Title Page

  • Vehicle

  • Driver

  • Date

  • Location

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

COMPLETION

  • Driver's Name & Signature

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