Nathan Adelson Hospice - Daily Vehicle Inspection

• Vehicle

• Driver

• Date

  Date
• Location
  Address

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

  Sign