EMS Services

Summit County ALS Ambulance Inspection Form

Date of inspection: Place of inspection:

Ambulance Service:

Chassis: Conversion/Type/Class:

Unit: VIN: License:

[] Registration [] Proof of insurance [] DOR Emergency Vehicle Authorization [] KKK-1822 certification

Emergency vehicle: [] Emergency warning lights Occupant protection: [] Siren [] Vehicle cab [] Appropriate identifying markings [] Attendant seats Radio communications: [] Squad bench [] Ambulance to dispatch [] CRS b/i infl s/g pmate ppal conv [] Ambulance to medical control [] Operation of cot/cot mount [] Ambulance to receiving facility [] All items in patient compartment secured [] Ambulance to mutual aid agencies Ventilation and Airway Equipment: Oropharyngeal airways: [] Bulb syringe [] Infant [] Child [] Sm Adult [] Adult [] Lg Adult [] Ambulance suction unit (or backup suction unit) [] Nasopharyngeal airways: (24 -32 fr, 6-8 mm) [] Portable suction unit with wide-bore tubing Intubation equipment: [] Rigid pharyngeal curved suction tip [] Uncuffed ET tubes, sizes 2.5-5.5 mm [] Soft catheter suction tips, size 6-14fr (inclusive) [] Cuffed ET tubes, sizes 6.0-8.0 mm Oxygen equipment: [] Stylettes [] Ambulance oxygen supply with regulator [] Stabilization device [] Portable oxygen tank with regulator [] Laryngoscope handle [] Portable oxygen tank [] Laryngoscope blades (size 0-4, straight or curved) Non-rebreather oxygen masks: McGill forceps: [] Adult [] Pediatric [] Adult [] Pediatric [] Adult nasal cannulas Hand-operated, self-inflating resuscitator w/oxygen reservoir: [] End tidal CO2 detector or alternate, FDA-approved device [] Neonate/Infant [] Child [] Adult [] Nebulizer apparatus Masks to fit: (mask with expanded size range OK): [] Chest decompression equipment [] Neonate [] Infant [] Child [] Adult [] Cricothyrotomy tray or equipment Diagnostic Equipment: Blood pressure cuffs: [] Electronic blood glucose measurement device [] Large adult [] Regular adult [] Child [] Infant [] Cardiac monitor-defibrillator with recorder (w/AED []) [] Penlight Electrocardiograph electrodes: [] Stethoscope [] Adult [] Pediatric [] Pulse oximeter Defibrillation electrodes, or paddles and conducting gel: [] Adult probe [] Pediatric probe [] Adult [] Pediatric Splinting Equipment: [] Rigid cervical collars (Tall, Regular, Short, No-neck, [] Short spine board, extrication device or equivalent Pediatric and Baby no-neck sizes, or equivalent) [] Backboard straps or equivalent [] Head immobilization equipment, adult and pediatric [] Upper extremity splint [] Long spine board, Scoop, vacuum mattress or equivalent [] Lower extremity splint [] Pediatric immobilization device, adapter or equivalent [] Lower extremity traction splint Bandaging and Dressing Supplies: Bandages: Dressings: [] Triangular [] Roller [] Other [] Occlusive [] Large [] Small [] Other [] Adhesive tape [] Sterile burn sheets

Obstetrical Supplies: [] Sterile obstetrical kit (must include towels, 4”x4” dressings, [] Newborn heat retention cap umbilical clamps or tape, scissors or scalpel, bulb syringe, sterile exam gloves and thermal absorbent blanket) Personal Protective Equipment: [] Non-sterile disposable gloves [] HEPA masks [] Latex [] Latex-free [] Isolation kits [] Protective eyewear [] Turnout gear, helmet & heavy gloves (if applicable) [] Non-sterile surgical masks Miscellaneous Equipment: [] ABC fire extinguisher(s)(1-10 lb or 2-5 lb) accessible from: [] Sharps container [] patient compartment [] vehicle exterior [] Treatment protocols [] Blankets [] Approved triage tags 4 color ID# Bar code [] Two (2) working flashlights [] Triangular warning reflectors (set of 3) [] Heater for patient compartment [] Extrication equipment (if applicable) [] Heavy-duty shears Vascular Access Supplies: [] IV solutions [] Surgical tape or transparent dressings [] IV administration sets IV Arm boards: [] IV catheters [] Adult [] Pediatric [] Butterfly catheters Intraosseous access device [] Venous tourniquets [] Adult [] Pediatric [] Site prep pads Pharmacological Agents: (per medical director protocol) [] Pediatric drug dosage tape [] Adenosine (Adenocard) [] Ondansetron (Zofran) [] Albuterol sulfate solution (Proventil) [] Opthalmic anesthetic solution tetracaine proparacaine [] Amiodarone (Cordarone) [] Phenylephrine (Neo-Synephrine) [] Aspirin [] Racemic epinephrine (VapoNefrin) [] Atropine sulfate [] Sodium bicarbonate, 4.2% 8.4% [] Dextrose 25% 50% [] Sublingual glucose [] Diphenhydramine (Benadryl) [] Succinylcholine chloride (Anectine) [] Dopamine (Intropin) [] Vecuronium bromide (Norcuron) [] Droperidol (Inapsine) [] [] Epinephrine 1:1,000 1:10,000 autoinj [] [] Glucagon (GlucaGen) [] Ipratropium bromide solution (Atrovent) [] Diazepam (Valium) [] Lidocaine pfs premix visc [] Fentanyl (Sublimaze) [] Magnesium sulfate [] Ketamine (Ketalar) [] Methylprednisolone (Solu-Medrol) [] Midazolam (Versed) [] Naloxone (Narcan) [] Morphine sulfate [] Nitroglycerine [] [] Acceptable [] with corrections [] Not acceptable Comments/Required Corrections:

Ambulance Company Representative: Inspector: