Ambulance Daily Check Off Sheet - Greenbrier Co.
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1GREENBRIER CO. AMBULANCE DAILY CHECK OFF SHEET
DATE:____________
TIME:_________
UNIT:_________
MEDICAL CHECK OFF
VEHICLE CHECK OFF
Installed O2________psi _________psi
Mileage ________________
Adult MAST ____ Ped MAST _____
Fuel Level _______
Fire Extinguisher (1)
Wipers
Streamlight (1 or 2)
Turn signals
Traction Splint (1) adult & (1) pediatric KTD
Back up lights
K.E.D. (1)
Brake lights
Stair Chair (1)
Heater Front/Rear
Backboards & straps # of boards:______Minimum (2)
A/C Front/Rear___
Pediatric Immoblizer (1)
Horn/Siren
Child Restraint System
Headlights High/Low
Long Splints (2) each S,M,L
Emergency Lights
C-Collars, (4) Stiff neck adj. (2) ped & child
Scene lights
Headblocks (4)
Engine Oil Ok Qts. Added ________
Portable O2_______psi
Washer Fluid
Portable 02 Bag stocked (NC,NRB,Neb w/albuterol)
Power stering fluid
Spare portable oxygen (1)
Transmission fluid
Bandaging Supplies (tape, gauze pads, kling, tri-
Brake fluid
bandages, elastic bandages, SAM splint, etc)
Engine coolant
Infection Control (gowns,masks,hand cleaner)
Tires
IV Supplies - start kits, cathlons, adm. sets
Mag Light (1)
fluids - (4) each
Traffic Vests (Minimum 3)
(can be on shelf and in 1st out bag)
Airway :(oral,nasal,NG,BVM,suction, Combitubes)
Fuel Cards x 5 (
)
DOH, Reynolds, Citgo, Exxon, Kroger
Thermometer & Ring Cutter (1 each)
Credit Card
Adult Nasal Cannula (4) Ped (2)
Cell Phone
Adult NonRebreathers (4) Ped (2)
Protocol Books
Nebulizers (4)
Map Book
Bed Pan / Urinal (1 ea.)
MCIM Book
Portable Suction, tubing, big stick, CHECK BATTERY
Clip Board w/appropriate forms
Intubation Kit - (ET tubes, BVM, ETCO2, tube holder,
Pt. Compartment - CLEANED and ORGANIZED
stylettes, blades, handle, CHECK LIGHT,nasal kit)
Pt. Compartment Lights
Burn Sheets (2) Trauma Dressings (3)
Trash Emptied
Hot / Cold packs (Shelf - 3 ea; 1st Out Bag 1 ea.)
Helmets, gloves, safety glasses (2 each)
Cardiac monitor: __ Electrodes __ Defib pads
__SpO2 __Cables __BP Cuffs __ETCO2
Window Punch
Narcotic Box Tag #___________________
OB Supplies: (2) OB kits (1) Baby Bunting Blanket
First Out Bag: __Glucometer __NTG & ASA __Glucose
Drug Bag Tag #_______________________
__Adult BP Cuff __Ped BP Cuff__Stethescope
Multicuff (1)
Pediatric Bag Tag #___________________
Installed Suction w/ tubing, big stick
Gloves XL,L,M,S and assorted Nitrile
Charcoal (50 grams)
Sterile Water/Saline (minimum 1000ml)
1 __________________________________
Triage Bag w/tape and tags
Printed Name of Person Checking Unit
Arterial Tourniquet (1)
Body Bags ( 1 Lightweight and 1 Heavy Duty)
2 __________________________________
BP Monitor and Pulse Ox (IF AVAILABLE)
Printed Name of Person Checking Unit
AED: __Defib pads __Batteries OK (IF AVAILABLE)
Cot made w/sheet, pillow & blankets.
Please note that this check-off sheet is not all-inclusive and other items should also be verified while checking trucks.
MAKE SURE TO DOCUMENT VERIFICATION OF DRUG TAG NUMBER ON DAILY INVENTORY DRUG SHEET IN CLIPBOARD
Please list any problems that you find: _________________________________________________________
____________________________________________________________________________________________
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Parent category: Miscellaneous