Delaware County, IN / Action Center / Delaware County EMS Daily Equipment and Vehicle Inspection /

Date*

MonthDay Year,

Medic Unit #*

State Cert #*

Mileage*

Crew*

General Maintenance

Verify: Oil, Brake fluid, washer fluid/wipers, tires, exhaust system, windows/mirrors, marker lights, headlights high/low, fuel (add level below), gas card.

Body Damage?*

Yes No

Fluid Leaks?*

Yes No

General Maintenance Problems?*

General Maintenance Problem Narrative (if necessary)

Fuel Level*

Driver Compartment

Check cab for contraband, was anyting found?*

Yes No

Verify: Turn Signals, brake lights, battery status, parking brake(HI IDLE), backup warning device, emergency lights/sirens, radio (9VHF/800), heating/Air Conditioning, Seats/safety belts, clipboard w/forms, rear load lights.

Driver Compartment Problems*

Driver Compartment Problem Narrative (if necessary)

Outside Compartments

Verify: Long backboard(3), Board straps head beds (6 each), C-Collars (4 each - tall-regular-no neck-peds-infant), stair chair, KED w/accessories, scoop stretcher, long and short board splints (2 each), portable suction w/rigid and soft tips, traction splint w/accessories, ladder splints (2), wrecking bar/hammer, fire extinguisher, body bags (2), Portable O2w/nonrebreather N/C peds and infant masks(verify PSI below), Celox (2 pkg), tourniquet (2)

Problems with Outside Compartments*

Outside Compartment Problem Narrative (if necessary)

Patient Compartment

Verify: [PT Compartment Lights], [heating/Air Condition], [Flashlight], [On-Board suction w/tips], [Oxygen Equipment (5 each: Adult N/C, nonreabreathers, nebulizers)], [Peds and infant (2 each, nonrebreathers)], [Cot w/3 straps/pillow/clean linens], [Extra linens for at least 1 cot change], [Extra pillow], [Sharps container], [Protocols], [OP, NP airways (2 each-adult, child, infant)], [Combi Tube (2)], [BVM w/masks (1 each-adult, child, infant)], [ET Tubes (2 each 3-9)], [IV Fluids (1000cc) bags(5)], [Administration sets (5)], [Sterile gauze pads 3x3 or larger (50)], [Kerlex (5 rolls)], [Vaseline gauze (4)], [Triangular bandages (4)], [Adhesive tape(2)], [Bandage Shears], [Trauma Dressings (2 minimum)], [Burn Sheets (2 minimum)], [Bulb syringe - individually wrapped (2 minimum)], [Sterile water (2)], [OB kit (1)], [Gowns (2)], [Face masks w/shields (2)], [Gloves (1 box each size)], [Anti-bacterial hand cleaner], [BP cuffs (all sizes)], [Stethoscope (adult & peds)], [Pocket mask (1)], [Biohazard bags], [Heart monitor], [BLS box], [Airway box], [Drug box], [Glucometer w/strips],

Main O2 psi*

Portable O2 psi*

Video Scope Charged with 4 blades?*

Yes No

Problem with Patient Compartment?*

Digital Thermometer*

Helmets with Flashights (x2)*

Problem with Patient Compartment Narrative (if necessary)

Medications (minimum required)

Verify: [Adenmocard 30mg], [Aminodarone 450mg], [Aspirin 1 bottle], [Albuterol 6 vials], [Atropine 3mg], [Atrovent 6 vials], [Benadryl 100mg], [Brethine 2mg], [Calcium Chloride 1000mg], [Calcium Gluconate 100mg], [Cardizem 100mg], [Epinephrine 1:100 1 multidose], [Epinephrine 1:1000 5mg], [Glucagon 2 vials], [Haldol 20mg], [Instant Glucose 2 tubes], [Dopamine 1600mcg] [Lasix 120mg], [magnesium Sulf. 4mg], [Narcan 2mg], [Nitro spray 1 bottle], [Nitro paste 1 tube], [Vasopressin 40 units] [Sod Bicarb 50 meq], [Solu-medrol 125mg], [Zofran IV 8mg], [Compazine 10mg], [Lidocaine Inj 300mg], [Dextrose 50% 50gms], [Lidocaine premix 4mg/cc bag], [Racemic EPI 5 vials], [Tetracain 1 bottle], [Zofran ODT 16mg]

Problems with Medications?*

Problems with Medications (if necessary)

Narc Box

Narc Box Tag#*

Verify: [Ativan(Loreazepam)4mg], [Fentanyl 200mg], [Morphine 20mg], [Valium 20mg], [Versed (Midazolam) 10mg],

Problems with Narc Box?*

Problems with Narc Box Narrative (if necessary)

Station Status

Station Clean?*

Yes No

Station Cleanliness Notes

Out of Service Vehicles Mileage, Vehicle CERT, Narc Box CERT

Add the vehicle CERT# followed by the (mileage) for all vehicles. Example: #2207 (80,392) Also add the Cert# of the Narcotics Seal Tag.

Out Of Service Vehicle Mileage*

Person Filling out this Form*

Please Do Not Complete The Following Field

Delaware County, Indiana

Discover Delaware County - an east central Indiana community of opportunity

Delaware County EMS Daily Equipment and Vehicle Inspection

General Maintenance

Driver Compartment

Outside Compartments

Patient Compartment

Medications (minimum required)

Narc Box

Station Status

Out of Service Vehicles Mileage, Vehicle CERT, Narc Box CERT

By submitting this form, you are verifying that all information provided is accurate and complete!

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