Monthly Mechanical Inspection (Ambulance)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Unit Number

• Unit Checked

  2151

  2152

  2153

• Current Milage

• Insurance Expiration Date

• Motor Vehicle Registration Expiration Date

• Fuel Card Present

  Yes

  No

  N/A

Under the Hood

• Oil

  Ok

  Low

• Transmission Fluid

  Ok

  Low

• Coolant

  Ok

  Low

• Brake Fluid

  Ok

  Low

• Power Steering

  Ok

  Low

• Washer Fluid

  Ok

  Low

• Belts

  Good No Visible Damage

  Visible Damage Found

• Hoses

  Good No Visible Damage

  Visible Damage Found

Exterior of Unit

• Headlights (low beam)

  Functional

  Defect Found (see notes)

  N/A

• Headlights (high beams)

  Functional

  Defect Found (see notes)

  N/A

• Parking Lights

  Functional

  Defect Found (see notes)

  N/A

• Marker Lights

  Functional

  Defect Found (see notes)

  N/A

• Left Turn Signals (Front and Back)

  Functional

  Defect Found (see notes)

  N/A

• Right Turn Signals (Front and Back)

  Functional

  Defect Found (see notes)

  N/A

• Hazard Lights

  Functional

  Defect Found (see notes)

  N/A

• Fog Lights

  Yes

  No

  N/A

• Left Scene Lights

  Functional

  Defect Found (see notes)

  N/A

• Rear Scene Lights

  Functional

  Defect Found (see notes)

  N/A

• Right Scene Lights

  Functional

  Defect Found (see notes)

  N/A

• Reverse Lights

  Functional

  Defect Found (see notes)

  N/A

• Brake Lights

  Functional

  Defect Found (see notes)

  N/A

• Compartment Lights

  Functional

  Defect Found (see notes)

  N/A

• Auto Eject Plug

  Functional

  Defect Found (see notes)

  N/A

Tires

• Drivers Side Front Tire (75 psi for 51& 53, 65 psi for 52)

  Ok

  Low

• Driver's Side Rear Inner Tire (80 psi)

  Ok

  Low

• Driver's Side Rear Outer Tire (80 psi)

  Ok

  Low

• Passenger Side Front Tire (75 psi for 51& 53, 65 psi for 52)

  Ok

  Low

• Passenger Side Rear Inner Tire (80 psi)

  Ok

  Low

• Passenger Side Rear Outer Tire (80 psi)

  Ok

  Low

Emergency Lights

• Front Lightbar

  Functional

  Defect Found (see notes)

  N/A

• Rear Lightbar

  Functional

  Defect Found (see notes)

  N/A

• Primary / Secondary Flashers

  Functional

  Defect Found (see notes)

  N/A

• Headlight Flashers

  Functional

  Defect Found (see notes)

  N/A

• Intersection Lights

  Functional

  Defect Found (see notes)

  N/A

• Load Manager

  Functional

  Defect Found (see notes)

  N/A

Interior of Cab

• Interior Lights

  Functional

  Defect Found (see notes)

  N/A

• Dash Lights

  Functional

  Defect Found (see notes)

  N/A

• Map Light

  Functional

  Defect Found (see notes)

  N/A

• Spot Light

  Functional

  Defect Found (see notes)

  N/A

• Turn Signal Indicators

  Functional

  Defect Found (see notes)

  N/A

• High Beam Indicator

  Functional

  Defect Found (see notes)

  N/A

• Emergency Brake Indicator (both dash and console)

  Functional

  Defect Found (see notes)

  N/A

• High Idle

  Functional

  Defect Found (see notes)

  N/A

• Factory Horn

  Functional

  Defect Found (see notes)

  N/A

• Air Horn / Siren

  Functional

  Defect Found (see notes)

  N/A

• Heat / AC

  Functional

  Defect Found (see notes)

  N/A

• AM/FM Radio

  Functional

  Defect Found (see notes)

  N/A

• High Band Mobile

  Functional

  Defect Found (see notes)

  N/A

• High Band Portable Radio

  Functional

  Defect Found (see notes)

  N/A

• Low Band Mobile

  Functional

  Defect Found (see notes)

  N/A

• On-Spot Chains / 4WD (including Differential Locks)

  Functional

  Defect Found (see notes)

  N/A

• Power Locks (Factory and Rear Module)

  Functional

  Defect Found (see notes)

  N/A

• Power Windows

  Functional

  Defect Found (see notes)

  N/A

• Power Mirrors (51 only)

  Functional

  Defect Found (see notes)

  N/A

Patient Compartment

• Dome Light (High / Low Mode)

  Functional

  Defect Found (see notes)

  N/A

• Fluorescent Lights

  Functional

  Defect Found (see notes)

  N/A

• Action Are Lights

  Functional

  Defect Found (see notes)

  N/A

• Onboard Suction

  Functional

  Defect Found (see notes)

  N/A

• Oxygen Connections

  Functional

  Defect Found (see notes)

  N/A

• Onboard Oxygen Regulator

  Functional

  Defect Found (see notes)

  N/A

• Heat / AC

  Functional

  Defect Found (see notes)

  N/A

• Clock

  Functional

  Defect Found (see notes)

  N/A

• Inverter

  Functional

  Defect Found (see notes)

  N/A

• Cabinet Doors

  Functional

  Defect Found (see notes)

  N/A

• Exhaust Fan

  Yes

  No

  N/A

• High Band Radio

  Functional

  Defect Found (see notes)

  N/A

Signature of Individual Conducting Check

• Add signature

  Sign