I. GENERAL INFORMATION: Date Stickers: Yes No Decals: Yes No
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1 PENNSYLVANIA DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES Vehicle # ALS Mobile Care and BLS Inspection Checklist I. GENERAL INFORMATION: Date Stickers: Yes No Decals: Yes No Name of Ambulance Service: Address: (Primary Headquarters) City State Zip License Plate # : Year: Make: Model: Vehicle Identification # (VIN): Date Inspected: Affiliate # : Regional EMS Council: Mileage: Type of Service: BLS: ALS Mobile Care: II. DOCUMENTS/POLICIES PRESENT DEFICIENT CORRECTED Personnel Roster Staffing Plan Policy Statements Documentation Requirements Patient Records Secured Medical Director's Agreement License Displayed Infection Control Plan III. VEHICLE/EQUIPMENT PRESENT DEFICIENT CORRECTED Word Ambulance on front of vehicle in "RI" min. 4", also on rear of vehicle min 4", name of service on each side min. 3", also on each side word ambulance or words "Emergency Medical Services" min. 3", Stars of Life (2) 3" min. on hood, (1) 16" min. on each side, (2) 12" min. on rear, (1) 36" on roof Audible Warning Signal Emergency lights exterior must meet DOT requlations Lights interior all must be working on high & low beam Dual Battery System FireExtinguisher (2) after January 1, Both must be securely mounted & easily accessible rated at least 2A:10B:C (1) in cab or outside compartment & one in patient area Power Supply Current Vehicle Inspection Current Vehicle Insurance Interior Requirements: Floor Dimensions Patient Area Partition Storage Cabinets IV Hangers Patient Litter Doors Side & Rear (gaskets, latches & hinges)
2 III. VEHICLE/EQUIPMENT (Cont) PRESENT DEFICIENT CORRECTED No Smokimg Signs & Fasten Seat Belt signs (1 each in cab and patient area Radio Equipment that meets Regional Requirements Installed O/2 tank with 500 liters & (3) restraning straps Installed Suction Operational Heating/Cooling/Ventilation Equipment IV, MEDICAL SUPPLIES/EQUIPMENT Portable Suction with wide bore tubing, must achieve 300 mmm/hg or 11.8" of water in 4sec. Suction Catheters: Rigid (2) French (2) 6-8, (2) 10-12, (2) total (6) Airways: Oropharyngeal (6) Nasopharyngeal (5) Rescue Airways King sizes 3, 4 &5 or Combitubes sizes small and adult one each Oxygen Delivery Devices: Nasal Cannulas (Adult/Pediatric- 1 each) High concentration Masks Adult/Pedi/Infant (1each) Portable O/2 cylinder securely mounted at all times Spare O/2 cylinder securely mounted at all times (1) Portable O/2 flow meeter 0-25 lpm (1) Wall mounted O/2 flow meeter 0-25 lpm Pocket Mask with One-Way Valve (1) Humidifer Bottle (1) CPAP for ALS & approved BLS services w/flow control Dressings: Multi-Trauma (10" x 30" ) (4) Sterile Burn Sheets (4' x 4') (2) Occlusive ( 3" x 4" ) (4) Sterile Gauze Pads ( 3" x 3" ) (25) Soft Self Adhering ( 6 rolls ) Adhesive Tape ( 4 rolls ) Bandage Shears (1) Immobilization Devices: Lateral Cervical Spine Device (1) Long Spine Board (1) Short Spine Board (1) Rigid/Semi Rigid Neck Immobilizers (Sm., Med., Lg., Ped.) (1 each) Straps 9' (5) Folding Litter (1) Splinting Devices: Traction Splint ( Ad/Child-1ea.or Comb) Upper and Lower Extremity (2 each) Bag Valve Mask Devices: (Adult and Pediatric- 1 each) Pediatric Equipment Sizing Tape/Chart-BLS Pediatric Length-Based Drug Dosing/Sizing Tape-ALS
