Vehicle Inspection Form For Registered Ambulances
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4VEHICLE INSPECTION FORM FOR REGISTERED AMBULANCES
SERVICE NAME:
DATE:
UNIT VID NUMBER:
UNIT VIN NUMBER:
RESPIRATORY EQUIPMENT
COMPLIANT
QTY
ITEM / DESCRIPTION
Y
N
PRI
1
1
Mounted Electric or Manifold Operation Suction Aspirator
1
1
Portable Suction Aspirator – as approved by the Department
4
1
Sterile Suction Catheters, assorted sizes
2
3
Irrigation Liquids, 1000 ml each or equivalent
Bag-Valve-Mask Resuscitator, disposable, with transparent adult mask. The valve
must operate in cold weather, and the unit must be capable of use with an oxygen
2
1
supply. The unit must be capable of delivering approximately 100% oxygen.
Pediatric Bag-Valve-Mask Resuscitator, disposable, with transparent child and infant
mask. The valve must operate in cold weather, and the unit must be capable of use
2
1
with an oxygen supply. The unit must be capable of delivering approximately 100%
oxygen.
4
1
Adult Oxygen Mask with Reservoir
2
3
Adult Oxygen Mask
3
1
Pediatric Oxygen Mask with Reservoir
3
3
Pediatric Oxygen Mask
3
3
Nasal Cannula
3
3
Oxygen Supply Tubing
1
1
Oropharyngeal Airways, with adult, child and infant sizes
1
1
Nasopharyngeal Airways, with adult, child and infant sizes
Tracheal / Pharyngeal Airway Adjunct (device not intended to be placed into the
1
1
trachea)
Oxygen: fixed system with at least two wall-mounted oxygen outlets and one
flowmeter. The system shall also include a yoke, pressure reducer gauge and an
approved cylinder-retaining device that meets DOT standards. The system shall be
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capable of delivering an oxygen flow of at least 15 liters per minute. If the oxygen
source is of a size less than “M” cylinder or equivalent, an additional full spare
cylinder for the fixed system shall be carried in the ambulance
Oxygen: portable unit consisting of at least a “D” cylinder or equivalent, yoke,
pressure gauge, flowmeter and cylinder wrench or hand wheel. The unit shall be
capable of delivering an oxygen flow of at least 15 liters per minute. Cylinder holders
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with a quickrelease fitting shall be furnished to allow the use of the portable unit
outside the vehicle. Ambulances manufactured 12 months after adoption of these
rules must meet Ambulance Manufacturers Division (AMD) Oxygen Tank Retention
Standard 003.
Oxygen: full spare cylinder for use with the above portable oxygen unit. In all
ambulances manufactured 12 months after adoption of these rules, the oxygen unit
must be secured in a manner that meets Ambulance Manufacturers Division (AMD)
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Oxygen Tank Retention Standard 003.
Vehicle Inspection Form for Ambulances – Revised 06/01/2010 – Form R-E-01-A – Page 1 of 4 – VID #____________
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