Lumiform Mobile audits & inspections
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Ambulance Inspection Form

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Ambulance Physical Condition
General Vehicle Condition
Is the exterior of the vehicle clean and free of damage?
If damage is noted please take a photo of the damaged area?
Is the interior cab of the truck clean and free off damage?
If there is damage noted in the cab of the truck please take a picture.
Is the patient compartment clean and free of damage?
If damage is noted in the patient compartment please take a picture.
Protocol book on unit?
Fuel and general engine fluids check
Fuel level at checkout? (Indicate the closest amount)
Are engine oil levels acceptable?
Are windshield wiper fluid levels acceptable?
Is there any indication of leaking fluids?
Emergency Alert Systems and General Lights
Headlights functional?
Clearance lights functional?
Emergency lights functional?
Scene lights functional?
Sirens functional?
Backup alarm functional
Brake lights functional
Tail lights functional?
Turn lights functional?
General Vehicle Section Narrative
Enter additional detail as necessary for any negative findings above?
Patient care equipment
Stretcher/Response bags/Monitor
Stretcher is present, functioning normally. Batteries are charged?
Stretcher patient restraints including shoulder straps present?
Airway bag is present, stocked correctly with a charged oxygen cylinder?
Portable oxygen pressure level? (Indicate to the nearest hundred)
Heart Monitor is present, clean, fully charged, with spare batteries on the charger?
Monitor passed user test?
Response bag present, clean and fully stocked with no expired items?
Narrative for Stretcher/Response bags/Monitor section. (Only required if you marked a no answer)
Patient Compartment
Linens stored and clean?
Regular Trash Can Present?
Bio Hazard Trash Can Present?
Portable Suction present and functional?
On Board Suction present and functional?
Transport Ventilator present, clean and functional?
CPAP present, clean and functional?
Safety Equipmeent
Safety Equipment
2 Hard hats with goggles?
2 Pair gauntlet gloves?
2 Safety Vests
2 Flashlights?
2 BSI Kits
Window Punch
Sharps Container
3 Road Reflectors
Hand Sanitizer
1 Fire Extinguisher Cab, 1 Fire Extinguisher Outside compartment, 1 Fire Extinguisher patient compartment?
Basic Life Support Supplies
Adult Nasal Cannula Count
Pediatric Nasal Cannula Count
Adult Non-Rebreather Count
Pediatric Non-Rebreather Count
Adult Nebulizer Count
Pediatric Nebulizer Count
Oropharyngeal Airway, 1 each size
Advanced Airway Supplies
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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