BUREAU OF EMERGENCY MEDICAL SERVICES
BLS Ambulance Inspection Checklis
t
I. GENERAL INFORMATION: Date Stickers:
Decals:
Name of EMS Agency:
Dominate Lettering (as displayed on EMS unit)
License Plate # : Year: Make: Model:
Vehicle Identification # (VIN):
Date Inspected: Affiliate # :
Regional EMS Council: Mileage:
VEHICLE/EQUIPMENT
PRESENT
AND
OPERATING
DEFICIENT CORRECTED
Identified as Meeting the Fed KKK 1822 Specs
Exterior Markings
Audible Warning Signal
Lights:
Exterior
Interior
Dual Battery System
Fire Extinguisher (1) (5# ABC dry chem. or CO2) (Body of Amb.)
Fire Extinguisher (1) (5# ABC dry chem. or CO2) (Patient Comp.)
Power Supply
Current Vehicle Inspection
Current Vehicle Insurance
Current Vehicle Registration
Interior Requirements:
General Safety Concerns
Floor
Patient Area Partition
Storage Cabinets
IV Hangers flush with ceiling (2)
Patient Litter Compliant With 5 Manufacture Approved Straps
Doors (side and rear gasket, latches and hinges)
No Smoking /Oxygen Equipped Sign - In Cab of Vehicle (1)
No Smoking /Oxygen Equipped Sign - In Patient Compartment (1)
Fasten Seat Belts Sign - In Cab of Vehicle (1)
Fasten Seat Belts Sign - In Patient Compartment (1)
Radio Equipment (meets regional comm. requirements)
Installed Oxygen
AMD Standard 003 for crashworthiness (3) Straps
with mounted O2 flow meter 0-25 lpm (1)
On Board Oxygen with at least 500 Liters of O2 at the time of
inspection
Installed Suction (300mm/Hg in 4 sec.)
Results:
Installed Suction - Gauge with the ability to control suction
PENNSYLVANIA DEPARTMENT OF HEALTH
Version 9/1/2017
1
-BLANK-
-BLANK-
PRESENT
AND
OPERATING
DEFICIENT CORRECTED
Operational Heating/Cooling Equipment-Maintained between 6
8
⁰F &
78⁰F (at patient stretcher) Results:
Ventilation / Exhaust Equipmen
t
Current Version of Statewide EMS Protocols
Portable Suction Unit (1)(300mm/Hg in 4 sec.)
Results:
Suction Catheters: (Sterile)
Rigid (2)
6 Fr. Suction Catheter (1)
8 Fr. Suction Catheter (1)
10 Fr. Suction Catheter or 12 Fr. Suction Catheter (2)
14 Fr. Suction Catheter or 16 Fr. Suction Catheter (2)
Oropharyngeal - (to include 6 different Sizes)
Size 0 (1)
Size 1 (1)
Size 2 (1)
Size 3 (1)
Size 4 (1)
Size 5 (1)
Nasopharyngeal (5 different Sizes)
Size 16 (1)
Size 24 (1)
Size 26 (1)
Size 32 (1)
Size 34 (1)
Lubrication (2cc or Larger tube) sterile water soluble (2)
Portable O2 flow meter 0-25 lpm (1)
Non-Sparking wrench/tank opening device (1)
Portable Oxygen with a min. tank capacity of 300 liters and min
. of
500 PSI (1)
Full Spare O2 cylinder with a 300 liters capacity (1)
Pediatric Nasal Cannula (1)
Adult Nasal Cannula (1)
Adult High Concentration Masks (1)
Pediatric High Concentration Mask (1)
Infant High Concentration Mask (1)
Humidifier bottle (1)
Adult Bag Valve Mask Device (700cc) (1)
Pediatric Bag Valve Mask Device (450cc) (1)
Adult Mask (1)
Child Mask (1)
Infant Mask (1)
Neonatal Mask (1)
Sphygmomanometer (interchangeable gauges are permitted)
Child Cuff (1)
Adult Cuff (1)
Thigh Cuff (1)
Adult Stethoscope (1)
Pediatric Stethoscope (1)
Penlight (1)
Version 9/1/2017
2
PRESENT
AND
OPERATING
DEFICIENT CORRECTED
Multi-Trauma (10" x 30" ) (4)
Occlusive ( 3" x 4" ) (4)
Sterile Gauze Pads ( 4" x 4" ) (25)
Soft Self Adhering ( 6 rolls )
Sterile Burn Sheets (4' x 4') (2)
Adhesive Tape ( 4 rolls assort., 1 must be hypoallergenic)
Bandage Shears (1)
Commercial “Tactical” Tourniquet (2)
Lateral Cervical Spine Device (1)
Long Spine Board (1)
Short Spine Board (1)
Rigid/Semi Rigid Neck Immobilizers - Small or Multi Size (1)
Rigid/Semi Rigid Neck Immobilizers - Medium or Multi Size (1)
Rigid/Semi Rigid Neck Immobilizers - Large or Multi Size (1)
Rigid/Semi Rigid Neck Immobilizers - Peds or Multi Size (1)
Straps 9' (5) (May sub spider straps or speed clips for 3)
Folding Litter/Collapsible Device (1)
Stair Chair (1)
Traction Splint Adult or Comb) (1)
Traction Splint Child or Comb) (1)
Upper Extremity Splints (2)
Lower Extremity Splints (2)
Pediatric Safe Transport Device (between 10 and 99lbs)
Sterile Water/Normal Saline - 2 liters
Cold Packs, Chemical (4)
Heat Packs, Chemical (4)
Triangular Bandages (8)
Sterile OB Kit (2)
Separate Bulb Syringe (1) Sterile
Thermal Blanket-Silver Swaddler or roll of 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 Paper Drinking Cups (3 oz.) (4)
Emergency BLS Jump Kit (1)
Thermometer (1) electronic digital non-tympanic
Instant Glucose (45 grams - 40% dextrose-d-glucose gel) or food
grade substitute
Pulse Oximetry (1)
Aspirin 81 mg (1 small bottle)
AED
Adult Defibrillator Pads (1)
Pediatric Defibrillator Pads (1)
Hand light (2)
Hazard Warning Device (3)
Version 9/1/2017
3
PRESENT
AND
OPERATING
DEFICIENT CORRECTED
High-visibility safety apparel (1/crew member)
Helmet (1 per crew member)
Gloves (1 pair per crew member)
Eye Protection - Goggles (1 pair per crew member)
Regional Approved Triage Tags (20)
DOT Emergency Response Guide (1) - Current Edition
PERSONAL INFECTION CONTROL KIT
Eye Protection - clear & disposable*
Gown/Coat*
Surgical Cap*
Foot Coverings*
Exam Gloves*
Red Bags - (per infectious control plan)
Sharps container - (per infectious control plan)
N-95 Respirator Mask*
Hand Disinfectant/cleaner - Non-water (1 container)
* Disposable -one set/pair per responding crewmember
Optional Equipment
CPAP Ventilation - portable equipment with (2) disposable masks
Naloxone
Electronic Glucose Meter (1)
Epinephrine Auto Injector, Adult & Pediatric (2) of Each
Y
ES NO
Was a deficiency notification issued for this vehicle?
Is a copy of the deficiency notification attached to this form? *
Is a reinspection required?
Electronic Deficiency Form Completed
Digital Images Captured
Vehicle Placed Out of Service (Per I.B. 2013-001)
** All deficiencies are required to be documented on approved form and submitted with this form.
Inspected By: ________________________
(Printed Name)
Signature:
Date Forwared to BEMS: _______________
Version 09/01/2017
4
