EMT Truck Check

• Date

  Date

• Vehicle: select one.

  AC 1

  AC 2

  AC 3

• Your name.

• Previous shift EMT:

  Select ARMITAGE, K AUSTIN, B BAIER, D BRYANT, J COFFEE, J DEACON, K HERON, K HYATT, S JULIAN, D LUSHER, A MASTROGIUSEPPE, N MCKNIGHT, M MELZER, J MESSIER, J MILLER, C MILLER-EVANS, T PAPPAS, P SKIDMORE, J SMITH, B SUMNER, T WASHINGTON, F YANCHUNIS, A

  • ARMITAGE, K
  • AUSTIN, B
  • BAIER, D
  • BRYANT, J
  • COFFEE, J
  • DEACON, K
  • HERON, K
  • HYATT, S
  • JULIAN, D
  • LUSHER, A
  • MASTROGIUSEPPE, N
  • MCKNIGHT, M
  • MELZER, J
  • MESSIER, J
  • MILLER, C
  • MILLER-EVANS, T
  • PAPPAS, P
  • SKIDMORE, J
  • SMITH, B
  • SUMNER, T
  • WASHINGTON, F
  • YANCHUNIS, A

Exterior damage check.

• Take photo if needed.

  Media

• Lights: all operational and functioning? <br><br>Headlights<br>Turn signals<br>Marker (red /yellow)<br>Skirt (red / white) <br>Brake <br>Ground <br>Emergency <br>Flood / Scene

  Yes

  No

  N/A

• Doors operational: open and close, lock and unlock? <br><br>Cab / crew <br>Box / patient compartment <br>Exterior storage

  Yes

  No

  N/A

• Lift operational? <br><br>Without any hydronic fluid leaks. <br>Secures when locked. <br>

  Yes

  No

  N/A

• Tires in safe and operational condition? <br><br>Cat eyes / low pressure indicator functioning. <br>Free of nails and road debris. <br>Tread greater than 1/8" for front tires. <br>Tread greater than 1/16" for rear tires. <br>Rims free from hub/bearing grease. <br>

  Yes

  No

  N/A

• Exterior if ambulance clean?

  Yes

  No

  N/A

Exterior storage compartments.

• Fire extinguisher present and up to date with tag, secured safely?

  Yes

  No

  N/A

• Date of next due service / check:

  Date

• Road triangles present?

  Yes

  No

  N/A

• Two Stryker/Ferno antlers and two lock bars present and in usable condition?

  Yes

  No

  N/A

• Shore lines plugged in and operational?

  Yes

  No

  N/A

• Inverter operational with no tripped breakers?

  Yes

  No

  N/A

• BLS bag present and in service?

  Yes

  No

  N/A

• NEO and PEDI immobilizers present and ready for service?

  Yes

  No

  N/A

• Long Spine board and applicable straps present and ready for service?

  Yes

  No

  N/A

• Medical O2 tank present and free from audible regulator leaks with remaining tank pressure above 1200psi?

  Yes

  No

  N/A

• Tank psi as read:

• Medical Air tank present and free from audible regulator leaks with remaining tank pressure above 1200psi?

  Yes

  No

  N/A

• Tank psi as read:

Engine compartment

• Oil in range?

  Yes

  No

  N/A

• Coolant in range?

  Yes

  No

  N/A

• Transmission fluid in range?

  Yes

  No

  N/A

• Power steering fluid in range? <br>

  Yes

  No

  N/A

• Windshield washer fluid full?

  Yes

  No

  N/A

• Belts free of cracks and frays?

  Yes

  No

  N/A

• Truck parking spot free from fresh fluid on ground indicating new leak?

  Yes

  No

  N/A

Generator

• Generator hours.

• Oil in range?

  Yes

  No

  N/A

• Coolant in range?

  Yes

  No

  N/A

• Belt free of cracks and frays?

  Yes

  No

  N/A

Interior: cab area check.

• Air brakes operational?

  Yes

  No

  N/A

• Air brake test completed and passed?

  Yes

  No

  N/A

Dash

• Mileage:

• Next PM mileage:

• Fuel level:

  Full

  3/4

  1/2

  1/4

• Dashboard free from engine indicator / warning lamps? <br><br>Examples: <br>ABS, Low Air, check engine ...

  Yes

  No

  N/A

• Oil pressure between 40 to 60 psi when running?

  Yes

  No

  N/A

• Voltage meters reads greater than 12.0 Volts?

  Yes

  No

  N/A

Cab

• Insurance present and current?

  Yes

  No

  N/A

• Issue date:

  Date

• Registration current and present?

  Yes

  No

  N/A

• Issue date:

  Date

• Two reflective vests present?

  Yes

  No

  N/A

• Fuel credit card present?

  Yes

  No

  N/A

• Direction book present?

  Yes

  No

  N/A

• GPS present and functioning?

  Yes

  No

  N/A

• Sirens functions and ready for service?

  Yes

  No

  N/A

• Climate control functions and ready for service?

  Yes

  No

  N/A

• Fire extinguisher present and up to date with tag, secured safely?

  Yes

  No

  N/A

• Date of next due service / check:

  Date

• Flashlight present and functioning?

  Yes

  No

  N/A

• Trash emptied and new liner placed in can?

