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UDOH Paramedic Ground Ambulance ChecklistName of Agency:Agency Service Number:Inspected by:Date of Inspection:Vehicle InformationVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Vehicle License NumberVIN NumberYear of VehicleType of Vehicle (Ambulance,Fire Truck Transport, Reserve,Other)Type of Inspection (Annual,New Vehicle, New License)Defibrillator/AED Serial NumberVehicle ChecklistVehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Approved waiverApproved variancesTriage systemSanitary conditionsEmergency ResponseGuidebook (ERG)Flashing lights and sirenRadio equipmentWritten standing ordersPediatric Reference Manual1 Blood pressure cuff (adult)1 Blood pressure cuff (pediatric)1 Stethoscope (adult)1 Stethoscope (pediatric) orcombination2 Heavy duty shears1 OB kit (includes cord clamp,scissors, scalpel, bulb syringe,drapes, towels, gloves, femininenapkin, and biohazard bags)

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 712 4x4 Gauze pads8 Soft roller type bandages 4” x5 yards2 Rolls tape2 Triangular bandages2 5x9, 8x10 sterile dressings2 Occlusive sterile dressings orequivalent1 Commercial tourniquet2 Biohazard bags1 Box non-sterile, latex freegloves1 Fire extinguisher with currentinspection sticker, dry chemicaltype with rating of 2A10BC orHalogen. (Weight 2.5-10pounds)2 Immobilization devices (heador equivalent)1 Lower extremity tractionsplint (adult)1 Lower extremity tractionsplint (pediatric)1 Upper extremity, non-tractionsplint1 Lower extremity, non-tractionsplint1 Long spine board1 Short spine board1 Full body immobilizationdevice (pediatric)3 Cervical collars or equivalent(adult)1 Cervical Collar or equivalent(pediatric)2 Disposable pillows2 Sheets2 Blankets1 Mylar blanket3 Towels1 Thermometer1 Glucose measuring device andsupplies

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 72 Emesis basins or bag, or largebasin2 Urinals (male and female) oruniversalFull body substance isolationprotection (one per crewmember)N95 or N100 TB mask (one percrew member)Protective eyewear, goggles orface shield (one per crewmember)Reflective Safety vest, OSHAapproved (one per crewmember)1 Car seat, federal safetystandard approved1 Ring cutter1 Hard commercial eye shieldDisinfecting agent for cleaningin accordance with OSHAstandards1 Suction device, portableand/or fixed with wide-boretubing and rigid pharyngealsuction tip.1 Bag valve mask (adult)1 Bag valve mask (pediatric)with child and infant mask1 Bulb syringe (infant) separatefrom OB kit1 Oropharyngeal airway (adult)1 Oropharyngeal airway(pediatric)1 Oropharyngeal airway (infant)1 Nasopharyngeal airway(adult)1 Nasopharyngeal airway(pediatric)1 Nasopharyngeal airway(infant)

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 72 Non-rebreather or partial nonrebreather O2 mask (adult)2 Non-rebreather or partial nonrebreather O2 mask (pediatric)1 Portable oxygen deliverysystem with metered flow andadequate tubing1 Permanent, large capacity O2delivery system1 Tube water based lubricant2 Nebulizer containers, smallvolume for aerosol solutions1 Pulse oximeter with adult andpediatric probe1 Magill forceps (adult)1 Magill forceps, (child/infant)Supraglottic airways – adultsizesSupraglottic airways – pediatricsizesLaryngoscope curved andstraight blades with 2 extrabatteries and 2 extra bulbs1 Endotracheal tube, uncuffed 3Fr1 Endotracheal tube, uncuffed3.5 Fr1 Endotracheal tube, uncuffed 4Fr1 endotracheal tube, uncuffed4.5 Fr1 Endotracheal tube, uncuffed 5Fr1 Endotracheal tube, cuffed 5.5Fr1 Endotracheal tube, cuffed 6 Fr1 Endotracheal tube, cuffed 6.5Fr

