UDOH AEMT Ground Ambulance Inspection ChecklistName of Agency:Agency Service Number:Inspected by:Date of Inspection:Vehicle InformationVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Vehicle License Plate NumberVIN NumberYear of VehicleType of Vehicle (Ambulance,Fire Truck Transport, Reserve,Other)Type of Inspection (Annual,New Vehicle, New License)Defibrillator/AED Serial NumberVehicle ChecklistVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Approved waiverTriage systemSanitary conditionsEmergency ResponseGuidebook (ERG)Flashing lights and sirenRadio equipmentWritten standing ordersPediatric Reference Manual1 Blood pressure cuff (adult)1 Blood pressure cuff (pediatric)1 Stethoscope (adult)1 Stethoscope (pediatric ofcombination)2 Heavy duty shears1 OB Kit (includes cord clamp,scissors, scalpel, bulb syringe,drapes, towels, gloves, femininenapkin, and biohazard bags)12 4”x4” sterile gauze pads2 Sterile dressings, 5”x9”,8”x10” or equivalent

8 Bandages, soft roller type,4”x5 yards or equivalent2 Rolls tape2 Triangular bandagesVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 72 Occlusive sterile dressings orequivalent1 Box gloves, non-sterile, latexfree or equivalent1 Thermometer1 Glucose measuring device andsupplies1 Commercial tourniquet3 Cervical collars or equivalent(adult)1 Cervical collar or equivalent(pediatric)1 Fire extinguisher with currentsticker, dry chemical rating(2A10BC) or halogenextinguisher, 2.5 – 10 pounds2 Immobilization devices, heador equivalent1 Lower extremity tractionsplint (adult)1 Lower extremity tractionsplint (pediatric)1 Upper extremity splint1 Lower extremity splint, nontraction1 Short spine board (wood mustbe coated and sealed)1 Long spine board (wood mustbe coated and sealed)1 Full body immobilizationdevice (pediatric)2 Pillows (with vinyl cover orsingle use disposable)2 Blankets1 Mylar blanket2 Sheets3 Towels2 Bio-hazard bags

2 Emesis basins or bags, orlarge basins2 Urinals (male and female) oruniversalVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 71 Full body substance isolationprotection (one per crewmember)1 N95 or N100 mask (one percrew member)1 Eyewear, protective (gogglesor face shield) per crewmember1 Car seat or equivalentapproved by federal safetystandardsReflective safety vest (OSHAapproved) for each crewmember1 Bottle disinfecting agent forcleaning vehicle and equipmentof body fluids in accordance toOSHA standards. Bleach dilutedbetween 1:10 – 1:100 withwater1 Ring cutter1 Hard commercial eye shield1 Suction device, portableand/or fixed with wide-boretubing and rigid pharyngealsuction tip1 Bag valve mask (adult)1 Bag valve mask (pediatric)with a child and infant mask1 Syringe/aspirator infant bulbtype. Separate from the OB kit1 Oropharyngeal airway (adult)1 Oropharyngeal airway (child)

1 Oropharyngeal airway (infant)1 Nasopharyngeal airway(adult)1 Nasopharyngeal airway (child)Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 71 Nasopharyngeal airway(infant)2 Non-rebreather or partial nonrebreather 02 mask (adult)2 Non-rebreather or partial nonrebreather 02 mask (pediatric)2 Nasal cannulas (adult)1 Nasal cannula (child)1 Nasal cannula (infant)1 Oxygen delivery system,permanent, large capacity1 Portable oxygen deliveryapparatus, metered flow withadequate tubing1 Tube or equivalent, waterbased lubricant1 Pulse oximeter, with adultand pediatric probes2 Nebulizer containers, smallvolume for aerosol solutions1 Magill forceps (adult)1 Magill forceps (child/infant)1 Supraglottic airway device(adult)1 Supraglottic airway device(pediatric)1 Defibrillator with ECG displayor Automated ExternalDefibrillator (AED) portablebattery operated2 Electrode pads fordefibrillation (adult)2 Electrode pads fordefibrillation (pediatric)

10 Alcohol or iodine prep pads2 IV start kits or equivalent2 arm boards or equivalent(Sam Splints)5 Extension tubing1 Sharps container1 Safety razorVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 72 Saline locks4 Normal saline forinjection/inhalation2 60cc syringes2 10cc syringes2 3cc syringes2 1cc syringes2 14g over the cath. IV needles2 16g over the cath. IV needles2 18g over the cath. IV needles2 20g over the cath. IV needles2 22g over the cath. IV needles2 24g over the cath. IV needles5 IV tubing capable of microand macro drip or equivalent2 Albuterol Sulfate 2.5mgpremixed8 81mg chewable aspirin2 Dextrose 50%, 25gm preloador dextrose 10% 250mlEpinephrine 1:1000 1cc(1mg/1cc): 15mg 1cc syringe 22gauge needle or equivalent1 1mg vial Glucagon500cc Irrigation solution2 2mg Naloxone HCL

1 Nitroglycerine, 0.4mg (tabletsor spray)2 Oral glucose tubes 15mgconcentrated or equivalent4000cc Ringer’s lactate ornormal saline or combination ofbothVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Must have at least one of the following pain medications200mcg Fentanyl2 10mg Morphine sulfate10mg NalbuphineNitrous Oxide and requiredadministration setsOptional Equipment and MedicationsHemostatic gauze or agentWhole body vacuum splintInflatable back raftTranscutaneous carbonmonoxide detector1 60cc cath. tip syringeEnd-tidal C02 monitorCPAP deviceMorgan lens for ocularirrigationOro nasogastric tubes (adultand/or child)Automated transport ventilatorImpedance threshold deviceAutomated chest compressiondevice12 lead ECG with transmissioncapability1 Intraosseous needle – 15g or16g or delivery system1 Intraosseous needle – 18g ordelivery system

1 Volutrol pediatric IV chamberMucosal atomization deviceVacutainer holdersVacutainer tubesThree-way stopcockAcetaminophen elixir160mg/5mlActivated charcoalVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Optional Equipment and MedicationsAmiodarone 300mg IVAtropine Sulfate 1mg eachCalcium gluconateCyanoKitDiazepamDiphenhydramine 50mg2 Epinephrine 1:10000 1mgeachIbuprofen (adult and pediatric)Ipratropium Bromide(nebulizer)Lidocaine (IV for cardiac use)LorazepamMidazolamOndansetron 8mg2 Promethazine HCL 25mg eachSodium Bicarbonate 50mEgeachNerve Agent Antidote – Mark 1or Duodote

Feb 12, 2020 · Vehicle Information Vehicle Checklist UDOH AEMT Ground Ambulance Inspection Checklist Name of Agency: Agency Service Number: Inspected by: 8 Bandages, soft roller type, 4”x5 yards or equivalent 2 Rolls tape 2 Triangular bandages Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7File Size: 469KBPage Count: 7