Vehicle Inspection Form For Registered Ambulances Page 3
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1
2
3
4MISCELLANEOUS EQUIPMENT. . . continued
COMPLIANT
QTY
ITEM / DESCRIPTION
Y
N
PRI
1
2
Flashlight
1
1
Fire Extinguisher, 10 pound ABC type or functional equivalent, charged
2
3
Emesis Basins or Emesis Bags or equivalent
1
3
Bedpan
1
3
Urinal
4
3
Restraints, 2 ankle and 2 wrist, leather or nylon
1
3
Shears
2
3
Clean Wrapped Sheets or Burn Sheets
1
3
Nonporous Infant Insulating Device, foil swaddler or equivalent
Obstetrical Kit: Receiving blanket, sterile bulb aspirator, wrapped sanitary napkin,
sterile scissors or scalpel blade, 4inch gauze pads, one pair of sterile gloves, 2
1
2
cord clamps and plastic bag for placenta. All items are to be in a container with
identifying label showing contents.
IV Solution Kit with the list of contents, to include expiration dates, affixed to the
1
1
outside of the sealed kit established and approved by the local or regional medical
director
1
3
Sharps Container
U. S. Department of Transportation Emergency Response Guidebook, current
1
3
edition
Resource Handbook providing information on chemical, biological, and nuclear
1
3
agents
1
2
Mark I Plus Kit
(CHECK IF PRESENT, BUT NOT REQUIRED)
2
2
Escape Hoods, SCBA, or equivalent / higher
(CHECK IF PRESENT, BUT NOT REQUIRED)
2
2
N-95 or > Particulate Mask
20
1
Exam Gloves, assorted sizes
2
2
Disposable Splash Protection (gowns, EMS turnout gear, etc.)
EXTRICATION EQUIPMENT
The following extrication equipment is required to be on each vehicle except where the provider has
written verification from the Regional EMS Program Director that this equipment is immediately
available from sources within the zone.
COMPLIANT
QTY
ITEM / DESCRIPTION
Y
N
PRI
1
1
Spring Loaded Center Punch
1
1
Rescue Ax or Halligan Tool, able to pry, cut, remove sheet metal
1
1
Flathead Screwdriver, minimum 6 inches
1
1
3 Pound Hammer
1
1
Hacksaw with extra Bimetal-type Blades
1
1
Roll Duct Tape
1
1
One Ton Come-A-Long and 2 Rescue-Rated Chains or Straps
2
1
Helmets with Face Shields
2
1
Gloves, work gloves or leather gloves
Vehicle Inspection Form for Ambulances – Revised 06/01/2010 – Form R-E-01-A – Page 3 of 4 – VID #____________
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