Daily Ambulance Check Sheet
This check sheet is for a standard ambulance layout.
EMS Crew
*
Lead
Partner
Unit #
*
Please Select
2
3
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 radio 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 Cabinet
Pediatric Airway Bag
Drug Box or Med Bag w/seal
LP 35/LP 15
Lucas (Backboard, neck strap, extra suction/battery, charger)
Orange PPE bag - N95s, Surgical Masks, Gowns, Hand Sanitizer
Small Passenger Rear Compartment
Adult Cervical Collars/ Head-blocks (4)
Pediatric Cervical Collars/ Head-blocks (2)
Spider Straps (2)
Tall Passenger Rear Compartment
Adult Back Boards (2)
Pediatric Back Board (1)
Driver Rear Compartment
Stair Chair
KED
Pelvic Binder
Speed Splint
Driver Middle Compartment
Mega-Mover
Triage Tarps (Red/Yellow/Green)
Body Bags With Tags (2 White/ 2 Black)
Jumper Cables
02 Compartment
M Cylinder Securely Fastened
Pry Bar
Min. 300 PSI
2 Ballistic Vests
Yes
No
Ambulance Patient Box
D/E Cylinder minimum 500 PSI
Yes
No
D/E Cylinder SPARE Tank (1 or 2)
Yes
No
High pressure O2 connector on vent hose
Yes
No
Tablet/Laptop with Charger
Yes
No
Rectal/Oral Thermometers
Yes
No
Adult Regular and Adult Large BP Cuff
Yes
No
Glucometer Stocked
Yes
No
Stethoscope
Yes
No
Portable Suction
Yes
No
Narcotics
Yes
No
Emesis Bags
Yes
No
Vent
Yes
No
IV Rolls (1 on each side)
Yes
No
IV Cabinet Stocked
Yes
No
Kit Cabinet Stocked
Yes
No
Airway Cabinet Stocked
Yes
No
O2 Delivery Device Cabinet Stocked
Yes
No
Pediatric Cabinet Stocked
Yes
No
Trauma Cabinet Stocked
Yes
No
Linen Cabinet Stocked
Yes
No
Extras Cabinet Stocked
Yes
No
Bench Seat Stocked
Yes
No
Disaster Cabinet Stocked
Yes
No
Stat Pack G3 Checksheet
Jump Bag Fully Stocked
*
Yes
No
Glide Scope Present
*
Yes
No
Jump Bag Number
*
Med Cell Number
*
Airway Cell Number
*
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.
Submit
Should be Empty: