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AMBULANCE STATE INSPECTION FORM
Date Time
*
MM
/
DD
/
YYYY
INSPECTED BY
*
CREW NAMES
*
STATION
*
VEHICLE NUMBER
*
HEADLIGHTS - HIGH AND LOW BEAM
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
MARKER LIGHTS
*
YES
NO
N/A
HIGH BEAM DASH INDICATOR LIGHT
*
YES
NO
N/A
DASH AND INTERIOR LIGHTS (IF ALL LIGHTS ARE OUT)
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
LEFT AND RIGHT TAIL LIGHT
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
LEFT AND RIGHT FRONT TURN SIGNAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
LEFT AND RIGHT REAR TURN SIGNAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
ALL BRAKE LIGHTS
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
LICENSE PLATE LIGHT
*
YES
NO
N/A
BACK UP LIGHTS
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
EMERGENCY LIGHTING (ONLY IF ENTIRE SYSTEM IS OUT)
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
TIRE TREAD 1/16 MINIMUM ON ALL TIRES
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
TIRE TREAD AND SIDEWALL FREE OF ALL DEFORMITIES
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
RIMS AND WHEELS FREE OF SIGNIFICANT DAMAGE
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
BRAKE PEDAL FOR POWER BRAKES OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
EMERGENCY / PARKING BRAKE OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
STEERING SHAFT SECURE / NO EXTRA PLAY
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
POWER STEERING OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
TIRES HAVE FULL RANGE OF MOTION WITHOUT RUBBING
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SHOCKS / SPRINGS MOUNTED AND INTACT
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
AIR RIDE SUSPENSION PROPERLY INFLATES AND DEFLATES
*
YES
NO
N/A
WINDSHIELD WITHOUT BREACH, UNOBSTRUCTED
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
WINDSHIELD WIPERS AND WASHER OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
WINDOWS WITHOUT BREACH AND OEM
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
REAR VIEW MIRROR WITHOUT BREACH
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
HORN OPERATIONAL AND AUDIBLE
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
AUDIBLE BACK UP ALARMS OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SIREN OPERABLE AND AUDIBLE
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SEAT BELTS OPERATIONAL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SEAT BELTS FREE OF DEFECT
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SEAT BELTS FASTENED TO THE FLOOR
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
FLOOR INTACT AND FREE OF HOLES
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
INTERIOR FREE OF PROTRUSIONS, TRASH AND DEBRIS
*
YES
NO
N/A
STRUCTURAL INTEGRITY WITHOUT BREACH (BODY AND FRAME)
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
HEATER, DEFROSTER, AND A/C INSTALLED AND OPERATIONAL (FRONT AND BACK)
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
EXHAUST SYSTEM SECURED AND WITHOUT BREACH
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
FUEL TANK FREE OF LEAKS AND SECURELY MOUNTED
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
LICENSE PLATES FRONT AND REAR
*
YES
NO
N/A
TWO-WAY COMMUNICATIONS WITH DISPATCH AND MED CONTROL
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
SERVICE NAME / LOGO PERMANENTLY ON VEHICLE
*
YES
NO
N/A
CONFORMANCE PLACARD, STICKER, OR AFFIDAVIT
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
ABC FIRE EXTINGUISHERS MINIMUM CLASSIFICATION OF 2-A: 10-B COMPLIANT (2)
*
YES
NO
N/A
EXTINGUISHERS PERMANENTLY MOUNTED
*
YES
NO
N/A
ANNUAL EXTINGUISHER MAINTENANCE
*
YES
NO
N/A
PERMANENTLY INSTALLED MAIN OXYGEN SYSTEM
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
PERMANENT VARIABLE FLOW REGULATOR
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
TWO PORTABLE OXYGEN TANKS - SECURED
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
ONE PORTABLE FLOW REGULATOR
*
YES
NO
N/A
BVM
*
YES
NO
N/A
BVM MASK - ADULT, CHILD INFANT (1 EACH) OR ADULT, COMBO CHILD/INFANT.
