Vehicle Additional Information

Start Mileage

End Mileage

Vehicle Inspection

Visual Inspection for Exterior Damage/Leaks under vehicle

Check inside Engine compartment for Leaks/loose items

O2 Supplies, i.e: Charged Tanks, Regulator, Extra Cannulas and Regulator Wrench.

Gloves, Sterilizing Pads, Masks, Extra Sheets for Gurney, Hazmat Bags for Waste.

Straps for Wheelchair Transfers.

Check Tires for wear and pressure.

Check Floor for Cleanliness & Debris

Check Windshield Wipers / Washers

Check Highlight / Signal lights / 4 way flashes / Tail lights / Backup lights / Horn

Check Mirrors for damage and adjustments

Check Fuel level (Should Not Be Less Than 1/4 Tank)

Check Fire Extinguisher on board / Gauge showing charged, proper seal & pin

Charged battery on the gurney, sheets, survey forms

D Tank Pressure (PSI)

E-Tank Pressure (PSI)

List down the discrepancies noted

Driver's Name & Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.