Rig Check Form

Ambulance Number

Mileage

Date & Time

Date

Hour MinutesAM/PM Option

Fuel Level

New Damage

Shoreline Charging

Truck Clean

Crew

iPad

General Vehicle Standards

Rows	In working order/not expired/not damaged
All Emergency Lights
All Flood Lights
All Head And Tail Lights
All Sirens And Horns
All Turn Signals
Cabin Interior Lights
Cabin Heat And AC
Current NJ DMV Inspection Sticker
Rear Interior Heat And AC
Rear Interior Lights
Interior Clean And OK
Exterior Clean And OK
Clipboard With PCR, QuickReg, and Pens
DOT Hazmat Guidebook
Flashlight (Check Working)

Occlusive Dressings Expiration Dates (In ambulance and Tech Bag)

Glucose Gel Expiration Dates (In ambulance and Tech Bag)

OB Kit Expiration Dates (In ambulance and Tech Bag)

Portable Oxygen Tank: Minimum 750 PSI

Tech Bag (separate from rig)

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Adult BVM (1)
Pediatric BVM(1)
Infant BVM(1)
HEPA Filter(1)
PEEP Valve(1)
Adult Nasal Cannulas (4)
Pediatric Nasal Cannulas (4)
Adult Non-Rebreather(4)
Pediatric Non-Rebreather(4)
Tracheostomy Mask (1)
Nasopharyngeal Airways (Two each sizes 18-36 even numbers only)
Oropharyngeal Airways (One each 110,100,90,80, 70,60,55,50,40) mm
Bulb Syringes (2)
Sterile Lubricant (6)
Convenience Bags (4)
Trauma Shears (1)
Burn Sheets (2)
Trauma Dressings (2)
Tourniquets (2)
Occlusive Dressings (2)
Hemostatic Dressings (2)
Israeli Bandage (2)
Sterile Dressing 4x4 (10)
Sterile Dressing 5x9 (2)
Sterile Dressing 8x10 (2)
4 inch Roller Bandages (2)
3 inch Roller Bandages (4)
2 inch Roller Bandages (4)
1 inch Roller Bandages (2)
Glucose Gel (2)
Sterile Water (1)
Blood pressure cuff (Adult) (1)
Blood pressure cuff (Adult Large) (1)
Blood pressure cuff (Child) (1)
Adult Stethoscope (1)
Child Stethoscope (1)
Pulse Oximeter (1)
Pen Light (1)
Triangular Bandages (6)

PPE Bag

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
KN95 Masks (4)
N95 Masks (10)
Surgical Masks (20)
Isolation Suits (4)
Goggles (4)
Face Shields (2)

Gloves

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Small (2)
Medium (2)
Large (2)
Extra Large(2)

AED Battery GoodReplace Number Of Razors Adult Pads Connected Exp. On: Date Adult Pads Extra Exp. On: Date Pediatric Pads Exp. On: Date

On-Board Oxygen Tank: Minimum 500 PSI

Was the on-board oxygen tank changed?

Portable Suction Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Portable Suction Canister (1)
Suction Catheter 14 French (2)
Suction Catheter 6 French (2)
Suction Catheter 8 French (2)
Suction Catheter 12 French (2)
Suction Catheter Hard Tip (1)
Sterile water (250ml) (1)
Suction Tubing (1)

On Board Suction Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
On Board Suction (1)
Suction Canister (2)
Suction Catheter 16 French (2)
Suction Catheter 14 French (2)
Suction Catheter 8 French (2)
Suction Catheter Hard Tip (4)
Suction Tubing (4)
Suction Catheter 12 French (2)
Suction Catheter 10 French (2)
Suction Catheter 6 French (2)

On Board Oxygen Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
On Board Oxygen Cannister (1)
Bag Valve Mask Adult (1)
Bag Valve Mask Child (1)
Bag Valve Mask Infant (1)
Nasal Cannulas Adult (4)
Nasal Cannulas Pediatric (4)
Non-Rebreather Masks-Adult (4)
Non-Rebreather Masks-Pediatric (4)
Tracheostomy Mask (1)
PEEP Valve (1)
HEPA Filter (1)
Nasopharyngeal Airways (Two each sizes 18-36 even numbers only)
Oropharyngeal Airways (One each 110,100,90,80,70,60,55,50,40) mm
Oxygen Delivery Tubing (3)
Sterile Lubricant (4)

General Patient Care Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Band Aid 0.75 by 3 inches (A Bunch)
Band Aid 2 by 4.5 inches (A Bunch)
4 inch Roller Bandages (4)
3 inch Roller Bandages (6)
2 inch Roller Bandages (6)
1 inch Roller Bandages (6)
Biohazard Bags (small) (5)
Biohazard Bags (large) (5)
Burn Sheets (4)
Cold Packs (4)
Convenience bags (6)
Eye pad (3)
Glucose Gel (3)
Irrigation cap (2)
OB kit (2)
Paper bags (3)
Paper towels (1)
Pediatric Reference Sheet (1)
Pen Lights (2)
Purple wipes (2)
Sterile water (500ml or 250ml) (4)
NJ Disaster Triage Package (25 Tags)
Sterile Dressing 8X10 (6)
Sterile Dressing 5X9 (6)
Sterile Dressing 4X4 (10)
Surgical Tape 3 inch (3)
Surgical Tape 2 inch (3)
Surgical Tape 1 inch (3)
Trauma Sheets (4)

Vital Sign Measurement Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Blood pressure cuff (Adult) (1)
Blood pressure cuff (Child) (1)
Blood pressure cuff (Infant) (1)
Blood pressure cuff (Large Adult) (1)
Pulse Oximeter (1)
Stethoscope Child (1)
Stethoscope Adult (1)

Bleeding Control

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Tourniquets (4)
Occlusive Dressings (4)
Hemostatic Dressings (4)
Israeli Bandages (2)
Trauma Shears (1)

Immobilization and Carrying Devices

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Backboard (2)
Cervical Collar Adult (4)
Cervical Collar Pediatric (4)
KED (Check Headboard and Padding) (1)
PediMate (1)
Reeves (with sheet) (1)
Scoop Stretcher (1)
Stair Chair (with sheet) (1)
Traction Splint (Check ankle hitch and three straps) (1)
Pediatric Backboard (1)
CPR Board (1)
Bariatric Sliding Sheet (2)
Large splints (2)
Medium splints (2)
Small splints (2)

Portable Suction Equipment

Rows	In working order/not expired/not damaged	Amount In Ambulance	Needs to be replenished
Axe (79 only) (1)
Cribbing Equipment (77 and 79 only) (1)
Fire Extinguisher (1)
Hard Hats/Goggles (4 Each)
Heavy Duty Work Gloves (2)
Jumper Cables (1)
Jump Start Kit (1)
Pry Bar (79 only) (1)
Road Salt (Amount Unspecified)
Shovel (1)
Trailer Hitch (77 only) (1)
Triangle Emergency Warning Devices (3)
Triage Bag (50 tags) (1)
Spare Straps (4)
High Visibility Public Safety Vests (4)

Notes:

Rig Equipment