Sd Ems Ambulance Inspection Form: Ground Service
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1SD EMS AMBULANCE INSPECTION FORM: GROUND SERVICE
Ambulance Service: _________________________________________
Town: ____________________________________
Person in charge: _______________________________ Non-emergency Business Phone Number____________________________
Patient Care Equipment: Airway and Ventilation
Portable & fixed oxygen equipment
Nasal cannulas (adult)
Nonrebreather masks (adult, child, infant)
Minimum 1 hour oxygen supply
Nasal airways (adult)
BagValveMask device (adult, child, infant)
Portable & fixed suction equipment
Oral airways (adult, child, infant)
Pocket mask with oxygen port
Rigid suction catheters
Tongue depressors
Water soluble lubricant
Flexible suction catheters(5)(6-14F)
Wide bore tubing
Patient Care Equipment: Cardiac
Automatic External Defibrillator (1)
Extra Supplies (pads, razor, etc.)
Patient Care Equipment: Orthopedic & Transport
Rigid extrication collars (infant, child, adult)
Long & short spine boards with accessories (infant, child, adult)
Splints (2) for upper/lower extremities (child, adult)
Lower extremity traction splint with supports
Stair or carry chair
Portable folding type stretcher with straps
Adjustable wheeled cot
Patient Care Equipment: Bandages & Dressings
Sterile gauze pads (12--4x4)
Universal dressings 10”x 36”
Soft roller self-adhering bandages
4” gauze rolls (12)
Roll adhesive tape (2)
Occlusive dressing or equivalent
ABD(5x9)dressing or equivalent (12)
Elastic bandages
Band Aids
Bandage shears
Burn sheets (2)
Triangular bandages (2)
Patient Care Equipment: Obstetrical
Sterile OB kit
APGAR chart
Thermal absorbent blanket & head cover
Patient Care Equipment: Examination
Sphygmomanometer (adult, child, infant)
Stethoscope (adult, pediatric)
Penlight
Thermometer with low temp capability
Glascow Coma Scale reference
Pediatric trauma score reference
Pediatric vital signs reference
Patient Care Equipment: Infection Control
Eye and face protection
HEPA mask
Gloves
Jumpsuits or gowns
Antimicrobial hand wash
Cleaning disinfectant
Sharps container
Trash bags
Biohazard bags
Patient Care Equipment: Miscellaneous
Emesis basin or convenience bag
Cold Packs (6)
1 qt. bottles/bags saline or water (6)
Towels (6)
Hot packs
Linen or paper sheets (4)
Pillows (2)
Blankets (4)
Bedpan
Urinal
Triage tags
Heavy duty shears
Glucose
Activated charcoal
Current edition BLS protocol manual
Ambulance Equipment: General
Adequate lighting (min. 50 ft. candles)
Appropriate restraints (seatbelts, airbag, etc.)
Flashlight (2)
Fire Extinguisher (5lb BC or ABC)
No Smoking Signs (front & rear compartments)
Emergency Response Book
Communication devices (digital radio, cell phone)
Traffic signaling devices (flares or reflectors)
The following equipment should be placed in the ambulance or immediately available from other source.
Crescent wrench (1)
Screwdriver (Phillips & flat head)
Vise grip pliers
16 ounce hammer (1)
Bolt cutter (1)
4 ton capacity hydraulic jack or spreader tool
Fire ax, crow bar, or wrecking bar (1)
Mileage:______________ Ambulance License number:________________ Ambulance VIN:________________________________
Local Representative:________________________________________________ Date:____________________________________
State Inspector:_____________________________________________________ Date:____________________________________
Revised 04/21/2015
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