Multi-County Ambulance Inspection Basic Life Support Checklist

Company Name: ______Date: ______Sticker Number: ______Previous Sticker Number: ______Based in the following counties:

Adams Arapahoe Broomfield Douglas Elbert Jefferson

Unit No.: ______VIN: ______Lic #: ______Exp. Date: ______Ambulance Make: ______Manufacturer: ______Year: ______Odometer: ______Insurance Company: ______Policy No.: ______Exp. Date: ______

__Basic Life Support __Basic Life Support with Advanced Life Support Capabilities __Advanced Life Support (BLS) (BLS/ALS) (ALS) __ Reserve Vehicle (Will be fully stocked according to this Inspection list before going into service.)

Basic Life Support Check List Emergency Systems: __ AED-Automatic External Defibrillator Serial No ______Ambulance Service Medical Treatment __Adult Pads __Pediatric Pads Protocols (Current) __Computerized __Printed __ Passed Self-Test Date:______Running Lights Date of Last Service: ______Emergency Lights __Siren __Opticom __Wipers Dressings and Bandages: __ Communications appropriate for jurisdiction served. __ ABD Pads __cell phone __ Portable Radio __ Bandages, roller type, self-adhesive __ Dispatched by: ______Multi Trauma Dressing (10 x 36) __ A set of 3 warning reflectors or devices. __ Sterile Burn Sheets ______Occlusive Dressing __ Spare Tire __Fleet __ Road side service __ Triangular bandages (2) __ Fire Ext. (ABC 5-10 lbs) - vehicle exterior __ Trauma Tourniquet Due Date: ______Sterile 4 x 4’s __ Oxygen (house supply) __ Adhesive Tape ___2” ___1” __ Two (2) Flash lights or lanterns __ Adhesive Bandages __ Crew Reflective Vests __ Hemastatic Gauze*

Splints and Immobilization Equipment: Ventilation and Airway Equipment: __ Spine board (long) with straps __ Suction Units: ___House___ Portable __ Spine board (short) with straps _____ KED __ Rigid Suction Tips Covered __ Patient extrication device __ Pediatric board __ Soft Catheter Fr. 6, 8, 10, 12, 14, other______Scoop stretcher with straps __ Bulb suction __ Mushroom Suction __ Cervical collars – rigid – adults and peds. __ Two (2) Portable Oxygen with regulators __ Head immobilization devices adult and peds. __ Nasopharyngeal Airway: Adult: 24,26,28,30,32 Type: ______Oropharyngeal Airway: Infant, Child, Small Adult, Adult, __ Assorted splints and arm boards, adult & peds. Large Adult __ Traction splint (lower extremity) with anklet __ Nasal Cannula: ___Adult ___ Pediatric __ Child safety seat (per state guidelines) __ NRB with Transparent Oxygen Masks: __ Adjustable gurney (4-6 wheels) with holder __ Adult___ Child __ Blankets (4) __ Bag Valve Mask O2 Resuscitators __ Pelvic Splint ___ Commercial ___ Other 500cc___ 750cc ___ 1000cc___ __ Stair Chair* with transparent masks, oxygen reservoir, and standard fittings 15mm – 21 mm Diagnostic Equipment: ___ *Supraglottic Airway__ IGELS Kings Combi-tube __ Blood Pressure Cuffs ___ Atomizer __Large adult__ Reg. Adult__ Child__ Infant __ Stethoscope NOTES: __ Diagnostic Pen Light (pupil gauge) __ Thermometer - adult and pediatric. __ Pulse Oximeter __ Electronic Glucose measuring device

*Optional Updated: 4/5/2019 Intravenous and Irrigation Equipment: and storage of medical waste and biohazards __ Sterile Irrigation __ Sharps container in Jump Kit __ IV solution volume expander, __1000mL__ 500mL __ Heated storage: __Yes ___ No * Safety Equipment: __ IV Arm boards, __Adult __Pediatric __ Fire Ext. (ABC 5-10 lbs) - vehicle interior __ Constricting bands Due Date: ______Alcohol Wipes __ Other: ______No smoking sign (patient compartment) __ IV administration sets: __Micro__ Macro __ Shears, heavy duty (Trauma) Blood pumps __ Other: ______Ring cutter * __ IV venipuncture needles: sizes: ______thru______Safety seat belts, including squad bench (If required by Medical Director or company.) __ Restraining devices for all equip. in Pt. Comp. __ *Blood specimen equipment Additional Equipment and Supplies: Obstetrical Equipment: __ Appropriate cleaning supplies including: __ Sterile OB kit to include towels, 4x4’s, disinfectant cleaner. ______ABD pads, umbilical tape or cord clamps, scissors ______or scalpel, bulb syringe, sterile gloves, drapes, __ Trash Bags (biohazard). Disposed at: ______blanket, or thermal absorbent blanket, stocking ______cap, heat source: ______Vehicle cleanliness: __Cab __ Patient Compartment __ Meconium/mucous trap/mushroom suction __ Storage Cupboards __ Triage tags Body Substance Isolation (BSI): __ Extrication Equipment * __Yes__ No __ Protective eyewear __ All Equipment on the ambulance is properly secured __ Sterile Gloves __Supplies are maintained and stored according to the __ Non-sterile Latex Free Gloves manufacturer’s recommendations and requirements __ N95 masks which can be universal of size __ Sharps containers for the appropriate disposal __ *Masks, non-sterile surgical

NOTES: Other comments: ______

Medical Director: ______Medical Facility: ______

❑ Approved Basic Life Support (BLS) ❑ Not Approved. - Re-inspection required.

Inspection Expires: Date of Re-inspection:

Please print Ambulance Service Representative’s Name:

Ambulance Service Representative Signature Date

Mona Fellers, Multi-County Ambulance Inspector Date