Emergency Medical Services (Ems) Systems Ambulance Inspection Form

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Emergency Medical Services (EMS) Systems
State of Illinois
Illinois Department of Public Health
Ambulance Inspection Form
Provider__________________________________________________________ License No. ________________________
Garage Address _______________________________________________________________________________________
VIN _____________________________ Level of Care_______ Local ID ______________ EMS System No. __________
Inspection Type _____________________________________ Inspected By______________________________________
Inspection Date ___________________ Inspection Status __________________ Action ___________________________
Patient Transport Equipment
Suction and Airway Equipment
[1] Wheeled multi-level cot w/three sets of straps
[20] Onboard suction capable of obtaining 300 mmHg suction
+ over shoulder straps
within four seconds of clamping tube
[2] Three-Point fastener for cot
a) Vacuum level can be adjusted
[3] Cot fits securely in fastener
b) Collection bottle holds 1,000 ml
[4] Secondary stretcher w/three sets of straps
[21] Two packages suction tubing capable of reaching second
patient being transported on squad bench
Main On-board Oxygen Equipment
[22] Portable battery operated suction capable of obtaining 300
mmHg suction within four seconds of clamping tubing
[5] Main (on-board) oxygen cylinder not empty
a) Capable of charging from vehicle 12-volt DC/115-volt AC
-- volume (psi): ____________________
OR
[6] Adult size non-rebreather oxygen mask (minimum one)
b) Operated from internal rechargeable battery
c) Operates for 20 continuous minutes (perform if battery
[7] Child size oxygen mask (minimum one)
sounds weak)
[8] Infant size oxygen mask (minimum one)
OR
d) Manually operated suction device (IDPH approved)
[9] Adult size nasal cannulas (minimum three)
[23] Sterile, single-use suction catheters, two each size: 6, 8, 10,
[10] Child size nasal cannulas (minimum three)
12, 14, 16, 18 French with thumb suction control port
(one set with on-board suction; one set with portable suction)
Portable Oxygen Equipment
[24] Semi-rigid pharyngeal suction tips, with thumb suction control
port (three)
[11] Portable oxygen cylinder: (minimum size “D”)
[25] Airway, oropharyngeal, adult, child and infant sizes 00-5
-- volume (psi): ____________________
[26] Airway, nasopharyngeal, sizes 12-34 French
[12] Dial flowmeter/regulator for 15 lpm
[27] Lubricant for nasopharyngeal airways
[13] Full spare portable oxygen cylinder (minimum size “D”)
[14] Quick-release, crash-stable mounting racket for portable
Resuscitation Equipment
oxygen cylinders
[28] Adult size squeeze bag-valve-mask ventilation unit with
[15] Adult size non-rebreather oxygen mask (minimum one)
transparent adult mask (minimum one)
[16] Child size oxygen mask (minimum one)
[29] Child size squeeze bag-valve-mask ventilation unit with
[17] Infant size oxygen mask (minimum one)
child, infant and newborn transparent masks (minimum one)
[18] Adult size nasal cannulas (minimum one)
[30] CPR mask with safety valve to prevent backflow of expired
air and secretions (minimum one)
[19] Child size nasal cannulas (minimum one)

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