BLS Rig Check Form
Please complete all fields below. If you require immediate re-stock assistance contact your duty officer.
* Required
Ambulance
*
Choose
BLS 43-51
BLS 43-52
BLS 43-53
BLS 43-55
Date
*
MM
/
DD
/
YYYY
Next Oil Change Mileage
*
Your answer
Any Damage To Ambulance
*
Your answer
Fuel Level
*
Full
7/8
3/4
5/8
1/2
<1/2
Cab Equipment
*
Portable Radio
Tablet (Charging)
Toughbook (Logged In)
Out of Service Sign
Reflective Vests (2)
Paper Clipboard (Stocked)
Triage Tags In Each Door Pocket (2 Packs Total)
GPS
Gate Cards (2)
Garage Door Opener
Binoculars
HazMat Guidebook
Streamlight Flashlights (1-2)
Required
Vehicle Lights/Emergency Warning Devices
*
All Flashing Lights Functional (Run Diagnostic Test)
Siren(s) Functional
All Scene Lights Functional
Headlamps & Fog Lamps Functional
Turn Signals Functional
Required
Exterior Compartments
*
Life Vests (2)
Rope
KED
Reeves
Helmets (2), Turnout Coats (2), Extrication Gloves (4)
MCI Cones
Tool Box (Hailligan, Crow Bar, etc.)
Seatbelt cutter
Traffic Safety Triangles
Rehab Bin
Collar Bag Stocked (Min. 3 Adult, 3 Ped., Spiders)
Short Board
Long Boards (Min. 2) with CID/Head Chocks
Scoop
Stair Chair
Case of Water
Required
On-Board O2 PSI
*
Your answer
AED / ZOLL
*
AED - Ready
Razor
CPR Board
ZOLL ResQPUMP (& 2 Pods)
Required
AED Adult Pads (min 2)
*
Pad #1
Pad #2
Required
AED Pediatric Pad
*
Present
Absent
Required
Portable Suction
*
Portable Suction Charged & Functional (Test Suction Pressure)
Yankauer, Tubing, Soft Tip Suction Catheter (Sealed)
Sterile water
Required
Blue Jump Bag
*
Adult NRB (Min. 3)
Adult NC (Min. 3)
Adult BVM (1)
O2 Tubing
Various OPAs (Sealed)
Various NPAs (Sealed) w. Lube (Check Dates)
Tourniquet (2)
Crevats (2)
Stethescope
Adult BP Buff
Trauma Sheers
Pen Light (2)
Pulse Ox
Assorted First Aid Supplies (Gauze, Roller Gauze, Tape, Band-Aids, Abdominal Pad)
O2 Tank & Regulator (List PSI Below)
Chest Seals
CPAP
Required
Blue Jump Bag O2 PSI
*
Your answer
Blue Bag Glucose (min 2)
*
Glucose #1
Glucose #2
Required
Blue Bag Aspirin 1 Bottle
*
Present
Absent
Required
Blue Bag Naloxone (min of 2)
*
Narcan #1
Narcan #2
Required
Blue Bag Adult Epi-Pen
*
Present
Absent
Required
Red Jump Bag
*
Ped. NRB (Min. 2)
Ped. NC (Min. 2)
Adult NRB (Min. 2)
Adult NC (Min. 2)
Pediatric BVM (1) & Infant BVM (1)
O2 Tubing
Various OPAs (Sealed)
Various NPAs (Sealed) w. Lube (Check Dates)
Crevats (Min. 2)
Stethescope
Pediatric BP Cuff
Adult BP Buff
Trauma Sheers
Pen Light
Tourniquet (2)
Assorted First Aid Supplies (Gauze, Roller Gauze, Tape, Band-Aids, Abdominal Pad)
O2 Tank (List PSI Below)
Required
Red Jump Bag O2 PSI
Your answer
Red Bag Glucose (min of 2)
*
Glucose #1
Glucose #2
Required
Red Bag Pediatric Epi-Pen
*
Present
Absent
Required
Fire Extinguisher
*
Present
Absent
Required
Bleeding Control Kit (Tagged)
*
Present
Absent
Required
Burn Kit (Tagged)
*
Present
Absent
Required
PPE and Sanitation Supplies
*
Tyvek suits (min 4)
Lab Coats/Gowns (min 4)
N95 (min 4)
Surgical masks (min 10)
Splash Shield/Goggles
Purple Top Wipes
Blue Top Wipes
Envirocide Cleaner
Goggles/ Shields
Required
Interior Equipment
*
Stretcher Made (Must have at least 1 sheet and 1 blanket)
Linens Stocked (Min 2 blankets, 2 sheets, 4 towels)
(2) Full Spare O2 D-Tanks (Outside on 51/53)
Adult O2 - NRB (Min. 5) & NC (Min. 5)
Pedi. O2 - NRB (Min. 5) & NC (Min. 5)
BVMs: (1) Adult, (1) Pediatric & (1) Infant
O2 Tubing
Various OPAs
Various NPAs (Sealed) w. Lube
Trauma Sheers
Trauma Dressing (min 4)
Occlusive Dressing
4x4 Gauze ( min 24)
Pen light (2)
Roller gauze (12)
Crevats (Min. 12)
Stethescope & Adult BP Cuff (Action Tray)
BP Cuff Basket: Large Adult, Pediatric, Infant Cuffs
Sterile Water (Min. 3 / Check Dates)
Hot & Cold Packs (Min. 4 Each)
Vomit Bags or Basins
SAM Splint (Min. 1)
Sharps Container & Spare Bio-Hazard Bags
Gloves - Small, Med., Large, XL (2 Boxes Each)
Pulse Oximeter
Window Punch
Pedi Mate (baby seat)
Assorted first aid supplies (bandaids, alcohol prep pads 2x2 dressing)
Required
CPAP Mask
*
Present
Absent
Required
On-Board Aspirin 1 Bottle
*
Present
Absent
Required
On-Board Glucose (min 2)
*
Glucose #1
Glucose #2
Required
OB Kit (min 2)
*
OB Kit #1
OB Kit #2
Required
Bench Seat
*
Frac. Pack
Pediatric Immob. Board
Adult Hare Traction (Min. 1) with Ankle Hitch
Pediatric Hare Traction with Ankle Hitch
Padded Board Splints
Required
Additional Comments or Missing Supplies
Your answer
Crew Names
*
Your answer
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