  Yes

  No

  N/A

• Cab clean and free of garbage and debris?

  Yes

  No

  N/A

Interior: patient compartment check.

• Is patient compartment clean?

  Yes

  No

  N/A

• Take photo if needed.

  Media

• Miscellaneous All supplies present? <br><br>Flashlight - 3 suction wall canisters w/ tubing & yankauer - 2ea. Air / O2 flow meters - Gloves (Small Medium Large) - Remotes - EPCR cable<br>

  Yes

  No

  N/A

• Sealed Cabinet # 1 All supplies present?<br><br>Diapers – Wipes – Ped/Neo electrodes – Thermometers – Pressure Infuser – 2x Transwarmer Mattresses – 4X4s – Spare BP Cuffs (Philips/Propaq)

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 2 All supplies present? <br><br>Two Liter bags: NS <br>Two Liter bags: ½ NS <br>Two 500cc bags: D5 0.9% NS <br>Two 500cc bags: D10W <br>Two Liter bags: D5 ¼ NS <br>Two Liter bags: D5 ¼ NS 20K <br>Two Liter bags: D5 ½ NS <br>Two Liter bags: D5 ½ NS 20K <br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 3 All supplies present? <br>​2 Turkel Chest Tube Trays – 1 Umbilical Catheter Kit – Transducer – 1 neo cooling pack – Infusion Sets - Gastroschesis bag

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet #4 All supplies present? <br><br>​Sterile Gowns – Non-sterile gowns – Surgical Masks – Box N95 Masks – 3 goggles – Surgical masks w/ eye shield

  Yes

  No

  N/A

• Sealed Cabinet # 5 All supplies present? <br><br>​Aspen collars (P1-5, Adult small, reg, tall) <br>Spare Suction Supplies (canisters and tubing) <br>Behavioral Restraint Bag<br>

  Yes

  No

  N/A

• One O2 E-cylinder - Full (2000psi minimum) and present?

  Yes

  No

  N/A

• Two O2 D-cylinders - Full (2000psi minimum) and present?

  Yes

  No

  N/A

• One Air E-cylinder - Full (2000psi minimum) and present?

  Yes

  No

  N/A

• Cabinet # 6 / Storage Area All supplies present? <br><br>​Nitric Bag (plugged in and charging) <br>Spare RT bag <br>

  Yes

  No

  N/A

• Sealed Cabinet # 7 All supplies present? <br><br>22mm Vent Circuit, 15mm Vent Circuit, Neo Vent Circuit <br>Sterile Suction Cath (2x6fr, 2x8fr, 2x10fr, 2x14) <br>Nasal Cannulas: Two NEO, Two PEDI, Two ADULT <br>Non-Rebreather Masks: adult and pedi <br>Two Ventimasks<br>BVMs (infant, ped, adult)<br>Neo-Tee (w/ infant and neo masks) <br>Two Nitric kits<br>

  Yes

  No

  N/A

• Next expiration date.

  Date

• Sealed Cabinet # 8 All supplies present? <br><br> Urinal – Bedpan – Emesis Basin – Sheets – Bath Blankets – Towels – Cleaning Spray/Wipes

  Yes

  No

  N/A

• Drawer A All supplies present? <br><br>Assorted Syringes (20cc, 30cc, 60cc) <br>Med labels <br>Alcohol Preps <br>Rapid Fill Connector <br>Dispensing Pins <br>​Syringe Tubing (filtered and non-filtered) <br>EZ Lubricating Jelly<br>

  Yes

  No

  N/A

• Drawer B All supplies present? <br><br>Assorted Syringes (1cc, 3cc, 5cc, 10cc) – 18g needles - Filter Needles<br>Blunt access – Twin Pack

  Yes

  No

  N/A

• Drawer C / Action Area All supplies present? <br><br>4x4s <br>Assorted Syringes <br>Flushes <br>18g needles <br>Med Labels <br>Alcohol Preps <br>Hand Sanitizer <br>Emesis Bags <br>24g IV Catheters <br>Tape

  Yes

  No

  N/A

• Drawer D All supplies present? <br><br>Emesis Bags – Hot/Cold Packs – ID/Allergy Bands – Drug Reference – (2) NG/OG Syringes

  Yes

  No

  N/A

• Drawer E All supplies present? <br><br>Truck Check Sheets – Spare Charts (2 neo, 2 ped) - Spare Forms – Vehicle Contact – Printer Paper (Philips/Propaq) - DVDs

  Yes

  No

  N/A

• Drawer F All supplies present? <br><br>​Bio Bags – Seals – Bolts – Extra Cables – Spare Regulators

  Yes

  No

  N/A

• Phillips Defibrillator OPS check - Passed (select YES or NO to indicate pass or fail or NA if not Monday)

  Yes

  No

  N/A

• Drug Refrigerator - temperature between 38-42*F? <br><br>

  Yes

  No

  N/A

• Yellow Code Bag present and sealed?

  Yes

  No

  N/A

• Next expiration date:

  Date

• Black Med Bag present and sealed?

  Yes

  No

  N/A

• Next expiration date:

  Date

• Ambulance safe to operate? If not, please explain why?

  Safe

  At Risk

  N/A

• I herby affirm that all information listed is accurate and correct as indicated in this report. EMT signature:

  Sign