Title Page

  • MoMo Unit Number

  • Rescue Unit

  • Officer-Paramedic

  • Driver-Paramedic/AEMT/EMT

  • Date & Time


  • Mileage

  • Fuel level

  • Oil Level

  • Def fluid level

  • Lights and Siren- functioning correctly?

  • Head Lights, Scene Lights, Brake Lights, Blinkers, Back up alarm/camera, Patient compartment electronics- functioning correctly?

  • Tires- do they appear to be in good condition?

  • Stretcher and Mount- functioning properly?

  • Windshield Wipers- do they appear to be in good condition

  • Inverter and Outlets- functioning properly?

Damage to Report

  • Do you see any damage that appears new or you are unsure of? Truck or Equipment?

Outside Compartments

Compartment 1 ( Behind Driver)

  • Main O2 Level

  • Stair Chair Clean, functioning, battery charged?

  • Broom?

Compartment 2 ( Drivers side next to Main O2)

  • Drivers Tactical Gear (Vest and Helmet)

  • Fire Extinguisher

  • Toolbox

  • Rescue Blanket

  • Driver Tactical Gear Helmet and Vest

Compartment 3 ( Drivers Side Rear)

  • Lucas- Suction cup, head strap, backboard? Clean/Battery Charged?

  • LSB with Straps x2

  • Pedi LSB

  • C-Collars 5 Adult, 5 Child, 2 Infant

  • Head Blocks - 5

  • Arm/Leg Splints 2 of each size

  • Adult & Pedi Traction Splint. Clean with all pieces.

  • KED- Clean and with all pieces

Compartment 4 (Passenger side compartment)

  • Passenger Tactical Gear Helmet and Vest

Patient Compartment

  • Stretcher- Clean with sheet, Straps ( Shoulder/Chest straps 2 leg straps) in good condition- not ripped or frayed, charging?

  • Stretcher O2- PSI

Compartment A

  • Fixed Suction Unit with canister, tubing , and catheter

  • Med Box A&B Locked - Keys with Primary Medic

  • Jump Bag

  • Portable Suction with canister, tubing, yanukers

  • Linen- 10 Sheets, 5 blankets

  • Trash Can- emptied

  • Airway Bag with portable O2

Captain's Chair

  • 2-Spare O2 Bottles- Sealed and secured

Compartment B

  • BVM 2 of each Adult, Pediatric and Infant<br>1 Set of NPA 20,24,28,30,32,34<br>1 Set of OPA 00,0,1,2,3,4,5,6<br>3 of each size i-gel<br>ETT 2 of each size, 2.5 - 9.0<br>5- Bougies<br>5- In-Line ETCO2 monitors<br>Laryngoscope handle with blades and spare batteries- Mac 1-4, Miller 1-4<br>ET Holder 5 adult and 5 pediatric

Compartment C

  • 10-Adult Nasal Cannula <br>10- Adult Nasal Cannula with ETCO2<br>10- Adult NRBM<br>10- Adult Neb with mask and tubing<br>

  • 5- Pedi Nasal Cannula<br>5-Pedi NRBM<br>5- Pedi Neb with mask and tubing<br>5- O2 Supply Tubing

  • 2 of each- Sterile Suction Catheters 6,8,10,14 fr<br>2- Suction Canisters<br>2- Ridgid Yaunkers<br>2- Suction Tubing<br>2- Portable suction Canisters

Compartment D

  • 2 Sets of restraints 4-ankle, 4-wrist<br>10-emesis bags<br>10- packs of electrodes<br>2- Adult Defibrillator pads<br>2- Pedi Defibrillator pads

Compartment E

  • 5- 1000mL NS<br>5- 1000mL LR<br>5- 100ml NS<br>5- 10gtt sets<br>5- 60gtt sets

Shelf A

  • IV Tray - <br>10 each IV Catheter 14,16,18,20,22,24<br>10 INT Caps<br>10 NS Flush<br>20 Band-Aids<br>20 Tegaderm<br>10 Tourniquets<br>20 Alcohol Preps<br>10 10cc Syringes<br>10 5cc Syringes<br>10 3cc Synringes<br>10 1cc Syringes<br>10 4x4s<br>2 Rolls 1in Tape<br>Glucometer with 1 Bottle of Strips<br>20 Lancets

  • 1 Fluid Warmer with dated 1000ml IV bags no more than 2 weeks old

  • Main O2 Flow meter (Green tree attached)

  • Gloves 1 box each size S, M, L XL

  • Resource Books. Protocols, CBRNE.. Etc.

Shelf B

  • Cardiac Monitor- Self Test Passed?

  • Cardiac Monitor Supplies:<br>Limb Lead Cables<br>SaO2 Cable<br>B/P Cuff Pedi, Adult, Large Adult<br>12 Lead Cables<br>Roll of Printer Paper<br>Defibrillation Cable<br>2 Sets Adult/Child Defib Pads<br>1 Set Infant Defib Pads<br>3 Pouches Electrodes<br>Defib Test module<br>Inline ETCO2 <br>High Flow O2 NC with ETCO2<br>Spare roll of printer paper<br>2 Charged batteries

Compartment F

  • 10 Triangular Bandages<br>2 Trauma Dressings 10x30<br>2 Packs 4x4s<br>10 5x9s<br>10 Rolls 3 Inch Kling<br>10 Rolls 6 Inch Kling<br>5 ACE Wrap 3 Inch<br>5 ACE Wrap 6 Inch<br>5 Petroleum Guaze 4x4<br>5 Rolls 2in Silk Tape<br>5 Rolls 3in Silk Tape <br>2- DART Decompression Needles<br>5- Chest Seals

Compartment G

  • Lucas- Clean, Charged and ready to go?

Compartment H & I

  • 2-OB Kit<br>Foil Swaddle<br>5 each Size N95 Masks<br>15 Surgical Masks<br>2 Safety Glasses<br>2- Burn sheets<br>2- 500mL bottles of sterile water


  • Sharps Container - please replace when almost full.

  • Bio-Hazard Trash- Empty

  • Manual BP Cuffs Adult, Pedi, Infant

  • Stethoscope

Under Bench Seat

  • Pedi-Mate

  • 1 Ben Pan<br>1 Urinal<br>4 Splash PPE Kits<br>5 Small Redbags<br>2 Large Redbags<br>Large roll 6 mil plastic<br>2 Rolls Duct Tape

Inside of Cab

  • US DOT Emergency Response Guide

  • 2 Safety Vests, one in each door

  • CAD/MDT- functioning properly?

  • Base Radio- operational?

  • Ipad with charger- functioning properly?

  • iphone with charger- functioning properly?

Supply Needs

  • Please list any items needed for the rescue so we can order them from supply.

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