Vehicle Inspection Form For Registered Ambulances (Page 4 of 4) in pdf

ADVANCED LIFE SUPPORT (ALS) EQUIPMENT

The ambulance, staffed by at least one Cardiac Technician or Paramedic, must have all the above

required equipment and additional equipment as follows:

COMPLIANT

QTY

ALS AIRWAY EQUIPMENT

PRI

ALS Airway Kit with endotracheal tubes (assorted sizes, adult, child, and infant), 10

ml syringes, stylette, appropriately sized laryngoscope handles, blades (assorted

Kit

sizes, small, medium, and large) and Magill Forceps

COMPLIANT

QTY

ALS CARDIAC EQUIPMENT

PRI

Cardiac Monitor / Defibrillator (with print-out), configuration and supplies such that

one is capable of delivering defibrillation to pediatric and adult patients

COMPLIANT

QTY

ALS PHARMACOLOGICAL EQUIPMENT

PRI

Drug Kit containing appropriate medications with the list of contents established

and approved by the local or regional medical director. The list of contents and

earliest expiration dates shall be affixed to the outside of the sealed kit. Drug kits

Kit

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. DHR window decal will not be

applied. The only exception is EXTRICATION EQUIPMENT where the provider has written verification from the Regional EMS Program Director that this equipment is

immediately available from sources within the zone or county.

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.

COMMENTS:

Signature of Inspector:

Signature of Agency Representative Reviewed With:

Vehicle Inspection Form for Ambulances – Revised 06/01/2010 – Form R-E-01-A – Page 4 of 4 – VID #____________