3 IV. MEDICAL SUPPLIES/EQUIPMENT (Cont) Sphygmomanometer (Sm.,Med.,Large) Stethoscope Adult & Pediatric (1 each) Penlight (1) Sterile Water/Normal Saline- 2 liters Cold Packs, Chemical (4) Heat Packs, Chemical (4) Triangular Bandages (8) Sterile OB Kits (2) Separate Bulb Syringe (1) Thermal Blanket/Sterile Foil (1) Pillow (1) Blankets (2) Sheets (4) Pillow Cases (2) Towels (4) Disposable Tissues (1 box) Emesis Container (1) Bedpan (1) Urinal (1) Disposable Drinking Cups (3 oz.) (4) Emergency Jump Kit (1) Thermometer- electronic or digital (1) Instant Glucose ( 45 grams) Actvated Charcoal (50 grams) Optional Epinephrine Auto-Injector-Adult/Ped (2 ea)** Pulse Oximetry (for services with medical director)** AED with(2) adult pads for BLS services after 1/1/2011 V. ALS EQUIPMENT/SUPPLIES Phlebotomy Equipment Meconium Aspirator (1) Electronic Glucose Meter (1) Sponges/Preps/Wipes-Alcohol (10) Endotracheal Tubes: 2.5 mm or 3.0 mm (uncuffed) (2) 3.5 mm or 4.0 mm (uncuffed) (2) 4.5 mm or 5.0 mm (2) 5.5 mm or 6.0 mm (2) 6.5 mm or 7.0 mm (2) 7.5 mm or 8.0 mm (2) 8.5 mm or 9.0 mm (2) Stylette, Malleable (Adult (1)/Ped.(2) Laryngoscope: Handle with Batteries (1) Spare Batteries and Bulbs Blades: Straight # 1,# 2,# 3- (1 each) Curved # 3, # 4- (1 each) Lubrication-water Soluble ( 2cc) (2) Forceps, Magill (Adult/Pediatric- 1 each)
4 V. ALS EQUIPMENT/SUPPLIES (Cont) IV Therapy Supplies: Catheters Over the Needle: 14 gauge (4) 16 gauge (4) 18 gauge (4) 20 gauge (4) 22 gauge (4) 24 gauge (2) Sharps Receptacle - must be secured (1) IV Administration Supplies: Microdrip (50-60 drops/ml) (2) Macrodrip (10-20 drops/ml) (2) IV Solutions (2250 ml total) Tourniquets for IV Use (2) Medications and Supplies: Emergency Drugs Hypodermic Needles: gauge (4) gauge (4) gauge (4) Intraosseous (14-18 gauge ) (2) Syringes Defibrillator/Monitor Supplies: Defibrillator/Monitor Spare paper (1) Paddle Pads (4) or gel ( 2 tubes) Electrodes, ECG (Adult/Ped.) (6 each) Waveform Capnography VI. RESCUE PROTECTION EQUIPMENT Current DOT Emergency Response Guide (1) Hazard Warning Device (3) Hard Hat ( 1 per crew member) Gloves (leather) ( 1 pair per crew member) Goggles ( 1 set per crew member) Handlight ( 6 volts or more ) (2) Regional approved Triage Tags (20) ea VII. PERSONAL PROTECTION EQUIPMENT PRESENT DEFICIENT CORRECTED Clear Eye Protection* Face Mask* Gown/Coat* Surgical Cap/Foot Coverings* Double Barrier Gloves* * one set/pair per responding crewmember Biological Waste Container Red bags for waste container Fit-tested disposable N95 masks (1) per crew Hand disinfectant/cleaner- Nonwater (1) container
5 VI. Optional Access Equipment Screwdrivers: Phillips (1-large ) Slotted (1-large) Pliers: Slip Joint (1) Lineman's (1) Needlenose (1) Arc Joint (Water) (1) Locking (1) Sledge Hammer ( 3 lbs.) (1) Metal Cutting Tool (1) Short Pry Bar (12") (1) Cold Chisel ( 7" x 3/4") (1) Hacksaw with 2 blades Adjustable Wrench (10") (1) Center Punch (1) Inspected By (Printed Name) Signature Date forwarded to EMS office
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