Last 5 Checkout Sheets

DATE:
FENDER:
Enter UnitID:

Enter Ambulance Mileage:
Region:
Chevin Daily Vehicle Inspection (DVI) submitted:

Vehicle Inspection


MAIN O2 PSI:(MIN. 500 PSI)
STAIR CHAIR FUNCTIONING(IF APPLICABLE)
FIRE EXTINGUISHER CHARGED (1)
ENGINE OIL (WNL)(CHECK WITH ENGINE OFF)
STEERING / TRANSMISSION FLUID (WNL)
COOLANT LEVEL (WNL)
ALL GAUGES FUNCTIONING PROPERLY
ELECTRICAL / CHARGING SYSTEM (WNL)
ALL LIGHTS and SIRENS FUNCTIONING
ALL RADIOS FUNCTIONING
IN-CAB WARNING LIGHTS
Door Handles Functioning Properly:
Body Damage:
Tire Pressure Good:
TIRES IN GOOD CONDITION
WIPERS FUNCTIONING AND GOOD COND.
FRONT HVAC SYSTEM (HEAT / AC TESTED)
REAR HVAC SYSTEM (HEAT / AC TESTED)
FLASHLIGHT (OPERATIONAL)
VEHICLE CAR JACK W/ HANDLE
WARNING TRIANGLES (3)

Vehicle Paperwork


REGISTRATION
INSURANCE
CURRENT CHP
CURRENT EMS BUSINESS LICENSE / PERMIT
APPROPRIATE MAP BOOKS
APPROPRIATE ERG BOOK
FUEL CARD MATCHING (FENDER #)


IT Equipment


Cell Phones (2):
ePCR Tablet/iPad Present:
EPCR TABLET FUNCTIONING
ePCR Tablet/iPad Damaged:
EPCR SCANNER FUNCTIONING

PPE


Gloves (S):
Gloves (M):
Gloves (L):
Gloves (XL):
N95 1860 (4 EACH)
N95 1860S (4 EACH) S
Surgical Masks:(10 EACH)
ISOLATION GOWNS (8)
SAFETY GLASSES (4)
RED BAGS (5)
BRUSH COAT (2)
REFLECTIVE SAFETY VEST (2)
HELMET (2)
HEARING PROTECTION (4 PAIRS)
WORK GLOVES (4 PAIRS)
BALLISTIC VEST (2) ( IF APPLICABLE)

Cleaning Supplies


Hand Wipes: (2)
Foaming Disinfectant Spray:
Purple Tops:
Bleach Wipes:
Towel Exchange Required:
Tire Dressing:
Car Wash Soap:
Quick Detailer Spray:

Gurney


GURNEY W/Pt Restraint System:4
BREAK AWAY FLAT
MATTRESS CLEAN AND DAMAGE FREE
PILLOW AND BLANKET ON GURNEY
I.V. POLE FUNCTIONING PROPERLY
Portable O2 Tank W/ Regulator Secured to Gurney:
RESTRAINTS (4) VELCROED TO GURNEY
Blood Pressure Cuff Components Functioning/Damage Free: (1)
Stethescope Components Functioning/Damage Free:
STORAGE POUCH CLEAN:

Splints/Backboards/Extrication Equipment


(MIN. 2) BACKBOARDS W/ 4 STRAPS
KED BOARD WITH ALL STRAPS (1)
ADULT HARE TRAC W/ HEEL STRAP (1)
Pediatric Hare Traction Splint W/ Heel Strap (1):
PEDIATRIC IMMOBILIZATION BOARD (1)
PEDI-MATE (1)
Cardboard Splints Wrist (4):
Cardboard Splints Arm (4):
Cardboard Splints Leg (4):
C-COLLAR ADULT (10)
C-COLLAR PED (5)
HEAD BEDS (10)

Patient Compartment


AED (1)
D Tanks (3) SECURED IN HOLDER
PAPER PATIENT CARE REPORT (25)
SUPPLEMENTAL NARRATIVE (50)
MEDICAL NECESSITY FORM (50)
HIPAA (Blue) PRIVACY FORM (50)
SHARPS CONTAINER
WALL MOUNTED O2 FLOW METER (2)
SUCTION (VACUUM OVER (300 MM Hg)
HANDHELD SUC W/TIP (1)
SUCTION CANISTERS (4)
SUCTION TUBING (4)
RIGID SUCTION CATHETERS (6)
SUCTION CATH (4 EACH) 8fr
SUCTION CATH (4 EACH) 10fr
SUCTION CATH (4 EACH) 12fr
SUCTION CATH (4 EACH) 14fr
SUCTION CATH (4 EACH) 18fr
ADULT BVM (2) (LARGE,MEDIUM, SMALL MASKS) INSPECT BAG FOR ALL 3 MASKS
PED BVM (2) TODDLER, INFANT, NEONATE MASKS) INSPECT BAG FOR ALL 3 MASKS
ORALPHARYNGEAL KIT COMPLETE (1)
NASOPHARYNGEAL KIT W/ KY JELLY (1)
ADULT MASK (10)
ADULT CANNULA (10)
PEDS MASK (8)
PEDS CANNULA (8)
INFANT MASK (8)
BLOOD PRESSURE CUFF AND STETH (1)
BP KIT W/ THIGH / CHILD / INFANT CUFF GAUGE ZEROED OUT WITH NO DAMAGE (1)
TAPE (3 EACH) 1"
TAPE (3 EACH) 2"
TAPE (3 EACH) 3"
TRAUMA DRESSING 10X30 (4)
4 X 4 GAUZE SPONGE (50)
3 X 3 GAUZE SPONGE (25)
COMBINE DRESSING 8 X 9 (4)
PETROLEUM GAUZE (2)
OBSTETRICAL KIT (2)
COLD PACK (6)
BURN SHEET (3)
ROLLER BANDAGE (6)
TRAUMA SHEARS (1)
STERILE WATER (4L)
SODIUM CHLORIDE (4L)
SMALL EMESIS BASIN (10)
LARGE EMESIS BASIN (6)
EXTRA PILLOWS (2)
Bedpan (1)
Urinal (1):
SANTITARY PATIENT LINEN PACK (20)
EQUIPMENT MEDKIT (ORANGE BAG)(LA LICENSED ONLY) (1)
GALLON OF WATER(1)
DISPOSABLE THERMOMETER(1)

