Standard Ambulance Check Sheet
This check sheet is for a standard ambulance layout.
EMS Crew
*
Lead
Partner
Unit #
*
Please Select
2
4
5
5-2
7
8
9
10
11
12
Unit Location
*
Please Select
Headquarters
Station 2
Station 3
Station 4
County Garage OOS
Cloninger Ford OOS
Other Location OOS
Front Line or Spare Unit?
*
Frontline Unit
Spare Unit (response ready)
Offline Spare Unit (no equipment)
Shift Exchange Checklist
Rows
Done
Notes
Day/Night switch or pager turned to DAY mode?
2 Portable VIPER radios present?
2 Portable VHF radios present?
Lead Medic keys exchanged? (spare key, narc key, hosp. fob)
Spare Key with hospital fob for partner?
Controlled Substances inventoried and signed for?
MDIS Logged in and Updated?
Samsara device powered on?
*
Yes
No
Tremco/Vista Brake Lock Engaged?
*
Yes
No
Ambulance Operation
Front Cab
*
Ambulance Exterior Compartments
ALS Compartment
*
Cervical Collar Compartment
*
Backboard Compartment
*
Exterior Splint Compartment
*
Exterior Triage Compartment
*
Exterior O2 Compartment
*
Ambulance Patient Box Checklist
Patient Box General Checklist
*
Adult Airway
*
Oxygen Supplies
*
Kits
*
Pediatric Cabinet
*
Hemorrhage
*
Disaster Supplies
*
Top Linen Cabinet
*
Linen Cabinet
*
IV Cabinet
*
Bench Seat
*
Extra Supply Cabinet
*
Fluid Cabinet
*
Stat Pack G3 Checksheet
If no jump bag is present, list the reason and skip this section:
No jump bag present.
Click here and list the reason.
Top Flap Outside
*
Top Flap Inside (mesh compartment)
*
Trauma Pocket
*
Vitals Pocket
*
Large Main Flap Mesh Pockets
*
Airway Cell
*
Middle Section (large)
*
Middle Section (small)
*
Med Cell (medication side)
*
Med Cell (IV Side)
*
Drug Box
If no drug box select the reason and skip this section:
Spare Unit, No Drug Box
Other
Top Lid Section
*
Upper Clear Section
*
Lower Clear Section
*
Bottom Section
*
Cardiac Monitor
Complete the Checklist for the Monitor that is on the unit.
If no cardiac monitor on this Unit, input reason in OTHER and skip this section:
Select other and list reason.
Other
LP 35 Checklist
LP 15 Checklist
Missing Items or Concerns (Do NOT list NONE. ONLY list items that you need supervisor action. Select on duty supervisor below.)
On Duty Supervisor Alert (If missing items/concerns)
Please Select
Capt. Wood
Capt. Leopold
Capt. Patton
Lt. Donnelly
Lt. Blanton
Lt. Whitmoyer
Lt. Guthrie
Sgt. English
Sgt. Cmaylo
Select the supervisor to alert directly about missing items/concerns.
Checksheet Suggestions (Temporary)
If you have updates or changes that you want to suggest, add them here and it will alert us for review.
Deep Clean/Inspection Completed (If the unit you are submitting this checksheet for is assigned for deep clean/inspection today, check the box below to confirm it was completed.)
Sunday - Truck 3
Monday - Truck 4
Monday - Truck 11
Tuesday - Truck 5
Tuesday - Truck 12
Wednesday - Truck 7
Thursday - Truck 8
Friday - Trucks 9
Friday - Truck 10
Saturday - Truck 2
Submit
Should be Empty: