Title Page
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Inspector Name (Last, First)
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Date and Time of Inspection
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Inspection Location
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Unit Number (DA XXX)
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Vehicle Status At Start of Inspection
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Vehicle Fender#
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Vehicle License Plate #
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Vehicle Exterior Appearance (Clean, washed, windows clean, tires shined, etc)
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Vehicle Exterior Appearance
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All required vehicle permits and licensure present and current on vehicle (Inspection, Registration, DSHS, City of Dallas Ambulance Permit, Insurance
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Describe any "no" responses to the above question here
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Photos of "no" responses
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Vehicle Interior Appearance (cab, behind seats, walls & ceiling in patient compartment, inside cabinets, cup holders, door panels, dash, etc)
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Vehicle Interior Appearance
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All items secure and prevented from becoming a projectile
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Photos of any "no" responses
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Crew 1 Name
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Crew 1 Appearance
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All required credentials present and in date?<br>Wheelchair: Driver's License & City of Dallas Wheelchair Permit<br>EMT: DSHS EMT Cert, CPR, City of Dallas Ambulance Permit<br>Paramedic: DSHS Paramedic Cert, CPR, ACLS, City of Dallas Ambulance Permit<br>Critical Care Paramedic: DSHS Paramedic Cert, CPR, ACLS, City of Dallas Ambulance Permit
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Crew 2 Name
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Crew 2 Appearance
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All required credentials present and in date?<br>Wheelchair: Driver's License & City of Dallas Wheelchair Permit<br>EMT: DSHS EMT Cert, CPR, City of Dallas Ambulance Permit<br>Paramedic: DSHS Paramedic Cert, CPR, ACLS, City of Dallas Ambulance Permit<br>Critical Care Paramedic: DSHS Paramedic Cert, CPR, ACLS, City of Dallas Ambulance Permit
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List any deficiencies found during supply and equipment inspection
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What remedies were done to correct deficient supplies and equipment
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Inspector Comments
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Vehicle Status Post Inspection
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Crew 1 Name and Signature
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Crew 2 Name and Signature
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Inspector Name and Signature
