4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

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Ambulance Physical Condition

General Vehicle Condition

Is the exterior of the vehicle clean and free of damage?

Yes No N/A

If damage is noted please take a photo of the damaged area?

ADD PHOTO

Is the interior cab of the truck clean and free off damage?
Yes No N/A

If there is damage noted in the cab of the truck please take a picture.

ADD PHOTO

Is the patient compartment clean and free of damage?

Yes No N/A

If damage is noted in the patient compartment please take a picture.

ADD PHOTO

Protocol book on unit?

Yes No N/A

Fuel and general engine fluids check

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4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

Fuel level at checkout? (Indicate the closest amount)

1/8 1/4 1/2 3/4 Full

Are engine oil levels acceptable?

Are windshield wiper fluid levels acceptable?

Is there any indication of leaking fluids?

Emergency Alert Systems and General Lights

Headlights functional?
Yes No N/A

Clearance lights functional?

Yes No N/A

Emergency lights functional?

Yes No N/A

Scene lights functional?

Yes No N/A

Sirens functional?
Yes No N/A

Backup alarm functional

Yes No N/A

Brake lights functional

Yes No N/A

Tail lights functional?

Yes No N/A

Turn lights functional?

Yes No N/A

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4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

General Vehicle Section Narrative

Enter additional detail as necessary for any negative findings above?

Patient care equipment

Stretcher/Response bags/Monitor

Stretcher is present, functioning normally. Batteries are charged?

Yes No N/A

Stretcher patient restraints including shoulder straps present?

Yes No N/A

Airway bag is present, stocked correctly with a charged oxygen cylinder?

Yes No N/A

Portable oxygen pressure level? (Indicate to the nearest hundred)

(check name not set)

Yes No N/A

Heart Monitor is present, clean, fully charged, with spare batteries on the charger?
Yes No N/A

Monitor passed user test?

ADD PHOTO

Response bag present, clean and fully stocked with no expired items?
Yes No N/A

Narrative for Stretcher/Response bags/Monitor section.

(Only required if you marked a no answer)

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4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

Patient Compartment

Linens stored and clean?

Yes No N/A

Regular Trash Can Present?

Yes No N/A

Bio Hazard Trash Can Present?

Yes No N/A

Portable Suction present and functional?

Yes No N/A

On Board Suction present and functional?

Yes No N/A

Transport Ventilator present, clean and functional?

Yes No N/A

CPAP present, clean and functional?

Yes No N/A

Safety Equipmeent

Safety Equipment

2 Hard hats with goggles?

Yes No N/A

2 Pair gauntlet gloves?

Yes No N/A

2 Safety Vests
Yes No N/A

2 Flashlights?
Yes No N/A

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4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

2 BSI Kits
Yes No N/A

Window Punch
Yes No N/A

Sharps Container
Yes No N/A

3 Road Reflectors
Yes No N/A

Hand Sanitizer
Yes No N/A

1 Fire Extinguisher Cab, 1 Fire Extinguisher Outside compartment, 1 Fire Extinguisher patient
compartment?
Yes No N/A

Basic Life Support Supplies

Adult Nasal Cannula Count

Pediatric Nasal Cannula Count

Adult Non-Rebreather Count

Pediatric Non-Rebreather Count

Adult Nebulizer Count

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4/30/2023 Ambulance Inspection Form - Download FREE Template | Lumiform Templates

Pediatric Nebulizer Count

Oropharyngeal Airway, 1 each size

Yes No N/A

Advanced Airway Supplies

Please note that this checklist template is a hypothetical example and provides only standard information.
The template does not aim to replace,
among other things, workplace, health and safety advice, medical advice,
diagnosis or treatment, or any other applicable law. You should seek
your professional advice to determine whether
the use of such a checklist is appropriate in your workplace or jurisdiction.

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