AMBULANCE BUS VEHICLE INSPECTION REPORT Office of Emergency Medical Services 2707 Mail Service Center Date: ___________________________ Raleigh, NC 27699-2707 Location: ________________________ PROVIDER INFORMATION VEHICLE INFORMATION Provider Name: ______________________________ Current Permit #: _________ VIN: _________________________________________ System Affiliation: ____________________________ Assigned Vehicle Number: _______________ Model Year: ________ Patient Capacity: ________ Manufacturer: ______________________ Fuel Type: _____ Gas _____ Diesel _____ Viper ID #: ____________________________________ Ramp Inspections Require Mandatory Items; Spot Inspections Require A Full Inspection EMT Inspection Required Items Continued: TOTAL INSPECTION SCORING ___ Stair Chair or Folding Stretcher Mandatory (Automatic Failure) Items: ___ Cervical Spine Immobilization Device (S,M & L) ___ Vehicle Body & Function ___ Femur Traction Device (Adult/PED) Missing an entire Mandatory (Automatic ___ Appropriate Restraints for Crew & Non-patient Passenger ___ PED Restraint Device Available to Restrain <40lbs. Failure) Item may result in Summary ___ Warning Devices (Lights & Sirens) ___ Pediatric Spinal Immobilization Device or Short Backboard Suspension or refusal of a permit. ___ Two-way Radio in Front & Radio Control Device Mounted in with Straps Patient compartment ___ Adult Spinal Immobilization Extrication Device or Short ___ Wheeled Cot with Securing Straps Backboard with Straps ___ O2 Cylinder with Regulator (2 Sources) ___ Upper & Lower Extremity Immobilization Devices If the vehicle has all mandatory equipment ___ Head Immobilization Device ___ Suction Apparatus (2 Sources) ___ Burn Sheet (Automatic Failure Items) and missing no ___ Bag Valve Mask (Adult & Child Sized Bags with Adult, Child, ___ Cold Packs more than (2) of the Required Items the Infant, & Neonatal Mask) ___ Dressings, Bandages, Roll Gauze vehicle permit will be issued. ___ Defibrillator with Adult & PED Pads ___ Triangular Bandages (At Least 2) ___ Sphygmomanometer (Cuffs & Devices PED, Normal Adult, ___ Heavy Duty Scissors Large Adult) ___ Occlusive Dressing ___ Stethoscope ___ Adhesive Tape Inspection Results ___ Heating & Cooling Sources ___ Sterile Irrigation Solution ___ Patient Compartment Lighting ___ Alcohol Wipes PASSED ___ Trauma Tourniquet ___ Bed Pan ≤ 2 missing items = Satisfactory ___ Copy of Protocols ___ Urinal ___ Carbon Monoxide Monitors (Front & Rear Patient ___ Emesis Collection Device > 2 missing items = Unsatisfactory Compartment) ___ Pediatric Medication/Equipment System Guides ___ Sheets, Pillows, Pillow Cases, & Towels Deficiencies corrected during inspection Mandatory for Expanded Scope of Practice: ___ Lubricating Jelly Approved ___ Sterile OB Kit (Scissors, Bulb Suction, Cord Clamps) Acetaminophen or NSAID Not Approved ___ ___ Thermal Blanket (or Other Heat Conserving Device) ___ Blind Insertion Airway Device with Syringe (Adult & PED Sizes ___ Thermometer (Low Temperature Capability) ___ Capnometry (Color)/Capnography EtCO2 Detector ___ Triage System Permit #: _________________ ___ Beta-agonists (Albuterol, etc.) ___ Disinfectant Hand Wash/Sanitizer ___ Nebulizer ___ Disinfectant for Cleaning Equipment Expiration: _______________ ___ Aspirin ___ Disposable Biohazard Trash Bags ___ Infection Control Kit (Mask, Gowns, Jumpsuits, Eye ___ Epinephrine for Anaphylaxis/Allergic Reaction Protection, Shoe Covers) ____ FAILED ___ Needles/Syringes ___ Gloves (Latex Free) Refusal of a Permit ___ Nitroglycerin ___ Sharps Container (2 Sources) ___ Naloxone ___ Exterior Cleanliness Failed – Temporary ___ Nasal Administration Device ___ Interior Cleanliness Failed – Suspension Issued ___ Medications and Fluid Kept in Climate-Controlled Environment Required Items: ___ Provider Name Displayed on Each Side ___ Bulb Syringe (Separate From OB Kit) ___ Reflective Tape on All Sides ___ Nasal Cannula (Adult/PED) ___ Equipment Secured in Patient Compartment ___ Nasopharyngeal Airways (3 Adult/3PED Sizes) ___ Mounted Fire Extinguisher (Minimum 5lbs. Front & Rear) ___ Oropharyngeal Airways ( 3 Adult/3 PED Sizes) ___ Sliding Curtain Behind Driver ___ Non-rebreather with Tubing (Adult) & (PED) ___ Rigid Pharyngeal Suction Device ___ Suction Catheters (One Between 6 & 10F) ___ Suction Catheters (One Between 12 & 16F) ___ Wide Bore Suction Tubing ___ Glucose Measuring Device ___ Pulse Oximeter (Adult & PED Sizes) ___ Long Backboard with three (3) Backboard Straps or Equivalent Comments: ________________________________________________________________________ Compliance Inspection: _____ Ramp _____ Spot __________________________________________________________________________________ __________________________________________________________________________________ Provider Representative: For NCOEMS Use Only: PERSONNEL – P# LEVEL Inspector: #1:__________________________ EMR EMT AEMT Paramedic Date entered in Continuum: #2:__________________________ EMR EMT AEMT Paramedic DHHS/DHSR/EMS 4933 Rev. 2/2019.