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 71 Endotracheal tube, cuffed 7 Fr1 Endotracheal tube, cuffed 7.5FR1 Endotracheal tube, cuffed 8 Fr1 Endotracheal tube stylet(adult)1 Endotracheal tube stylet(pediatric)1 Endotracheal tube securingdevice (adult)2 Endotracheal tubeconfirmation devices2 Endotracheal suctioncatheters, 5-12 Fr1 Nasal cannula (adult)1 Nasal cannula (pediatric)1 Nasal cannula (infant)1 Oro-nasogastric tube (adult)1 Oro-nasogastric tube(pediatric)2 Tongue blades1 Meconium aspirator1 Cricothyroidotomy kit1 Cardiacmonitor/defibrillator/pacerwith adult and pediatriccapabilities2 Sets of electrodes2 Sets defibrillator pads,combination type (pacing,cardioversion, defibrillation)10 Alcohol preps or iodine pads2 IV start packs2 Arm boards or equivalent1 60cc cath. tipped syringe1 Sharps container1 Safety razor2 Saline locks4 Normal saline forinjection/inhalation

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 72 60cc syringes2 10cc syringes2 3cc syringes2 1cc syringes2 Each, 14, 16, 18, 20, 22, 24ga.over the needle catheters1 15 or 16ga, intraosseousneedle or delivery system1 18ga, intraosseous needle ordelivery system5 IV tubing capable of microand macro drip chambers orequivalent2 Albuterol Sulfate, 2.5mgpremixed2 Atropine Sulfate, 1mg8 Chewable aspirin, 81mg2 Dextrose 50% 25mg preload,or Dextrose 10% 250ml2 Diphenhydramine IV, 50mg2 Dopamine HCL 400mg; OREpinephrine drip, 2 mics/ml(2cc Epinephrine 1:1, 000 to1000cc LR or NS) or bothEpinephrine 1:1,000 1cc(1mg/1cc); 5mg 1cc syringe22ga needle or equivalent2 Epinephrine 1:10,000 1mg1 1mg vial glucagon500cc irrigation solution2 Lidocaine (IV for cardiac use)or Amiodarone 300mg IV (orboth)4 Naloxone HCL, 2mg1 Nitroglycerine 0.4mg(bottle/tablets or spray)2 Oral glucose tubes, 15mgconcentrated or equivalent2 Promethazine HCL, 25mg orOndansetron, 8mg; or both

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 74,000cc Ringer’s lactate ornormal saline or both2 Sodium Bicarbonate 50mgRequired to carry at least one –Diazepam, Lorazepam, orMidazolamRequired to carry at least one pain medicationFentanyl 200mcg2 Morphine Sulfate 10mgNalbuphine 10mgNitrous Oxide and requiredadministration equipmentOptional equipment, supplies, and drugsHemostatic gauze or agentInflatable back raftWhole body vacuum splintTranscutaneous CO detectorVideo laryngoscopeBougie deviceImpedance threshold deviceAutomated transport ventilatorCPAP deviceEnd tidal CO2 monitorMorgan lens for ocularirrigationPortable sonographic deviceAutomated chest compressiondevice12 Lead ECG with transmissioncapability1 30cc Cath. tipped syringeMucosal atomization deviceVacutainer holderVacutainer tubesVacutainer multiple sample lueradaptorsIV infusion pump2 Three-way stopcock

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7Optional equipment, supplies, and drugs (continued)IV tubing with bloodadministration setsAcetaminophen elixir160mg/5mlActivated charcoalAdenosineCalcium dromorphoneIbuprofen adult or pediatricIpratropium namideVasopressinNerve agent antidote (Mark 1kits or Duodote)

Vehicle Information Vehicle Checklist UDOH Paramedic Ground Ambulance Checklist Name of Agency: Agency Service Number: Inspected by: Date of Inspection: Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 Vehicle 7 12 4x4 Gauze pads 8 Soft roller type bandages 4" x 5 yards