PENNSYLVANIA DEPARTMENT OF HEALTH
BUREAU OF EMERGENCY MEDICAL SERVICES
ALS
Ambulance Inspection Checklist
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
Operational Heating/Cooling Equipment-Maintained between
68⁰F & 78⁰F (at patient stretcher) Results:
Ventilation / Exhaust Equipment
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DEFICIENT CORRECTED
MEDICAL SUPPLIES/EQUIPMENT
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)
Non-Sparking wrench/tank opening device (1)
Portable Oxygen with a min. tank capacity of 300 liters and a
minimum of 500 psi (1)
Full Spare O2 cylinder with a 300 liters capacity (1)
Oxygen Delivery Devices:
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
Adult Cuff
Thigh Cuff
Adult Stethoscope (1)
Pediatric Stethoscope (1)
Penlight (1)
Multi-Trauma (10" x 30" ) (4)
Occlusive ( 3" x 4" ) (4)
Sterile Gauze Pads ( 4" x 4" ) (25)
Sterile Burn Sheets (4' x 4') (2)
Soft Self Adhering Gauze ( 6 rolls )
Adhesive Tape ( 4 rolls assort., 1 must be hypoallergenic)
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PRESENT
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OPERATING
DEFICIENT CORRECTED
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)
Pediatric Equipment/Dosing Sizing Tape (Current) (1)
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 ALS Jump Kit (1)
Thermometer (1) electronic, digital, non-tympanic
Instant Glucose (45 grams-40% dextrose-d-glucose gel) or (food
grade substitute)
CPAP Ventilation - portable equipment with (2) disp. Masks
Pulse Oximetry
ALS EQUIPMENT/SUPPLIES
Endotracheal Tubes:(must be sterile & indiv. wrapped)
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)
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PRESENT
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DEFICIENT CORRECTED
Laryngoscope:
Handle with Batteries (1)
Spare Batteries and Bulbs
Blades:
Straight # 1 (1)
Straight # 2 (1)
Straight # 3 (1)
Curved # 3 (1)
Curved # 4 (1)
Stylette - Malleable (1 Adult) must be sterile
Stylette - Malleable (2 Pediatric) must be sterile
Forceps, Magill (1 - Adult)
Forceps, Magill (1 - Pediatric)
Non-surgical Alternative/Rescue Airways - Either (3) Kings (size
3,4,5) or (2) Combitubes (small & adult - 1 each) or (3) i-gel
(size 2, 3, 4)
Meconium Aspirator (1)
Nebulizer System (1)
Phlebotomy Equipment (per regional protocol)
Sponges/Preps/Wipes-Alcohol (10)
Electronic Glucose Meter (1)
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)
IV Administration Supplies:
Microdrip (50-60 drops/ml) (2)
Macrodrip (10-20 drops/ml) (2)
Tourniquets for IV Use (2)
Medications and Supplies:
Adenosine
Aspirin (81 mg)
Atropine Sulfate
Benzodiazepines (at least one):
Diazepam
Lorazepam
Midazolam
Bronchodilators (Albuterol or Albuterol Ipratropium Bromide)
Dextrose
Diphenhydramine HCl
Epinephrine (1:1,000)
Epinephrine (1:10,000)
Lidocaine HCl
Naloxone
Narcotic Analgesics (at least one):
Fentanyl
Morphine Sulfate
Nitroglycerine,sublingual
IV Solutions (2,000 ml total)
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PRESENT
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DEFICIENT CORRECTED
Sodium Bicarbonate
Hypodermic Needles:(must be sterile & indiv. wrapped)
16-18 gauge (4)
20-22 gauge (4)
23-25 gauge (4)
Intraosseous (14-18 gauge ) (Total of 2)
3 1/4" over the needle catheter : 10, 12 or 14 gauge (2)
Syringes (2 with at least one being 1 mL volume)
12 Lead Cables & Pacing & Transmitting Capabilities (Adult &
Pedi)
Adult Defibrillator Pads (1)
Pediatric Defibrillator Pads (1)
Electrodes, ECG (Adult) (12)
Electrodes, ECG (Pediatric) (12)
Electronic Waveform Capnography
Hand light (2)
Hazard Warning Device (3)
High-visibility safety apparel (1/crew member)
Helmet (1 per crew member)
Gloves (leather) (1 pair per crew member)
Eye Protection (1 pair per crew member)
Regional Approved Triage Tags (20)
DOT Emergency Response Guide (1) - Current Ed.
PERSONAL INFECTION CONTROL KIT
Eye Protection*
Gown/Coat*
Surgical Cap*
Foot Coverings*
Exam Gloves*
Red Bags - per infectious control plan
Sharps Containers - per infectious control plan
N-95 Respirator Mask*
Hand Disinfectant/cleaner - Non-water (1 container)
* Disposable -one set/pair per responding crew member
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: _______________
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