar

  Yes

  No

• Quantity (Min 2, Max 3)

• PED C-collar

  Yes

  No

• Quantity (Min 2, Max 3)

• Trauma shears

  Yes

  No

• Ring cutter

  Yes

  No

• OB kit

  Yes

  No

• Quantity (Min 2, Max 3)

• Nose clamp

  Yes

  No

• Quantity (Min 2, Max 3)

• Eye wash/saline

  Yes

  No

• Quantity (Min 2, Max 4)

Airway cabinet

• Adult BVM

  Yes

  No

• Quantity (Min 1, Max 2)

• Adolecent BVM

  Yes

  No

• PED BVM

  Yes

  No

• Bulb Syringe

  Yes

  No

• Quantity (Min 2, Max 4)

• PEEP valve

  Yes

  No

• Quantity (Min 1, Max 2)

• CPAP

  Yes

  No

• Quantity (Min 2, Max 3)

• I-gels

  Select 5 4 3 2.5 2 1.5 1

  • 5
  • 4
  • 3
  • 2.5
  • 2
  • 1.5
  • 1

• Quantity (Min 1, Max 2)

• Water soluble lube

  Yes

  No

• Quantity (Min 4, Max 6)

• Oxygen tubing

  Yes

  No

• Quantity (Min 2, Max 3)

• Adult nasal cannula

  Yes

  No

• Quantity (Min 4, Max 5)

• PED nasal cannula

  Yes

  No

• Quantity (Min 2, Max 3)

• Adult NRB mask

  Yes

  No

• Quantity (Min 4, Max 5)

• PED NRB mask

  Yes

  No

• Quantity (Min 2, Max 3)

• Nebulizer, handheld

  Yes

  No

• Quantity (Min 2, Max 3)

• Nebulizer, mask

  Yes

  No

• Quantity (Min 2, Max 3)

• Suction cannister

  Yes

  No

• Quantity (Min 2, Max 3)

• Suction tubing

  Yes

  No

• Quantity (Min 2, Max 3)

• DuCanto

  Yes

  No

• Quantity (Min 2, Max 3)

• Yankeur

  Yes

  No

• Quantity (Min 2, Max 3)

• French catheter

  Select 6F 8F 10F 12F 14F 16F

  • 6F
  • 8F
  • 10F
  • 12F
  • 14F
  • 16F

• Quantity (Min 2, Max 3)

• OPA set

  Yes

  No

• Quantity (Min 1 set, Max 2 sets)

• NPA set

  Yes

  No

• Quantity (Min 2 sets, Max 3 sets)

• ETCO2, adult nasal cannula

  Yes

  No

• Quantity (Min 2, Max 3)

• ETCO2, PED nasal cannula

  Yes

  No

• Quantity (Min 2, Max 3)

• ETCO2, inline

  Yes

  No

• Quantity (Min 2, Max 3)

IV cabinet

• 60 gtts set

  Yes

  No

• Quantity (Min 3, Max 5)

• 10 gtts set

  Yes

  No

• Quantity (Min 5, Max 7)

• Extension set

  Yes

  No

• Quantity (Min 5, Max 7)

• NS flush

  Yes

  No

• Quantity (Min 8, Max 10)

• Syringe

  Select 1ml 3ml 5ml 10ml 20ml 60ml

  • 1ml
  • 3ml
  • 5ml
  • 10ml
  • 20ml
  • 60ml

• Quantity 1ml, 3ml, 5ml, 10ml (Min 4, Max 5) 20ml, 60ml (Min 2, Max 3)

• IM needle

  Select 22g 25g

  • 22g
  • 25g

• Quantity (Min 2, Max 5)

• Twinpak

  Yes

  No

• Quantity (Min 6, Max 8)

• Filter needle

  Yes

  No

• Quantity (Min 2, Max 3)

• IV catheter

  Select 14g 16g 18g 20g 22g 24g

  • 14g
  • 16g
  • 18g
  • 20g
  • 22g
  • 24g

• Quantity 14g, 16g (Min 3, Max 5) 18g, 20g, 22g, 24g, (Min 5, Max 7)

