BLS Check Sheet

JUMP BAG - MAIN COMPARTMENT
Adult BVM w/extra mask
Portable O2 tank >1000 psi
Portable O2 tank psi
Adult NRBM
Adult NC
40mm OPA Size 00
50mm OPA Size 0
60mm OPA Size 1
70mm OPA Size 2
80mm OPA Size 3
90mm OPA Size 4
100 mm OPA Size 5
22 Fr NPA
24 Fr NPA
26 Fr NPA
28 Fr NPA
30 Fr NPA
32 Fr NPA
34 Fr NPA
36 Fr NPA
Surgilube
Trauma Shears
Penlight
PO Glucose

JUMP BAG -PEDIATRIC COMPARTMENT
Pediatric BVM
Infant Mask
Small Mask
Child Mask
Peds NRBM
Peds NC
5/6 Fr Suction Cath
8 Fr Suction Cath
10 Fr Suction Cath
Bulb Syringe
Peds IV Arm Board
Infant Swaddler
Pediatric Stethoscope
Child BP Cuff
Infant BP Cuff

JUMP BAG - TRAUMA COMPARTMENT
4 X 4
5 X 9
10 X 30
Sterile Burn Sheet
Cravats
2" Kling
3" Kling
1" Tape
2" Tape
3" Tape
Cold Packs

JUMP BAG - END COMPARTMENT
Adult Stethoscope
Adult BP Cuff
500cc NS Irrigation
Pairs of Gloves

CABINET 1
Short Board
Stair Chair

COLLAR BAG
Adjustable Adult Collars
Pediatric Collar
Pediatric Short Collar
Quick-Clip Straps
Set Head Blocks
3" Cloth Tape

CABINET 2
Obese BP Cuff
Emesis Basins
Oxygen Spare Seal Kit
500cc Sterile Water
O2 Humidifier
Nebulizer
Adult NRBM
Adult NC
Peds NRBM
Peds NC
Please check this box if you have an immediate issue with your ambulance that needs attention by the management team. The comments box will be sent by email.

CABINET 3
OPA Kit - 7 Sizes
Oxygen Tubing
Suction Tubing
Yankauer Tip
5/6 Fr Suction Caths
8 Fr Suction Caths
10 Fr Suction Caths
Suction Bags or Canisters*
Set ETT 2.5-8.0

CABINET 4
4 X 4
5 X 9
Occlusive Dressings
Cravats
2" Kling
3" Kling
6" Kling
1" Tape
2" Tape
3" Tape
Cold Packs
Hot Packs
Trauma Shears
Penlight
PO Glucose
Pens

CABINET 5
10 X 30
Sterile Burn Sheet
Roll Occlusive Dressing
500cc NSS Irrigation
Sterile OB Kit
OB Pads

CABINET 6
Adjustable Collar
Quick-Clip Straps
Set Head Blocks
Web Straps
Extension Straps

CABINET 7
Disposable Fitted Sheets
Disposable Top Sheets
Disposable Pillow Cases
Disposable Towels

CABINET 8
Urinal
Bedpan
Umbrella
Biohazard Bags
HEPA Masks
Goggles / Face shields
Gowns
Lantern
Finger Lakes Bear
Boxes Tissues

CABINET 9
Adult BVM
1000cc NS IV
10 gtt Sets
Extension Sets
Activated Charcoal 25 grams
Key Ring

MISCELLANEOUS
Full Spare "D" Tanks
psi. Main O2 >500 psi
Backboards
KED
Set Velcro Splints
Board Splint Set
Traction Splint
Spare Pillow
Portable Suction
Ansi Vest
Onboard Suction unit appropriately attached and working?

Mechanical Check
MILEAGE:
- Current Mileage
- Service Due Mileage

VEHICLE LIGHTS:
Headlights -Low
Headlights -High
Parking Lights
Turn Signals
Brake Lights
Hazard Lights
Reverse lights and alarm working

EMERGENCY LIGHTS:
Light Bar
Flashers -Body
Flashers -Grille
Wig Wags
Scene Lights -L/R
Load Lights

RADIOS
FLA Transmit and Receive Channel 1
FLA Transmit and Receive Channel 2
FLA Transmit and Receive Channel Back Up

FLUIDS
Engine Oil
Washer Fluid
Fuel Level above 3/4 tank

MISCELLANEOUS
Climate Control -Front
Climate Control -Rear
Horn / Siren
Tires (inflation, wear, damage)
Fire Extinguisher
Road Triangles
Rig Clean Inside & Outside
All Equipment Secure

Medical Equipment left in shop for repair:

New Body Damage:

Comments:

Which vehicle are you in?

What is your employee number?

What is your partners employee number?

Was your ambulance clean at the beginning of shift?

Is there a gas card in your ambulance?

Is there HIPAA forms on your ambulance?

Confirm that your GPS unit is on?

Do you have a student, observer or new employee onboard today?

By submitting this form you're affirming that you have completed an entire check of your supplies and equipment
© 2009 Finger Lakes Ambulance
Version 1.5