Daily Unit Inspection Report

1

Date of Inspection

Date

2

Unit Number* This field is required.

3

Who are you?* This field is required.

4

Who is your partner?* This field is required.

5

Are you an ALS Unit?* This field is required.

YESNO

6

Drug Box #* This field is required.

7

Seal #* This field is required.

8

Expiration Date* This field is required.

9

Current Mileage* This field is required.

10

Next Oil Change Mileage* This field is required.

11

Oil Level Adequate?* This field is required.

See Operation ReportNO

12

Washer Fluid Adequate?* This field is required.

See Operation ReportNO

13

Portable Oxygen PSI* This field is required.

14

Main Oxygen PSI* This field is required.

15

General * This field is required.Current State Inspection Exterior Clean Interior Clean Current EMS Permit Seatbelts for All Medications protected from climate extremes

PassFail

16

General Failure Comments

17

BLS Equipment* This field is required.AED w/ Set of Pads (2) Pocket Masks (2) O/P Airways (6) (Sizes 0 --- 5, 1 ea.) N/P Airways (4) (1 ea. of var sizes) Soluble Lube Adult BVM w/ Adult/Peds Mask (1 ea.) Infant BVM w/ Infant Mask (1)

PassFail

18

BLS Equipment Failure Comments

19

Dressings and Supplies* This field is required.Durable First Aid Kit Trauma Dressings (8x10) (4) Sterile 4x4's (24) Occlusive Dressings (3x8) (4) Assorted Roller Gauze (12) Cravats (10) Tape 1" and 2" (4 rolls) Trauma Scissors (1) Emesis Basins (2) NS for Irrigation (4 L) Oral glucose (2) Alcohol preps (12)

PassFail

20

Dressings and Supplies Failure Comments

21

Warning Devices and Tools* This field is required.Adjustable Wrench, 10" (1) Standard Screwdriver (1) Phillips Screwdriver(1) Center Punch (1) Flares or Cones/Triangles (3) Current USDOT ERG (1) Emergency Lights on All Sides Min. 2 Flashing Lights in Grill Audible Warning Device

PassFail

22

Warning Devices and Tool Failure Comments

23

Patient Assessment Equipment* This field is required.Adult Stethoscope (2) Peds Stethoscope (1) B/P Cuffs: Child, Adult, LG (1 ea.) Vinyl Triage Tape Rolls: R, B, G, Y (1 ea.) OEMS Approved Triage Tags (25) Penlight (1) Current Medical Protocols (1)

PassFail

24

Patient Assessment Equipment Failure Comments

25

Splinting * This field is required.Rigid Collars- Adjustable (3) Adult and Pediatric Traction splint w/ ankle hitch A & P (1 ea.) Padded board splint upper ext. (2) Padded board splint lower ext. (2) Backboard (2) Short spine board (1) Peds immobilization device (1) Cervical immobilization device set (2)

PassFail

26

Splinting Failure Comments

27

Communications* This field is required.Vehicle to Base Vehicle to Vehicle AIC to Med Control (ALS only)

PassFail

28

Communications Failure Comments

29

Suction Apparatus * This field is required.Battery Powered Portable Suction Suction Catheters: Rigid tonsil tip FR18, FR14, FR8 & FR6 (2 ea.) Suction Canister in Wall and Portable Unit

PassFail

30

Suction Apparatus Failure Comments

31

Linen* This field is required.Towels (2) Blankets (2) Pillows (2) Pillowcases (2) Sheets (4)

PassFail

32

Linen Failure Comments

33

Safety Equipment* This field is required.D---Cell Flashlight (1) ABC Extinguisher (5#) (2) Traffic safety apparel (2) Sharps Container Stretcher w/ 3 straps min. (1) No Smoking Sign

PassFail

34

Safety Equipment Failure Comments

35

PPE* This field is required.Waterless Antiseptic Hand Wash (1) Exam Gloves --- 10 pr/ea. size Disposable Gowns (4) Face---shield/Eyewear (4) Infectious Waste Bags (4) Bedpan and toilet paper (1) Male Urinal (1)

PassFail

36

PPE Failure Comments

37

OB Kits (2)* This field is required.Each Must Include: Pair of sterile surgical gloves (2) Scissors or other cutting instrument(1) Umbilical cord ties (4) Sanitary pads (1) Cloth/Disposable hand towels (2) Soft tip bulb syringe (1)

PassFail

38

OB Kit Failure Comments

39

Advanced Airway* This field is required.(BLS & ALS) King Airway Size 3-5 (1 each) (ALS) Complete ETT Kit (1)

PassFail

40

Advanced Airway Failure Comments

41

Markings* This field is required.Agency Contrast/Reflective 3" Min. Lettering 4" Min. Reflective Band

PassFail

42

Markings Failure Comments

43

Oxygen Apparatus* This field is required.Main O2 --- 1000 psi min Portable O2 --- 1150 psi min Adult HC (NRB) Masks (4) Peds HC (NRB) Masks (4) Adult Nasal Cannula (4) Child Nasal Cannula (4)

PassFail

44

Oxygen Apparatus Failure Comments

45

ALS Equipment * This field is required.Drug Kit (EMT---A/I/PM) (1) ECG Mon/Defib/Cardio/Pac (1) Electrodes, Adult & Peds (2 ea.) Defib Electrodes, A&P (2 ea.) Pace Electrodes, A&P (2 ea.) Sterile Needles, Syringes IV Solutions/Tubing IV Start Kits Pediatric Assessment Guide (1)

PassFail

46

ALS Equipment Failure Comments

47

Is Unit Now Stocked and Ready for Service?

YESNO