*
YES
NO
N/A
NRM - ADULT, PEDIATRIC, INFANT (2 EACH)
*
YES
NO
N/A
NC - ADULT, CHILD (2 EACH)
*
YES
NO
N/A
ON BOARD SUCTION
*
YES
NO
N/A
PORTABLE SUCTION (POWERED OR HAND)
*
YES
NO
N/A
SUCTION TIP (2)
*
YES
NO
N/A
FRENCH SUCTION - 2 SIZES - 1 BETWEEN 6 AND 10, 1 BETWEEN 12 AND 16
*
YES
NO
N/A
STERILE WATER/SALINE - 1000ML MINIMUM, EXCLUDING IV SOLUTIONS
*
YES
NO
N/A
STERILE GLOVES (2 PAIR)
*
YES
NO
N/A
SUCTION TUBING (2)
*
YES
NO
N/A
OPA - INFANT THROUGH ADULT
*
YES
NO
N/A
NPA - INFANT THROUGH ADULT
*
YES
NO
N/A
INTUBATION KIT
*
YES
NO
N/A
EXTRA BATTERIES AND BULBS
*
YES
NO
N/A
SYRINGES - ASSORTED SIZES
*
YES
NO
N/A
STYLET - ADULT AND PEDIATRIC
*
YES
NO
N/A
MAGILL FORCEPS
*
YES
NO
N/A
ET TUBES - CUFFED - 6, 7, 8
*
YES
NO
N/A
ET TUBES - CUFFED OR UNCUFFED - 2.5, 3, 3.5, 4, 4.5, 5, 5.5
*
YES
NO
N/A
KY JELLY
*
YES
NO
N/A
LAYNGOSCOPE HANDLE
*
YES
NO
N/A
LARYNGOSCOPE BLADES - CURVED AND STRAIGHT - 1, 2, 3, 4
*
YES
NO
N/A
END TIDAL OR CAPNOGRAPHY
*
YES
NO
N/A
ET TUBE SECURING DEVICE
*
YES
NO
N/A
CRIC KIT
*
YES
NO
N/A
IGEL/KING - ADULT AND PEDS
*
YES
NO
N/A
BAND AIDS (10)
*
YES
NO
N/A
2X2 AND 4X4 (20)
*
YES
NO
N/A
5X9 (4)
*
YES
NO
N/A
ASSORTED KLING (4)
*
YES
NO
N/A
TRAUMA DRESSING
*
YES
NO
N/A
DEFIB PADS FOR NONPOROUS DRESSING (4)
*
YES
NO
N/A
ASSORTED TAPE (4)
*
YES
NO
N/A
ISOLATION KIT (4) *OR*
*
YES
NO
N/A
GOGGLES AND MASK OR MASK/SHIELD COMBO (4)
*
YES
NO
N/A
GOWNS (4)
*
YES
NO
N/A
GLOVES (4)
*
YES
NO
N/A
N95 MASK (4)
*
YES
NO
N/A
BIOHAZARD BAGS (4)
*
YES
NO
N/A
SHARPS CONTAINER
*
YES
NO
N/A
PURPLE WIPES
*
YES
NO
N/A
HAND SANITIZER
*
YES
NO
N/A
EXTREMITY IMMOBILIZATION DEVICES (BOARD SPLINTS AND SAM SPLINT)
*
YES
NO
N/A
TRACTION SPLINT
*
YES
NO
N/A
BACKBOARDS (2)
*
YES
NO
N/A
BACKBOARD STRAPS (3 PER BOARD)
*
YES
NO
N/A
ADULT CID (2)
*
YES
NO
N/A
C-COLLAR - ADULT, CHILD, INFANT
*
YES
NO
N/A
STAIRCHAIR
*
YES
NO
N/A
TRAUMA SHEARS
*
YES
NO
N/A
STETHOSCOPE
*
YES
NO
N/A
BP CUFF - LARGE ADULT, ADULT, PEDIATRIC
*
YES
NO
N/A
THERMOMETER
*
YES
NO
N/A
PENLIGHT
*
YES
NO
N/A
FLASHLIGHT
*
YES
NO
N/A
OB KIT
*
YES
NO
N/A
EXAM GLOVES - 2 DIFFERENT BOXES
*
YES
NO
N/A
COT WITH 3 STRAPS
*
YES
NO
N/A
PILLOWS AND CASES (2)
*
YES
NO
N/A
SHEETS (2)
*
YES
NO
N/A
HEAVY BLANKETS (2)
*
YES
NO
N/A
TOWELS (2)
*
YES
NO
N/A
EMESIS BAGS (2)
*
YES
NO
N/A
URINAL (1)
*
YES
NO
N/A
BEDPAN (1)
*
YES
NO
N/A
PERSON TOWLETTES (10)
*
YES
NO
N/A
RESTRAINTS (4)
*
YES
NO
N/A
REFLECTIVE VEST (2)
*
YES
NO
N/A
PEDIATRIC RESTRAINT
*
YES
NO
N/A
ALCOHOL, IODINE, OR IV PREP PAD (10)
*
YES
NO
N/A
ARM BOARD (1)
*
YES
NO
N/A
IV TUBING (4)
*
YES
NO
N/A
IV CATHETERS - ASSORTED SIZES
*
YES
NO
N/A
IO NEEDLES OR KIT (2)
*
YES
NO
N/A
NEEDLES - ASSORTED SIZES
*
YES
NO
N/A
MEDICATIONS PER DRUG LICENSE
*
YES
NO
N/A
IV SOLUTIONS PER DRUG LICENSE
*
YES
NO
N/A
CARDIAC MONITOR WITH PACING
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
DEFIB PADS - ADULT AND PEDS
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
EKG LEADS
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
PACING PADS
*
YES
NO
N/A
*AUTOMATIC REINSPECT*
COMMENTS
