Jump Bag - Main
BVM / extra mask
ea Shears / Penlight, Glucose
Portable O2 tank >1000 psi psi
ea Adult NRB/NC
Set OPA's / NPA's with lube
Spare Yankauer and tubing
Jump Bag - Peds
Peds BVM
ea Infant / Small / Child BVM Masks
ea 5fr/8fr/10fr suction catheters
Bulb Syringes
ea Infant / Small / Child OPA's
ea Peds NRB / NC
Peds Stethoscope
ea B/P cuff Infant and Child
Peds IV Arm Board
Infant Swaddler
Jump Bag - Trauma
Occlussive Dressing
4 X 4
5 X 9
10 X 30
Sterile Burn Sheet
Cravats
ea 2", 3", 4" or 6" Kling
ea 1", 2", 3" Tape
Cold Packs
Jump Bag - End
ea Adult BP Cuff / Stethoscope
500 cc NS
pr Gloves
Miscellaneous Items
Full Spare Oxygen Tank
Short Board or KED
Portable Suction
Wool Blankets
Flashlight
Fire Extinguisher
Set Road Triangles
Smart triage system
Blanket
Short board or equivalent with straps.
Collar Bag Contents
Pair of Head Blocks
Adult Collars
Pediatric Collar
Sets of Quick Straps
Roll of 2" or 3" Tape
OPA Kit Contents
Large Adult 110mm
Adult 100mm
Medium Adult 90mm
Small Adult 80mm
Small Adult 70mm
Pediatric 60mm
Pediatric 50mm
Infant 40 mm
Front Cab
1 Map Book
1 Clipboard
1 Gas Card
Main Compartment
Pre-mix Lidocaine 4mg/ml
60gtt /cc IV sets
Dextrose 25%
2% Lidocaine pre-filled 100mg
Epinephrine 1:10,000 1mg
Atropine 1mg
Dextrose 50%
Sodium Bicarbonate 50mEq
Etomidate 20mg
250 ml NS IV
Activated Charcoal 25 grams
Nebulizer
Oral Glucose
Sharps Container 1qt size
10cc Syringes
50ml D5W IV
1000cc NS IV
Macrodrip IV Set
Extension Set
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.
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Airway Management
Pair of Goggles or Glasses
Handles (1ea Adult/Ped)
ea. Miller 0,1,2,3,4 Blades
ea. Mac 1,2,3,4 Blades
Grandview
10cc Syringes
Stylettes (2 adult)
Stylettes (1 ped)
End Tidal CO2 Detector
Magills Forceps (adult/peds)
Meconium Aspirator
2.5 -5.5 ET Tubes
6.0,7.0,7.5,8.0 ET Tubes
Gum Bougie
King LT (red, yellow)
Thomas ET Tube Holder
BAAM Whistle
Lifepak 12
Adult Fast Patches
Pediatric Fast Patches
Adult Electrodes
Razors
Extra Battery
Ped Electrodes
Extra Paper
Adult NIBP cuff
CO2 Sensors
Small Drug Box
Adenosine 6mg
Amiodarone 150mg
Metoprolol 5mg
Epinephrine 1:1,000 1mg
Diphenhydramine 50mg
Thiamine 100mg
Magnesium Sulfate 1gm
Dopamine 400mg
Epinephrine 1:1,000 30cc
Furosemide 100mg
Narcan 2mg
Calcium Gluconate 10%
Baby ASA 81mg/ea (8 minimum)
Nitroglycerin 0.4mg (6 minimum)
Haldol 5mg
Vecuronium
Vasopressin 20u
Procainimide 1gram
Phenergan 25mg
Diltiazem 25mg
Glucagon 1mg
Succinylcholine 100mg
Albuterol 2.5mg
Atrovent 0.5mg
Right Compartment
Controlled Substance Box
Seal Number
Date
IV Supplies
1cc Syringes
5cc Syringes
10cc Syringe
14g Long Catheter
ea. 14g-20g Catheters
2 ea. 22g-24g Catheters
IV Start Kits
Alcohol Preps
2x2 Gauze Pads
Tegaderms
Saline Locks
1" Clear Tape
Touriquets
ea. Ports,Caps,Butterflies
BandAids
Saline Flushes
Glucometer
Peds IO Kit (with Braselow)
EZ- IO Kit w/ 3 needles
Top Cover Pouch
CPAP Generator
Set of O2 Connectors
Disp CPAP Circiut
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Comments:
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
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
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:
Service Issues:
Which vehicle are you in?
What is your employee number?
What is your partners employee number?
Was your vehicle clean at the beginning of shift?
Is there a gas card in your vehicle?
Did you complete a user test?
Did you do a defibrillator shock test?
Shock test at
Shock test Successful?
By submitting this form you're affirming that you have completed an entire
check of your supplies and equipment.
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