Vehicle Inspection Form For Registered Air Ambulances
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3VEHICLE INSPECTION FORM FOR REGISTERED AIR AMBULANCES
SERVICE NAME:
DATE:
VIN:
VID:
RESPIRATORY EQUIPMENT
COMPLIANT
QTY
ITEM / DESCRIPTION
Y
N
PRI
1
1
Portable Suction Aspirator, Hand Operated or Battery Power
1
4
Sterile Suction Catheters, assorted sizes
Adult Bag-Valve-Resuscitator, disposable. The valve must operate in cold
1
1
weather, and the unit must be capable of use with an oxygen supply. The
unit must be capable of delivering approximately 100% oxygen.
Pediatric Bag-Valve-Resuscitator, disposable, with transparent child and
infant masks. The valve must operate in cold weather, and the unit must be
1
1
capable of use with an oxygen supply. The unit must be capable of
delivering approximately 100% oxygen.
1
1
Adult Oxygen Mask with Reservoir
1
1
Adult Oxygen Mask
1
1
Nasal Cannula
1
1
Pediatric Oxygen Mask with Reservoir
1
1
Pediatric Oxygen Mask
1
1
Oxygen Supply Tubing
1
1
Set of Oropharyngeal Airways, with adult, child and infant sizes
1
1
Set of Nasopharyngeal Airways, with adult, child and infant sizes
Tracheal / Pharyngeal Airway Adjunct (device not intended to be placed in
1
1
the trachea)
Oxygen – an adequate amount for anticipated liter flow and length of flight
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1
with an emergency reserve available for every mission
Oxygen – portable unit consisting of at least a “D” cylinder or equivalent,
yoke, pressure gauge, flowmeter and cylinder wrench or hand wheel. The
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1
unit shall be capable of delivering an oxygen flow of at least 15 liters per
minute. Cylinder holders with a quick-release fitting shall be furnished to
allow the use of the portable unit outside the aircraft.
BANDAGES / DRESSINGS
COMPLIANT
QTY
ITEM / DESCRIPTION
Y
N
PRI
3
2
Universal Dressings, 10" x 30"
3
2
Sterile Gauze Pads, 4" x 4"
3
2
Bandages - Soft Roller Self Adhering Type, 2" x 5 yards
3
2
Bandages - Soft Roller Self Adhering Type, 4" x 5 yards
3
2
Bandages - Soft Roller Self Adhering Type 6" x 5 yards
3
2
Elastic Bandages, Assorted Sizes
Petroleum Gauze Pads, sterile, individually wrapped, 4 inches by 3 inches
3
4
or 9 inches by 3 inches
3
2
Adhesive Tape – Rolls, Assorted Sizes
3
2
Burn Sheets and / or Sterile Wrapped Sheets
3
1
Heavy Duty Bandage Shears
R-E-01-C: Vehicle Inspection Form for Air Ambulance Units – Revised 06/01/2010 – Page 1 of 3
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