Trauma Bag


CAT TOURNIQUET (3)
TRIAGE TAGS (20)
TRAUMA SHEARS (1)
ROLLER BANDAGE (4)
ROLLER BAND (4)
COMPRESS (12)
3 X 3 GAUZE (10)
TRIBAND (4)
4 X 4 GAUZE (10)
10 X 30 GAUZE (1)
TAPE (2) 1"
TAPE (2) 2"
TAPE (2) 3"
GLUCOSE (2)
PETROLEUM GAUZE (2)
ADULT BVM (1)
ORAL AIRWAY KIT (1)
NASAL AIRWAY (1)
HANDHELD SUC W/TIP (1)
Version 2016-1

CLEANING STANDARDS FOR AMBULANCES AND AMBULANCE EQUIPMENT AS SET BY STATE AND LOCAL EMS REGULATIONS

California Code of Regulations Title 22 and Title 13, California Health and Safety Code Div. 2.5
AFTER EVERY PATIENT USE
STANDARD
GURNEY
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
MATTRESS (Cover is damage free)
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
FLAT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
NEW PAPER LINEN
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
NEW PILLOW CASE
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
STAIRCHAIR
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
BACKBOARD
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
ALL REUSABLE MEDICAL EQUIPMENT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
DAILY As soon as contaminated
STANDARD
GURNEY
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
MATTRESS (Cover is damage free)
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
FLAT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
PAPER LINEN
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
PILLOW
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
STAIRCHAIR
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
BACKBOARD
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
ALL REUSABLE MEDICAL EQUIPMENT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
COMPUTER EQUIPMENT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
RADIOS
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
CEILING
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
CABINETS / DRAWERS / SHELVES
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
WALLS
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
WORKS SURFACES
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
WASTE RECEPTAVLES
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
STAINLESS STEEL O2 STORAGE BOX
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
WINDOWS
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
HANDRAILS
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
FLOOR
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
GURNEY MOUNTING EQUIPMENT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
FIRE EXTINGUISHER
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
HVAC GRILL
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
SHARPS CONTAINER
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
ELECTRICAL SWITCHES AND THERMO
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
MEDICAL GAS EQUIPMENT
Standard: All parts should be visibly clean with no blood, body substances, dust, dirt, debris, and adhesive tape or spillages
TRAUMA BAG
Bags taken into patient care areas must be wiped clean after every use with special attention given if contaminated with blood or body fluid. Any bag heavily contaminated with blood or body fluid should be disposed.
AMBULANCE DRIVER COMPARTMENT
Replace seatbelts if contaminated with blood or body fluids. Torn or damaged seat covers shall be replaced. Vacuum for dirt or debris and shampoo for blood or body substances
AMBULANCE OVERALL EXTERIOR
Routine cleaning should be performed weekly, or as necessary due to weather conditions if operational pressures prevent thorough cleaning of exterior, minimum health and safety laws should be met (i.e. windows, license plates)
AMBULANCE PATIENT COMPARTMENT
Replace seatbelts if heavily soiled. Torn or damaged seat covers shall be replaced.
END OF SHIFT RESPONSIBILITIES - REMOVE ALL TRASH FROM FRONT AND BACK OF UNIT. CLEAN AND SANITIZE LEAVING UNIT RESPONSE READY.
BY SIGNING THIS DAILY INSPECTION SHEET I DECLARE THAT ALL VEHICLE EQUIPMENT AND INSTALLED MEDICAL EQUIPMENT IS IN GOOD WORKING ORDER (OCEMS 720.30)
I warrant the truthfulness of the information provided in this application.
Print Name:
I understand that checking this box constitutes a legal signature.
I warrant the truthfulness of the information provided in this application.
Print Name:
I understand that checking this box constitutes a legal signature.
I warrant the truthfulness of the information provided in this application.
SUPERVISOR:
Print Name:
All identified supply and cleaning deficiencies have been corrected.
Please check to confirm signatures.