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


  • Driver's Name & Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.