• Alcohol prep pad

  Yes

  No

• Quantity (Min 1 box, Max 1box)

• Iodine prep pad

  Yes

  No

• Quantity (Min 10, Max 13)

• Tagederm

  Yes

  No

• Quantity (Min 5, Max 7)

• IV tourniquet

  Yes

  No

• Quantity (Min 5, Max 7)

• Luer adapter

  Yes

  No

• Quantity (Min 5, Max 7)

Decon cabinet

• Wipes

  Yes

  No

• Quantity (Min 1, Max 2)

• Paper towel

  Yes

  No

• Stretcher sets

  Yes

  No

• Quantity (Min 4, Max 6)

• Blankets

  Yes

  No

• Quantity (Min 2, Max 4)

• Pillows

  Yes

  No

• Quantity (Min 2, Max 3)

• Gloves

  Select S M L XL

  • S
  • M
  • L
  • XL

• Towels

  Yes

  No

• Quantity (Min 4, Max 5)

Diagnostic

• Pen light

  Yes

  No

• Quantity (Min 2, Max 3)

• Stethoscope

  Yes

  No

• Manuel BP cuff

  Select Adult Ped

  • Adult
  • Ped

• Thermometer

  Yes

  No

• Batteries

  Yes

  No

• Probe covers

  Yes

  No

• Glucometer

  Yes

  No

• Batteries

  Yes

  No

• Lancets

  Yes

  No

• Bandaids

  Yes

  No

• Alcohol prep pad

  Yes

  No

• Test strips

  Yes

  No

• Expiration date

• Portable SPO2 meter

  Yes

  No

• Batteries

  Yes

  No

Misc cabinet

• Soft restraints

  Yes

  No

• Quantity (Min 1 set, Max 2 sets)

• Toys

  Yes

  No

• Emesis bags

  Yes

  No

• Quantity (Min 5, Max 7)

• Urinal

  Yes

  No

• Quantity (Min 2, Max 3)

• Bed pan

  Yes

  No

• Quantity (Min 2, Max 3)

• Water

  Yes

  No

• Glycerin swab

  Yes

  No

• Quantity (Min 3, Max 5)

• Seat belt extensions

  Yes

  No

• Quantity (Min 3, Max 4)

• Cardboard splint

  Select Small Medium Large

  • Small
  • Medium
  • Large

• Quantity (Min 3, Max 5)

• Trauma blanket

  Yes

  No

• Triage tags

  Yes

  No

• Broselow tape

  Yes

  No

• Mega mover/lift blanket

  Yes

  No

• Quantity (Min 2, Max 3)

Ambulance exterior

• Spare tire

  Yes

  No

  N/A

• Fire extinguisher

  Yes

  No

• Charged

  Yes

  No

• Jumper cables

  Yes

  No

• Spare DEF

  Yes

  No

  N/A

• Spare coolant

  Yes

  No

  N/A

• Spare windshield washer fluid

  Yes

  No

  N/A

• Chains

  Yes

  No

  N/A

• Tool kit

  Yes

  No

  N/A

• Shovel

  Yes

  No

  N/A

• Sand

  Yes

  No

  N/A

• Flares

  Yes

  No

  N/A

• 2 Traffic control signs

  Yes

  No

  N/A

• Reflective triangles

  Yes

  No

  N/A

• Light sticks

  Yes

  No

  N/A

• Tarp

  Yes

  No

  N/A

• PEDI-save

  Yes

  No

• Vacuum splint

  Yes

  No

• Traction splint

  Yes

  No

• Stair chair

  Yes

  No

• 2 C-spine bags

  Yes

  No

• Adult C-collars (Min 2)

  Yes

  No

• PED C-collar (Min 2)

  Yes

  No

• Head bed sets (Min 2)

  Yes

  No

• Spider straps (Min 2)

  Yes

  No

• Towels (Min 4)

  Yes

  No

• Tape

  Yes

  No

• Water

  Yes

  No

• Long back board (Min 2)

  Yes

  No

• KED

  Yes

  No

• PED back board

  Yes

  No

• Scoop stretcher

  Yes

  No

• Cardboard splints

  Yes

  No