Ambulance Inspection - Download Form | Lumiform

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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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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.