Vehicle Inspection Form For Registered Air Ambulances (Page 3 of 3) in pdf

ADVANCED LIFE SUPPORT EQUIPMENT

ALS AIRWAY EQUIPMENT

COMPLIANT

QTY

ITEM / DESCRIPTION

PRI

ALS Airway Kit with endotracheal tubes (assorted sizes, adult, child, and

infant), 10 ml syringes, stylettes, laryngoscope handles and blades

(assorted sizes for adult, child and infant); Magill Forcepts (adult and

pediatric)

End Tidal Carbon Dioxide Detection Device

ALS CARDIAC EQUIPMENT

COMPLIANT

QTY

ITEM / DESCRIPTION

PRI

Cardiac Monitor / Defibrillator capable of use on pediatric and adult patients

– DC battery powered, portable, with paper printout, accessories and

supplies and with sufficient power supply to meet the demands of the

mission

External Cardiac Pacing Device to include pediatric and adult patients

ALS PHARMACOLOGICAL EQUIPMENT

COMPLIANT

QTY

ITEM / DESCRIPTION

PRI

IV Solution Kit with the list of contents, to include expiration dates, affixed to

the outside of the sealed kit established and approved by the local or

regional EMS medical director. Kit shall contain IVs of types, quantities, and

sizes as specified on a list signed by the EMS medical director; IV catheters

in various sizes and types; intraosseous needles, tourniquets; Macro and

Micro drip sets; assorted IV cannulas; assorted syringes; IV pressure infuser

bag

Intravenous Infusion Pump capable of strict mechanical control of an IV

infusion drip rate; passive devices such as dial-a-flow are NOT acceptable

Drug Kit containing appropriate medications with the list of contents

established and approved by the local or regional EMS medical director.

The list of contents and earliest expiration dates shall be affixed to the

outside of the sealed kit. Drug kits must be maintained in a temperature

controlled environment and must not be left unsecured.

Priority 1 (1): Critical Essential Equipment - Item must be on the unit at the time of the inspection or the unit will be taken out of service. DCH inspection decal will not

be applied.

Priority 2 (2): Item must be on the unit at re-inspection in five (5) business days. Deficiencies will be noted as minor deficiencies in the inspection report.

Priority 3 (3): Item must be on the unit upon the next routine re-inspection. Deficiencies will be noted as minor deficiencies in the inspection report.

OOS (out-of-service): If the unit is marked OOS, the vehicle will be immediately taken out of service and will remain out-of-service until re-inspected within two (2)

business days. DHR window decal will be removed from the vehicle. This will include the mechanical / safety condition of the vehicle.

Signature of Inspector:

Signature of Agency Representative Reviewed With:

R-E-01-D: Vehicle Inspection Form for Air Ambulance Units – Revised 06/01/2010 – Page 3 of 3 VID #_____